Clinical Nutrition 34 (2015) 951e955

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Original article

Individualized measurement of disease-related malnutrition's costs  n-Payer b, M. Leo  n-Sanz c C. Gastalver-Martín a, *, C. Alarco a

Department of Pharmacy, Hospital Universitario 12 de Octubre, Madrid, Spain Department of Pharmacy, Hospital Universitario Virgen de las Nieves, Granada, Spain c Department of Clinical Nutrition, Hospital Universitario 12 de Octubre, Madrid, Spain b

a r t i c l e i n f o

s u m m a r y

Article history: Received 9 July 2014 Accepted 15 October 2014

Background & aims: Disease-related malnutrition has a significant economic impact in hospitals, but accurate measurements of these costs have rarely been reported. The aim of this study is to calculate the actual costs of disease-related malnutrition in hospitals, taking into account every cost that patients generate during their hospital stay. Methods: Patients admitted to medical wards were included in this study. Nutritional evaluation was carried out by two methods (Nutritional Risk Screening 2002 and Short Nutritional Assessment Questionnaire) at admission and/or at discharge. Hospitalization costs were measured for each patient individually, considering the cost of the bed, the Intensive Care Unit, the physicians' services, the laboratory tests and diagnostic procedures, and the drug costs. Differences in costs between malnourished patients and non-malnourished patients were calculated. Results: Malnourished patients incurred higher costs than non-malnourished ones. The cost increase for malnourished patients ranged between 45% and 102%. The nutritional status accounted for most of this increase. The most outstanding difference in patients' costs was between those patients who maintained their nutritional status, either well or malnourished, during their hospital stay. Conclusions: Disease-related malnutrition clearly has an impact on the cost of hospital care provision, particularly in malnourished patients who do not improve their nutritional status during their hospital stays. Individualized cost analyses are needed to identify the real costs of malnutrition. © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Keywords: Disease-related malnutrition Costs Hospitalization costs

1. Introduction Malnutrition is a condition caused by the insufficient or imbalanced consumption of nutrients in comparison with nutritional requirements. It is a common disease in hospitals all over the world, and elderly people are especially at risk of developing it. There is a mutual influence of disease and malnutrition, and three different malnutrition syndromes have been defined according to the degree of systemic inflammation. The term “disease-related malnutrition” (DRM) has been proposed to reflect this interaction between nutritional status and medical conditions [1e6]. Many studies have reported the association of DRM with complications that patients suffer from during their hospital stays. In turn, they imply longer periods of hospitalization and further use of resources [7,8]. The economic consequences of DRM have been analysed from different perspectives, such as resource utilization

(for example, antibiotics or readmission rates) or as monetary outcomes [7,9]. In relation to these economic terms, it is estimated that DRM originates an important increase of the total hospitalization costs of malnourished patients [10,11]. DRM costs have already been measured by several groups of researchers [12e14]. By and large, they have been calculated based on estimations of general costs of the hospital stays, such as by hospital bed costs per day, or disease costs, for example, obtained from the Diagnosis-Related Group (DRG) database [15,16]. Other authors have used a more thorough procedure, also taking into account drug and diagnostic procedures costs. [17,18]. The goal of this study is to calculate the costs associated with DRM based on an individualized analysis of costs per patient, including ward and Intensive Care Unit (ICU) stays, laboratory tests', diagnostic procedures', drugs' and nutrition supplements' costs. 2. Material and methods

* Corresponding author. Servicio de Farmacia, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain. Tel.: þ34 686044893. E-mail address: [email protected] (C. Gastalver-Martín).

Demographic, nutritional, and economic data were collected from patients admitted between March 2011 and May 2013 to four

http://dx.doi.org/10.1016/j.clnu.2014.10.005 0261-5614/© 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

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C. Gastalver-Martín et al. / Clinical Nutrition 34 (2015) 951e955

units of the Department of Internal Medicine, Hospital 12 de Octubre, Madrid, a third level hospital with 1365 beds. Any patient admitted to these wards was eligible to be included in the study if he or she was able to collaborate in the study, was 18 or older, and had an estimated stay in the hospital of longer than two days. Exclusion criteria were (1) length of stay shorter than seven days, (2) rejection of participation or continuation in the study, or (3) pregnancy. Furthermore, all patients had to give their consent to participate in the study. All data were collected by the same researcher, who was not involved in these patients' care. Collected information included age, gender, comorbidity (measured by Charlson Index [19]), weight, height (measured at admission and discharge), duration of hospital stay, nutritional status, and hospital costs. Nutritional status was estimated by two methods, the Nutritional Risk Screening 2002 (NRS-2002®) and the Short Nutritional Assessment Questionnaire (SNAQ®), which were applied within 48 h of admission or at discharge. NRS-2002® measures patients' nutritional status in two phases, taking into account comorbidity and degree of malnutrition [20]. If patients have three or more points, they are considered malnourished or at risk of malnutrition. SNAQ® is based on the occurrence of weight loss, decrease of appetite, and use of supplemental drinks or tube feeding over the past month [21]. If patients have a score of two or more, they are considered malnourished. In this study, a patient was classified as malnourished when he or she was considered malnourished or at risk of malnutrition by either of these methods. Hospitalization costs were calculated using the following variables: daily costs of stay either in wards or in the ICU, costs of every laboratory parameter measured for each patient, costs of every non-laboratory diagnostic procedure carried out for each patient, costs of medical consultations to any medical specialist other than the physicians taking care of the patient in the ward, costs of administered drugs, and costs of nutritional support, when applicable. The costs of drugs and nutritional supplements were obtained from the Pharmacy service. All other expenses were provided by the Economic Management Unit of Hospital 12 de Octubre and adjusted for the year of the study. Daily costs (ward and ICU stay) were multiplied by the number of days each patient stayed in the unit. All costs were individually measured for each patient, with the exception of the daily costs of the hospital stays. All costs were calculated in euros (V). The study was conducted in agreement with the standards of the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of Clinical Investigation of Hospital 12 de Octubre before the beginning of the study. Patients were informed about the objectives and procedures of the study, as well as about their right to refuse or leave the study at any moment. Statistical analysis was carried out with SPSS® 18 version for Windows (SPSS Inc., Illinois, United States). The results were expressed as arithmetic mean ± standard deviation for quantitative variables, and as frequencies and percentages of patients for qualitative variables. To compare categorical variables, the chi-square test was chosen, and for continual variables the student-t test was selected. In order to analyse which variable had a major impact on hospitalization costs, a multivariate linear regression analysis was applied to the main parameters (nutritional status, age, gender, and comorbidity). The statistically significant level that was established to detect significant differences was 0.05.

expressed their desire not to take part in the study or even for leaving it. Therefore, 210 patients were interviewed and analysed. The nutrition status was assessed in 126 patients within the first 48 h of admission, and 148 patients were nutritionally evaluated at discharge. Nutritional data of 64 patients were available both at admission and at discharge (Fig. 1). Patients were split into two classes, malnourished or well-nourished, and the different costs incurred during hospitalization were individually calculated per patient. Demographic characteristics (age, gender, and comorbidity) were compared between both groups, but no significant differences were observed (Table 1). 3.1. Cost of malnourished patients at admission Among the 126 patients evaluated at admission, 33.33% of them were classified as malnourished. There was not any significant difference between them and the well-nourished patients regarding gender, age, or comorbidity. Taking into consideration all of the economic variables assessed in the study, the total cost of hospitalization of malnourished patients (4158.90 V ± 4148.51) significantly exceeded, by 45.2%, the cost of non-malnourished patients (2864.21 V ± 1747.95) (p ¼ 0.015) (Fig. 2). As most patients were old and suffered from multiple diseases, we also studied the possible influences of age, gender, and comorbidity on costs. Interestingly, we found that these characteristics had no influence on costs. However, nutritional status did explain the differences between the groups, as it was further supported by the multivariate linear regression analysis (p ¼ 0.029) (Table 2). 3.2. Cost of malnourished patients at discharge A total of 148 patients were nutritionally screened at discharge. Among them, 45 were considered malnourished (30.5%). The main demographic characteristics were similar in malnourished and well-nourished individuals. The mean cost of malnourished patients (6329.33 V ± 6460.65) went over the mean cost of non-malnourished patients by 80.1% (p ¼ 0.000) (Fig. 2). Nutritional status was the main reason for these costs differences, without a significant impact of other variables such as age, gender, or comorbidity (p ¼ 0.000) (Table 2).

3. Results A total number of 260 potential candidates were evaluated for inclusion in the study, but 50 of them were left out for different reasons, such as for meeting exclusion criteria or for having

Fig. 1. Patients recruitment flow-chart.

C. Gastalver-Martín et al. / Clinical Nutrition 34 (2015) 951e955 Table 1 Demographic characteristics of patients.

Age Gender Charlson Index

Age Gender Charlson Index

Age Gender Charlson Index

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Table 2 Multivariate linear regression analysis.

Well-nourished at admission (N ¼ 84)

Malnourished at admission (N ¼ 42)

p

Variables

64.63 ± 18.59 H: 50%; M: 50% 3.56 ± 2.92

64.02 ± 20.80 H: 45.2%; M: 54.8% 4.05 ± 3.13

0.979 0.614 0.411

Multivariate linear regression analysis at admission Nutritional status at admission 0.029 Age 0.343 Gender 0.986 Comorbidity 0.71

Well-nourished at discharge (N ¼ 103)

Malnourished at discharge (N ¼ 45)

p

66.36 ± 18.69 H: 53.4%; M: 46.6% 4.35 ± 2.97

70.27 ± 13.84 H: 66.6%; M: 33.3% 5.33 ± 2.62

0.21 0.133 0.057

Well-nourished at admission and at discharge (N ¼ 39)

Malnourished at admission and at discharge (N ¼ 9)

p

66.08 ± 17.52 H: 53.84%; M: 46.15% 3.77 ± 3.2

70.67 ± 18.44 H: 66.6%; M: 33.3% 6.56 ± 2.07

0.486 0.611 0.017

3.3. Cost of patients that keep their nutritional status during all the hospital stay We also compared the costs of patients who were malnourished throughout the hospital stay with those of patients who were wellnourished at admission and at discharge. To carry out this enquiry, we considered 48 patients, 18.75% of whom were malnourished, but who were comparable regarding all other demographic variables. The mean cost of malnourished patients resulted in much higher costs (7324.51V ± 6245.44) than those of non-malnourished patients (3621.11V ± 2173.78, p ¼ 0.004), or a 102.27% increase (Fig. 2). As in the previous comparisons, only nutritional status was responsible for this difference, according to the multivariate linear regression analysis (p ¼ 0.013) (Table 2). Table 3 is particularly informative. Data are displayed in three layers, corresponding to different nutritional statuses: at admission, at discharge, and without change between the two. Drug and procedure costs increased across the three situations. Medical nutritional therapy also increased. However, these figures reflect real-life situations, and a limited prescription of nutrition products was observed. There was also a gradient of hospital costs among the

p

Multivariate linear regression analysis at discharge Nutritional status at discharge 0 Age 0.239 Gender 0.305 Comorbidity 0.32 Multivariate linear regression analysis at admission and at discharge Nutritional status at admission 0.013 Nutritional status at discharge 0.013 Age 0.571 Gender 0.445 Comorbidity 0.145

three classes, but this result is justified by the difference in lengths of stay, which shows a clear increase from those malnourished at admission to those who were poorly nourished at admission and at discharge.

4. Discussion Our study indicates that DRM is associated with an increase in hospitals' costs, ranging from 45% to 100%. Previous studies have detected the rise of costs associated with hospital malnutrition. However, our study intended to provide a more detailed picture of the health economics of malnutrition, taking into consideration different individual expenses that contribute to the total cost. A literature analysis revealed that in older studies, researchers had only collected information about either length of hospital stay and medication costs or cost as defined by disease-related groups (DRGs). However, there were no studies in Europe that had prospectively and individually calculated all costs associated with hospitalization, such as hospital or ICU stay, diagnostic procedures, laboratory tests, drugs, medical consultations and nutritional support. We prospectively collected these data for each patient included in the study, as recommended by Norman et al. [13] and

Fig. 2. Costs comparison.

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Table 3 Detailed hospitalization costs and days of stay. Costs (V)

Malnourished

No-malnourished

p

Nutritional status at admission Hospitalization costs 4158.90 Costs of stay 2413.08 ICU costs 647.73 a Procedure costs 796.02 Drug costs 300.74 Nutritional treatment costs 7.88 Days of admission 14.00

± ± ± ± ± ± ±

4148.51 1814.91 2651.66 850.50 700.75 30.18 10.44

2864.21 2100.43 0.00 608.66 152.24 0.4 11.96

± ± ± ± ± ± ±

1747.95 1116.51 0.00 675.21 276.63 3.51 6.34

0.015 0.059 0 0.181 0.092 0.026 0.602

Nutritional status at discharge Hospitalization costs 6329.33 Costs of stay 3497.78 ICU costs 1410.61 Procedure costsa 990.27 Drug costs 559.57 Nutritional treatment costs 4 Days of admission 19.96

± ± ± ± ± ± ±

6460.65 2472.2 3978.92 1196.42 885.09 34.14 14.01

3514.26 2589.14 52.83 680.94 227.14 11.08 14.68

± ± ± ± ± ± ±

2075.36 1476.56 398.02 611.51 378.22 34.05 8.38

0 0.002 0 0.039 0.002 0.001 0.005

Nutritional status stable during hospitalization Hospitalization costs 7324.51 ± 6245.44 3621.11 ± 2173.78 Costs of stay 4210.66 ± 3125.13 2594.19 ± 1408.31 ICU costs 1007.58 ± 3022.73 0.00 ± 0.00 Procedure costsa 1279.25 ± 1525.68 813 ± 800.76 Drug costs 827.03 ± 1315.6 212.99 ± 392.23 Nutritional treatment costs 31.54 ± 60.78 0.82 ± 5.15 Days of admission 24.44 ± 17.49 14.69 ± 7.99

0.004 0.001 0 0.199 0.015 0.002 0.014

a Costs of laboratory tests, diagnostic procedures, and medical consultations were included in the procedures costs.

Meijers et al. [22]. Because of these measures, we were able to have a more accurate picture of malnutrition costs in hospitals. Lim et al. used a similar approach in their study of the economic consequences of malnutrition in hospitalized patients in Singapore [23]. They carried out a prospective study where costs were individually measured for each patient. In their study, the costs of patients who were malnourished at admission were 24% higher than those of non-malnourished individuals. In another study in the USA in which hospital costs were calculated according to DRGs, Chima et al. [12] determined that the difference was about 36%. Other rez de la investigations in Europe have had similar results to ours. Pe Cruz et al., in a study in Spain in 2004, had results showing that the cost increase attributable to hospital malnutrition was about 68.04% [9]. Amaral et al., in a study in Portugal in 2007, found that the costs for malnourished patients at admission were 121.93% higher than the costs for non-malnourished patients [15]. A few years later, Rice et al. [24], in their work about malnutrition costs in Ireland, estimated the increase of costs in malnourished patients as more than 5000V. Finally a nation-wide study carried out in Spain, the PREDyCES study [25,26] showed that the costs between malnourished and non-malnourished patients was a 20% higher for those who were malnourished. Nevertheless, the measure of costs in those studies is not as comprehensive as ours. For example, the PREDyCES [25,26] study did not consider the actual costs of drugs administered to patients, and Amaral [15] made an estimation of hospital costs based on DRGs that did not allow for much assessment of individual expenses. The differences of the results between those studies and ours could be because we performed a more precise individual measurement of hospital costs, avoiding general assumptions and estimations. There are other reasons that justify the differences found between our results and the others. Nutritional screening methods may vary from one study to another, making more difficult the comparison of results. Length of stay may also be different and have a marked influence on the results. In that sense, we excluded all the patients who have a length of stay shorter than seven days.

In our study, when nutritional status was maintained as stable from admission, either as mal- or well-nourished, we observed a remarkable difference in hospital costs, equivalent to an increase of 100% in the first group. A corollary is that the difference between these groups became even greater when no action was taken against the poor nutritional status of the patients. There are no similar publications showing the consequences of good or bad nutritional status during patients' entire stay. In fact, most studies rather evaluated nutritional status at admission or at discharge, preventing the possibility of comparing hospitalization costs of patients who were persistently mal- or well-nourished. As many other authors have previously described, our findings show that malnutrition is highly prevalent and leads to poor clinical outcomes. This translates into poor Quality of Life experienced by patients and into huge costs for the health care system. Policymakers and health administrators may be concerned with the obesity epidemic pervasive in many societies. However, thorough analysis of costs incurred by malnourished patients will undoubtedly increase the awareness of the magnitude of disease-related malnutrition and will lead to implementing medical nutrition therapy to improve this often overlooked condition. The significant economic impact caused by malnutrition should alert health professionals of the real magnitude of this problem. A closer identification and treatment of malnutrition will not only serve to save costs but to decrease morbidity and increase Quality of Life of patients. In some countries, like Denmark and The Netherlands, nutrition screening on patient admission is mandatory and it is required for successful hospital accreditation. Raising awareness among health professionals will lead to better malnutrition diagnosis and documentation with lower LOS and infection rates. As we have discussed, longer LOS is associated with experiencing more complications during their period of hospitalization. Furthermore, if health professionals document the presence of malnutrition, as a comorbidity or complication, in clinical records and discharge reports, they will better define the actual case mix of health care facilities with a clear potential to attract greater hospital reimbursement [27]. 5. Conclusions Disease-related malnutrition clearly has an impact on the costs of hospital care provision. This influence becomes more evident when malnourished patients do not improve their nutritional status during their hospital stay. Individualized cost analyses are needed to identify the real costs of malnutrition. Statement of authorship Each author participated appropriately in the work to take responsibility for the content of this article, including the conception, design, and conducting of the study and for the interpretation. ML devised the study, participated in its design, and contributed to the data analysis and drafting of the manuscript. CG outlined the research, carried out the study and data analysis, and drafted the manuscript. CA participated in the design of the study, the data analysis, and revising critically the manuscript. All authors read and approved the final manuscript. Funding sources This work has no funding sources. All equipment necessary for its development has belonged to the Nutrition department since the beginning of the study.

C. Gastalver-Martín et al. / Clinical Nutrition 34 (2015) 951e955

Conflict of interest None declared.

Acknowledgements Thanks to Hospital 12 de Octubre for all their support, particularly to the nursery team of medical wards in which this work was carried out. We are very grateful to the Economic Management Unit and to the Pharmacy Department for making easier the data collection process. Special acknowledgment must also be given to Dr. de la Cruz and Mr. Lora for supporting the data analysis.

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Individualized measurement of disease-related malnutrition's costs.

Disease-related malnutrition has a significant economic impact in hospitals, but accurate measurements of these costs have rarely been reported. The a...
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