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Reduced Readmissions—In a Bottle?

 |  By Philip Betbeze  
   November 01, 2013

Healthcare organizations can lower readmissions and improve patient care significantly through a simple move that doesn't involve fancy data systems or expensive care coordinators, according to new research. If your organization doesn't use an oral nutritional supplement protocol, why not?

New research suggests healthcare organizations can lower readmissions and improve patient care significantly, and it doesn't involve fancy data systems or expensive care coordinators. In fact, it may come in a bottle or can.

That's because a recent study by researchers at the University of Southern California, Stanford University, The Harris School at The University of Chicago, and Precision Health Economics finds that hospitals and health systems could conceivably reduce readmissions for Medicare patients by 8.4% and significantly reduce length of stay simply by incorporating oral nutritional supplements into care protocols for hospital stays.

One reason doing so works so well, says Julia Thornton Snider, PhD, a research economist with Precision Health Economics, is that other studies suggest that as many as 50% of patients are clinically malnourished after discharge.

"We have defined malnutrition through advanced nutrition statistics," she says. "It's the frail person you think of, but it also includes those who could also technically be obese."

The six clinical characteristics of malnutrition, as defined in 2012 by the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition, are:

    • Insufficient food and nutrition intake compared with nutrition requirements
    • Weight loss over time
    • Loss of muscle mass
    • Loss of fat mass
    • Fluid accumulation
    • Measurably diminished grip strength

A patient who exhibits any two of the six characteristics should be diagnosed with malnutrition, the groups say.

Kelly Tappenden, PhD, of the Academy of Nutrition and Dietetics and its representative to the Alliance to Advance Patient Nutrition, says the Joint Commission mandates a nutrition screening within 24 hours of admission. Yet the screening is often not completed or the results may not flag timely follow-up before a patient is discharged.

"Additionally, priority is put on addressing high-acuity patient health needs," says Tappenden, who is Professor of Nutrition and Gastrointestinal Physiology at the University of Illinois at Urbana-Champaign. "As a therapy, nutrition is often overlooked and undervalued in the hospital setting." She adds that one in three patients enter the hospital malnourished.

"The good news is that as the body of science supporting nutrition is advancing, we are seeing hospital administrators and interdisciplinary clinician teams take notice of the benefits of nutrition on patient outcomes," she says.

Snider was the project leader on the study, which came about after an earlier study found strong benefits to providing oral nutrition supplements to the general inpatient population.

"That [study] basically looked at the general inpatient population and found that providing oral nutrition supplements had impressive benefits on reduced readmissions and reduced length of stay. But while it's interesting in the general patient population, hospitals don't see a general patient. They see someone with a specific diagnosis or diagnoses. They wanted to know who to apply it to," Snider says.

Now they have at least a partial answer.

The newer study, presented last week at the Society for Medical Decision Making meeting in Baltimore, showed that providing oral nutritional supplements was associated with the decreased probability of 30-day readmission among Medicare patients. The study further breaks down results from that population based on diagnosis of acute myocardial infarction, congestive heart failure, and pneumonia, which are among the diagnoses CMS penalizes hospitals for based on 30-day readmission rates.

The results are compelling. Among them:

  • An 8.4% reduction for patients with any diagnosis
  • A 10.1% reduction for congestive heart failure patients
  • A 12% reduction for acute myocardial infarction patients

Given the penalties that are accruing for hospitals and health systems for 30-day readmissions, those results should get your attention. But if that's not enough, the study also found that the use of oral nutritional supplements delivered improvements in patient length of stay and hospital costs. Oral nutritional supplements were even more impactful and statistically significant on length of stay and cost of care when looking at all Medicare patients aged 65 and older with any primary diagnosis:

  • 16%, or 1.65 days, reduction in length of stay
  • 15.8%, or $3,079, in cost savings per episode

The study looked at 11 years of hospital data (2000–2010) on hospitalized Medicare patients aged 65 and over with any diagnosis, as well as breakouts for patients with AMI, CHF, and pneumonia.

These results are impressive enough, and the cost of implementing an oral nutrition program so minimal compared to other interventions that aim to reduce readmissions, that I'm amazed more CEOs don't demand that it be included in their hospital stay care protocols—not only for Medicare patients but for all inpatients. According to Snider, only 1.6% of patients in the study were provided oral nutritional supplements during and after their stay. Given the findings, which admittedly cover a long time period during which less was known about this issue, I would expect that percentage to rise dramatically in coming years. So be cynical based on the study's funding at your peril.

"Overall, there needs to be a cultural shift where nutrition is valued through interdisciplinary collaboration," says Tappenden. "Probably one of the most important changes hospital administrators can make is to provide nutrition-related ordering privileges to registered dietitians, rather than it being the responsibility of the physicians on staff."

She also says that as hospitals increasingly move to EHRs, it is critical to incorporate malnutrition screening and criteria, with automated triggers for the registered dietitians, and to incorporate nutrition into discharge planning and patient education.

If you're interested in improving nutritional screening and nutrition among your patient population, help is available. In June, the Alliance to Advance Patient Nutrition released its nutrition care recommendations, which outline six principles to help transform nutrition practices in hospitals nationwide.

"I think the evidence is compelling and it's a call to action for a lot of reasons—one being the new [CMS] penalties," says Snider. "But ultimately people come to their jobs in healthcare to help people get better, and in this case it's a win-win."

Philip Betbeze is the senior leadership editor at HealthLeaders.

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