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To what extent do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?
Clinical Nutrition xxx (2014) 1e5
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Original article
To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?* mi C. van Nie-Visser a, *, Judith M. Meijers a, Jos M. Schols a, b, Christa Lohrmann c, Noe Marieke Spreeuwenberg a, Ruud J. Halfens a a b c
Caphri, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands Caphri, Department of Family Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands Institute of Nursing Science, Medical University Graz, Graz, Austria
a r t i c l e i n f o
s u m m a r y
Article history: Received 26 October 2013 Accepted 4 December 2014
Background & aims: Many residents in European healthcare institutions are malnourished, with reported malnutrition prevalence rates of up to 60%. Due to the negative effects of malnutrition it is important to optimize the quality of nutritional care. If structural quality indicators of nutritional care might improve resident care and outcome is not yet known. The aim of this study is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. Methods: This study follows a cross-sectional, multi-center design. Data were collected by using a standardised questionnaire at resident, ward and institution level. Results: Data from 214 nursing homes (NL ¼ 133, G ¼ 61, A ¼ 20) were analysed. The prevalence of malnutrition varied significantly between the three countries (NL ¼ 18.2% G ¼ 20.1% A ¼ 22.5%). Two structural quality indicators at ward level namely (1) the policy that the care file should include the nutritional intake for each patient and (2) having a weight measurement policy at ward level are predictive for malnutrition prevalence. Furthermore also the variable country was of influence. Conclusions: A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence. © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords: Malnutrition Structural quality indicators Nursing homes
1. Introduction In European nursing homes malnutrition prevalence rates are found between 2 and 74% [1e3]. Diagnosing malnutrition is difficult due to the fact that there is no golden standard, resulting in a large variety of prevalence rates of malnutrition [4,5]. Malnutrition has been defined as a nutritional condition in which an insufficient or disproportionate intake of energy, protein, and other nutrients adversely affects tissue/body form (shape, size and composition) and function, and clinical outcomes [6]. Malnutrition has many negative consequences. It increases the chance of complications and worsens the immune function, leading to a
*
Conference presentation: ESPEN, Leipzig 2013, outstanding poster. * Corresponding author. Maastricht University, Faculty of Health Medicine and Life Sciences, Department of Health Services Research, School for Public Health and Primary Care (Caphri), P.O. Box 616, NL-6200 MD Maastricht, The Netherlands. Tel.: þ31 43 388 17 65, þ31 621 590 690 (mobile); fax: þ31 43 388 41 62. E-mail address: [email protected] (N.C. van Nie-Visser).
higher risk of infections and impairment of wound healing. Malnutrition influences the quality of life and costs of health care [7e10]. Due to the negative effects and the high prevalence rates of malnutrition it is important to optimize the quality of nutritional care as far as possible. Donabedian's [11] framework of quality of care offers a model to investigate the quality of care. Following this model, it is not only important to focus on outcome but also on structure and process aspects to improve quality of care. Structure is defined as the attributes of settings where care is delivered, while process is defined as whether or not good medical and/or nursing practices are followed. Finally outcome involves the impact of the care on health status. Donabedian's framework implicates that improvements in structure and process of care may lead to better outcomes [11]. Different studies show that structural quality indicators such as defining professional responsibilities, guidelines, availability of nutritional advisory teams, education of both health care professionals and patients, screening and monitoring policy are of influence on the quality of nutritional care [9,12e14].
http://dx.doi.org/10.1016/j.clnu.2014.12.003 0261-5614/© 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
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N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
In scientific literature, it is hard to compare international malnutrition prevalence rates due to the use of different measurement definitions, instruments and methodology. Furthermore various studies focus on different factors to investigate the structural quality indicators of nutritional care which may influence the prevalence of malnutrition. It is interesting to investigate whether structural quality indicators of nutritional care may explain differences in malnutrition prevalence rates in different countries using the same instrument and methodology. The aim of this study therefore is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. The following research questions will be addressed: (1) What is the prevalence of malnutrition in nursing homes in the Netherlands, Germany and Austria? (2) Are there differences between these countries in structural quality indicators of nutritional care? (3) Which structural quality indicators of nutritional care at institution and ward level influence malnutrition prevalence? 2. Materials and methods In 2004 the project group of the Dutch National Prevalence Measurement of Care Problems (in Dutch: Landelijke Prevalentiemeting Zorgproblemen (LPZ)) from Maastricht University started to measure the prevalence, process and relevant structural quality indicators of malnutrition in hospitals, care homes and home care [15]. Since 2008 the LPZ measurement is also performed in Germany and Austria [3,16,17]. In this study we focus on nursing homes. 2.1. Design The LPZ follows a cross-sectional, multi-center design [17]. In this study, data collected in April 2009 and April 2010 in nursing homes in the Netherlands, Germany and Austria were explored. 2.2. Instrument LPZ uses a standardised questionnaire at three levels: institution, ward and resident. At institution and ward level questions focused on kind of institution and wards and on structural quality indicators of nutritional care. These structural quality indicators for nutritional care were assessed with 8 questions at institutional level, and 13 questions at ward level, each with dichotomous answer categories (yes/no) (see Table 2). The indicators were developed using an international expert panel and review of the literature as relevant for a high quality of care. The questionnaire concerning the structural indicators on institutional level en ward level were filled in by the appointed institutional coordinator of the survey (quality manager, head nurse). The original questionnaire and instruction material were developed in Dutch. For international purposes, the questionnaires have been translated into German by a professional translator. The LPZ project group discussed the translations with the German and Austrian project groups to get consensus about the translation. To make the translation fit to both German speaking countries the questionnaires have been adapted only to cultural differences like nomenclature for wards and professions present in Germany and Austria. At resident level resident characteristics (age, gender, date of admission, comorbidity, care dependency, weight, height and unintentional weight loss) are registered. Care dependency is measured with the Care Dependency Scale (CDS) [18]. The care dependency scale consists of 15 items, with a 5 point Likert scale
and is validated for different health care settings in different countries [19,20]. The definition of malnutrition used in this study is: (1) Body mass index (BMI) 20 (age > 65), (2) unintentional weight loss (more than 6 kg in the previous six month or more than 3 kg in the last month) and (3) no nutritional intake for three days or reduced intake for more than ten days combined with a BMI between 20 and 23.9 (age > 65) [21]. This operationalization of malnutrition was furthermore tested positively for face validity and criterion validity [2]. 2.3. Population All nursing homes in the Netherlands, Germany and Austria were invited by (e)mail to take voluntarily part in the LPZ measurements. Residents of 65 years and older (or their legal representative) who gave their informed consent were incorporated in the study. Residents who refused, who were not available, were too ill, comatose or terminal were omitted from the study. Ethical improvement for this study in the Netherlands was given by the medical ethical committee of the Maastricht University Medical Centre (MUMC). For Germany and Austria the ethical committee of the Institute of Nursing Science at Witten/Herdecke University and the medical ethical committee of the Medical University Graz gave approval to carry out the study. 2.4. Data collection Nursing homes that participated, pointed out an internal coordinator who was responsible for the measurement. All coordinators were trained collectively by each national project group on how to perform the data collections. Furthermore they were instructed in how to use the questionnaires and the specially designed internet data-entry program. To perform the measurement in the right way, all health care professionals who would perform the data collection at the day of the measurement were trained by the institutional coordinators. The coordinators received a protocol and training package from the national project group to support them in training the health care professionals. To enhance reliability, all residents were evaluated by two health care professionals: one employed on the resident's ward and one from another ward. Interrater reliability has been tested for different health care settings (Cohen's kappa of 0.87) [2]. For a more in-depth description of the data collection see the article of Van Nie et al [17]. 2.5. Data analyses For the statistical analyses SPSS version 19 (SPSS Inc, Chicago, IL) was used. To describe differences in residents characteristics and the structural quality indicators of nutritional care at institution and ward level in the Netherlands, Germany and Austria, student's t-test, Chi-square tests, or ANOVA (with post hoc analyses Bonferroni method) and odds ratios were used. Univariate logistic regression analyses were used to describe the relation of each baseline independent variable (country: Netherlands (0), Germany (1) and Austria (2)) and all structural quality indicators at institution and ward level with the prevalence of malnutrition. The dependent variable was malnourished/not malnourished. Variables which were significant (p-value smaller than 0.10) in the univariate analyses were comprised in the multi-level GEE analysis with an exchangeable structure in order to build the prediction model [22]. Data were assessed for congruence with regression assumptions prior to multivariate analysis. P-values were based on two-sided tests, and the cut-off point for statistical significance was <0.01. For the GEE analyses all data were analysed at patient level.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
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Table 1 Population characteristics and prevalence of malnutrition per country.
Nursing homes, n (%) Wards, n (%) Residents, n (%) Gender Female Mean age in years (sd) Length of stay, median in days (mean, sd) Care dependency Dependent, n (%) Independent n, (%) Prevalence of malnutrition
The Netherlands
Germany
Austria
133 (62.2) 465 (58.1) 16,612 (72.9)
61 (28.5) 248 (31.0) 4212 (18.2)
20 (9.3) 87 (10.9) 2062 (8.9)
12,561 (74.3) 84 (7) 754 (1111, 1433)
3305 (78.5) 83 (8) 791 (1412, 2084)
1767 (85.7) 85 (8) 752 (1233, 1872)
10,143 (60.0) 6768 (40.0) 18.2%
3129 (74.3) 1082 (25.7) 20.1%
1674 (81.2) 388 (18.8) 22.5%
p-value
<0.001a,b,c <0.001a,b,c <0.001a,b,c <0.001a,b,c
<0.001a,b,c
Significant level at p0.01. a Significant difference between the Netherlands and Germany. b Significant difference between the Netherlands and Austria. c Significant difference between Germany and Austria.
3. Results 3.1. Population For this study data from 214 nursing homes from the Netherlands (133), Germany (61) and Austria (20) were included. Altogether 22,886 residents from 800 wards took part in the measurement. The response rate in Austria (80.8%) and Germany (82.0%) was lower (p < 0.01) than in the Netherlands (92.9%). The main reason for not taking part was refusal (78.5%) followed by not being available at the ward at the day of the measurement, being comatose or too ill (2.8%) and a terminal status (2.3%). Furthermore the residents in Austria were older and more care dependent and more often female than those in Germany and the Netherlands. The residents in Germany had the longest length of stay in the nursing home, 791 days (median) (see Table 1).
The prevalence of malnutrition varied significantly between the three countries. In the Netherlands the prevalence was lowest (18.2%), followed by Germany (20.1%) and Austria (22.7%). 3.2. Structural quality indicators of nutritional care compared between the countries Seven of the eight structural quality indicators at institution level differed significantly between the three countries. For example an agreed protocol for the prevention and treatment of malnutrition was available in 45% of the Austrian institutions whereas this was the case in 87% and 77% of the institutions in respectively the Netherlands and Germany. The same counts for working in accordance with this protocol (Austria 45%, Germany 81% and the Netherlands 73%) and for keeping this protocol updated (Austria 40%, Germany 74% and the Netherlands 79%) (see Table 2).
Table 2 Quality indicators for nutritional care. The Netherlands Quality indicators institution (n ¼ 214) 1. There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition. 2. Malnutrition-related work is carried out in a controlled fashion or in accordance with the malnutrition protocol/guideline. 3. There is a multi-disciplinary advisory committee for malnutrition. 4. There is someone responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol. 5. Criteria have been defined for determining malnutrition. 6. There are dieticians employed. 7. Over the last two years, a refresher course and/or a meeting was organised for caregivers, which was/were specifically devoted to the prevention and treatment of malnutrition. 8. An information brochure is available for clients and/or family members about malnutrition. Quality indicators ward (n ¼ 800) 1. There is at least one nurse in the ward who is specialized in the area of malnutrition. 2. Clients who are at risk and/or malnourished are discussed in the multi-disciplinary work consultations. 3. Work is done in a controlled fashion or in accordance with the malnutrition protocol/guideline. 4. Upon admission, every client is weighed as a matter of standard procedure. 5. Upon admission, the height of each client is determined as a matter of standard procedure. 6. The nutritional status is assessed upon admission. 7. The care file includes an assessment as to the risk of malnutrition for each client. 8. The care file/care plan specifies which activities must be implemented for clients who are at risk of malnutrition. 9. In case of (expected) malnutrition, a protein- and energy-enriched diet is provided as a matter of standard procedure. 10. Every client who is malnourished (or at risk of becoming so) receives an information brochure for clients and/or family about malnutrition. 11. Is the ambience at mealtimes taken into account (e.g. no interruptions during meal times, setting the table, and choice of meals)? 12. The care file includes the intake for each client. 13. Does the ward have a weight policy?
Germany
Austria
p-value
87% 73%
77% 81%
45% 45%
<0.001b,c <0.001c
52% 79%
24% 74%
67% 40%
<0.001a,c <0.001b,c
78% 90% 53%
94% 46% 79%
90% 80% 65%
<0.001a <0.001a,c <0.001a
15%
22%
20%
0.429
45% 93%
17% 71%
47% 99%
<0.001a <0.001a,c
74% 85% 58% 69% 57% 89%
82% 100% 100% 100% 100% 89%
81% 100% 97% 100% 99% 99%
0.415 <0.001a <0.001a,b <0.001a,b <0.001a,b 0.288
40%
84%
83%
<0.001a,b
10%
6%
18%
0.189
97%
85%
100%
<0.001a
71% 84%
97% 88%
100% 83%
<0.001a,b 0.799
The shade denotes significant level at p0.01. a Significant difference between the Netherlands and Germany. b Significant difference between the Netherlands and Austria. c Significant difference between Germany and Austria.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
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N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
Nine of the thirteen structural quality indicators at ward level showed a significant difference between the countries (see Table 2). For example only 40% of the Dutch nursing home wards had the policy to provide a protein- and energy-enriched diet as a matter of standard care in case of (expected) malnutrition, which is much more common in Germany (84%) and Austria (83%). In the Netherlands and Austria in about 50% of the wards at least one nurse is specialized in the area of malnutrition. For Germany, such a nurse was only available in 17% of the wards.
3.3. Relation between structural quality indicators of nutritional care and malnutrition Next the relationship between malnutrition and the structural quality indicators of nutritional care at institution and ward level were tested. At institution level only the indicator organization of a refresher course on prevention and treatment of malnutrition for Table 3 Structural quality indicators of nutritional care related to malnutrition.
Quality indicators institution (n ¼ 214) 1. There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition. 2. Malnutrition-related work is carried out in a controlled fashion or in accordance with the malnutrition protocol/guideline. 3. There is a multi-disciplinary advisory committee for malnutrition. 4. There is someone who is responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol 5. Criteria have been defined for determining malnutrition. 6. There are dieticians employed at the institution. 7. Over the last two years, a refresher course and/or a meeting was organised for caregivers, which was/were specifically devoted to the prevention and treatment of malnutrition. 8. An information brochure is available for clients and/or family members about malnutrition. Quality indicators ward (n ¼ 800) 1. There is at least one nurse who is specialised in the area of malnutrition. 2. Clients who are at risk and/or malnourished are discussed in the multi-disciplinary work consultations. 3. Work is done in a controlled fashion or in accordance with the malnutrition protocol/ guideline. 4. Upon admission, every client is weighed as a matter of standard procedure. 5. Upon admission, the height of each client is determined as a matter of standard procedure. 6. The nutritional status is assessed upon admission. 7. The care file includes an assessment as to the risk of malnutrition for each client. 8. The care file/care plan specifies which activities must be implemented for clients who are at risk of malnutrition. 9. In case of (expected) malnutrition, a protein- and energy-enriched diet is provided as a matter of standard procedure. 10. Every client who is malnourished (or at risk of becoming so) receives an information brochure for clients and/or family about malnutrition. 11. Is the ambience at mealtimes taken into account (e.g. no interruptions during meal times, setting the table, and choice of meals)? 12. The care file includes the intake for each client. 13. Does the ward have a weight policy? The shade denotes significant level at p0.01. Mþ ¼ malnourished M ¼ not malnourished.
Mþ
M
p-value
83.1%
83.2%
0.932
74.6%
74.1%
0.436
47.2%
46.6%
0.516
74.3%
74.8%
0.485
83.4%
81.9%
0.017
82.4% 66.0%
82.6% 63.2%
0.765 <0.001
19.1%
18.2%
0.207
43.0%
41.3%
0.039
91.9%
90.4%
<0.001
76.7%
75.9%
0.215
88.0%
86.2%
<0.001
61.5%
59.2%
<0.001
73.7% 64.2%
71.0% 60.7%
<0.001 <0.001
88.2%
86.4%
<0.001
53.8%
50.2%
<0.001
13.2%
13.9%
0.212
94.6%
95.2%
0.094
76.8% 88.3%
72.6% 86.7%
<0.001 <0.001
caregivers over the last two years showed a significant relation with malnutrition. At ward level 9 out of 13 structural quality indicators of nutritional care showed a significant relation with residents malnourished (see Table 3).
3.4. Influence of structural quality indicators of nutritional care on malnutrition prevalence? The GEE analyses showed that two structural quality indicators of nutritional care at ward level influence malnutrition prevalence in nursing home residents: the policy that a care file should include the nutritional intake for each resident and the ward having a weight measurement policy. Furthermore an effect was found for the country where the resident is residing (see Table 4).
4. Discussion The aim of this study was to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. Malnutrition prevalence rates differed significantly between the countries. In the Netherlands the prevalence was the lowest (18.2%) compared to Germany (20.1%) and Austria (22.5%). These prevalence rates are comparable to other studies performed in these countries [3,4,23,24]. The GEE analyses showed that two structural quality indicators at ward level influence malnutrition prevalence in nursing home residents (the care file includes the nutritional intake for each resident and the ward has a weight measurement policy). Other studies including the review of Arvanitakis et al. [9] indicated these 2 structural indicators also as important [12,25]. To be able to prevent and treat malnutrition and monitor nutritional status it is important to have a weight measurement policy [7,12,25]. Since undesired weight loss is the most important nutritional problem in care homes [26]. Although the causes of weight loss in these residents can usually be treated, they are rarely identified in nursing homes which implies that a policy of measuring weight is essential. From other studies we know as well that it is important to register food intake of patients [7,12,27]. It is important to assess the food intake of the patients as part of the nutritional risk screening and monitoring of nutritional status. Since nutritional status depends on adequate intake of food. It is well known that ageing causes not only alterations in body composition and organ functions but ageing also affects the ability to achieve an adequate energy intake [28]. Swallowing disorders, bad oral health, lack of taste and smell, eating dependency and chewing problems are also often part of this problem in frail and disabled elderly in care homes [28]. Therefore food intake and the registration of this are essential in this elderly nursing home population. Due to new findings in research and a report of the Health Council of the Netherlands the definition of malnutrition has been Table 4 Final prediction model.
Intercept The care file includes the intake for each client. Does the ward have a weight policy? Country a b
B
Wald
p-value
ORa
CI 99%b
0.126 0.025
17.409
<0.01
1.025
1.013e1.037
0.025
11.395
<0.01
1.025
1.011e1.040
0.017
14.913
<0.01
1.017
1.008e1.026
OR odds ratio. CI confidence interval.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
changed in the LPZ study by leaving out the component about food intake [29]. The analysis showed that no structural quality indicators at institution level were of influence but only the structural quality indicators at ward level. An explanation could be that a ward policy has more direct influence on the process of preventing or treating malnutrition since it is more focused on the actual care process and more concretely in line with daily practice than an institutional policy which is more static. Also ward policies are mostly built on institutional policies so when analysing these both ward could have a more profound effect. Moreover research shows that improving the quality of care is a complex process that does not follow prescribed and linear paths [30]. At last Donabedian [11] describes that quality is assessed by the way in which care is provided (process) by an individual or care team and less by the structure component of the model. Although in this study we found a direct effect of structural aspects of care on ward level on the outcome component malnutrition prevalence. In Donabedian's model [11] the structure of care comprises the organizational structure, the material resources (environment, technology) and the human resources (care provider, tasks) [31]. In this study the focus on structural quality indicators is related to the policy of nutritional care and not the organisational and material resources, which may have limited the effect of structure on outcome as Donabedian [11] defines it. At last an influence of country was indicated in the GEE analysis which could be explained by the fact that most of the structural indicators were significantly different between the countries or could be the effect of the countries' cultural or political differences which were not specifically addressed. 5. Conclusion A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence. Statement of authorship N.v.N., J.M., J.S., and R.H. contributed to the design of the study. N.v.N., J.M., J.S., C.L. and R.H. helped in data collection. Data analyses were done by N.v.N, J.M., M.S. and R.H. The manuscript was written by N.v.N, J.M., J.S., C.L, M.S. and R.H. M.S. provided significant advice and consultation concerning statistical issues. Final manuscript approval was done by N.v.N, J.M., J.S., C.L., M.S. and R.H. Funding sources We thank Nutricia Advanced Medical Nutrition for providing an unrestricted grant to perform this study. Conflict of interest None. Acknowledgements None. References [1] Pauly L, Stehle P, Volkert D. Nutritional situation of elderly nursing home residents. Gerontol Geriat 2007;40:3e12. [2] Meijers JMM, Halfens RJG, Van Bokhorst-de van der Schueren MAE, Dassen T, Schols JMGA. Malnutrition in Dutch healthcare: prevalence, prevention, treatment and quality indicators. Nutrition 2009;25:512e9.
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Original article
To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?* mi C. van Nie-Visser a, *, Judith M. Meijers a, Jos M. Schols a, b, Christa Lohrmann c, Noe Marieke Spreeuwenberg a, Ruud J. Halfens a a b c
Caphri, Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands Caphri, Department of Family Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands Institute of Nursing Science, Medical University Graz, Graz, Austria
a r t i c l e i n f o
s u m m a r y
Article history: Received 26 October 2013 Accepted 4 December 2014
Background & aims: Many residents in European healthcare institutions are malnourished, with reported malnutrition prevalence rates of up to 60%. Due to the negative effects of malnutrition it is important to optimize the quality of nutritional care. If structural quality indicators of nutritional care might improve resident care and outcome is not yet known. The aim of this study is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. Methods: This study follows a cross-sectional, multi-center design. Data were collected by using a standardised questionnaire at resident, ward and institution level. Results: Data from 214 nursing homes (NL ¼ 133, G ¼ 61, A ¼ 20) were analysed. The prevalence of malnutrition varied significantly between the three countries (NL ¼ 18.2% G ¼ 20.1% A ¼ 22.5%). Two structural quality indicators at ward level namely (1) the policy that the care file should include the nutritional intake for each patient and (2) having a weight measurement policy at ward level are predictive for malnutrition prevalence. Furthermore also the variable country was of influence. Conclusions: A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence. © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords: Malnutrition Structural quality indicators Nursing homes
1. Introduction In European nursing homes malnutrition prevalence rates are found between 2 and 74% [1e3]. Diagnosing malnutrition is difficult due to the fact that there is no golden standard, resulting in a large variety of prevalence rates of malnutrition [4,5]. Malnutrition has been defined as a nutritional condition in which an insufficient or disproportionate intake of energy, protein, and other nutrients adversely affects tissue/body form (shape, size and composition) and function, and clinical outcomes [6]. Malnutrition has many negative consequences. It increases the chance of complications and worsens the immune function, leading to a
*
Conference presentation: ESPEN, Leipzig 2013, outstanding poster. * Corresponding author. Maastricht University, Faculty of Health Medicine and Life Sciences, Department of Health Services Research, School for Public Health and Primary Care (Caphri), P.O. Box 616, NL-6200 MD Maastricht, The Netherlands. Tel.: þ31 43 388 17 65, þ31 621 590 690 (mobile); fax: þ31 43 388 41 62. E-mail address: [email protected] (N.C. van Nie-Visser).
higher risk of infections and impairment of wound healing. Malnutrition influences the quality of life and costs of health care [7e10]. Due to the negative effects and the high prevalence rates of malnutrition it is important to optimize the quality of nutritional care as far as possible. Donabedian's [11] framework of quality of care offers a model to investigate the quality of care. Following this model, it is not only important to focus on outcome but also on structure and process aspects to improve quality of care. Structure is defined as the attributes of settings where care is delivered, while process is defined as whether or not good medical and/or nursing practices are followed. Finally outcome involves the impact of the care on health status. Donabedian's framework implicates that improvements in structure and process of care may lead to better outcomes [11]. Different studies show that structural quality indicators such as defining professional responsibilities, guidelines, availability of nutritional advisory teams, education of both health care professionals and patients, screening and monitoring policy are of influence on the quality of nutritional care [9,12e14].
http://dx.doi.org/10.1016/j.clnu.2014.12.003 0261-5614/© 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
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N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
In scientific literature, it is hard to compare international malnutrition prevalence rates due to the use of different measurement definitions, instruments and methodology. Furthermore various studies focus on different factors to investigate the structural quality indicators of nutritional care which may influence the prevalence of malnutrition. It is interesting to investigate whether structural quality indicators of nutritional care may explain differences in malnutrition prevalence rates in different countries using the same instrument and methodology. The aim of this study therefore is to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. The following research questions will be addressed: (1) What is the prevalence of malnutrition in nursing homes in the Netherlands, Germany and Austria? (2) Are there differences between these countries in structural quality indicators of nutritional care? (3) Which structural quality indicators of nutritional care at institution and ward level influence malnutrition prevalence? 2. Materials and methods In 2004 the project group of the Dutch National Prevalence Measurement of Care Problems (in Dutch: Landelijke Prevalentiemeting Zorgproblemen (LPZ)) from Maastricht University started to measure the prevalence, process and relevant structural quality indicators of malnutrition in hospitals, care homes and home care [15]. Since 2008 the LPZ measurement is also performed in Germany and Austria [3,16,17]. In this study we focus on nursing homes. 2.1. Design The LPZ follows a cross-sectional, multi-center design [17]. In this study, data collected in April 2009 and April 2010 in nursing homes in the Netherlands, Germany and Austria were explored. 2.2. Instrument LPZ uses a standardised questionnaire at three levels: institution, ward and resident. At institution and ward level questions focused on kind of institution and wards and on structural quality indicators of nutritional care. These structural quality indicators for nutritional care were assessed with 8 questions at institutional level, and 13 questions at ward level, each with dichotomous answer categories (yes/no) (see Table 2). The indicators were developed using an international expert panel and review of the literature as relevant for a high quality of care. The questionnaire concerning the structural indicators on institutional level en ward level were filled in by the appointed institutional coordinator of the survey (quality manager, head nurse). The original questionnaire and instruction material were developed in Dutch. For international purposes, the questionnaires have been translated into German by a professional translator. The LPZ project group discussed the translations with the German and Austrian project groups to get consensus about the translation. To make the translation fit to both German speaking countries the questionnaires have been adapted only to cultural differences like nomenclature for wards and professions present in Germany and Austria. At resident level resident characteristics (age, gender, date of admission, comorbidity, care dependency, weight, height and unintentional weight loss) are registered. Care dependency is measured with the Care Dependency Scale (CDS) [18]. The care dependency scale consists of 15 items, with a 5 point Likert scale
and is validated for different health care settings in different countries [19,20]. The definition of malnutrition used in this study is: (1) Body mass index (BMI) 20 (age > 65), (2) unintentional weight loss (more than 6 kg in the previous six month or more than 3 kg in the last month) and (3) no nutritional intake for three days or reduced intake for more than ten days combined with a BMI between 20 and 23.9 (age > 65) [21]. This operationalization of malnutrition was furthermore tested positively for face validity and criterion validity [2]. 2.3. Population All nursing homes in the Netherlands, Germany and Austria were invited by (e)mail to take voluntarily part in the LPZ measurements. Residents of 65 years and older (or their legal representative) who gave their informed consent were incorporated in the study. Residents who refused, who were not available, were too ill, comatose or terminal were omitted from the study. Ethical improvement for this study in the Netherlands was given by the medical ethical committee of the Maastricht University Medical Centre (MUMC). For Germany and Austria the ethical committee of the Institute of Nursing Science at Witten/Herdecke University and the medical ethical committee of the Medical University Graz gave approval to carry out the study. 2.4. Data collection Nursing homes that participated, pointed out an internal coordinator who was responsible for the measurement. All coordinators were trained collectively by each national project group on how to perform the data collections. Furthermore they were instructed in how to use the questionnaires and the specially designed internet data-entry program. To perform the measurement in the right way, all health care professionals who would perform the data collection at the day of the measurement were trained by the institutional coordinators. The coordinators received a protocol and training package from the national project group to support them in training the health care professionals. To enhance reliability, all residents were evaluated by two health care professionals: one employed on the resident's ward and one from another ward. Interrater reliability has been tested for different health care settings (Cohen's kappa of 0.87) [2]. For a more in-depth description of the data collection see the article of Van Nie et al [17]. 2.5. Data analyses For the statistical analyses SPSS version 19 (SPSS Inc, Chicago, IL) was used. To describe differences in residents characteristics and the structural quality indicators of nutritional care at institution and ward level in the Netherlands, Germany and Austria, student's t-test, Chi-square tests, or ANOVA (with post hoc analyses Bonferroni method) and odds ratios were used. Univariate logistic regression analyses were used to describe the relation of each baseline independent variable (country: Netherlands (0), Germany (1) and Austria (2)) and all structural quality indicators at institution and ward level with the prevalence of malnutrition. The dependent variable was malnourished/not malnourished. Variables which were significant (p-value smaller than 0.10) in the univariate analyses were comprised in the multi-level GEE analysis with an exchangeable structure in order to build the prediction model [22]. Data were assessed for congruence with regression assumptions prior to multivariate analysis. P-values were based on two-sided tests, and the cut-off point for statistical significance was <0.01. For the GEE analyses all data were analysed at patient level.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
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Table 1 Population characteristics and prevalence of malnutrition per country.
Nursing homes, n (%) Wards, n (%) Residents, n (%) Gender Female Mean age in years (sd) Length of stay, median in days (mean, sd) Care dependency Dependent, n (%) Independent n, (%) Prevalence of malnutrition
The Netherlands
Germany
Austria
133 (62.2) 465 (58.1) 16,612 (72.9)
61 (28.5) 248 (31.0) 4212 (18.2)
20 (9.3) 87 (10.9) 2062 (8.9)
12,561 (74.3) 84 (7) 754 (1111, 1433)
3305 (78.5) 83 (8) 791 (1412, 2084)
1767 (85.7) 85 (8) 752 (1233, 1872)
10,143 (60.0) 6768 (40.0) 18.2%
3129 (74.3) 1082 (25.7) 20.1%
1674 (81.2) 388 (18.8) 22.5%
p-value
<0.001a,b,c <0.001a,b,c <0.001a,b,c <0.001a,b,c
<0.001a,b,c
Significant level at p0.01. a Significant difference between the Netherlands and Germany. b Significant difference between the Netherlands and Austria. c Significant difference between Germany and Austria.
3. Results 3.1. Population For this study data from 214 nursing homes from the Netherlands (133), Germany (61) and Austria (20) were included. Altogether 22,886 residents from 800 wards took part in the measurement. The response rate in Austria (80.8%) and Germany (82.0%) was lower (p < 0.01) than in the Netherlands (92.9%). The main reason for not taking part was refusal (78.5%) followed by not being available at the ward at the day of the measurement, being comatose or too ill (2.8%) and a terminal status (2.3%). Furthermore the residents in Austria were older and more care dependent and more often female than those in Germany and the Netherlands. The residents in Germany had the longest length of stay in the nursing home, 791 days (median) (see Table 1).
The prevalence of malnutrition varied significantly between the three countries. In the Netherlands the prevalence was lowest (18.2%), followed by Germany (20.1%) and Austria (22.7%). 3.2. Structural quality indicators of nutritional care compared between the countries Seven of the eight structural quality indicators at institution level differed significantly between the three countries. For example an agreed protocol for the prevention and treatment of malnutrition was available in 45% of the Austrian institutions whereas this was the case in 87% and 77% of the institutions in respectively the Netherlands and Germany. The same counts for working in accordance with this protocol (Austria 45%, Germany 81% and the Netherlands 73%) and for keeping this protocol updated (Austria 40%, Germany 74% and the Netherlands 79%) (see Table 2).
Table 2 Quality indicators for nutritional care. The Netherlands Quality indicators institution (n ¼ 214) 1. There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition. 2. Malnutrition-related work is carried out in a controlled fashion or in accordance with the malnutrition protocol/guideline. 3. There is a multi-disciplinary advisory committee for malnutrition. 4. There is someone responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol. 5. Criteria have been defined for determining malnutrition. 6. There are dieticians employed. 7. Over the last two years, a refresher course and/or a meeting was organised for caregivers, which was/were specifically devoted to the prevention and treatment of malnutrition. 8. An information brochure is available for clients and/or family members about malnutrition. Quality indicators ward (n ¼ 800) 1. There is at least one nurse in the ward who is specialized in the area of malnutrition. 2. Clients who are at risk and/or malnourished are discussed in the multi-disciplinary work consultations. 3. Work is done in a controlled fashion or in accordance with the malnutrition protocol/guideline. 4. Upon admission, every client is weighed as a matter of standard procedure. 5. Upon admission, the height of each client is determined as a matter of standard procedure. 6. The nutritional status is assessed upon admission. 7. The care file includes an assessment as to the risk of malnutrition for each client. 8. The care file/care plan specifies which activities must be implemented for clients who are at risk of malnutrition. 9. In case of (expected) malnutrition, a protein- and energy-enriched diet is provided as a matter of standard procedure. 10. Every client who is malnourished (or at risk of becoming so) receives an information brochure for clients and/or family about malnutrition. 11. Is the ambience at mealtimes taken into account (e.g. no interruptions during meal times, setting the table, and choice of meals)? 12. The care file includes the intake for each client. 13. Does the ward have a weight policy?
Germany
Austria
p-value
87% 73%
77% 81%
45% 45%
<0.001b,c <0.001c
52% 79%
24% 74%
67% 40%
<0.001a,c <0.001b,c
78% 90% 53%
94% 46% 79%
90% 80% 65%
<0.001a <0.001a,c <0.001a
15%
22%
20%
0.429
45% 93%
17% 71%
47% 99%
<0.001a <0.001a,c
74% 85% 58% 69% 57% 89%
82% 100% 100% 100% 100% 89%
81% 100% 97% 100% 99% 99%
0.415 <0.001a <0.001a,b <0.001a,b <0.001a,b 0.288
40%
84%
83%
<0.001a,b
10%
6%
18%
0.189
97%
85%
100%
<0.001a
71% 84%
97% 88%
100% 83%
<0.001a,b 0.799
The shade denotes significant level at p0.01. a Significant difference between the Netherlands and Germany. b Significant difference between the Netherlands and Austria. c Significant difference between Germany and Austria.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
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Nine of the thirteen structural quality indicators at ward level showed a significant difference between the countries (see Table 2). For example only 40% of the Dutch nursing home wards had the policy to provide a protein- and energy-enriched diet as a matter of standard care in case of (expected) malnutrition, which is much more common in Germany (84%) and Austria (83%). In the Netherlands and Austria in about 50% of the wards at least one nurse is specialized in the area of malnutrition. For Germany, such a nurse was only available in 17% of the wards.
3.3. Relation between structural quality indicators of nutritional care and malnutrition Next the relationship between malnutrition and the structural quality indicators of nutritional care at institution and ward level were tested. At institution level only the indicator organization of a refresher course on prevention and treatment of malnutrition for Table 3 Structural quality indicators of nutritional care related to malnutrition.
Quality indicators institution (n ¼ 214) 1. There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition. 2. Malnutrition-related work is carried out in a controlled fashion or in accordance with the malnutrition protocol/guideline. 3. There is a multi-disciplinary advisory committee for malnutrition. 4. There is someone who is responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol 5. Criteria have been defined for determining malnutrition. 6. There are dieticians employed at the institution. 7. Over the last two years, a refresher course and/or a meeting was organised for caregivers, which was/were specifically devoted to the prevention and treatment of malnutrition. 8. An information brochure is available for clients and/or family members about malnutrition. Quality indicators ward (n ¼ 800) 1. There is at least one nurse who is specialised in the area of malnutrition. 2. Clients who are at risk and/or malnourished are discussed in the multi-disciplinary work consultations. 3. Work is done in a controlled fashion or in accordance with the malnutrition protocol/ guideline. 4. Upon admission, every client is weighed as a matter of standard procedure. 5. Upon admission, the height of each client is determined as a matter of standard procedure. 6. The nutritional status is assessed upon admission. 7. The care file includes an assessment as to the risk of malnutrition for each client. 8. The care file/care plan specifies which activities must be implemented for clients who are at risk of malnutrition. 9. In case of (expected) malnutrition, a protein- and energy-enriched diet is provided as a matter of standard procedure. 10. Every client who is malnourished (or at risk of becoming so) receives an information brochure for clients and/or family about malnutrition. 11. Is the ambience at mealtimes taken into account (e.g. no interruptions during meal times, setting the table, and choice of meals)? 12. The care file includes the intake for each client. 13. Does the ward have a weight policy? The shade denotes significant level at p0.01. Mþ ¼ malnourished M ¼ not malnourished.
Mþ
M
p-value
83.1%
83.2%
0.932
74.6%
74.1%
0.436
47.2%
46.6%
0.516
74.3%
74.8%
0.485
83.4%
81.9%
0.017
82.4% 66.0%
82.6% 63.2%
0.765 <0.001
19.1%
18.2%
0.207
43.0%
41.3%
0.039
91.9%
90.4%
<0.001
76.7%
75.9%
0.215
88.0%
86.2%
<0.001
61.5%
59.2%
<0.001
73.7% 64.2%
71.0% 60.7%
<0.001 <0.001
88.2%
86.4%
<0.001
53.8%
50.2%
<0.001
13.2%
13.9%
0.212
94.6%
95.2%
0.094
76.8% 88.3%
72.6% 86.7%
<0.001 <0.001
caregivers over the last two years showed a significant relation with malnutrition. At ward level 9 out of 13 structural quality indicators of nutritional care showed a significant relation with residents malnourished (see Table 3).
3.4. Influence of structural quality indicators of nutritional care on malnutrition prevalence? The GEE analyses showed that two structural quality indicators of nutritional care at ward level influence malnutrition prevalence in nursing home residents: the policy that a care file should include the nutritional intake for each resident and the ward having a weight measurement policy. Furthermore an effect was found for the country where the resident is residing (see Table 4).
4. Discussion The aim of this study was to explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German and Austrian nursing homes. Malnutrition prevalence rates differed significantly between the countries. In the Netherlands the prevalence was the lowest (18.2%) compared to Germany (20.1%) and Austria (22.5%). These prevalence rates are comparable to other studies performed in these countries [3,4,23,24]. The GEE analyses showed that two structural quality indicators at ward level influence malnutrition prevalence in nursing home residents (the care file includes the nutritional intake for each resident and the ward has a weight measurement policy). Other studies including the review of Arvanitakis et al. [9] indicated these 2 structural indicators also as important [12,25]. To be able to prevent and treat malnutrition and monitor nutritional status it is important to have a weight measurement policy [7,12,25]. Since undesired weight loss is the most important nutritional problem in care homes [26]. Although the causes of weight loss in these residents can usually be treated, they are rarely identified in nursing homes which implies that a policy of measuring weight is essential. From other studies we know as well that it is important to register food intake of patients [7,12,27]. It is important to assess the food intake of the patients as part of the nutritional risk screening and monitoring of nutritional status. Since nutritional status depends on adequate intake of food. It is well known that ageing causes not only alterations in body composition and organ functions but ageing also affects the ability to achieve an adequate energy intake [28]. Swallowing disorders, bad oral health, lack of taste and smell, eating dependency and chewing problems are also often part of this problem in frail and disabled elderly in care homes [28]. Therefore food intake and the registration of this are essential in this elderly nursing home population. Due to new findings in research and a report of the Health Council of the Netherlands the definition of malnutrition has been Table 4 Final prediction model.
Intercept The care file includes the intake for each client. Does the ward have a weight policy? Country a b
B
Wald
p-value
ORa
CI 99%b
0.126 0.025
17.409
<0.01
1.025
1.013e1.037
0.025
11.395
<0.01
1.025
1.011e1.040
0.017
14.913
<0.01
1.017
1.008e1.026
OR odds ratio. CI confidence interval.
Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003
N.C. van Nie-Visser et al. / Clinical Nutrition xxx (2014) 1e5
changed in the LPZ study by leaving out the component about food intake [29]. The analysis showed that no structural quality indicators at institution level were of influence but only the structural quality indicators at ward level. An explanation could be that a ward policy has more direct influence on the process of preventing or treating malnutrition since it is more focused on the actual care process and more concretely in line with daily practice than an institutional policy which is more static. Also ward policies are mostly built on institutional policies so when analysing these both ward could have a more profound effect. Moreover research shows that improving the quality of care is a complex process that does not follow prescribed and linear paths [30]. At last Donabedian [11] describes that quality is assessed by the way in which care is provided (process) by an individual or care team and less by the structure component of the model. Although in this study we found a direct effect of structural aspects of care on ward level on the outcome component malnutrition prevalence. In Donabedian's model [11] the structure of care comprises the organizational structure, the material resources (environment, technology) and the human resources (care provider, tasks) [31]. In this study the focus on structural quality indicators is related to the policy of nutritional care and not the organisational and material resources, which may have limited the effect of structure on outcome as Donabedian [11] defines it. At last an influence of country was indicated in the GEE analysis which could be explained by the fact that most of the structural indicators were significantly different between the countries or could be the effect of the countries' cultural or political differences which were not specifically addressed. 5. Conclusion A policy of registering nutritional intake in the file of the patient and a policy to assess the patient's weight regularly have a positive influence on malnutrition prevalence. Statement of authorship N.v.N., J.M., J.S., and R.H. contributed to the design of the study. N.v.N., J.M., J.S., C.L. and R.H. helped in data collection. Data analyses were done by N.v.N, J.M., M.S. and R.H. The manuscript was written by N.v.N, J.M., J.S., C.L, M.S. and R.H. M.S. provided significant advice and consultation concerning statistical issues. Final manuscript approval was done by N.v.N, J.M., J.S., C.L., M.S. and R.H. Funding sources We thank Nutricia Advanced Medical Nutrition for providing an unrestricted grant to perform this study. Conflict of interest None. Acknowledgements None. References [1] Pauly L, Stehle P, Volkert D. Nutritional situation of elderly nursing home residents. Gerontol Geriat 2007;40:3e12. [2] Meijers JMM, Halfens RJG, Van Bokhorst-de van der Schueren MAE, Dassen T, Schols JMGA. Malnutrition in Dutch healthcare: prevalence, prevention, treatment and quality indicators. Nutrition 2009;25:512e9.
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Please cite this article in press as: van Nie-Visser NC, et al., To what extend do structural quality indicators of (nutritional) care influence malnutrition prevalence in nursing homes?, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.12.003