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Nutrition screening or malnutrition: Potential economic impact at a community hospital VICKI G. SAYARATH, MPH, RD
alnutrition among hospitalized patients was first recognized as a problemin severallandmark studies from the mid 1970s and early 1980s (1-4). These studies and others (3-6) have identified an increased risk of morbidity and mortality in hospitalized patients who are malnourished. The need for nutrition screening systems that identify malnourished hospitalized patients is evident and well supported by previous studies (7-14). The diagnostic-related group (DRG) payment system has implications beyond just identifying hospital malnutrition. tUnder the DRG payment system, rates of payment for hospitals are determined by the DRG code assigned to a patient for a specific admission. The system accounts for principal diagnosis, principal procedure, comorbidity and complicating conditions, sex, age, and status at discharge. Because malnutrition is considered a comorbidity or complicating condition under the DRG system, identifying and coding for malnutrition could affect increasing hospital Medicare payments. In a retrospective study at a 374-bed community hospitalin NewJersey, Trimble (15) examined the relationship between coding for malnutrition under that state's DRG-based prospective payment system and reimbursement enhancement. The study found that coding for malnutrition could potentially enhance hospital reimbursement by $103,000 annually. tnder New Jersey's DRG-based prospective paymerit system, malnutrition is considered a major comorbidity by nonfederal payers, but not by Medicare. However, Trimble (15) found that a diagnosis of malnutrition can affect Medicare payment if it is the only comorbidity present. Our study was undertaken at New England Memorial Hospital, a 200-bed com-
munity hospital in Stoneham, Mass. The purposes of the study were to evaluate the feasibility of using specific nutrition screening criteria to identify malnutrition in selected DRGs; determine the prevalence of malnutrition in selected Medicare DRGs using the proposed screening criteria; and determine the potential economic impact of coding for malnutrition on Medicare payments to the hospital. The results of this evaluation were used by dietitians to determine whether the current nutrition screening system should be changed to one that emphasizes the identification and treatment of malnutrition. METHODS With assistance front the hospital's medical records department, dietitians were able to determine the hospital's most frequently used Medicare DRGs. All patients covered by Medicare who were discharged within the 12-month period from March 1990 to February 1991 with L)RGs No. 198 total cholecystectomy, No. 181 gastrointestinal obstruction, No. 211 hip and femur procedures, No. 149 small- and large-bowel procedures, and No. 8 respiratory infections and inflammations were identified for retrospective evaluation by a senior clinical dietitian (the author) and a student in the preprofessional practice program. These particular DRGs were selected because they were least likely to have a comorbidity added at the time of discharge and, under the Massachusetts DRG sys-
tern, the addition of only one comorbidity will enhance Medicare reimbursement. Nutrition screening criteria used to identify malnutrition in the selected DRGs included percent of ideal body weight for height, equal to or less ttan 90% of standard weight (16); unintentional weight loss of 10% or more of usual body weight over a 6-month period (17); serum alburin level equal to or less than 3.7 (according to New England Memorial Hospital laboratory standards, 3.8-5.0 = normal), except in persons with liver disease, trauma, infection, fluidi imbalance, and carcinoma; clear liquid diet or nothing by mouth (NPO) status for 3 or more consecutive days as doculet tted by physic ian orders (18); and inadequate dietary intake for 3 or more consecutive days as doct unented in nursing, dietitian, or' physician progress notes (18). Patients tleet:ing two or more ccriteria were identified as malnourished. To determine potential economic irnpact, the amocurt of uncovered charges for patients meeting nalnlt;rition criteria was determined using a omrtputterized accounting system (IS, version 6, 1988, Massachusetts Hospital Association, Burlington) with the help of a medical records technician. Te lCD-t)-('M code used for the malnutrition comnorbidity was: ICD-9-(CM code 263.9, nonspe( ific nmalnuttritiol (18). RESULTS For the 12-mronth period, 44 patients with the specified DRGs were discharged front the hospital. Of these 44, 10 stayed less than 3 days and were eliminated from the study. Availability of specific nutrition screening criteria in the 34 study subjects ranged from 0 to 100% (Table 1). Data concerning uninltentioltnal weight loss were not avail able in the records of any of the 34 patients included in the stutidy, but documentation of clear liquid diet or NPO status was available in all of the cases. The overall prevalence of malnutrition in the studlv group was 29 per 100 patients (ic 1() of our subjects). ithe prevalence
Table 1 Availability of nutrition screening criteria in 34 patients Nutrition screening criteria Percent of ideal body weight for height < 90% of standard we ght
At the tine of the study, VI G. Sayarath Un ntentional weight loss over 6 months - 10% of usual body we ght was senior clinical dietitians at New Albumin eve - 3 7 England Memorial Hospital, Stoneham, MA 02180. Currently, she is a Nothing by mouth or clear I qu d diet for three consecutive days or more nutritionistwith the Orleans and Northern Essex Home Health Agency, Inadequate dietary intake for 3 consecutive days or more Inc, in Newport, VT 05855. 1440 / DECEMBER 1993 VOLUME 93 NUMBER 12
Percent of patients with data available 75 0 53 100 82
Table 2 Economic impact of add ng a malnutrition comorbidity (CC) to records of the 10 patients who met two or more nutrition screening cr teria over a 1-year period Diagnostic-related group
No 198 Total cholecystectom,
Total no. of patients
No. of malnourished patients
Payment Without CC With CC
Amount of increased payment
Percentage of increased payment
9
2
7530
13.820
6.290
54
3
1
4.128
6,721
2 593
61
No 211 H p and femur procedures
6
2
10 772
15,025
4 253
72
No 181 Gastro ntestina obstruction
12
2
3941
6,965
3024
57
4
3
18.461
36,475
18,014
51
34
10
44 832
79,006
34,174
No 8 Respiratory infections and
inflammations
No 149 Sma I- and argebowel procedures Totals
varied dramatically between DRGs. The malnutrition rate was highest in DRG No. 149 small- and large-bowel procedures and lowest in DRGs No. 198 total cholecystectomy and No. 181 gastrointestinal obstruction (Table 2). The potential economic impact of codbig for malnutrition was notable in this retrospective study. Had a malnutrition comorbidity been added to the DRG codes of the 10 patients meeting two or more malnutrition criteria, payment to the hospital could have been $34,174 for the 12month period (Table 2). Payment increases were highest for )RG( No. 211 hip and femur procedures and lowest for DRG No. 149 small- and large-bowel procedures. Although these results indicate that additional income for the hospital could be obtained by coding for malnutrition, they must be interpreted with caution. The figures represent potential income; actual payment frorn Medicare to the hospital was not assessed in our study.
DISCUSSION/APPLICATIONS The results of our evaluation were used to implement a nutrition screening system that emphasizes identifying malnutrition. By conducting a pilot evaluation such as ours, dietitians were able to identify areas to improve before implementing the systent. For example, a quality assurance approach was taken to improve the availability of weight data in the medical record. The evaluation also helped dietitians identify potential problems with the use of NPO or clear liquid diets for three or more consecutive days. For example, three of the DRGs evaluated were gastrointestinal diagnoses (No. 149 small- and large-bowel procedures, No. 181 gastrointestinal ob-
struction, and No. 198 total cholecystecomy). Physician orders for NPO and clear liquid diets are indicated in these diagnoses. The use of these nutrition screening criteria for gastrointestinal diagnoses was reevaluated. To reduce the subjectivity of the other dietary criterion (ie, inadequate intake for 3 days or more), it was necessary to quantify the percentage of food consumed. To determine the actual economic impact of coding for malnutrition, a prospective study that tracks actual Medicare payment to the hospital for patients identified and coded as malnourished under the DRG system is needed as a follow-up to this evaluation. Additional follow-up studies should be done to evaluate the impact of the screening system on patient care. For example, once malnourished patients are identified, it is important to evaluate what types of nutrition interventions are used and what clinical effect they have on patient outcomes. Such studies are essential to demonstrate quality of nutrition care. Dietitians at other community hospitals can attempt similar evaluations at their facilities. Such efforts are useful to assess the magnitude of hospital malnutrition and to determine whether nutrition screening programs that identify malnutrition are justifiable from an economic perspective. Furtherinformation generated on this topic is needed to contribute to a data pool dietitians can use to demonstrate the value of nutrition services at financially strapped community hospitals. · The authoracknowledges the assistance of Mary Constanteno, Medical Records Department, New England Memorial Hospital, aznd Sylvia Dellas,
an AP4 studentfrom Loma Linda University, for their roles i gathering datafor this study. The author also acknowledges the assistance of Ellen Nordquist, RI), a ad P1tlat Moffat, MIS, RD, senior clinical dietitiansat NAew England MermorialHospital, in developing the nutrition screening criteria evaluated in ,his slt ody.
References 1. Bistrian BR, Blackburn G(L, Hallowell E, Heddle R. Protein status of general surgical patients. JAM/IA. 1974 230:858-86(0.
2. Bistrian BR, Blackburn GL. Vitale J, Cocran D,Naylor J. Prevalence of malnutrition in general medical patients. JA,1A. 1976; 235:15671570. 3. Mullen JL, Gertner MH, Buzby GD, Goodhart GL, Rosato EF. Implications of malnutrition in the surgical patients.Arch ¥So . 1979; 14:121125.
4. Seltzer MH, Bastidas JA. Cooper DM, Engler P, Blocum B, Fletcher HS. Instarnt nutritional assessment. JPEN. 1979; 3:157-159. 5. Reilly JJ, Hall SF, Albert N. Walter A, Bringardener S. Economic impact t of malnutrition: a model system for hospitalized patients. JPEN. 1988; 12:371-376. 6. Reinhardt GF, Myscofiski JW, Wilkens I)B,
Dorbin PB, Mangan JE, Stannard RT. Incidence and mortality of h ypoalblnnineiric patient.s in hospitalized vetcrans. JPEN. 1980; 4:357-359. 7. Kamath SK, Lawler M. Smith AE, halat. T, Olson K. Hospital malnutriti(n: a 33 hospital screeningstudy.. Am Diet Asso 1986 86:203206. 8. Thompson JS, Burrough CA. Green JL, Brown GL. Nutrition screening in surgical patients. JAm Di t Assoc. ].984; 84:337-:338. 9. Seltzer MH, Slocum BA, Cataldi-Betcher EL, Filetic C, Gerson N. Instant nutritional assessment: absolute weight, loss and surgical
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mortality. JPEN. 1982; 6:218-220. 10. Christensen KS, Gstudtner KM. Hospital-
wide screening improves basis for nutrition intervention. J Am Diet Assoc. 1985; 85:704706. 11. Huniiit DR, MasloxitzA, Rowlaiids BJ, Brooks
B. A simple nutrition screening procedure for hospital patients. J Am Diet Assoc. 1985; 85:332-335. 12. HedbergA, Garcia N, Trejus lI, WeinmanrnWinkler S, Gabriel M,Lutz AL. Nutritional risk screening: development of a standardized protocol using dietetic technicians. ,1 Am Diet Assoc. 1988; 88:1553-1556. 13. Delhey DM, Anderson EJ, Lararmee SH. Implications of malnutrition and diagnosticrelatedigroups (DRGs).JAmDietAssoc. 1989; 89:1448-1451. 14. MacIrnnis P, Swanbon G. The malnutrition
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Diel Assoc. 1992; 92:737-738. 16. Waterlow, J(. Classification and Definilion of Proteini-Eneigy Malnutrition. In: Beaton GH. Bengoa JM, eds. Nutritionin Prelentive Medicn.e. Geneva, Switzerland: World Health Organization; 1976. 17. Blackburn GL, Bistrian BR, Baltej MS. Schlanim HT, Silith MF. Nutritional aiid metaholic assessment of the hospitalized patient. JPE 1977 1:1 22. 18. Inter' national Class;ficationt and Defi'tio/z of Diseases. 3rd ed. Los Angeles, Calif: Practice Management Information Corporalion: 1991.
Cooking oil absorption by foods during Chinese stir-frying: Implications for estimating dietary fat intake WEN-HARNPAN, PhD; HSIAO-LIN iANG, MS; SU-CHIEN CHANG, PhD; MOU-LIANG CHEN, MS
ooking oil is a major contributor of fat in the Chinese diet (1) because stirfrying is the most popular cooking method. Accurately quantifying the amount of oil ingested with stir-fried foods is not an easy task. The amount of cooking oil required for stir-frying varies from food to food. Some foods absorb or adsorb more oil than others. The amount of cooking oil ingested, therefore, depends on the amount added, the amount absorbed/adsorbedbythe food, and whether the juices of the dishes are consumed. The general practice followed by dietitians in Taiwan has been to add 5 g fat per 100 g (raw weight) stir-fried vegetable consumed (personal communication with dietitians). We question this approach for the following reasons: (a) the amount. of oil added during cooking has increased considerably during the past few decades; (b) the approach ignores individual variation in cooking practices and W -H. Pan correspondinggauthor) and H.-L. Wanzg are with the Institute of Biomtoedical Sciences, Academia Sinica, Taipei, Taiwan 115, Republic of China. S.-C. Chang and M.-L. Chen are with the Departrment of Biochemistry, National Defense Medical Center; Taipei, Taiwan.
eating habits; and (c) many people no longer consume the juices of dishes. The purpose of our study was to determine the relationship between the
amount of cooking oil used and the amount absorbed/adsorbed by various foods during stir-frying.
METHODS The foods stuclied are all used frequentlyin Taiwan in stir-fried dishes; they included selected vegetables, shredded hard bean curd, egg, and the majorumeat types (Table). The weight of oil absorbed/adsorbed by the various foods was examined after cooking in 15 g soybean oil per 100 g raw food. The weight of oil absorbed or gained by foods was estimated by subtracting the amount of cooking oil left in the juice from the amount of cooking oil added. The raw weights of the uncooked edible portions were measured after removing roots, rough sterns and leaves, debris, and seeds. The foods were then washed, dripdried, and cut to a popular size. The foods were stir-fried with soybean oil (5, 10, 15, or 20 g), 1 g salt., andi 0.'3 g monosodium glutamate per 100 g raw food using the most poplilar type of gas stove and cooking utensils in Taiwan. After cooking was finished, the foods were lifted out. with chopsticks, piece by piece, and the juices were collected. Cooking utensils were washed twice with a mixture of petroleum ether and ethanol (1/1 vol/vol). The juice and washing fluid were combined and stored at -20°C. We used the Association of Official Analytical Chemists method, with modifications, for deternumatioin of crude fat (2). Juice from the stir-fried foods was extracted five times with a mixture of petroleum ether and ethanol (1/1 vol/vol). The
Relation between weight of oil added per 100 g rawcjbfod ( d sorbed/adsorbedduring stir-frying. *P <. 05. ***P<. 001.
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eight ab-