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Using simple checklist can improve patient health
Grandma was right: An apple a day keeps the doctor away. In fact, studies prove that adding routine nutrition screening and intervention to your pathways deliver the competitive edge you need to position your disease management programs above others in your market. These are low-cost services with a proven track record of reducing medical costs and improving overall health in the chronically ill.
If you doubt the necessity and potential benefits of adding routine nutrition screening and intervention into your disease management initiatives, consider these findings from several recent studies:
• More than 80% of elderly Americans have one or more chronic conditions known to benefit from nutrition intervention.1
• Medical nutrition therapy for hypertension can result in an estimated cost savings of roughly $4,075 per case through a reduction in drug use and by the prevention of drug-related complications, such as stroke.2
• Elderly patients with diabetes and/or cardiovascular disease who use the services of a dietician decrease the frequency of their physician visits and their use of hospital services.2
• Hospital costs for patients at nutritional risk were $12,683, or four times greater than the $2,968 price tag for patients who were well nourished.3
• The consistent and appropriate use of medical foods for hospitalized patients prevents complications in the treatment of the critically ill and injured. The routine provision of medical foods or nutritional supplements could save an estimated $1.3 billion in health care dollars in a seven-year period.4 (See related story on p. 65 for one health plan’s nutrition program success story.)
"People with sub-optimal nutrition status — particularly the elderly — run a greater risk of falls, disease exacerbation, or at the very least, have compromised immune systems that cause them to get sick more quickly," says Janis M. Verderose, RD, MS, CDN, ACCA, manager of clinical outcomes for Prime Care 2000, a large medical practice group in Albany, NY.
"Malnourished chronically ill patients often succumb to their disease or develop co-morbidities that better-nourished patients are able to fight."
Assessing your patient’s nutrition status is simple. The Nutrition Screening Initiative (NSI) in Washington, DC, developed the DETERMINE checklist, a screening tool that can be used by consumers or providers to evaluate nutrition risk. (See checklist on p. 63.)
"When providers first look at the DETERMINE checklist, the language is so simple their first reaction is, Oh, I won’t learn anything valuable from this.’ But to reach your patients and get them to understand what you are asking, the language must be simple," notes Jane V. White, PhD, RD, LDN, professor in the department of family medicine at the Graduate School of the School of Medicine at the University of Tennessee in Knoxville and president-elect of the American Dietetic Association in Chicago.
Ironically, the checklist has proven not only to be an effective initial screen of nutrition risk, but has also proven to be an excellent indicator of chronic depression, adds White. "Depression has a big impact on nutrition status and chronic disease. Often, people who score high on the checklist have multiple problems."
The checklist is now incorporated into roughly 60 health plans, says David A. Smith, MPP, director of NSI.
"So many chronic disease are directly related to nutrition status — diabetes, high blood pressure, cardiac disease — that assessing nutrition status in patients, especially elderly and/or chronically ill patients, should be an institutionalized part of health care in this country," Smith says. "NSI wants providers to look at the chronically ill and see the whole person, not just the disease. In other words, don’t focus on sodium alone when you counsel congestive heart failure (CHF) patients about diet."
NSI has developed a nutrition care manual for patients with chronic disease. Some of the materials in the manual appear in the supplement inserted in this issue.
In addition, many chronic conditions respond well to nutrition intervention alone. "Diabetes is an obvious example," says Verderose. "Nutrition intervention can go along with pharmacological intervention or be given a trial as the first step. For example, why not recommend a controlled diet for coronary artery disease before writing a prescription for a lipid-lowering drug? Nutrition intervention is less expensive and often provides greater quality of life."
If you’re not ready to add even a simple screening tool to your arsenal, you should, at the very least, measure the height and weight of your patients a minimum of every five years, says White. Some, like CHF patients, should be weighed more often.
"We measure the height and weight of young children every time they come into a pediatrician’s office, yet too many providers forget to take routine measurements of height and weight for adults," she notes.
"A decline in height is an early symptom of osteoporosis, but too many providers simply ask patients their height without taking a measurement. Involuntary weight change can be an ominous sign of impending problems from cancer and heart disease to depression and poor oral health," says White. "By simply improving our patients’ diets, we can intervene early and prevent serious complications."
Even bedridden patients should be routinely weighed and measured, adds Albert Barrocas, MD, FACS, a general surgeon and medical director of nutrition support and home health services at Pendleton Memorial Methodist Hospital in New Orleans.
"We must start looking at height and weight as routine vital signs, just as we do blood pressure and temperature," he says. "You wouldn’t let your patients walk in and tell you their blood pressure based on a reading now five years old. You wouldn’t simply ask patients what their temperature is today. You shouldn’t do that with their height and weight."
Barrocas screens all of his new surgical patients using the DETERMINE checklist. "The receptionist helps patients fill it out. If there are any positive findings, my LPN addresses them, or brings them to my attention. I don’t know of any condition or disease where starvation is a recommended therapeutic modality. If my patients are malnourished, I want it taken care of before surgery."
The relationship between chronic disease and nutrition is symbiotic, Barrocas says. "Poor nutrition may contribute to the disease, or perhaps, the disease interferes with appropriate nutrition. Nutrition is the basis of all physiologic and structural functions of the body, and it also plays a role in the pathology. Nutrition, put simply, can either cause or contribute to chronic disease but must always be considered," he says.
Even very healthy patients can be at nutrition risk, White notes. "Women who are running or exercising vigorously without adequate calcium intake, or who have a low percentage of body fat, which alters their estrogen production, run a high risk of developing osteoporosis early in life. By routinely measuring height and weight, providers can catch changes in height early enough to intervene before these women develop vertebral fractures."
White says providers can also catch early signs of malnutrition by simply looking at routine laboratory reports with new eyes.
"Providers are already receiving useful information about nutrition from the routine screens taken to monitor chronic conditions, but they simply don’t think of the data in terms of nutrition risk," she says.
For example, one of the most sensitive indicators of initial nutrition status in an ambulatory population is serum albumin level.
"A serum albumin level of less than three is associated with poor outcomes for a number of diseases, including pneumonia, CHF, failure to thrive, and chronic obstructive pulmonary disease," notes White. "I think it’s important as providers look at blood pressure, blood sugars, and lipids that these are as much an indicator of nutrition status as of disease state. And, also remember that poor nutrition definitely could adversely affect the disease state being monitored."
Health plans and providers that add nutrition into their disease management initiatives also may improve their scores on managed care report cards and accreditation surveys. The Health Plan Employer Data and Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA) in Washington, DC, do not yet have specific performance measures for nutrition care and screening; however, the standards do include implications for nutrition. For example, NCQA and the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, both require health plans and providers to demonstrate the delivery of preventive health services, an area where nutrition can clearly play a significant role. (See box on left for a recent statement from NSI to NCQA about proposed changes to HEDIS 2000.)
And remember, sometimes the simplest interventions are the most effective. "When a patient walks in with a complaint, nutrition is not the thing that providers consider. Sometimes, we neglect the simple things that can have a big impact on health outcomes," says White.
Barrocas agrees that providers should always ask patients about their nutritional status. "If you don’t care to use the DETERMINE checklist, at least ask several questions directly related to nutrition." He suggests providers ask:
• Who last asked you about your nutrition?
• Who does the shopping and cooking at your house?
• How many medications are you taking?
• Are you taking your medications as prescribed?
• Are you taking any medications that have not been prescribed by a physician?
• What do you normally eat each day?
• What dietary supplements are you taking?
"Dietary supplements often interfere with the absorption of food and prescription medicines, yet few providers ask questions about supplements," notes Barrocas. "Two-thirds of patients try integrative therapies without telling their physicians. Don’t leave out questions about supplements." (For more information on herbal supplements, see p. 66.)
1. Peter D. Hart Research Associates. National survey on nutrition screening and treatment for the elderly. Washington, DC; 1993.
2. Lewin Group. The cost effectiveness of covering medical nutrition therapy under Medicare: 1998 through 2004. J Am Diet Assoc April 1997.
3. Reilly JJ, et al. Economic impact of malnutrition: A model system for hospitalized patients. JPEN 1988; 12:371-376.
4. Barent’s Group: Peat Marwick. The clinical and cost effectiveness of medical nutrition therapy: Nutrition Screening Initiative. Washington, DC; 1996.
Note: The Nutrition Screening Initiative is a project of the American Academy of Family Physicians, The American Dietetic Association and the National Council on the Aging. It is sponsored by Ross Products Division of Abbott Laboratories.
The following groups offer a wide range of free or low-cost provider and consumer resources on nutrition:
• The Nutrition Screening Initiative, 1010 Wisconsin Ave., Suite 800, Washington, DC 20007. Telephone: (202) 625-1662. Fax: (202) 338-2334.
• The Nutrition Institute of Louisiana, 5620 Read Blvd., New Orleans, LA 70127. Telephone: (504) 244-5078. The institute has a consumer brochure and poster set that helps professionals teach patients the basics of good nutrition, including tips for interpreting the food pyramid.
• The American Dietetic Association, 216 W. Jackson Blvd., Suite 800, Chicago, IL 60606. Telephone: (312) 899-0040. Or, telephone the ADA’s National Center for Nutrition at (800) 366-8114. Web site: www.eatright.org. The ADA is currently completing an education module on dietary supplements, due out in early fall.