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The verdict is in. The adage is true: Your patients are what they eat. Studies now prove that well-nourished chronically ill patients are better equipped to manage all aspects of their conditions. Health plans not yet incorporating routine nutrition screening and intervention in their disease management initiatives should bear in mind that these low-cost services have a proven track record of reducing medical costs and improving overall health in the chronically ill and the elderly.
If you doubt the necessity and potential benefit of making nutrition screening and intervention routine health care practice for the chronically ill, consider these findings from 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 resulted in an estimated cost savings of roughly $4,075 per case through a reduction in drug use and 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 decreased 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 prevented 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 spending in a seven-year period.4
• A routine nutrition screening and intervention program of all Medicare members at one independent practice association cost only 21 cents per member per month and resulted in a post-intervention decrease in the number of claims, claim dollars, and emergency department visits in its Medicare members that resulted in an overall 538% return on its investment.5
"People with suboptimal nutrition status, particularly the elderly, run a greater risk of falls, disease exacerbation or, at the very least, have comp - romised 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 simple screening tool, that can be used by consumers, case managers, or providers to evaluate nutrition risk. (For other articles on the NSI, see Case Management Advisor, December 1995, pp. 161-166, and November 1996, pp. 156-158. The DETERMINE checklist is inserted in this issue.)
"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. White is a 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.
The DETERMINE checklist has proven not only to be an effective initial screen of nutrition risk, but also an excellent indicator of chronic depression, White says. "Depression has a big impact on nutrition status and chronic disease. Often, people who score high on the checklist have multiple problems."
The DETERMINE checklist is now incorporated into roughly 60 health plans, says David A. Smith, MPP, director of NSI. "So many chronic diseases 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. 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 chronic disease. The manual provides disease-specific nutrition protocols. For ordering information, see box, p. 103.)
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 a screening tool to your arsenal, White says, be sure to ask providers to measure the height and weight of your patients a minimum of every five years. "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 says.
"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," she explains. "And, 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. 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 every new surgical patient 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." In addition, nurses ask all patients admitted to Pendleton Memorial several questions related to nutrition status as part of their admission intake, he notes.
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."
Even 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 case managers may catch early signs of malnutrition simply by looking at routine laboratory reports with new eyes. "You are already receiving useful information about nutrition from the routine screens taken to monitor chronic conditions, but you simply may not be thinking 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," White explains. "I think it’s important as providers and case managers look at blood pressure, blood sugars, and lipids to remember 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 that add nutrition to 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, require health plans to demonstrate the delivery of preventive health services, an area where nutrition clearly plays a significant role. (See box, p. 104, for a recent statement from NSI to NCQA about proposed changes to HEDIS 2000.)
Also consider that the simplest interventions sometimes 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 case managers and providers should make a habit of asking 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 asking these questions:
• 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 health care professionals ask patients questions about supplements," notes Barrocas. "Two-thirds of patients try integrative therapies without telling their physicians. Don’t leave out questions about vitamins and herbal supplements."
(For guidelines on discussing complementary therapies with your patients, see story, below. For additional information on herbal supplements, see Case Management Advisor, May 1999, pp. 69-73.)
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 Medi - cal Nutrition Therapy under Medicare: 1998 Through 2004. Chicago: American Dietetic Association; April 1997.
3. Reilly JJ, et al. Economic impact of malnutrition: A model system for hospitalized patients. J Parental and Enteral Nutrition 1988; 12:371-376.
4. Barent’s Group: Peat Marwick. The Clinical and Cost Effectiveness of Medical Nutrition Therapy. Washington, DC: Nutrition Screening Initiative; 1996.
5. Coombs J. The role of nutrition screening and intervention programs in managed care. Managed Care Quarterly 1998; 6:43-50.