1) Treatment of malnutrition leads to better clinical outcomes for patients. Evidence from meta-analyses of clinical trials shows that nutritional support improves outcomes like complications and mortality. 2) Screening studies in Denmark found high prevalences of malnutrition in hospitals, especially in orthopedic surgery, gastroenterology, and internal medicine. However, most malnourished patients did not receive nutritional treatment or monitoring. 3) Malnutrition in hospitals results in increased costs due to longer hospital stays and higher rates of complications. Treating malnutrition can reduce these costs. Applying UK cost estimates to Danish healthcare spending suggests that treating malnutrition could save over 140 million pounds.

2. loBMI Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003

3. Wt loss

4. E intake

5. Prevalence of undernutrition Stratton RJ, Green CJ, Elia M. Disease-related malnutrition CABI Publishing 2003 10 30 % of these undernourished 995 150 Prevalence (per 100.000) 10 100 % of these diseased 99.5 0.5 % of population Community Hospital

6. Europe 1 OOPS! 26 departments from 12 countries Interested, but limited experience with nutrition support. Sponsored by Fresenius-Kabi. 49 560 216 306 48 22 296 59 131 83 88 187 856 388 479 21 182 50 52 68 273 276 151 162 207 60

7. % at risk according to NRS-2002 Sorensen et al. Clin Nutr 2008; 27: 340-9 32 543 Gastroenterology 94 309 ICU 28 338 Oncology 5051 209 1783 1715 N 33 52 33 19 % At-risk Total Geriatrics Internal medicine Surgery

8. Complications Sorensen et al. Clin Nutr 2008; 27: 340-9 100 (1647) 14 (234) 16 (270) 69 (1143) At-risk * P<0.001 100 (3404) 5 (165) 6 (218) 89 (3021) Not at-risk Total Infectious Complication Non-infectious Complication No Complication At risk according to NRS-2002 Percent of patients with non-infectious or infectious complications (N) Cancer Age Region (Western Europe, Eastern Europe, Middle East) Speciality (geriatry, gastroenterology, oncology, internal medicine, surgical, ICU) Diagnoses (19 most frequent) Comorbidity Surgery Complications were independenly associated with NRS-2002 components (nutritional status and severity of disease), also when adjusted for:

9. Type of complications Sorensen et al. EuroOOPS: an international, multicentre study of nutritional risk screening and clinical outcome in 5.000 patients. Clin Nutr 27 340-9, 2008 Primary disease determines the type of complication - malnutrition makes it happen

10. LOS, all Sorensen et al. Clin Nutr 2008; 27: 340-9

11. Length of stay Sorensen et al. Clin Nutr 2008; 27: 340-9 12.9  0.4 (189) 11.2  0.4 (219) 8.9  0.2 (1055) At-risk Not At-risk No Complication versus all other groups: P<0.0001 for each 11.0  0.5 (127) 10.9  0.4 (199) 6.9  0.1 (2881) Not at-risk Infectious Complication Total Non-infectious Complication No Complication At risk according to NRS-2002: LOS (mean  SEM) in different categories (N) Cancer Age Region (Western Europe, Eastern Europe, Middle East) Death. Speciality (geriatry, gastroenterology, oncology, internal medicine, surgical, ICU) Diagnoses (19 most frequent) Comorbidity Surgery LOS was independenly associated with NRS-2002 components (nutritional status and severity of disease), also when adjusted for:

12. Length of stay; survival Sorensen et al. Clin Nutr 2008; 27: 340-9

13. Odds for discharge < 28 days Sorensen et al. Clin Nutr 2008; 27: 340-9 Cox regression analysis N = 5046; LOS  28 (N=379) are right censored <0.0001 0.78 Co-morbidity <0.0001 0.55 Complication <0.0001 0.74 Cancer 0.008 1.09 Surgery 0.003 1.09 Sex, male versus female <0.0001 0.76 At-risk P OR

14. Prevalence of malnutrition in Denmark 36 Orthoped surgery (249) 57 Gastro surgery (148) 42 Internal medicine (238) % at-risk NRS-2002 Speciality (N) A random selection of 5 departments for each of 3 specialities: internal medicine, gastro-surgery and orthopedic surgery in hospitals >200 beds. Result:15 departments in 12 out of 33 hospitals. Rasmussen et al. Clin Nutr 2004;23:1009-15 .

15. Prevalence: Care 14 (33:8) 1) Plan (req, food type, monitor) 1) Related to recent weight loss and severity of disease, but not to BMI or recent intake 20 (33:10) Recent dietary intake 12 (19:7) Recent weight loss 64 (similar) Weight % (at-risk:not at risk) Information in records Nutritional care Rasmussen et al. Clin Nutr 2004;23:1009-15.

17. Evidence is here! Meta-analysis of a large number of trials shows that nutritional support improves clinical outcome Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach. CABI Publishing 2003

18. RCT: Complications % mortality Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003 24% vs. 44% 1) Infections 2) 17 % vs. 24% 1) Mortality 1) P <0.001; 2) 10 RCTs only Meta-analysis of 27 RCTs with 1710 patients (complications) and 30 RCTs with 3250 patients (mortality). Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery, orthopaedic surgery, critical illness/injury, burns. Hospital or community Oral supplements or tube feeding 28% vs. 46% 1) Complications

19. Meta-analysis: Surgery Stratton RJ, Green CJ, Elia M. Disease-related malnutrition 2003

20. Meta-analysis: Internal medicin Stratton RJ, Green CJ, Elia M. Disease-related malnutrition 2003

21. Clinical effect: Gastro-intestinal surgery References in Kondrup et al. Clin Nutr 2003; 22: 321-336 infection/ON (82) infection/ON (79) infection/EN (20) infection/EN (37) infection/EN (83) infection/EN (84) infection/PN (1) infection/PN (19) infection/PN (38) infection/PN/EN (80) infection/PN (123) complications/ PN (77) complications/PN (78) complications/PN (87) complications/PN (124) LOS/EN (86) LOS/PN (21) survival/PN (43) survival/PN (125)

22. Clinical effect: References in Kondrup et al. Clin Nutr 2003; 22: 321-336 tolerance/ON (2) tolerance/PN (39) tolerance/PN (40) tolerance/ON (41) QoL/EN (35) survival/PN (44) survival/PN (91) Cancer Clin Index/PN (36) encephalopathy/EN (42) infection/EN (81) LOS/PN (88) survival/ON (93) Cirrhosis LOS/ON (3) LOS/ON (4) survival/EN (5) Femoral fracture infection/EN (18) LOS/EN (29) survival/PN (30) Trauma ADL/ON (34) ADL/ON (85) survival/ON (45) Geriatry survival/PN (89) survival/PN (90) Acute Renal Failure infection/burns/EN (28) survival/BMT/PN (31) survival/stroke/ON (92) Misc.

24. Impact of malnutrition on healthcare costs The pooled results from the analysis of all the hospital-based studies indicated a mean net cost saving from the use of oral nutritional supplements of £849 per patient based on bed-day costs and £298 per patient using complication costs. Russell C, Clinical Nutrition Supplements 2007; 2: 25–32 Elia M, Stratton RJ, Russell C, Green CJ, Pang F. The Cost of disease–related malnutrition in the UK. BAPEN 2005 The total direct costs of disease-related malnutrition represent approximately 10% of the total expenditure on health in the UK. 7.3 £ million is two fold greater than the reported costs of managing obesity and its consequences in the UK

25. UK Costs applied to Euro-OOPS. LOS + Complications Calculated from Cost of LOS (£ 258/day) + Cost of Complication (£ 1500) with extra LOS subtracted ((LOS compl-LOS no compl) x £ 258) Based on Elia M, Stratton RJ, Russell C, Green CJ, Pang F. The Cost of disease–related malnutrition in the UK. BAPEN 2005 1.6 0.3 1.3 408 Mal, compl 2.4 0.9 5.1 10 6 £ LOS 0.2 10 6 £ Compl >  LOS 1055 326 2881 N Total Mal, no compl Well, compl Well, no compl Group 5.1 10.2 2.4 1.1 10 6 £ Total

26. UK Costs applied to Euro-OOPS. Additional cost of malnutrition: (Cost of mal) – (# of mal x cost of average well  complications, £ 1929) Based on Elia M, Stratton RJ, Russell C, Green CJ, Pang F. The Cost of disease–related malnutrition in the UK. BAPEN 2005 11% Mal in % of total (1.1 x 100/10.2) 10.2 Total, £ million (2.4 +1.6) – (1,463 x 1,929) = 1.1 £ million

27. UK Costs applied to Euro-OOPS. Additional cost of treated malnutrition: (Cost of mal) – (# of mal x cost of average well  complications, £ 1929) Elia M, Stratton RJ, Russell C, Green CJ, Pang F.The Cost of disease–related malnutrition in the UK. BAPEN 2005 0.7 Cost of treated mal (0.4 + 0.3), £ million 0.3 Cost of treatment (# mal x LOS x £ 24.6), £ million 6% Treated mal, % of total (0.7 x 100/10.2) 10.2 Total, £ million (2.4 +0.7) – (1,463 x 1,929) = 0.4 £ million versus 1.1 in untreated

28. Results applied to DK health care (in £) 140 £ million = 1.3 milliarder DKK 140 Saving, £ million 7. 287 Mal, 11% of 2., £ million 5. 146 Treated mal, 6% of 2., £ million 6. 8. 4. 3. 2. 1. 5,442 Total costs for in-patients, £ million 6.0 Saving, % of Total DRG (=7./2.) 392 Av bed day cost DRG, £ (= 2./3.) 6.5 Bed days per year, million 2,547 Total DRG costs, £ million Item

33. Appendix: The level of government/health authority Editorial Clin Nutr 2004; 23:135-137 These key recommendations will help the level of government/health authority to: 1) evaluate the adequacy of nutrition activities in individual hospitals 2) evaluate unfortunate individual cases.

36. EU… Europaparlamentet vedtog den 25. September 2008 ændringer til EU kommissionens ’White paper on nutrition, overweight and obesity-related health issues’ fra Juni 2007 Malnutrition is a heavy burden both for individual wellbeing and for society, particularly the health care system, and it results in increased mortality, longer hospital stays, greater complications and reduced quality of life for patients; extra days in hospital and treatment of complications due to malnutrition cost billions of euros in public funding every year. Urges the Commission to take a more holistic approach to nutrition and make malnutrition, alongside obesity, a key priority in the fields of nutrition and health, incorporating it wherever possible into EU-funded research initiatives and EU-level partnerships.

39. Institut for Kvalitet og Akkreditering i Sundhedsvæsenet www.kvalitetsinstitut.dk

44. Key question: Nutritional support was effective in the RCTs – but how were the patients actually selected? Do the patients selected for these studies have a common denominator for risk of nutrition-related complications (= nutritional risk) ? To implement the evidence: develop a screening tool based on evidence that outcome will change, i.e. the available RCTs Other specialities? Fraction of patients  etc Speciality 4 Speciality 3 Speciality 2 Speciality 1

46. Concept Nutritional risk = risk of complications due to nutritional impairment

47. Components in Screening by NRS-2002 – ESPEN guideline Impaired nutritional status BMI (  present condition) Recent weight loss (  past tendency) Recent dietary intake (  future tendency) Nutritional requirements  Severity of disease  E.g. protein requirements in various disease states (stress metabolism) www.espen.org  education; Kondrup et al. Clin Nutr 2003; 22: 321-336 + 415-421

48. NRS-2002 _DK www.espen.org  education; Kondrup et al. Clin Nutr 2003; 22: 321-336 + 415-421 Hvis alder  70: læg 1 til Total. Ved Total  3: start ernæringsterapi Score = Total: Score + Kranietraumer, forbrænding > 50% S være infektioner (sepsis), intensiv ptt . Svær = 3 Vægttab > 5% på 1 måned/15% på 3 måneder 1 eller BMI  18,5 og påvirket almentilstand eller Kostindtagelse 0-25%  1 uge Svær = 3 Store abdominalkirurgiske indgreb (colektomi, gastrektomi, hepatektomi) Postoperativ ATIN, apopleksi Svær pneumoni Moderat = 2 Vægttab > 5% på 1 1/2 måned eller BMI 18,5-20,5 og påvirket almentilstand eller Kostindtagelse 25-50%  1 uge Moderat = 2 Collum femoris fraktur Kronisk prægede ptt., særligt ved akutte komplikationer: levercirrhose, KOL Kronisk prægede ptt. med nyreinsufficiens, IDDM eller cancer Let = 1 Vægttab > 5% på 3 måneder eller Kostindtagelse 50-75%  1 uge Let = 1 Sværhedsgrad af sygdom Underernæring

49. all

50. ON Kondrup et al. Clin Nutr 2003; 22: 321-336

51. EN Kondrup et al. Clin Nutr 2003; 22: 321-336

52. PN Kondrup et al. Clin Nutr 2003; 22: 321-336

54. Intake UPS  This is the solution 

55. RCT with 212 at-risk patients (NRS-2002) randomized to departments’ routine or daily follow-up by team of nurse and dietitian. Length of Stay Johansen N et al. Clin Nutr 2004; 23:539-550 1) Team versus Control: P = 0.028; ANOVA 17  2 1) 18 22  2 14 Complications 9  1 50 9  1 69 No complications Mean  SEM N Mean  SEM N Team Control

57. ESPEN guideline: screening linked to action ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22(4):415-421. 1. Screening 2. Nutrition Plan 3. Monitoring 4. Communication 5. Audit

58. Nutrition treatment: a structured process ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22(4):415-421.

59. Context of the structured process Kondrup Clin Nutr 2001; 20(suppl 2): 153-160, b ased on BAPEN report 1999: Hospital Food as Treatment

60. Copenhagen audit March 2006 Accreditation 2002 & 2005

61. Reliability of audit results in Copenhagen 480 patients in 24 departments in 5 hospitals Holm et al. ESPEN Congress 2006: Abstract # P 0281 91% 3) 74% 106/143 Dietary recording Correct, % Done, % n/N Activity Most frequent causes of errors: 1) Undiscovered weight loss 2) Undiscovered weight loss/wrong category of severity of disease 3) Erroneus calculation of requirements 89% 2) 98% 220/224 Final screening 85% 1) 78% 374/480 Initial screening

62. Causes of inadequate intake 111 of 246 at-risk patients had an intake <75% of requirement. The nurses gave max 1 answer in each of 5 categories: Patient, Nurse, Food, System, Other. An average of 3 reasons per patient. 83 different combinations. 74 patients had an individual combination. The combinations shared by  3 patients are shown here. Holm et al. ESPEN Congress 2006: Abstract # P 0281