High-quality nutritional interventions reduce costs

Healthcare Financial Management, August, 1997 by Philip E. Smith, Alice E. Smith

Analysis of clinical nutritional data provides valuable insight into the savings potential of high-quality nutritional intervention.

Research has documented the potential for cutting inpatient length of stay by implementing high-quality nutritional support for patients who exhibit protein-calorie malnutrition at some point during their hospital stays.(a) This research generally focuses on small subsets of patients who have specific diagnoses or who receive sophisticated and expensive parenteral nutrition and tube feedings.(b) Although this type of research is essential for specialty-oriented clinicians treating patients with specific conditions, it is too fragmented to clearly illustrate the impact that clinical nutrition can have on patient outcomes and a hospital's overall financial performance.

The Nutritional Care Management Institute developed a survey to quantify the relationships between nutritional risk, nutritional care quality, and financial performance from an institution-wide perspective. Nineteen hospitals submitted 2,337 abstracts for inpatient medical and surgical patients treated in 1993 and 1994 whose lengths of stay were more than seven days. These patients comprised a relatively small share of the participating hospitals' total inpatient volume (3.7 to 33.9 percent), but they accounted for a disproportionately high concentration of the hospitals' total patient days (8.2 to 67.3 percent). A subset of 1,767 patients was selected for study because their records included serum albumin values, which could be used to compare severity of illness.(c) A total of 1,672 (94 percent) of the records of this patient subset exhibited at least one of eight malnutrition risk factors (see sidebar).

Patients with the largest number of risk factors for protein-calorie mal-nutrition had the longest lengths of stay [ILLUSTRATION FOR EXHIBIT 1 OMITTED]. This finding is consistent with other evidence that links prolonged hospital stays with nutritional risk.(d) (Such analysis, however, does not take into account the quality of care the patients received during their hospital stays.)

Exhibit 2 shows how the quality of nutritional care affected the average length of stay of patients with one or more risk factors for malnutrition. High-quality nutritional care involved early intervention with a special nutritional product or feeding to increase the patients' protein calorie intake and frequent clinical nutrition services during their hospital stays. Medium nutritional care consisted of either early intervention or frequent nutritional services, but not both. Low-quality nutritional care involved either late or no feeding interventions, infrequent or no clinical nutrition services, or some combination of these factors.

Early interventions were defined as those that were started by the third hospital day. The products used for these interventions included extra servings or snacks of regular food (27.0 percent), prepackaged commercial supplements (28.9 percent), enteral tube feedings (18.0 percent), peripheral parenteral nutrition (10.5 percent), and central parenteral nutrition (14.5 percent). Frequent services were defined as those occurring at least once every four days of the hospital stay (although, in practice, the optimum frequency of services would vary with a patient's risk level). Nutritional services included screenings, assessments, and monitoring to determine patients' risk and track the effects of the interventions they received.

One hundred twenty-six (7.5 percent) patients who received high-quality nutritional care averaged 12.2 days in the hospital. Four hundred fifty-seven (27.3 percent) patients who received medium nutritional care averaged 14.0 days in the hospital. The remaining 1,089 patients (65.1 percent) who received low-quality nutritional care were hospitalized an average of 14.4 days.

The differences in average length of stay for the patients in the high-quality care group and patients in the other two groups were statistically significant (p [less than]0.001). The group that received the highest quality of care had a higher average risk level, as measured by their mean serum albumin levels and their average risk factor scores (p[less than]0.001), than the group that received the lowest quality of care. Differences in the expected length of stay based on patients' diagnosis, age, complications, and status as a surgical or medical patient were not statistically significant.

These values indicate that a lower severity of illness did not account for the average length-of-stay savings in the high-quality nutritional care group. On the contrary, high-quality nutritional care overcame the potential adverse effects of greater severity to produce better outcomes.

So few patients received high-quality nutritional care that it was not possible to conduct a useful statistical analysis for each study hospital individually. Aggregate data from all the hospitals, however, showed that a savings of 3,218 total patient days could be achieved by extending high-quality nutritional care to the 1,546 patients who fell into the medium- and low-quality nutritional care groups, assuming the results duplicated the high-quality nutritional care group's average length of stay of 12.2 days.