Original Title: Herramientas para la detección precoz de la desnutrición relacionada con la enfermedad para población adulta en el ámbito hospitalario

Authors' objectives: • Review the available scientific literature on the safety, effectiveness and cost-effectiveness of methods/strategies for early detection of DRM in the hospital setting in adult populations. • To estimate the cost of implementing different strategies for early detection of DRM from a hospital perspective. • Describe and assess the organizational, ethical, social and/or legal aspects of these programs.

Authors' results and conclusions: RESULTS: Fifty-one studies, five systematic reviews and 46 primary studies were identified. The studies were divided into 4 groups: studies in patients with different pathologies in adults and the elderly, and studies in patients with specific pathologies in adults and the elderly. In the group of specific pathologies, the number of studies in surgical patients stands out. SGA, MUST, MNA and NRS-2002 are the tools most studied in the literature. No tool presents evidence of being valid for all outcome measures in all patient groups, which points to a necessary complementarity between them. Stands out the complementarity of MNA and GNRI tools in elderly population and NRS-2002 and SGA in adults with several internal and surgical pathologies. [ORGANIZATIONAL, ETHICAL, SOCIAL AND/OR LEGAL ASPECTS RELATED WITH THE TECHNOLOGY] There exists a consensus on the ethical basis of the proposals to prevent malnutrition both in the hospital setting and at a general level. Selecting one specific detection tool versus another also requires ethical reflection. Some tools are more accurate for early detection DRM in certain patients but not in others and it will be necessary to consider who is most vulnerable and may suffer the greatest impact. DRM detection is only one part of the solution. It is important to establish and follow a protocol of subsequent patient identification, follow-up and treatment of patients to make it effective against DRM. The implementation of tools for the early detection of DRM or strategies against malnutrition are affected by several factors, including the organization of tasks related to screening, interventions and follow-up, the timing of screening, the ease of application of the tools and the training of the professionals involved. CONCLUSIONS: SGA, MUST, MNA and NRS-2002 are the most studied tools in the literature. MNA is ESPEN's recommended malnutrition screening tool for elderly patients. Based on the available evidence, depending on the particular characteristics and context of the health centre or system in which the detection system is intended to be implemented, it may be replaced by NRS-2002, MUST or MNA-SF if a short time is required, or by NRS-2002 again, SGA, or GNRI if patients present difficulty in self-reporting some measures. GNRI and MNA-SF require studies of sufficient quality and sample size to clarify the conflicting results they present, therefore they should be considered in the last place to replace MNA. In hospitalized patients in general, the recommended tool for detection of DRM by ESPEN is NRS-2002. Since no tool has been shown to be predictive for all outcome measures in both age groups of patients, an interesting approach is to implement different tools that have proven to be complementary in predicting the different outcome measures. This seems to be the case of MNA and GNRI for the elderly population and NRS-2002 and SGA in adults with various internal and surgical pathologies. In any case, it is convenient to carry out new studies that will deepen and extend these complementarities. Other automated detection systems such as CONUT have considerable advantages in terms of time and cost savings, but also have significant limitations implicit to their condition as biochemical tests. Therefore, they have yet to be validated in new comparative studies with a high-quality design. There is evidence outside the Spanish context that early detection of hospital malnutrition can be cost-effective and even cost-saving if the tool used is sufficiently simple and effective. However, quality economic evaluations carried out in the Spanish context that compare malnutrition detection tools are necessary. The systematic implementation of an early detection system for hospital malnutrition, including an easy-to-use tool for the healthcare professional, would save costs of up to 48 million euros in a hospital with more than 1,000 beds, considering a prevalence for hospital malnutrition of 23%. The calculations above are estimated under the assumption that prevalence of DRE remains constant with age and considering also a 100% effectiveness of the nutritional interventions adopted. Aspects related to the implementation of tools significantly affect effectiveness in mitigating DRM. It is necessary to incorporate a complete strategy of nutritional care that protocols the application and monitoring of the detection and treatment of people with or at risk of malnutrition and that provides training for health professionals. From the review carried out in this report it is not possible to derive which interventions, once malnutrition or the risk of malnutrition is detected, are most effective and cost-effective, which requires a specific assessment. Finally, the detection of nutritional risk or malnutrition through screening tools and nutritional assessment will never replace a complete nutritional assessment by a professional. This should be taken into account when developing strategies to address hospital malnutrition.

Authors' recommendations: • It is recommended the implementation in hospitals of comprehensive strategies of nutritional care that protocolize the implementation and monitoring of the detection and treatment of people with malnutrition or at risk of malnutrition and to provide training to health professionals. • It is recommended for the implementation of one or another of early detection tools for hospital malnutrition; consider the particular characteristics of the health centre or system, making a specific assessment for each particular implementation case. • It is recommended, once the malnutrition detection system is implemented, to carry out a continuous assessment of its effectiveness and cost-effectiveness.

Authors' methods: We systematically searched the following electronic databases for articles: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, since its creation until today (May 2017). In addition, the NHS EED of the CRD was searched for cost-effectiveness review. We also hand-searched bibliographic lists of included articles and identified systematic reviews; moreover, we searched for ongoing trials in clinicaltrials.gov. We included comparative studies evaluating the predictive validity of several screening or nutritional assessment tools in the same sample of patients on outcomes as mortality, complications, length of hospital stay, readmissions after discharge and quality of life. The participants had to be adults admitted to hospitals (not to socio-health centres), with any pathology. Two reviewers independently selected the studies. Data extraction from included studies was performed by one reviewer and checked by a second reviewer. Both reviewers discussed their decisions and in the event of any differences, they were resolved through discussion with a third member of the team until consensus was reached. We collected the data in electronic forms designed ad hoc. The methodological quality of the studies was assessed using validated instruments. The information collected was synthesized through a narrative review and the results were shown in tables. With regard to organizational, ethical, social and/or legal aspects, articles were systematically searched in the following electronic databases: MEDLINE, EMBASE and CINAHL from their inception until June 2017.

Project Status: Completed

Year Published: 2017

URL for published report: https://sescs.es/herramientas-deteccion-precoz-desnutricion-poblacion-adulta-ambito-hospitalario/

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es