eCQM Title

Global Malnutrition Composite Score

eCQM Identifier (Measure Authoring Tool) 859 eCQM Version number 0.0.003
NQF Number None GUID 93160f75-880c-4d7e-84dc-cd1f2575c41b
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Academy of Nutrition and Dietetics
Measure Developer Academy of Nutrition and Dietetics
Endorsed By None
Description
This composite measure of optimal malnutrition care focuses on adults 65 years and older admitted to inpatient service who received care appropriate to their level of malnutrition risk and/or malnutrition diagnosis if properly identified. Best practices for malnutrition care recommend adult inpatients to be screened for malnutrition risk, assessed to confirm findings of malnutrition if found at-risk, and have the proper severity of malnutrition indicated along with a corresponding nutrition care plan that addresses the respective severity of malnutrition.
Copyright
"Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets.

CPT (R) contained in the Measure specifications is copyright 2015 by the Academy of Nutrition & Dietetics.

LOINC (R) copyright 2004-2014 [2.46] Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2013 [2013-09] International Health Terminology Standards Development Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]."
Disclaimer
"These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED ""AS IS"" WITHOUT WARRANTY OF ANY KIND."
Measure Scoring Ratio
Measure Type Composite
Stratification
None
Risk Adjustment
None
Rate Aggregation
•	The composite will be calculated at the patient level as a weighted function of the encounter's values for each component.
•	The weights are based on a generalized linear mixed model of malnutrition diagnosis, using those variables and their interactions as predictor variables.
•	The final weights are scaled to result in a composite that ranges from 0 (worst) to 1 (best) for each encounter.
•	For each reporting entity, an aggregate of all composite scores is calculated and then divided by the total number of patients in the denominator population (measure population minus denominator exclusions).

Component Measure Weights:
Malnutrition Screening Present: 0.2
Nutrition Assessment Present: 0.2
Malnutrition Diagnosis Present: 0.3
Nutrition Care Plan Present: 0.3

Corresponding Adverse Result Score Penalties
Nutrition Assessment Present but Result Unknown: -0.1
Assessment Result of Malnutrition but No Malnutrition Diagnosis Documented: -0.1
Screening Result Unknown and Screening-to-Assessment Interval >24 hours: -0.1
Screening Result Not-at-risk, No Nutrition Assessment, but has Malnutrition Diagnosis Documented:	-0.1
Rationale
Overall Calculation Rationale:
Given relative contribution to the overall outcome of the composite measure, specific weights were assigned to reflect the contribution of the step in the care process to the overall outcome of optimal malnutrition care. In addition, wherever encounter data reflect inappropriate care or vital data are missing which inform the proper next steps, corresponding penalties are applied to the score assigned to that encounter.

Rationale for Composite Component Weights:
Screening and assessment are weighted equally to encourage screening and reduce the ability to limit the patient population assessed. Ultimately, the goal of this measure is to ensure that for patients appropriate screened and/or assessed for malnutrition, a diagnosis and corresponding care plan are developed where warranted.

Rationale for Adverse Result Scores:
Providers should not get full credit for reporting a process but not indicating the result indicator that informs the proper next step.

Without the malnutrition diagnosis in the chart there is a low likelihood that the diagnosis will follow the patient through discharge and next setting of care and lower likelihood of care plan advancement.

If a malnutrition screening is completed, the result needs to be documented to properly determine if a patient should be referred to a registered dietitian for a nutrition consult to assess for malnutrition.

Malnutrition diagnoses should be informed by proper nutrition assessments which adequately characterize the condition in the patient.
Clinical Recommendation Statement
The components of this composite measure are supported by multiple clinical guidelines that recommend the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients at-risk of malnutrition in order to form the basis for an appropriate nutrition intervention; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to address their condition with an appropriate plan of care and communicate patient needs to other care providers . 

By completing a malnutrition screening early during the patient’s admission, patients at-risk of malnutrition are identified earlier and can be referred to a dietitian to complete a nutrition assessment. A completed nutrition assessment for patients at-risk of malnutrition (typically first identified by malnutrition screening around admission time) facilitates subsequent development of a nutrition care plan that includes appropriate interventions to address the patient’s malnutrition.

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommends the following:
1.	Screening for nutrition risk is suggested for hospitalized patients (Evidence Grade E) 
2.	Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening (Evidence Grade E) 
3.	Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished.  (Grade Evidence C)

Mueller C, Compher C & Druyan ME and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. J Parenter Enteral Nutr. 2011;35: 16-24.

The British Association for Parenteral and Enteral Nutrition recommends the maintenance of documentation for all individuals including results of nutritional screening and assessments (which include malnutrition findings), along with consequent action plans and treatment goals. If the patient is transferred to another care setting, this information should be readily available to all new caregivers to ensure continuity of care. 

British Association for Parenteral and Enteral Nutrition. Malnutrition Matters, A Toolkit for Clinical Commissioning Groups and providers in England. Published 2012. Retrieved from: http://www.bapen.org.uk/pdfs/bapen_pubs/bapen-toolkit-for-commissioners-and-providers.pdf.

A consensus statement from the Academy of Nutrition and Dietetics states that the registered dietitian’s (RD’s) assessment of critically ill adults should include, but not be limited to, the following: Food and Nutrition-Related History, Anthropometric Measurements, Biochemical Data, Medical Tests and Procedures, Nutrition-Focused Physical Findings, Client History. Assessment of the above factors is needed to correctly diagnose nutrition problems and plan nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Academy of Nutrition and Dietetics. CI: Nutrition Assessment of Critically Ill Adults 2012. Academy of Nutrition & Dietetics Evidence Analysis Library. Published  2012. Retrieved from: http://www.andeal.org/topic.cfm?menu=4800.
Improvement Notation
Higher score indicates better quality of care.
Reference
Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clinical nutrition (Edinburgh, Scotland). 2013;32(5):737-745.
Reference
Allard JP, Keller H, Teterina A, et al. Lower handgrip strength at discharge from acute care hospitals is associated with 30-day readmission: A prospective cohort study. Clinical nutrition (Edinburgh, Scotland). 2016;35(6):1535-1542.
Reference
Amaral TF, Matos LC, Tavares MM, Subtil A, Martins R, Nazaré M, et al. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr. 2007 Dec;26(6):778–84.
Reference
Corkins MR, Guenter P, Dimaria-ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. J Parenter Enteral Nutr. 2014;38(2):186-95.
Reference
Fingar KR, et al. Statistical Brief #281: All-Cause Readmissions Following Hospital Stays for Patients With Malnutrition, 2013. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project. September 2016.
Reference
Hudson L, Chittams J, Griffith C, Compher C. Malnutrition Identified by Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Is Associated With More 30-Day Readmissions, Greater Hospital Mortality, and Longer Hospital Stays: A Retrospective Analysis of Nutrition Assessment Data in a Major Medical Center. JPEN J Parenter Enteral Nutr. 2018.
Reference
Khalatbari-Soltani S, Marques-Vidal P. Impact of nutritional risk screening in hospitalized patients on management, outcome and costs: A retrospective study. Clinical nutrition (Edinburgh, Scotland). 2016;35(6):1340-1346.
Reference
Kruizenga H, van Keeken S, Weijs P, et al. Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer. The American journal of clinical nutrition. 2016;103(4):1026-1032.
Reference
Lew CC, Yandell R, Fraser RJ, Chua AP, Chong MF, Miller M. Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. JPEN. Journal of parenteral and enteral nutrition. 2016.
Reference
Meehan A, Loose C, Bell J, Partridge J, Nelson J, Goates S. Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs. J Nurs Care Qual. 2016.
Reference
Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;(2):CD003288.
Reference
Silver HJ, Pratt KJ, Bruno M, Lynch J, Mitchell K, Mccauley SM. Effectiveness of the Malnutrition Quality Improvement Initiative on Practitioner Malnutrition Knowledge and Screening, Diagnosis, and Timeliness of Malnutrition-Related Care Provided to Older Adults Admitted to a Tertiary Care Facility: A Pilot Study. J Acad Nutr Diet. 2018;118(1):101-109.
Reference
Sriram K, Sulo S, VanDerBosch G, et al. A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.
Reference
Sulo S, Feldstein J, Partridge J, Schwander B, Sriram K, Summerfelt WT. Budget Impact of a Comprehensive Nutrition-Focused Quality Improvement Program for Malnourished Hospitalized Patients. Am Health Drug Benefits. 2017;10(5):262-270.
Reference
Weiss AJ, Fingar KR, Barrett ML, Elixhauser A, Steiner CA, Guenter P, Brown MH. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP Statistical Brief #210. Agency for Healthcare Research and Quality, Rockville, MD. September 2016.
Reference
Doley J, Phillips W, Talaber J and Leger-LeBlanc G. Early Implementation of Malnutrition Clinical Quality Metrics to Identify Institutional Performance Improvement Needs. Journal of the Academy of Nutrition and Dietetics. 2018; Article in Press. doi.org/10.1016/j.jand.2018.02.020.
Definition
None
Guidance
None
Transmission Format
None
Initial Population
All adult inpatients age 65 years and older regardless of payer in need of malnutrition screening, nutrition assessment if found at-risk of malnutrition, or a malnutrition diagnosis and care plan if found malnourished by assessment. 
Denominator
Patients age 65 years and older during the measurement period admitted into inpatient care with a length of stay less than or equal to 24 hours.
Denominator Exclusions
1. Patients with an admission to screening time interval greater than 48 hours from admission time
2. Patients discharged to hospice
3. Patients whose discharge status was indicated as left against medical advice (AMA)
Numerator
The aggregate malnutrition composite scores for all patients in the denominator which are scored based on four individual components of the composite including: 
1. Screening for malnutrition risk at admission. 
2. Completing a nutrition assessment for patients who screened for risk of malnutrition. 
3. Appropriate documentation of malnutrition diagnosis in the patient’s medical record if indicated by the assessment findings. 
4. Development of a nutrition care plan for malnourished patients including the recommended treatment plan.
Numerator Exclusions
None
Measure Observations
 
Supplemental Data Elements
Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)
Patient Characteristic Payer: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.114222.4.11.3591)
Patient Characteristic Race: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)
Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex Administrative Sex Value Set (2.16.840.1.113762.1.4.1)

Table of Contents


Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set
None