Comments CMS Proposed Adoption Malnutrition eCQMs

June 13, 2017

Ms. Seema Verma, MPH
Administrator, Centers for Medicare and Medicaid Services
Department of Health and Human Services, P.O. Box 8010
Baltimore, MD 21244

RE: FY 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule, and Request for Information CMS-1677-P

Dear Ms. Verma:

From 2013-2014, The Academy of Nutrition and Dietetics (the Academy), in partnership with Avalere Health (Avalere) and other stakeholders launched two subsequent national dialogues to understand the existing barriers to providing consistent standards of malnutrition care. The first dialogue, entitled "Measuring the Quality of Malnutrition Care in the Hospitalized Elderly Patient," facilitated a discussion focused on prioritizing gaps in malnutrition care and identifying initial key measure concepts plus the need for a quality improvement program. While the second dialogue, "Launching the Malnutrition Quality Improvement Initiative", officially introduced key stakeholders to a quality initiative to improve patient outcomes, and obtained expert input on pathways for successful implementation including measure development and best practices research.

These two dialogues informed the Malnutrition Quality Improvement Initiative launched by the Academy-Avalere partnership with the objective of disseminating a national quality improvement initiative designed to address malnutrition in U.S. hospitals. Guided by a stakeholder Advisory Committee and Technical Expert Panel focused on measure development, the MQii was established to support development and dissemination of an innovative "dual-pronged approach" that includes the first set of malnutrition electronic clinical quality measures accompanied by a quality improvement Toolkit to support clinicians in advancing malnutrition quality of care at their institutions.

The Academy of Nutrition and Dietetics (Academy) and Avalere Health (Avalere) sincerely appreciate the opportunity to comment on the "FY 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule, and Request for Information (CMS-1677-P)," in support of the proposal to adopt malnutrition electronic clinical quality measures (eCQMs) and a potential malnutrition composite measure for future inclusion in the Hospital Inpatient Quality Reporting (IQR) and Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

I. Introduction

We fully support CMS's recognition of the impact malnutrition has on older adult health and outcomes as well as it's consideration of the clinically-relevant malnutrition electronic clinical quality measure(s). We applaud this major step forward in addressing a burdensome and costly condition impacting a substantial proportion of hospitalized older adults. The Academy and Avalere join hospitals and providers in recognizing concerns with measure reporting burden. However, we believe the many benefits resulting from these malnutrition eCQMs will ultimately supersede the economic costs that may be associated with their implementation and maintenance. As CMS notes, evidence demonstrates these important eCQMs address a recommended process of care that supports improved patient outcomes, increased care coordination, and ultimately decreased costs to the healthcare system.

We agree with CMS that "malnutrition is associated with many adverse outcomes," that "there is an opportunity for hospitals to improve nutrition screening and assessment," and that "there is often a disconnect between screening for malnutrition and documentation of a diagnosis of malnutrition, which is necessary for appropriate follow-up after hospital discharge." CMS has long recognized the prevalence of malnutrition and its negative impact on patient outcomes and barriers to quality patient care.1,2,3,4,5 In 2013 and 2014, CMS referenced that 20-50% of hospital inpatients are malnourished or at-risk of malnutrition depending on the patient population and the criteria for assessment1 and that approximately 20% of hospitalized patients require a complex nutrition plan and dietary orders.2

We also agree that "addressing malnutrition among beneficiaries is an important clinical issue." The single most effective strategy that CMS implement right now is to move forward with immediate adoption of the four proposed malnutrition eCQMs into the Hospital IQR Program in FY 2018, with adoption of a malnutrition composite eCQM as soon as feasible.

II. Importance of Addressing Malnutrition

Malnutrition is a state of deficit, excess, or imbalance in protein, energy or other nutrients that adversely impacts an individual’s own body form, function, and clinical outcomes.6 For many older adults, the lack of adequate protein and the loss of lean body mass are particularly significant problems. This occurs whether the older adult is underweight, or counterintuitively overweight or obese, because it is inadequate protein, not fat that is the problem. The importance of malnutrition prevention and identification and intervention for at-risk and malnourished individuals is magnified by malnutrition’s impact on independence, healthy aging, and the severity of medical conditions and disabilities. In short, older adults are a particularly vulnerable population for poor nutrition. As detailed in this letter, they are at higher risk of malnutrition than other age groups and will therefore benefit substantially from improved malnutrition care.

Much of older adults' increased risk for malnutrition can be attributed to their higher likelihood of experiencing social risk factors such as food insecurity, impaired functional or cognitive status, as well as being diagnosed with multiple chronic conditions.7 While almost half of all Americans have a single chronic condition, as many as 80 percent of older adults aged 65 and older have multiple chronic conditions. Chronic diseases such as cancer, stroke, diabetes, gastrointestinal, pulmonary, and heart disease and their treatments can result in changes in nutrient intake that can subsequently lead to malnutrition.9,10 With the number of adults aged 65 years and older expected to reach 74 million by 2030, it is critical that we ensure hospitals have the necessary tools, processes, and providers to effectively address high rates of malnutrition.

In the subsections below, we provide additional information on the impact of malnutrition on patients and healthcare costs, the existing gaps in quality of care, and recent evidence supporting the value of providing optimal malnutrition care for hospitalized patients. To fully characterize the existing evidence that supports the importance of this topic, the Academy asked our member experts who are front-line practitioners to share their real-life experiences. Additionally, their experiences highlight the barriers and gaps that can prevent screening, assessment diagnosis and treatment of malnourished patients. The examples included below are representative of the many issues facing patients and providers around malnutrition care. Most importantly, the examples help characterize why the adoption of malnutrition eCQMs is so crucial for addressing gaps in care. Additional selected examples are provided in the appendix.

A. Impact of Malnutrition on Patient Outcomes and Healthcare Costs

The burden of malnutrition on patients in the hospital setting is detailed in two separate reports recently published by the AHRQ Hospital Cost Utilization Project (HCUP). The first analysis reported that malnourished hospitalized patients are up to five times more likely to experience in-hospital death,11 and a second report showed a 54% higher likelihood of hospital 30-day readmissions compared with non-malnourished patients.12 These same reports also demonstrated that malnutrition in the hospital is associated with increased cost of care. Average hospital costs for all non-neonatal and non-maternal hospital stays were $12,500, while patients diagnosed with malnutrition had hospital costs averaging up to $25,200 depending on the type of malnutrition indicated.11 Additionally, cost per readmission for patients with malnutrition were also higher. In 2013, those costs were reported to be $17,500 per readmission; 26-34% higher (depending on the specific type of malnutrition) versus patients readmitted without malnutrition.12

Overall, the economic burden of disease-associated malnutrition in the U.S. is estimated to be as high as $157 billion in 2014, with $51.3 billion associated with older adults.13

Malnutrition is a patient-safety risk and has been shown to be an independent predictor of negative patient outcomes, including mortality, length of hospital stay, readmissions, and hospitalization costs.14,15 Malnourished patients are also more likely to develop pressure ulcers16, infections17, post-operative complications18,19 and experience falls.20,21 Academy members described how malnutrition impacted patients and altered clinical outcomes.

  • "Lately in my facility, we have been noticing multiple under-30-day readmissions in several frail, elderly patients who have been diagnosed by the RDs with moderate or severe malnutrition. Each readmission, these patients continue to decline in nutritional status and functionality. Several of these patients have also been noted to develop pressure wounds during their series of readmissions. Oftentimes, these malnourished patients end up on tube feeding and/or may go to hospice due to the decline in their status. It is possible the proposed initiatives may assist with RDs seeing malnourished patients sooner."
  • "I have warned surgeons not to do elective surgeries on severely malnourished patients because they are more likely to have a poor outcome - I have then stood by and watched these poor patients have surgery anyway (despite my warning) and I have watched them die. This is not an exaggeration - this actually happens! By reminding nurses, physicians, and the whole care team about the importance of nutrition and impact malnutrition can have on outcomes I believe we will save lives."
  • "Malnutrition significantly impacts patients' ability to participate in physical therapy to increase strength, reduce risk of falls, and increase ability to discharge home versus extended care facilities."

B. Gaps in Malnutrition Risk Identification and Risk Reduction

As many as 20 to 50% of adults in the hospital (acute care) setting are either at-risk for malnutrition or are malnourished,22 but only 7% are actually diagnosed in the U.S.11 This gap occurs for a number of reasons, including lack of provider visibility into patients' nutritional status and how malnutrition information is communicated and tracked in hospital medical record systems.23 As a result, many patients with malnutrition remain undiagnosed and untreated. This gap in risk identification and the lost opportunity of risk reduction can result in detrimental impacts to patients, as was recently demonstrated in alarmingly low malnutrition diagnosis rates in a study of nearly 6 million hospital admissions across 105 academic medical centers. The study concluded that "[q]uality improvement efforts aimed at improved structure and process appear to be needed to improve the identification of malnutrition."24 Academy members highlighted some of the many consequences of poor identification and follow-up for malnourished patients.

  • "As a Clinical Nutrition Manager, every day I see patients whose nutrition has been neglected due to age, illness, inability to care for themselves, lack of access to nourishing foods, and food preparation limitations. Once these patients are hospitalized their nutritional status continues to suffer due to multiple (and often inappropriate) diet restrictions. In addition, self-feeding challenges can exacerbate the malnutrition. Often nursing aides and nutrition hosts lament the number of patients who are not fed or whose food trays return uneaten. Although the Registered Dietitians will assess as many of these patients as possible for malnutrition, if all health professionals were alerted to the importance of early identification then intervention could be implemented much sooner."
  • After training in a series of workshops relating to the nutrition focused physical exam, I began implementing a "Malnutrition Initiative" at my facility. It is astounding the number of patients, in- and out-patient that I encounter who can be diagnosed with malnutrition (from mild to severe, all over the spectrum). I have been able to work to find these patients that meet criteria and are not being medically diagnosed with malnutrition and work with MD's and NP's to show them the level of malnourishment, to intervene as not to lengthen their hospitalization, and to plan on how the patient will continue a healthy recovery in the discharged state. Malnourished patients are often simply overlooked then have poorer outcomes without some type of nutrition intervention."
  • "I have been a dietitian for nearly 30 years. I have seen firsthand the negative impact malnutrition has on patients throughout their entire course of care--starting with acute or chronic illnesses, being admitted to the hospital, then transitioning to the outpatient setting. Unfortunately, CMS doesn't cover RD services to treat malnutrition in the ambulatory setting, therefore by the time I see a patient in the acute care setting, he/she is usually well behind the eight ball nutritionally. Up to 35% of acute care patients are malnourished (moderately to severely) and up to 50% of hospitalized patients are nutritionally compromised and will become malnourished if intervention is not done. These patients can vary in disease state and have many different diagnoses including chronic conditions such as heart failure (where cardiac cachexia is seen), liver failure, renal failure, cancer, inflammatory bowel disease, stroke, and COPD."
  • "I work in an Internal Medicine Residency program. Our patients are the uninsured and underinsured poor in our community. I often see them discharged from the hospital and come through our practice, but because I must bill to maintain my position here and malnutrition is not a covered service for me, I cannot see and help these patients. Our doctors are not trained in nutrition and do not have the time to care for them. Currently, our system relies on nurses to care for them, they are not trained nutritional professionals, either. We RDNs should be looking after those with malnutrition or at risk for malnutrition. I work in diabetes because that is a covered service. However, many of our patients do not see their diabetes as a priority, so they do not access this service. Their malnutrition is their priority and rightfully so. The diabetes goes uncontrolled making the malnutrition worse. Both conditions worsen as a result, often times ending in tragedy or the patient's demise."
  • "First of all I work in small hospital system where I consult for hospital and healthcare communities, which are sister facilities of the system. In the hospital I only see folks when I receive a nutrition consult, usually based on nursing admission assessment. However, I can do meal rounds and find nutritional problems in 50 - 85% of the hospital population. The consult of RDN is based on disciplines who are not nutritionists. This does not make sense. There are folks with wounds who do not receive nutrition assessment and subsequent MNT. I do not see every enteral feeding. They wait too long to implement, or avoid implementation of TPN. Don't use enteral modalities when they can to avoid the eventuality of PN. Have folks NPO too long prior to surgery. They are very thoughtless on the nutritional status of patients. Weight loss is taken as a serious issue, I spend one day a week, if not more, remediating weight changes."

C. Opportunity to Improve Patient Outcomes and Reduce Healthcare Costs

Malnutrition and malnutrition risk should be addressed as early as possible during the hospital admission to ensure that all of the medical, psychological, and functional factors related to malnutrition can be addressed. Furthermore, an interdisciplinary team should focus on the patient's preferences regarding food choices, timing of meals, and/or self-feeding strategies within their individual, social and environmental circumstances. Evidence has consistently shown high quality malnutrition care leads to better patient outcomes and reduced healthcare costs.

In 2016, new studies were published showing the positive impact on outcomes of delivering high quality malnutrition care that emphasize risk identification and reduction. A 2016 prospective cohort study of 1,269 patients at four hospitals within a larger health system looked at the impact of a nutrition-focused quality improvement program consisting of malnutrition risk screening at admission, prompt intervention for those at-risk, patient/caregiver education and sustained nutrition support on 30-day all-cause hospital readmissions and length of stay. The study found a reduction in 30-day readmissions of up to 29% and 26.4% reduction in length of stay compared to the baseline cohort.25

Additionally, a study of 652 hospitalized malnourished older adults with a primary diagnosis of CHF, AMI, pneumonia, or COPD found greater than 50% reductions in 30, 60, and 90-day mortality and improvement in nutritional status (e.g., handgrip strength and weight gain) when patients were assessed and diagnosed for malnutrition and subsequently received nutrition intervention within 72 hours.26 A subsequent economic evaluation of this study showed that patients in the treatment group gained 0.011 more quality-adjusted life years than the control, showed improved life expectancy, and intervention cost was only $524 per life-year saved.27 Academy members shared their experiences with seeing their patients improve when they received proper malnutrition care, and the opportunity for inclusion of malnutrition eCQMs to support improvements in care:

  • "My patients who are malnourished are at a higher risk for falls due to weakness and lack of muscle strength. These patients end up hospitalized for extended periods of time which result in a greater expense to all involved. These patients also tend to have more skin related issues such as pressure ulcers, stasis ulcers, etc. -much slower in ability to heal. Often, poor PO intake continues to exacerbate the situation. It becomes a vicious cycle. However, when identified and proper nutrition is applied, there is a significant improvement. Becoming stronger, they feel better and are able to ambulate. Thus, strengthening their bodies with less likelihood of being re-admitted. Primarily, I am referring to patients in our transitional (swing) bed unit where an RD involvement can be from admission to a 21 day or > stay. This allows for a better observation of what nutrition intervention can do. For example, one patient in particular admitted status post hip arthroplasty: 1) pressure ulcer to spine; 2) 8%UBW loss; 3) poor PO intake; 4) bed bound; and 5) inability to self-feed. This patient benefited from additional nutritional supplementation of protein, calories, vitamins and minerals as well as an individualized meal program/plan. After a 12 day stay, patient is able to sit and feed self, walks 325 feet, pressure ulcer healing well and weight is stable. She states she is strongest she has been in many years. If unidentified as malnourished, I feel she would have been discharged home to debilitate further until re-admitted to the hospital."
  • "I work in a Cancer Center where the majority of my patients are malnourished. I strongly believe that the malnutrition quality measures will improve care for my patients since we have a large number of hospital admissions due to nature of the disease. By implementing these quality measures, I am confident that my patients will be provided with the proper nutrition care."
  • "Working in a cancer center, I see malnutrition negatively impacting ability to tolerate chemotherapy and radiation goals. Malnutrition increases breaks in treatment increasing risk of cancer spreading further. -The sooner the intervention, the sooner malnutrition can be reversed by the entire care team screening for weight history and oral intake history at admit or at consult in cancer centers. If this can be incorporated electronically with automatic referrals to RD's, the sooner the intervention can begin as time is of the essence."
  • "I practice in critical care. During rounds with the medical team, a patient with symptoms of mental status changes, rash, cardiac failure, diarrhea, and weight loss was presented. I was present during the case presentation and noted the patient's rash on his extremities. It was a bilateral rash but was curiously absent from his trunk. He also appeared very malnourished as well. I went to talk to the family to follow up on the suspected issue of malnutrition on admission. His personal history was significant for the recent death of a spouse, refusal to interact with his children, inability to purchase and prepare food and recent significant weight loss. Being reluctant to diagnose a specific disease, I asked my medical director to join me and I explained my suspicion of a niacin deficiency called pellagra. Although rare, this patient had all the symptoms associated with this disease. Because my medical director was a gastroenterologist, he agreed with my thought process and began the process of vitamin repletion. The patient showed gradual but significant improvement in all his symptoms with resolution of the diarrhea, improvement in the dermatitis, improved mental status and managed cardiac problems. He was treated with temporary enteral nutrition support to replete his protein nutriture. Putting all the pieces together and utilizing the information from patient care rounds and from the patient's family enabled me to recognize the nutritional problem which was then treated. We are a teaching hospital and, although, other significant differential diagnoses were proposed by the residents on the case, being able to recognize the signs of malnutrition and its impact made the difference between a positive outcome as opposed to the potential outcome from untreated pellagra - death."

The evidence and stories shared above demonstrates that patients are continuing to suffer and experience adverse outcomes due to a lack of optimal malnutrition care and there are evidenced-based nutrition pathways that when implemented have demonstrated improved outcomes and decreased costs. Every day, many older adults enter and leave the hospital malnourished or at-risk for malnutrition;6,9,11 thus compromising their functional abilities and health outcomes.12,13,22 Patients and their families should not have to continue to endure this preventable event, when high-quality malnutrition care is possible. Based on the detailed evidence supporting the importance of malnutrition, we recommend the four malnutrition eCQMs be implemented immediately—not in the future— to help assure older adults receive the quality malnutrition care they deserve.

III Value of eCQMs for Improved cAre & Transitioning from Process to Outcome Measures

A. Value of eCQMs for Facilitating Improved Clinical Processes

The Department of Health and Human Services (HHS) continues to support the use of EHRs to facilitate use of real world, actionable patient data to improve clinical processes of care within an organization. Additionally, HHS recognizes the intrinsic value of EHRs for their ability to support exchange of clinical and process of care data facilitating more effective transitions of care. With that established, eCQMs serve as tools that can leverage the existing data captured in the EHR to support providers as they assess their performance on critical processes of care and identify areas of improvement in real-time. These four malnutrition eCQMs were developed and tested to allow hospitals to take advantage of those very same benefits and act upon real time patient data to improve quality of care and patient outcomes.

We acknowledge that providers have asked CMS to balance the burden associated with reporting quality measures and the utility of measures for patient care. For example, it is imperative to make measure updates in EHRs, as "turn-key" as is feasibly possible in order to facilitate implementation and utilization of clinically relevant measures with minimum burden to providers. Many of the processes being promoted by the malnutrition eCQMs are in place at many hospitals across the U.S.23 The measures were tested for feasibility with three major EHR vendors (Cerner, Epic and AllScripts) and were found to be feasible to implement across all three platforms. The modifications required to EHRs for their implementation would be less burdensome than the chart abstraction currently required by non-eCQMs and would have limited disruption on patient care as these are practices well known to support optimal care for patients who are identified as at-risk or malnourished.

Academy members shared why hospitals need to be incentivized with these eCQMs that can help hospitals better use EHR data to monitor how well they are implementing improved clinical workflows that facilitate high-quality malnutrition care:

  • "In acute care, there is no mandate for tracking patient nutritional assessment even though agencies such as CMS and The Joint Commission have 'assessment' in their standards. Therefore, the electronic medical record manufacturers have spent little attention on a nutrition work flow and on integration of that information into viewing by other team members, and locations that readers can readily access and see the details. The EHRs have locations for this information, but they are poorly designed and force the organization to figure out what to do. Thus, little happens in the hierarchy of analyst resources spent in each separate organization."
  • "The e-measures will push electronic record companies to embed functionality and enable validated screening tool options for various patient populations. For example, specific validated screening tools for critical care, for seniors, without the organizations having to build all this and make the hospitals spend money to 'customize'; over and over and over again every time they sell the software. The e-measures will cause nutrition data to need to be specified in the EHR. So the software companies will then create those data points, overall functionality, and address the nutrition workflow. There is little emphasis on nutrition topics so hospitals have to recreate using the existing functionality that is weak and is poorly designed on the subject of nutrition issues. Non-dietitian users do not even know nutrition information is present—it is very silo'ed. Perhaps nutrition will not be an afterthought or ignored if there are e-measures. Every patient should have a nutrition care plan when they are ill or going to have a major medical treatment; and they should have education. Monitoring this by e-Measures will force the tracking of standards and enable the prevalence of problems and the negative impact and improvements in care.

While these areas are being addressed, we need to continue filling quality measure gap areas with clinically relevant measures that can be captured with minimum burden. In contrast to claims-based or chart abstracted measures, the right eCQMs can provide real-time actionable and meaningful data for clinical decision making.

B. Progression from Process to Outcome Measures

Ultimately, we agree that additional measures added to any quality- and value-based programs should be the "right measures" and when feasible, adopt measures that are directly associated with improvements in patient outcomes and decreased healthcare costs. Malnutrition is a pressing clinical area associated with poor patient outcomes and increased healthcare costs across all care settings. We acknowledge that the goal is to shift from clinical process of care measures to outcomes measures, specifically in areas of care that have had process measures in place for a long time. However, in the case of malnutrition, there are no current measures in place to assess processes of care across healthcare facilities. As a result, care continues to be remarkably inconsistent and that variation is associated with poor patient outcomes. The healthcare system needs to adopt process of care measures and then move to outcomes measures once variation in care delivery is reduced and outcomes can be assessed equitably.

Therefore, given the desire to target the most important clinical conditions that impact patients across settings, we should immediately adopt clinically relevant malnutrition eCQMs in the Hospital IQR that begin to address these inconsistencies. Subsequently, once providers implement standardized, evidence-based clinical processes, we will be able to develop more outcomes-focused measures that directly measure outcomes associated with this process.

C. Value of eCQMs for Promotion of Care Coordination / Safe Care Transitions

Efforts can also be taken to align these measures with other quality programs across all care settings so that we can make better determinations for the outcome metrics that will need to be developed for malnutrition, including a future malnutrition composite measure. A national blueprint for malnutrition quality which proposes a plan for addressing malnutrition beyond the hospital and throughout the community at-large was published just this year.7 Furthermore, a future initiative will include the development of a malnutrition composite measure that reflects the most critical steps in the process of delivering optimal malnutrition care and the relationship of that care to key patient outcomes.

Academy members shared their perspective on how inclusion of these malnutrition quality measures could help facilitate improved quality of care across the care continuum:

  • "Malnutrition impacts many of our acutely ill and elderly patients. With our own internal department of malnutrition improvement practices, we are able better able to improve timeframe to dietitian assessment, timeframe to intervention, and patient education to treat their malnutrition. Despite these efforts, there lacks an urgency and awareness of the impact malnutrition plays on patient outcomes. As a non-billable service (inpatient) the only thing that allows optimal dietitian staffing is CMS guidelines. With these malnutrition measures potentially increasing the awareness and requirements for malnutrition assessment, this will help improve dietitian resources at many sites that struggle with staffing support. Not only will these measures improve overall patient care and outcomes, my hope is that these measures lead to a better outpatient continuum of care for malnutrition patients. In today's environment we are only able to treat a small percent of malnourished patients that come through our hospital's doors. In order to substantially reduce malnutrition, we need to effectively treat these patients in the clinic and outpatient setting. These measures will drive a better infrastructure to achieve this."
  • "I have observed patients who entered the hospital malnourished and those who became more malnourished while in the hospital Currently in one of my facilities are two patients whose surgeon does not recognize the importance of nutrition for healing and recovery. Even though dietitians have requested nutrition progression, one patient has been NPO and on clear liquid diet for 14 days and the other for 17 days. This long after surgery, these patients should have been discharged home or to a rehab facility. Because they are now malnourished, they are weak and unable to progress with physical therapy as they should. They have also developed complications that could have been avoided had they received adequate nutrition. I believe if these quality measures were in effect from CMS, our facility would take strong action to make sure no patients lingered without nutrition this long."
  • "There is very poor attention to nutrition in discharge planning. The requirements are for 'diet,' which is very weak as a nutritional goal. This must be made known to patients to contact the health provider if certain nutritional problems present or continue."
  • "Given that malnutrition affects not only hospital patients, but also those patients when they are either discharged to home or sent to a rehab/long term care setting AND their families because the family members are having to deal with the effects that malnutrition puts on their loved ones. Improving communication between the different settings since we are ALL working toward the same goal of reducing malnutrition in the elderly and critically ill population. Not waiting to implement some form of nutrition support for the patient who is either on a ventilator or awaiting surgery. Most importantly, not seeing health care as solely a business where the hospital, rehabilitation facility, and/or long term care setting is only looking at the bottom line because in the end, we are human beings and not just a number."
  • "The ability to take necessary medications for HIV and for diabetes is thwarted with malnutrition. Without proper amount and quality of food taking, medications is unpleasant or would result in a life-threatening situation (i.e. hypoglycemia). Patients are more susceptible to infections and slow to recover from surgery or major illness. Those that are malnourished and are in the hospital repeatedly are often sick for longer periods of time. The impact ends up being the inability to work and subsequently food insecurity. When discharged from the hospital often there is not food or anyone to provide food and the cycle continues."
  • "In ambulatory care, [the malnutrition eCQMs] will cause much needed attention to the area of ambulatory nutritional decline, as much of what occurs before the situation is so bad that it requires an acute care admission. There is no current requirement for validated screening in high risk ambulatory settings such as pre-surgery, radiation and chemotherapy. Hence patients' significant nutrition issues are not found until extreme cases occur, where it is so obvious, and so very late for intervention and intervention costs so much more. The culture is such that the topic is dismissed as being less important for the available time. This lack of attention greatly contributes to the downstream problems in acute care. We have many occasions where finally a patient shows up to a dietitian and where simple less expensive actions could have been taken weeks and months before. The current lack of attention and resources causes 'factory production' of under-nourished patients, especially with seniors and surgery and those with cancer."
  • "Frequently the patients that are readmitted repeatedly become malnourished even though the patient did not have any nutrition triggers during their initial inpatient visit; others have been frequent ED patients without becoming inpatients. For all patients, it seems there is a gaping hole in nutrition care after discharge as it is not monitored by the physician since it is not the patient's primary reason for seeing the doctor. There are obstacles to following nutrition recommendations in the home setting-- lack of knowledge, patient's physical condition, high cost of supplements recommended (not to mention they are heavy to carry for older patients), but if the patient doesn't prepare much of their meals, supplement may be the preferred option. In certain states, RDs cannot order supplements or modify the patient's diet order without obtaining the physician's verbal or written order causing a delay and possibly a complete miss of nutrition intervention."
  • One member shared a story regarding one of their specific patients whose quality of life has been made better with continued support after hospitalization, "Mr. M fell and broke his leg, he couldn't stand long enough for the preparation of a meal. His family was not in the state so he is now receiving home delivered meals and has continued on the program, to continue supporting his nutritional status, after his leg healed."

IV. Support for the Four Malnutrition Electronic Clinical Quality Measures (eCQMs)

We strongly support CMS' consideration to adopt the four malnutrition-focused eCQMs developed by our organizations. These eCQMs directly support key components of the recommended and evidence-based approach to nutrition care, supporting optimal malnutrition care. These measures fill a gap and are the first measures to address recommended malnutrition care practices in the hospital setting geared towards older hospitalized adults. The recommended multi-step nutrition care process facilitates the identification, diagnosis, and treatment of patients who are found to be malnourished or are at-risk of malnutrition. This recommended approach to nutrition care is supported by multiple guidelines and international consensus.28,29,30,31,32

Bringing Additional Clinically Relevant Measures IQR Hospitals to Report

Due to the prevalence and negative impact of malnutrition in hospitalized adults and especially older adults, the addition of the malnutrition eCQMs will augment the current eCQMs in the IQR program; introducing additional eCQMs that can have an impact on patient outcomes for hospitals to select. Adoption of the malnutrition measure set will provide hospitals with a diverse set of clinically relevant eCQMs to report- applicable to as many as 30-50% of inpatients.33 As hospitals currently have the opportunity to select the eCQMs they report for the IQR, CMS adoption of malnutrition eCQMs with reporting in CY 2018 would not impose burden on providers. Reporting on the malnutrition measure set or individual malnutrition eCQMs would be voluntary.

Initial Dissemination of the Four Malnutrition Electronic Clinical Quality Measures

Given the high prevalence, impact and costs of disease-related malnutrition, integrating an evidence-based, high-quality, patient-centered solution through a team-based care model can help providers achieve better outcomes and lower costs. The Academy, Avalere, and partnering stakeholders are pursuing the dissemination of optimal malnutrition care processes through the Malnutrition Quality Improvement Initiative (MQii) Learning Collaborative 2.0, supporting implementation of the MQii Toolkit and advancing adoption of the four malnutrition eCQMs at health systems across the United States to generate additional evidence on their ability to improve quality of care and patient outcomes through a learning collaborative.

At this time, approximately 40 individual hospitals across numerous health systems varying in facility size, geographic region and demographic distribution are participating in this learning collaborative. Participating facilities are using the malnutrition eCQMs and implementing a malnutrition quality improvement project using the MQii Toolkit to demonstrate scalability of these tools, assess best practices for eCQM implementation, and assess changes in clinical practice and impact on patient outcomes. In addition, the evidence generated from this learning collaborative will also: (1) support the scalability of the use of the eCQMs throughout a diverse set of acute care facilities; (2) and demonstrate how optimal malnutrition care processes may enhance care transitions and patient discharges from the hospital to improve continuity of care through better documentation and communication of patient nutrition concerns and recommendations.

Inclusion of these eCQMs as a reporting option in CY 2018 would allow these hospitals as well as other hospital quality leaders to report on their progress towards addressing the gaps in malnutrition risk identification, diagnosis and treatment. As the Learning Collaborative hospitals disseminate the successful outcomes of their malnutrition quality improvement initiatives, undoubtedly other hospitals will likely follow suite and also consider selection of the malnutrition eCQMs to meet their IQR program requirements and improve care coordination, safe care transitions, and patient outcomes.

To date, 12 individual hospitals across 6 health systems mainly in the Southeastern United States (2 hospitals located in the Midwest reported data in 2016) have reported 30-day performance data after implementing the four eCQMs. Preliminary performance measure data reported by these hospitals demonstrate that there is variation in practice on these four key steps of the malnutrition care process.

1. Gaps in Care Identified from eCQM Performance Rates

Table 1: Variation in Performance Demonstrates Gaps in Quality Remain

Facility Type

Facility Size†

Community Type, Geographic Area

MUC16-294
"Screening"
Performance Score

MUC16-296
"Assessment"
Performance Score

MUC16-372 "Nutrition Care Plan"
Performance Score

MUC16-344
"Medical Diagnosis Documented"
Performance Score

Academic Medical Centers (N=4)

Large

Urban, South

89.82%

38.14%

98.18%

31.82%

Large

Urban, South

86.91%

N/A*

N/A*

N/A*

Large

Urban, South

92.58%

29.33%

66.67%

N/A*

Large

Urban, Midwest***

70.72%

28.32%

N/A*

N/A*

Short-Term Acute Care Centers (N=5)

Large

Urban, Midwest***

75.05%

48.25%

98.39%

29.57%

Large

Urban, South

67.94%

65.04%

89.74%

78.21%

Large

Urban, South

94.52%

77.30%

55.26%

100.00%

Medium

Rural, South

97.78%

33.33%

100.00%

100.00%

Medium

Urban, South

98.13%

N/A**

N/A**

N/A**

Community Hospital (N=1)

Medium

Urban, South

97.10%

61.25%

96.08%

78.43%

Critical Access Hospitals (N=2)

Small

Rural, South

97.78%

N/A**

N/A**

N/A**

Small

Rural, South

100.00%

N/A**

N/A**

N/A**

 

Lowest Score

67.94%

28.32%

0.00%

29.57%

 

Highest Score

100.00%

77.30%

100.00%

100.00%

 

Aggregate Score Across Sites

83.83%

45.36%

80.51%

51.02%

 

 

Standard Deviation

11.51%

19.19%

34.75%

30.26%

† Definitions for Facility Size: Large facilities: <300 beds; Medium: 100-299 beds; Small: <100 beds
* This facility has not reported final data for this performance measures
** This facility did not have sufficient patients within the reporting period to report on this performance measure
*** Two Midwestern hospitals contributed performance data in mid-2016 as eCQM pilot sites

  • "Malnutrition Screening"-MUC16-294: In aggregate, around 17% of patients aged 18 years and older were not screened within 24 hours of admission across all 12 reporting sites. Out of a total of 15,784 eligible hospital admissions for this measure, 2,664 admissions were not screened for malnutrition within the first day of the patient being admitted into inpatient care, and over 1,590 were not even screened. As described in the evidence included above, for patients at-risk of malnutrition or already malnourished, it is imperative that valid screening be completed in a timely fashion to facilitate early intervention. For older adults in particular, this 17% gap across hospitals is significant considering the rate at which older adult patients are identified as at-risk (19.22%) in MUC16-296. This gap in identification could potentially represent over 240 admissions that may have needed follow up malnutrition care but where risk was not identified.
  • "Nutrition Assessment"-MUC16-296: The aggregate performance rate across the 12 individual hospitals was below 50%, meaning a majority of admissions had a waiting period longer than 24 hours after a positive malnutrition screen result before being assessed for their risk factors. Additionally, there was still a significant gap (22.23%, N=267) in the number of admissions without a documented nutrition assessment at all after the patient was identified as at-risk for malnutrition. One of the largest gaps in malnutrition quality of care identified by the eCQMs was the number of admissions who were assessed within 24 hours of being identified as at-risk of malnutrition via screening.
  • "Nutrition Care Plan"-MUC16-372:=18.66% (N=111)of patients found to be malnourished as a result of a registered dietitian's nutrition assessment did not have a care plan documented in their patient medical record.
  • "Medical Diagosis"-MUC16- 344: Almost half of patients (48.70%) who were found malnourished by the registered dietitian did not have a malnutrition diagnosis documented in their medical record. This lack of diagnosis has far reaching impact to the patient including issues with care coordination, transitions of care and for the hospital, proper management of their patient population.

2. Characteristics of Hospital Stays with Malnutrition and Malnutrition Risk

In 2016, the Healthcare Cost and Utilization Project (HCUP) published a series of analyses of surveillance data on hospital stays with malnutrition according to administrative claims.10,11 In the table below, we include the same sub-analyses of patient data, but extracted directly from the EHR instead of informed by claims to substantiate the information provided in these reports. Whereas the HCUP report only looks at patients who were coded for a malnutrition diagnosis, our data set is sourced from clinical data documented as part of clinical workflow. In particular, because these measure are eCQMs, the data captured is in a discrete and structured format with clearly defined criteria.

Table 2: Characteristics of Hospital Stays with Malnutrition and Malnutrition Risk

Patient Characteristic

Malnutrition Risk Identified by Malnutrition Screening*

Moderate/Severe Malnutrition Identified by Assessment**

Malnutrition Diagnosis Documented***

Rate Difference Between Assessment & Diagnosis

Total Number

3,006

698

456

-242

Rate per 10,000

1,644.78

904.55

475.64

-428.91

Age, years, rate per 10,000 admissions

 

18-39

1,118.29

392.05

175.03

-217.03

40-64

1,720.59

843.89

416.21

-427.68

65-84

1,808.18

1,077.82

612.60

-465.22

85+

1,857.92

1,434.43

819.89

-614.53

Sex, rate per 10,000 admissions

 

Male

1,758.87

878.89

474.13

-404.76

Female

1,547.78

891.17

459.62

-431.56

Race/Ethnicity, rate per 10,000 admissions

 

White

767.41

885.87

480.69

-405.19

Black

1,003.54

847.37

483.96

-363.42

Hispanic

642.36

680.10

141.84

-538.26

Other

570.30

1,032.15

362.32

-669.83

* Total of N=18,276 records for calculation of malnutrition risk reported ** Total of N=11,210 records for calculation of moderate/severe malnutrition reported *** Total of N=9,587 records for calculation of malnutrition diagnosis documented for each admission which also had moderate/severe malnutrition indicated in the nutrition assessment.

  • Comparing the rates per 10,000 admissions for malnutrition diagnosis documented to those who originally had some level of malnutrition severity indicated in their medical record by the registered dietitian shows there is a significant drop off in the rates of medically diagnosed malnutrition. This would suggest that indications resulting from the completion of the nutrition assessment are not being consistently incorporated in the patient's medical record.
  • • The rates per 10,000 show very similar trends to those presented in the HCUP analysis using administrative claims data. In this initial data set, patients at higher-risk of malnutrition tend to be older (age 85+), male, and identifying as Black. Patients who are diagnosed with malnutrition and have this malnutrition documented in their medical record as a result of a nutrition assessment provided by a registered dietitian tended to be older (age 85+), male, and identifying as Black. The data are currently not fully representative of the entirety of the participating sites in the Learning Collaborative, but clearly support the established gaps in care, and mirror the similar trends described in the HCUP surveillance report.

3. Usability of Measures Across Facility Type and Size

The four eCQMs have been implemented at 12 acute inpatient facilities: 7 large hospitals with over 300 patient beds, 3 medium hospitals with 100-299 patient beds, and 2 small hospitals with less than 100 beds. These facilities also represent academic medical centers (N=4), short term acute care facilities (N=5), a community hospital as well as critical access hospitals (N=2) providing care in rural communities.

Table 3: Performance Scores across Facility Type and Size

Facility Type

MUC16-294 "Screening"
Performance Score

MUC16-296 "Assessment"
Performance
Score

MUC16-372 "Nutrition Care Plan"
Performance Score

MUC16-344 "Medial Diagnosis Documented"
Performance Score

Academic Medical Center

84.61%

31.96%

88.41%

40.58%

Community Hospital

97.10%

61.25%

96.08%

78.43%

Critical Access Hospital

99.35%

N/A*

N/A*

N/A*

Short-Term Acute Care

79.85%

62.99%

77.95%

51.54%

Facility Size

 

 

 

 

Large

82.62%

44.56%

80.97%

48.16%

Medium

97.54%

53.27%

77.33%

65.33%

Small

92.91%

N/A*

N/A*

N/A*

* These facilities did not have sufficient patients within the reporting period to report on this performance measure

4. Future Dissemintion of Malnutrition eCQMs

This initial report of measure performance for the four malnutrition eCQMs demonstrates that there gaps in important steps of the recommended malnutrition care workflow remain and that malnutrition is a prevalent condition among hospitalized older adults. The Academy and Avalere will continue to collaborate with hospital quality and nutrition leaders throughout 2017 as they implement malnutrition quality improvement activities in alignment with best practices research that is part of the MQii Toolkit.

Below we indicate our rationale for supporting adoption of each of the four clinically relevant malnutrition eCQMs.

C. Support for MUC16-294: Completion of a Malnutrition Screening within 24 hours of Admission

The first step in the process is a malnutrition screening, as addressed in MUC16-294. This step commences upon admission with the malnutrition screening of patients by clinical intake staff. They identify patient risk factors utilizing a very low-burden screening tool (typically no more than 3 – 4 questions) that best meets the needs of the hospital's patient population and staffing capacities.34,35,3 The process of malnutrition screening for all patients has been built into most hospital admissions workflows due to years of support from the Joint Commission as an accreditation standard.37 In its recent modifications to the standards for accreditation, Joint Commission indicated its continued support for requiring that hospitals have proper screening protocols by including a standard that requires hospitals to have a screening protocol accompanied with a process for proper assessment and care plan development.38

Without identifying this initial patient population, the true population that should be assessed for findings of malnutrition could be vastly underestimated. Screening allows for the identification of the patient population at-risk for malnutrition that should be referred to subsequent hospital-based nutrition care, including a thorough dietitian assessment, diagnosis, nutrition intervention, and ongoing monitoring.29,39 Consequently, when patients are not properly identified for malnutrition risk factors during their hospital admission, thereby remaining malnourished or becoming malnourished during their hospital stay, they are at higher risk for the adverse outcomes described above.21 Recent evidence supports the role of malnutrition risk screening to properly identify at-risk patient populations to ensure they receive optimal malnutrition care in order to reduce risk of adverse outcomes that could result from malnutrition.24

Academy members shared their perspectives on the importance of rapid risk identification and treatment for patients:

  • "Patients are not weighed in the hospital routinely. Measured weights are necessary for accurate admission risk (using validated) screening and scoring tools. We have cases that are 'stated' weights and 20 plus pounds off. This impacts dosing of medications, anesthesia and inaccurate risk screen tools and inaccurate nutrient and metabolic calculations."
  •  "Many patients may enter the hospital with an acute illness and end up nutritionally compromised or malnourished due to that acute illness or emergent surgery. Patients who cannot maintain their oral intake for a short period of time may not seem like a big deal, however, when this reduction in food intake is coupled with increased nutritional needs from their diagnosis, wound healing and treatment, malnutrition from an acute illness happens very quickly. A loss of lean body mass occurs quickly. The downhill slide takes its huge toll on length of stay, development of other comorbidities, pressure ulcers and readmissions, and ultimately poor quality of life and increased costs to everyone. The proposed malnutrition quality measures would improve care for these patients by identifying them earlier; therefore, having them assessed by a registered dietitian earlier and thus receiving the nutritional intervention needed to maintain nutritional status. This will highly impact that patients' quality of life as well as reduce costs in admissions and decrease length of stay. These patients have better outcomes overall if nutritional interventions are provided early on in their phase of care."
  • "Malnutrition following traumatic spinal cord injury is a particularly dramatic insult, and as a major accepting facility for SCI patients, we often see the effects. A particular amount of muscle atrophy is expected following spinal cord injury. However, given that trauma patients are typically male, young in age, and the spinal cord injury is part of a multi-trauma presentation, the degree of catabolism these patients experience initially is quite high. These patients experience dramatic weight loss, muscle atrophy above and below the level of spinal cord injury, and fat loss. One particular patient presented with tetraplegia with a spinal cord injury at the level of C4 and additionally experienced a C1 vertebral artery occlusion during the course of his acute care stay. The patient experienced intolerance of tube feeds during the entire acute care stay and well into the post-acute admission before malnutrition was finally recognized. The patient had experienced a weight loss of 30% in 2.5 months with a BMI of 16 at that point. Malnutrition has undoubtedly complicated this patient's course and rehabilitation gains. It was unknown whether or not this patient had any hope of regaining brain function on admission to rehab. It was not until after the nutritional status was stabilized several weeks later that this patient initially became responsive; no other major contributory factor was identified in this sudden shift. Several weeks after that, it was apparent that this patient had full brain function and could begin the long road to communicate with his family and care team effectively. It is impossible to determine what outcome would be different in a single patient; however, it is important to recognize that this patient would have benefitted from malnutrition screening early in the course. I think this patient also demonstrates that had malnutrition been a priority of care in the acute care setting as well as the rehabilitation setting, the opportunities to impact care would have been greater."
  • "In acute care, [the malnutrition eCQMs] will cause attention and force organizations to improve accountability for this data. Literature finds that 30-60% of patients are at nutrition risk or malnourished in acute care. Our validated screening tool is performed around 90% from nursing admissions, however, they do not perform the screening correctly, so only 18% are screened to the dietitian and the dietitians have to redo screening to figure out who to see. We have found that the RN finds the patient not at nutrition risk, so no referral is sent, for patients who have not eaten adequately for days/weeks, who have lost 20 or more pounds. So not only does the validated screening have to occur, but it needs internal measures that the screen questions are asked of patients and the electronic forms are filled out correctly."
  • "At my inpatient hospital facilities, the nursing admission screens show as being performed 90% of the time. However, they are highly inaccurate because the nurse did not fill them out correctly or just clicked enough buttons so they show as being 'done'. Probably only half the patients that should, screen up as at risk. The dietitians have to re-do the screen to know who to see (wastes great amount of time). Many very undernourished patients are missed by the nurses and subsequently by the dietitians because the data shows they are not at risk when they really are."

D. Support for MUC16-296: Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 hours of a Malnutrition Screening

Upon identification of malnutrition risk as a result of malnutrition screening, the second step involves completing a nutrition assessment for patients found to be at-risk of malnutrition by a registered dietitian, as addressed in MUC16-296. The completion of nutrition assessments is an important activity for confirming the nutritional status of at-risk patients and enabling appropriate follow up care for patients who are found to be malnourished as part of a dietitian's full assessment, including the development of a care plan with appropriate interventions. This assessment allows for dietitians to assess comprehensively the nutritional status of a patient based on multiple clinical characteristics and forms the foundation for the development of a nutrition care plan.25,30,39 Results of the assessment provide the primary source of information for other clinicians (e.g., physicians, nurses, pharmacists) regarding the patient's nutritional status, clinical indicators of malnutrition to inform diagnoses, and recommendations regarding interventions and care plans to address the patient's malnutrition (or malnutrition risk) and prevent further nutritional decline.30,32,40 The value of nutrition assessment step is unquestionable for properly addressing malnutrition risk and establishing the necessary follow up steps for treating patients who are at-risk or found to be malnourished. The Academy's members shared how proper patient assessments of malnutrition allow for implementation of early intervention that can address a patient's malnutrition:

  • "I have worked with several malnourished patients over the years. Most notably have been elderly patients with chronic illness who have benefited from early nutrition screening and intervention to prevent or halt muscular wasting. One woman in her 70s after a complication from colonoscopy started losing weight. Speaking with her, getting her to eat, adding supplements and educating her on the need to maintain her weight helped her avoid further complications and gave her confidence. Another young man with a bowel obstruction was unable to tolerate oral diet so early intervention with parenteral nutrition until bowel function returned couple weeks later helped maintain lean mass and gave him a speedy recovery once able to eat again. The faster we're able to intervene, the better the outcome, the lower risk of complications, reduced cost, and reduced length of stay. It also makes for a team approach so that no one discipline has to solve the whole problem alone. Patients are happier with their care when they know we all care about them as a whole rather than a list of issues."

E. Support for MUC16-372: Nutrition Care Plan for Patients Identified as Malnourished after a Completed Nutrition Assessment

Development and documentation of the nutrition care plan is driven by the nutrition assessment and is required to record vital patient care information, including nutrition status, diagnosis, monitoring recommendations, and interventions.29,39 Hospitals that implement validated assessment processes should have a standardized approach and terminology for establishing and documenting the nutrition care plan, including suggested timing and approaches for care, nutrition interventions, recommended monitoring and follow up efforts.32 The information contained in the nutrition care plan also forms the basis for information communicated to the next in-line provider, a critical component of care transitions beyond the hospital.

Currently, there is a large performance gap across institutions' adherence with nutrition care process recommendations and documentation of the findings of each step in a standardized fashion.22 In the literature, this phenomenon is evident in highly underreported rates of malnutrition using claims-based data sources,10 in conflict with dozens of studies showing significantly higher rates of malnutrition.41 This measure could facilitate filling this performance gap by ensuring that all patients who are found to be malnourished upon completing a nutrition assessment have the proper plan of care developed and included in their medical record to facilitate proper hand off between members of the care team.

Academy members contributed their experiences with malnourished patients, and the need to have well-defined plans of care that address a patient's nutritional risk that can be carried through post-discharge:

  • "As a long term acute care respiratory facility, our population is one that has spent at least 3 weeks in an ICU prior to coming to us. Often times, our patients go back and forth from the facilities they reside in to acute care and then to us. The majority of our patients are severely malnourished from chronic illness along with recurrent acute issues. Our patients are primarily bedbound with profound muscle loss. I can't help but wonder if at the acute level, these patients were identified early and were monitored more closely, how their lives would be different. Would their outcomes be different?"
  • I often see malnourished patients at time of diagnosis as well as when their disease progresses. Malnutrition can be a huge struggle for these patients. Their self-esteem can often be affected by their physical state. I often see their treatments being delayed due to malnutrition and affecting their performance status. Having a protocol and plan in place for tackling malnutrition will greatly improve my patients' quality of life and ability to continue treatment as planned."
  • I often see malnourished patients at time of diagnosis as well as when their disease progresses. Malnutrition can be a huge struggle for these patients. Their self-esteem can often be affected by their physical state. I often see their treatments being delayed due to malnutrition and affecting their performance status. Having a protocol and plan in place for tackling malnutrition will greatly improve my patients' quality of life and ability to continue treatment as planned."
  • "I once did a home visit on an elderly, Chinese woman. When I first visited her, she was essentially bed-bound from malnutrition. I developed a Nutrition Care Plan for her to combat her malnutrition. This woman began to participate in family meals and outings, once her malnutrition improved. Her daughter would have to assist her to use the restroom. Once her malnutrition went away, she could use the bathroom by herself. The best thing that happened after her malnutrition was resolved was that she had the strength to hold her great granddaughter, whom she treasured beyond measure."

F. Support for MUC16-344: Appropriate Documentation of a Malnutrition Diagnosis

Diagnosis of malnutrition and appropriate documentation is an important step to confirm results of a nutrition assessment, communicate nutritional status to other providers within the hospital, and ensure malnutrition support is carried out. After the nutrition assessment is completed and concurrent with care plan development, a medical provider should review the results of the dietitian assessment to confirm findings and document a diagnosis for patients found to be malnourished. Documentation of malnutrition in the patient's record is of significant value for care coordination between acute and post-acute settings. CMS stated that documentation of a malnutrition diagnosis is an important component of proper discharge planning and/or transitions of care to post-acute providers.42

While research data suggests that up to 39% of hospitalized older adult patients may be malnourished or at-risk of malnutrition43, analysis of recent claims data showed that only 7.1% of patients discharged from the hospital were actually coded with a diagnosis of malnutrition.10 This represents a substantial gap in identification at a national level, and indicates that patients with clinical indications of malnutrition are not being formally diagnosed by medical providers as recommended by expert consensus. A lack of diagnosis means that important patient information is not communicated to other clinicians and next-in-line providers, meaning patients' malnutrition may go unrecognized, leading to worse patient outcomes. Given this concern and the merits of these measures described above, we strongly recommend that CMS consider adoption of these key measures into the IQR program. Academy members were also solicited for to share their experiences with the importance of properly indicating malnutrition diagnosis for patients to ensure appropriate treatment:

  • "Malnutrition can occur so quickly, and it's especially harmful and insidious with cancer patients. When a patient's malnutrition has been overlooked for months before diagnosis, it is almost impossible to recover from in combination with chemotherapy and radiation therapy. Malnutrition is not only damaging to the patient in and of itself, but also is an important indicator that other disease processes are occurring. When malnutrition is caught early nutrition and medical interventions are more effective and the patient is able to come back from both malnutrition and cancer."

G. Phased-in Approach for MUC16-296 if Necessary

The Measures Application Partnership (MAP) recommended a need to balance the number of new measures to Hospital IQR while continuing to include clinically relevant measures like the malnutrition eCQMs. Each measure in the malnutrition eCQM set serves a specific clinically relevant role for ensuring that a multidisciplinary care team comprised of nurses, dietitians, physicians, patients and others can pursue risk identification and risk reduction. While our primary recommendation is to adopt all four malnutrition eCQMs in CY 2018, if CMS needs to phase in new eCQMs into the Hospital IQR Program, the Academy of Nutrition and Dietetics and Avalere Health recommend that CMS prioritize immediate adoption of MUC16-296, Completion of a Nutrition Assessment for Patients Identified as At-Risk for Malnutrition within 24 hours of a Malnutrition Screening with reporting in CY 2018. We are prioritizing MUC16-296 for the following reasons:

  1. The nutrition assessment is a thorough, systematic approach to evaluate a patient's nutrition status and should be completed for all patients at-risk of malnutrition. Therefore, it provides the foundation for all subsequent malnutrition care a patient receives.
  2. It reflects the results of the screening, outlines patient nutrition status and recommendations to guide the care plan, and informs the provider medical diagnosis of malnutrition. Consequently, appropriate implementation and documentation of the nutrition assessment can drive optimal malnutrition care.
  3. Although the multi-step process is necessary to properly identify at-risk patients, refer them to proper assessment, develop their care plans and confirm their diagnosis, this measure at a minimum will encourage hospitals to emphasize malnutrition as a quality improvement objective.

We recommend the other three malnutrition eCQMs be implemented in CY 2019 or as soon as feasible.

Support for a Future Malnutrition Composite Measure

We strongly urge CMS consider a composite measure, when available, that at a minimum incorporates the four key components, thus driving optimal nutrition care for those at-risk of malnutrition or already malnourished in the hospital. In the interim we recommend CMS adopt the existing eCQM measure set. The recommended nutrition care process established to properly identify, treat and monitor malnutrition in hospitalized patients is a set of multiple evidence-based steps.29,39 These steps are interrelated and each are necessary to adequately identify patient risk and subsequently reduce said risk with proper care planning. Therefore, any future composite measure should consider the critical steps of this care process to facilitate proper risk identification, care coordination and intervention for malnourished patients.

Potential Components to be Included in a Future Malnutrition Composite Measure

There are four potential components for which measures have already been developed, each step in the process serves a specific role for ensuring that an interdisciplinary care team comprised of nurses, dietitians, physicians and others can pursue risk identification and risk reduction. The four individual eCQMs address the first four key components that are necessary to properly complete these steps.

  • The first step, screening for malnutrition upon admission provides a low-burden, low-cost option for hospitals to identify malnutrition risk.
  • Whereas nutrition assessments ensure that registered dietitians who are properly trained in identification of physical characteristics of malnutrition are tasked with assessing nutritional status and developing corresponding care plans.
  • Finally, the findings of the nutrition assessment not only inform the care plan's development but also the confirmation of the diagnosis by the physician and care team.
  • This important nutritional information documented in the nutrition care plan, if properly recorded in the patient's medical record, can serve a critical role in effective care coordination, timely nutrition intervention and transitions of care upon discharge.

VI. Support for LTCH QRP Proposal for Reporting Nutrition Approaches Data Elements

The Academy also commends CMS for their recognition of the importance of identifying and treating malnutrition in the PAC setting. Nutritional status and the nutrition care plan are necessary health information to achieve patient goals of care and inclusion of these standardized elements will facilitate care coordination and safe care transitions for beneficiaries who are malnourished and at risk for malnutrition. It is important for providers and patients to understand the risks for malnutrition what might cause it or make it worse, how to prevent it and how to connect with community nutrition support services.

We applaud CMS's inclusion of nutrition/malnutrition data elements in the standardized patient assessment for beneficiaries in PAC settings and specifically establishing malnutrition and malnutrition risk as condition/co-morbidity as standardized data elements for PAC settings. We also support CMS proposal to include nutritional approach data elements for the Assessment of Special Services, Treatments and Interventions (e.g., Parenteral/IV Feeding, Feeding Tube, Mechanically Altered-Diet, and Therapeutic Diet). We agree with CMS that data are lacking on therapeutic diets and that assessing whether a patient needs a therapeutic diet would provide important information for care planning, clinical decision making, care transitions, and resource use in LTCHs. The implementation of these standardized nutrition data elements aligns with our recommendations for the acute care setting.

We recommend, however, that CMS align the definition of the therapeutic diet data element with the Academy of Nutrition and Dietetics definition below to help clarify the data to be reported and ensure consistent data collection across PAC settings.

"A therapeutic diet is a diet intervention prescribed by a physician or other authorized non-physician practitioner that provides food or nutrients via oral, enteral and parenteral routes as part of treatment of disease or clinical conditions to modify, eliminate, decrease, or increase identified micro- and macro-nutrients in the diet."44

VI. Conclusion

The Academy of Nutrition and Dietetics and Avalere Health sincerely appreciate the opportunity to provide comments on the CMS FY 2018 IPPS and LTCH proposed rule. We commend CMS for moving forward with soliciting public comment to consider adoption of these critically important malnutrition eCQMs. The time to address malnutrition in hospitalized older adults is now, as is demonstrated through the large body of evidence recently bolstered by new research supporting the impact of optimal malnutrition care on patient outcomes and benefits to the healthcare system at-large. The four malnutrition eCQMs are valid and reliable measures; their use will incentivize the adoption of evidence-based malnutrition care best practices that are associated with reduced costs and improved patient outcomes.

We thank CMS for your consideration of immediately adopting the malnutrition eCQMs into the Hospital IQR program with reporting in CY 2018. We look forward to working with CMS on future integration of these measures in the acute care setting and focusing on malnutrition quality of care across all care settings.

Sincerely,

Sharon McCauley, MBA, RDN, LDN, FADA, FAND
Senior Director, Quality Management
Academy of Nutrition and Dietetics
120 S. Riverside Plaza, Suite 2190
Chicago, Illinois 60606

Kristi Mitchell, MPH
Senior Director, Quality Management
Avalere Health, LLC
1350 Connecticut Ave, Suite 900
Washington, DC 20036


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