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1.4.3 Economic consequences

1.4.3.1 HEALTHCARE RESOURCE USE

  • Malnutrition is associated with increased morbidity in both acute and chronic disease,e.g. poor wound healing and postoperative complications such as acute renal failure, pneumonia and respiratory failure. The increased morbidity results in increased health care needs, resulting in increased costs (see Figure 1.28).324
Prognostic impact of malnutrition (adapted from Norman et al. 2008)

Figure 1.28

Prognostic impact of malnutrition(adapted from Norman et al. 2008)324

Malnutrition increases use of healthcare resources by adult and older hospital patients

In prospective and several large retrospective evaluations, studies demonstrate that adults and older patients in hospital (with a variety of conditions) use significantly more healthcare resources than well-nourished patients in terms of (see Table 1.15):

  • increases in length of hospital stay;
  • increases in readmission rates;
  • delays in hospital discharge;
  • greater use of healthcare resources.53

A case control study undertaken in adults (mean age 73.7 years) found that patients at risk of malnutrition on admission (according to NRS ≥3) had a significantly longer length of hospital stay. Patients that became at risk of malnutrition during their hospital stay also had a significantly longer length of hospital stay (Figure 1.29).325

Days of hospital stay according to the presence of nutritional risk at admission and discharge. (adapted from Leon-Sanz et al, 2015)

Figure 1.29

Days of hospital stay according to the presence of nutritional risk at admission and discharge. (adapted from Leon-Sanz et al, 2015) 325

A, admission; D, discharge.

Malnutrition increases use of healthcare resources by adults and older people in the community

Similarly, in prospective evaluations and 1 large retrospective evaluation, studies demonstrate that adults and older patients (with a variety of conditions) use significantly more healthcare resources than well-nourished patients in terms of (see Table 1.16):

  • increases in the number of diagnosed diseases;
  • increases in the number of visits to family doctors;
  • increases in hospital admissions and readmissions;
  • increases in length of hospital stay.

Malnutrition in children is associated with an increased length of hospital stay

  • A number of studies have demonstrated that malnourished children have a longer hospital stay compared with well-nourished children (see Table 1.17). This increase in use of healthcare resources is likely to increase the cost of care of malnourished children.
  • Abdelhadi et al conducted a large retrospective analysis of over 6 million hospitalised children aged ≤17 years and found that LOS among children with a coded diagnosis of malnutrition (CDM) was significantly longer than those without a CDM (Figure 1.30).

In addition, they found that discharge home with care was 3.5 times more common among malnourished patients (10.9% vs 3.1%, p<0.001).326

Hospital length of stay of children ≤17 years with a coded diagnosis of malnutrition vs. those without (adapted from Abdelhadi et al, 2016)

Figure 1.30

Hospital length of stay of children ≤17 years with a coded diagnosis of malnutrition vs. those without (adapted from Abdelhadi et al, 2016)326

 

Table 1.15

Examples of significantly increased use of healthcare resources by patients identified as malnourished or at risk of malnutrition compared with non-malnourished patients – hospital

Country/ Region Study Population (n) Study design Method Malnutrition/risk Outcome
Brazil Leandro-Merhi et al. (2011)327 Adults and elderly, surgical (n = 350) Prospective evaluation SGA for adults, MNA for elderly Adults: 19.3% slightly malnourished, 0.8% at risk Elderly: 11% malnourished, 32.9% at risk
  • ↑ LOS (malnourished 10.1±8.7 vs at risk of malnutrition 7.5±6.5 vs well-nourished 5.7±5.8 moderate days, p = 0.0005)
Canada Curtis et al. (2016)328 Adult patients ≥18 years admitted to surgical or medical wards (n = 958) Multi-center Prospective cohort study SGA 10.8% severely malnourished 33.5% moderately malnourished 55.7% well nourished
  • Severely malnourished LOS 34% longer than well-nourished (p=0.000) with medical stays increased by 53% (p = 0.001) Moderately malnourished LOS 18% longer than well-nourished (p = 0.014) with medical stays increased by 23% (p = 0.014) and surgical stays increased by 32% (p = 0.015)
Europe Pernicka et al. (2010)329 Adults (n = 1,346 pairs case/controls) Retrospective evaluation BMI + weight loss 7% malnourished
  • ↑ LOS (mean LOS 15.1 [95% CI 14.1–16.0] in malnourished cases vs 12.2 [95% CI 11.4–13.0] in non-malnourished controls)
France Melchior et al. (2012)330 Colorectal cancer patients undergoing surgery (n = 453). Post-hoc analysis of prospective study See details* 26.7% malnourished 73.3% well-nourished
  • ↑ LOS (malnourished 19.6 days vs. well-nourished 16.2 days; p= 0.017).
France Nitenberg et al. (2011)331 Adults, post-surgical colorectal cancer (n = 762) Post-hoc analysis of prospective data See details* Not reported
  • ↑ LOS (mean LOS was 3.1 days longer in malnourished patients than in well-nourished patients, p = 0.004) delays returning home (69.6% of malnourished patients referred to another facility compared with 54.2% of well-nourished patients, p = 0.027)
France Grigioni et al. (2010)332 Adults (n = 354) Prospective evaluation BMI/weight change/ albumin 29.5% moderate/severe malnutrition
  • ↑ LOS (11.7 days vs 7.9 days, p < 0.001)
France Pressoir et al. (2010)212 Adults cancer (n = 879) Prospective evaluation See details** 10.8% severely malnourished 33.5% moderately malnourished 55.7% well nourished
  • ↑ LOS (median 19.3±19.4 days vs 13.3±19.4 days, p < 0.0001)
Germany Thomas et al. (2016)333 Surgical patients (n = 1244) Prospective observational study NRS 2002 24.1% moderate to serious risk (NRS ≥3) 23% slight risk (NRS 1-2)
  • ↑ LOS (at risk 17.93 days ±19.66 vs. not at risk aat 9.42 days ± 10.05, p < 0.001)
Germany Pirlich et al. (2006)114 Adults (n = 1,886) Prospective evaluation SGA 27.4% malnourished (17.6% moderate and 9.8% severe)
  • ↑ LOS (average difference 4.6 days or 42%, p < 0.001)
Singapore Lim et al. (2012)73 Adults (n = 818; 530 matched for DRG group) Prospective evaluation SGA 29% malnourished (25% moderate and 4% severe)
  • ↑ LOS (mean 6.9±7.3 days vs 4.6±5.6 days, p = 0.001, DRG matched, adjusted) readmission within 15 days of index admission (RR 1.9; CI 1.1–3.2)
Spain Álvarez Hernández et al. (2015)334 Adults with dysphagia (n = 352) Observational study NRS 2002 tool 45.6% malnourished on admission (NRS≥3) 54.6% ≥70 years malnourished on admission 25.5% <70 years malnourished on admission
  • ↑ LOS (malnourished 11.53 ± 7.10 days vs. well-nourished 8.80 ± 6.06 days, p < 0.001)
Spain Gastalver- Martín et al. (2015)335 Adults Prospective observational study NRS-2002 and SNAQ 33% malnourished on admission (NRS ≥3 or SNAQ ≥2) 30% malnourished on discharge (NRS ≥3 or SNAQ ≥2) 19% malnourished on admission and discharge (NRS ≥3 or SNAQ ≥2)
  • LOS 14.00 days ± 10.44 (malnourished on admission) vs. 11.96 days ± 6.34, p = 0.602 (well-nourished on admission) ↑ LOS 19.96 days ± 14.01 (malnourished on discharge) vs. 14.68 days ± 8.38 (well-nourished on discharge), p = 0.005 ↑ LOS 24.44 days ± 17.49 (malnourished throughout hospital stay) vs. 14.69 days ± 7.99 (well-nourished throughout hospital stay), p = 0.014
Spain Leon-Sanz et al. (2015)325 Adults Case-control study NRS 2002 24.4% malnourished on admission (NRS ≥3) 22.6% malnourished at discharge (NRS ≥3)
  • ↑ LOS for patients at risk (11.5 days ± 7.5 vs 8.5 days ± 5.8, p< 0.001) ↑ LOS for patients that became at risk during hospitalisation vs. those not at risk during hospital stay (15.2 days ± 9.2 vs. 8 days ± 5.2, p< 0.001)
Spain Marco et al. (2011)74 Internal medicine (n = 1,567,659) Retrospective evaluation Diagnostic codes for malnutrition 1.4%†
  • ↑ LOS (18.1 vs 9.8 days, p< 0.001)
Spain de Luis & Lopez Guzman (2006)336 Adults, internal medicine (n = 213) Prospective evaluation MNA 23.9% (MNA < 17) 50.2% at risk (MNA 17–24)
  • ↑ LOS (increase of 2.6 days for each decrease of 1 kg of body weight, decrease of 3.2 days for each 1 point increase in MNA score)
Spain Planas et al. (2004)337 Adults (n = 400) Prospective evaluation SGA 46% malnourished
  • ↑ LOS (overall population 7.5±5.4 days vs 5.0±5.1 days; scheduled admissions 7.1±6.2 days vs 4.8±4.4 days, both p < 0.05) ↑ readmission rate (total – overall 30.1% vs 15.1%, scheduled 32.8% vs 15.9%, cancer 39.7% vs 21.4%, all p 0.05; non-elective –overall 20.7% vs 13.2%, scheduled 21.4% vs 12.8%, cancer 29.3% vs 17.2%, all p 0.05)
UK Gomes et al. (2016)338 Stroke patients (n = 342) Prospective study ‘MUST’ 64% at low risk 7% at medium risk 29% at high risk of Malnutrition
  • ↑ LOS across malnutrition risk categories (median (range)): Low – 14 days (2-173) Medium – 19 days (3-165) High – 48 days (2-194) (p0.001)
UK Slee et al. (2016)339 Older (frail) adults ‘MUST’ and MNA-SF Albumin <30g/l (severe) High risk 14% Medium risk 9% Low risk 77% MNA-SF Normal 9% MNA-SF At risk 45% MNA-SF Malnourished 46% Albumin <30g/l (severe) 42% Albumin 30-34.9 g/l (moderate) 29% Albumin >35 g/l (low/absent) 29%
  • ↑ LOS for albumin <30g/l (severe malnutrition) 25 days ± 21.6 vs. Albumin >35g/l (no malnutrition) 14.1 days ± 9.5, p < 0.05
US Weiss et al. (2016)110 All non-maternal and non-neonatal hospital inpatient stays (n = 27.6 million) Descriptive summary report of Heathcare Cost and Utilisation Project (HCUP) administrative health care data from the National (Nationwide) Inpatient Sample (NIS) Malnutrition was identified using a broad set of diagnostic codes that included the following six categories: Postsurgical nonabsorption Nutritional neglect Cachexia 1.95 million hospital stays involved malnutrition i.e. 7.1% of the 27.6 million total
  • ↑ LOS across all six types of malnutrition compared with average length of hospital stay overall:
  • All 2013 non-maternal/non-neonatal 4.9 days vs.
  • Postsurgical non-absorption 9.6 days
  • Nutritional neglect 9.2 days
  • Cachexia 7.5 days
  • Protein-calorie malnutrition 10.7 days
  • Weight loss or failure to thrive 6.5 days
  • Underweight 6.0 days
Poland Czapla et al. (2022)340 Hospitalised patients with atrial fibrillation (n = 1,813) Retrospective study NRS 2002 7% at risk of malnutrition (NRS 2002 ≥3) Patients with NRS ≥3 had significantly longer hospital stays (4.44 vs. 3.53 days, p = 0.005).
Netherlands van Vliet et al. (2020)341 Hospitalised adult patients (n = 584) Observational study Patient-Generated Subjective Global Assessment (PG-SGA) at admission, day 5, day 10, and predischarge 30% of well-nourished patients became malnourished and 82% of malnourished patients remained so Malnourished patients were more likely to have longer hospital stays
USA Hudson et al. (2018)342 Hospitalised patients (n = 3,907; (mean age: 61 years malnourished vs. 58 years in non-malnourished) Retrospective study AND/ASPEN Criteria 66.88% met criteria for moderate or severe malnutrition Malnourished patients had longer LOS (15 vs 12 days, P = .0067), were more likely to be readmitted within 30 days (40% vs 23%, P < .0001) and, had a higher in-hospital mortality rate (8% vs 5%, P = 0.0102). and were significantly less likely to be discharged early, p = 0.0001)
Italy Rinninella et al. (2018)343 Hospitalised adult patients (n = 300) Cross-sectional study NRS–2002, ESPEN Criteria, Bioelectrical Impedance Analysis (BIA) 157 (52.3%) patients were at risk of malnutrition; 116 (38.7%) were malnourished Malnourished patients had longer hospital stays (11.5 ± 8.0 days vs. 9.4 ± 6.2 days, p < 0.05).
Germany Meissner et al. (2020)344 Hospitalised oncological patients with gastrointestinal tumours (n = 363) Observational study NRS-2002 All patients had an NRS ≥ 3 Malnourished patients had hospital stays extended by 2 to 11.1 days compared to well-nourished patients.
USA Lengfelder et al. (2021)345 Hospitalised adult patients (n = 416) Prospective observational cohort study Modified AND/ASPEN 2012 Consensus Criteria 31.7% were malnourished Malnourished patients had 2.38 times higher odds of a hospital stay ≥3 days (P < 0.001) and 2.28 times higher odds of readmission within 30 days (P < 0.006).
Spain Martin-Palmero et al. (2017)346 Hospitalised adult patients (n = 384; 273 medical, 111 surgical) Cross-sectional observational study ‘MUST’, NRS-2002 Controlling Nutritional Status (CONUT), SGA 38% were mildly malnourished and 18% severely malnourished Malnourished patients had a longer hospital stay (9.29 vs. 7.10 days, p = 0.002), used more medications (9.2 vs. 7.4, p = 0.001), and underwent more diagnostic tests (16.4 vs. 12.5, p = 0.002). Malnutrition was associated with higher mortality.

SGA Subjective Global Assessment; MNA Mini Nutritional Assessment; BMI Body Mass Index; NRS Nutritional Risk Screening; SNAQ Short Nutritional Assessment Questionnaire; ‘MUST’ Malnutrition Universal Screening Tool’; MNA-SF Mini Nutritional Assessment Short Form; LOS Length of stay. *Malnutrition defined as weight loss greater than 10% of usual body weight in the 6 months pre-surgery and/or Body Mass Index (BMI) lower than 18.5 (patients under 70 years) or 21 (patients over 70 years). **See Table 1.10 for definitions of malnutrition used by Pressoir et al, (2010). † Low due to low communication of malnutrition in discharge reports.

Table 1.16

Examples of significantly increased use of healthcare resources by patients identified as malnourished or at risk of malnutrition compared with non-malnourished patients – community

Country/ Region Study Population (n) Study design Method Malnutrition/risk Outcome
Israel Feldblum et al. (2009)347 Older people (n = 204) Prospective evaluation MNA 38.7% at risk (MNA < 24) Healthcare use before index hospital admission:

  • ↑ no. diagnosed diseases (mean 7.4±0.21 vs 5.9±0.16, p = 0.001)
  • ↑ no. family physician visits (mean 7.7±0.95 vs 3.7±0.75, p = 0.001)
  • ↑ no. hospital admissions before current admission (mean 1.7±0.19 vs 1.1±0.15, p = 0.02) Healthcare use after index hospital admission:
  • ↑ LOS (current event) (mean 7.14±0.8 days vs 5.0±0.4 days, p = 0.01)
  • ↑ LOS (in following 3 months) (mean 2.8±0.54 days vs 1.4±0.29 days, p = 0.03)
UK Guest et al. (2011)84 Adult malnourished (n = 1,000) Retrospective analysis BMI < 18.5 kg/m2 + clinical indicators
  • ↑ no. GP visits in 6 months (mean 18.9 in malnourished cases vs 9.12 in non-malnourished controls, p < 0.001)
  • ↑ no. hospital admissions in 6 months (13% vs 5%, p < 0.05)
  • ↑ LOS (6.24 days vs 3.26 days, p < 0.001)
UK Cawood et al. (2010)348 Adult outpatients (n = 194) Prospective evaluation ‘MUST’ 18% at risk (12% medium, 6% high)
  • ↑ LOS (all hospital admissions: low risk 0.90±3.9 days vs medium risk 2.04±4.9 days vs high risk 4.92±8.1 days, p = 0.007)
  • ↑ no. hospital admissions in 6 months (12.6% vs 26.1% vs 66.7%, p = 0.000)
  • ↑ no. emergency admissions in 6 months (5.0% vs 8.7% vs 41.7%, p = 0.000)
  • ↑ no. planned admissions in 6 months (7.5% vs 21.7% vs 25.0%, p = 0.025)
UK Collins et al. (2010)301 Adult COPD outpatients (n = 205) Prospective evaluation ‘MUST’ 23.9% at risk (medium + high)
  • ↑ no. emergency and elective admissions per patient in 6 months (low risk 0.65±1.1 vs medium + high risk 1.10±2.0, p = 0.043)
  • ↑ no. emergency admissions per patient in 6 months (low risk 0.48±0.9 vs medium + high risk 0.92±1.8, p = 0.023)

COPD Chronic Obstructive Pulmonary Disease; MNA Mini Nutritional Assessment; BMI Body Mass Index; ‘MUST’ Malnutrition Universal Screening Tool’; LOS Length of stay.

Table 1.17

Summary of studies showing increased length of hospital stay in malnourished children or children at risk of malnutrition

Country/ Region Study Population (n) Study design Method of assessment/screening Outcome
Brazil Fernandez et al. (2008)147 Children aged < 3 years (n = 67) Prospective evaluation Gomez score (WFA) Linear regression analysis showed an association between longer hospital stay and no weight gain (r2 = 0.11, p = 0.005)
Canada Groleau & Babakissa (2008)138 Children aged 0–18 years (n = 173) Prospective evaluation A variety of methods (see Table A1.8, Appendix I) Length of stay was significantly correlated to nutritional status (r = -0.268, p < 0.05)
Canada Secker & Jeejeebhoy (2007)41 Children aged 31 days – 17.9 years scheduled for surgery (n = 175) Prospective evaluation Subjective Global Nutritional Assessment (SGNA) Postoperative stay was more than twice as long for severely malnourished (19.0±58.8 days) vs well-nourished children (5.3±5.4 days) and moderately malnourished children (8.4±11.1 days) (p = 0.002) (remained significant when extreme outlier removed from the analysis) When taken together, moderately and severely malnourished children had a 55% longer hospital stay than well-nourished children
The Netherlands Hulst et al. (2010)39 Children aged > 1 month, admission to paediatric ward and expected stay at least 1 day (n = 424) Prospective evaluation STRONGkids After adjustment for a variety of clinical factors including younger age, presence of underlying disease, non-surgical reason for admission and non-Caucasian ethnicity, increase in nutritional risk category was significantly related to a longer length of hospital stay (p = 0.017)
The Netherlands Joosten et al. (2010)141 Children aged > 1 month, admission to medium care unit and expected stay at least 1 day (n = 424) Prospective evaluation Acute malnutrition = WFH < -2 SD Chronic malnutrition = HFA < -2 SD Median duration of hospital stay of children with acute malnutrition was significantly longer vs non-malnourished children (median 4 [range 1–44] days vs 2 [1–24] days, p = 0.001)
US Abdelhadi et al. (2016)2326 Hospitalised Children (≤17 years) (n = 6,280,710) Retrospective analysis using patient-level data on hospital inpatient stays ICD-9-CM and ICD-10-CM codes that related to malnutrition LOS among children with a CDM was significantly longer than those without a CDM (9.7days vs. 3.8 days) Discharge with home care was 3.5 times more common among malnourished patients (10.9% vs 3.1%, p < 0.001)
Croatia Niseteo et al. (2020)349 Children hospitalised on four Paediatric Departments (Gastroenterology, Neurology, Pulmonology and Nephrology) paediatric patients (n = 367), aged ≤ 18 years Prospective longitudinal cohort study Body weight, height, and BMI (malnutrition classified as BMI -2 to -3 SDS for moderate, BMI < -3 SDS for severe) Malnourished children had significantly longer hospital stays (12.3 vs. 7.3 days, p = 0.004) and were 5 times more likely to acquire nosocomial infections (RR 5.1, 95% CI 2.276–11.485).

See Table A1.8, Appendix 1 for details of prevalence of malnutrition and risk of malnutrition. WFA weight for age; WFH weight for height; HFA height for age. ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification

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