PERSPECTIVES IN PRACTICE n>ERSPECTIVES POUR LA PRATIQUE

Hospital Diagnosis of Malnutrition:

A Call for Action
MARY ANN BOCOCK, PhD, RD, HEATHER H. KELLER, PhD, RD,

Department of Family Relations and Applied Human Nutrition, University of Guelph, Guelph, ON

Abstract The Canadian Institute for Health Information (CIHI) provides accurate health information needed to establish sound healtli care policies. The CIHI mandate is to develop and coordinate a uniform approach to health care information in Canada. The instittite uses the International Classification of Diseases (ICD) system to record the most responsible diagnosis for each hospital admission. This investigation was conducted to determine if six ICD protein-calorie malntitrition (PCM) codes could be used for health care utilization analyses. Aggregate data (1996 to 2000) from the CIHI discharge abstract database were used. The data analyzed were the most responsible diagnoses data for the six PCM codes and a single summaiy statistic for all other "non-malnutrition" diagnoses for all long-term care facility residents aged 65 or older who were transferred to an acute care facility. In this population, fewer than five hospital admissions per year were assigned a PCM code. There were too few PCM cases to do trend analyses for morbidity or mortality. This sttidy suggests a lack of recognition and documentation of PCM as a specific health condition in older adults. Lack of tracking of this diagnosis prevents documentation that could lead to policy changes to support older adults' nutrition. (Can J Diet Prac Res 2009;70:37-41 ) (DOI: 10.3148/70.1.2009.37)

Rsum L'Institut canadien d'infomiation sur la sant (ICIS) fournit l'information en sant prcise ncessaire potir tablir des politiques srieuses en matire de soins de sant. Le mandat de l'Institut est de concevoir et de coordonner une approche uniforme en matire d'inforniadon sur les soins de sant au Canada. L'In.stiait emploie la Classification internationale des maladies (CIM) pour consigner les diagnostics les plus responsables pour chaque admission l'hpital. La prsente tude a t mene pour dterminer si six codes CIM de malnutiition protino-calodque (MPC) pouvaient servir analyser l'utilisation des soins de sant. On a utilis les donnes agrges (1996 2000) de la b;ise de donnes abrge de l'ICIS stir les congs des patients. Les donnes analyses taient les diagnostics les plus responsables potir les six codes MPC et un simple rsum statistique de tous les autres diagnostics de non-malnutiition pour tous les rsidents de centres hospitaliers de soins de longtie dure de 65 ans et plus qui avaient t transfrs dans un centj e hospitalier de soins de courte dure. Dans cette poptilation, moins de cinq admissions l'hpital par anne comportiiient un code MPC. Il y arait trop peu de cas de MPC potir mener des anal)'ses de tendance quant la morbidit ou la mortalit. Cette tude suggre un manque de reconnaissance et de doctimentation de la MPC comme condition pathologiqtie distincte chez les adultes gs. L'absence de ce diagnostic empche de documenter des cas qui poun"aient mener des changements de politiques pour favoriser la nutrition des adultes gs. (Rev can prat rech ditt 2009;70:37-41 ) (DOI: 10.3148/70.1.2009.37)

INTRODUCTION Malnutrition is prevalent in Canadian long-term care facilities (LTCFs); estimates of overt malnutiition range from 20% to 60% (1-3) and up to 70% in the cognitively impaired elderly (4). In comparison with well-nourished older adults (5), malnourished instittitionalized older adults are more likely to be admitted to hospital (6), to have a longer stay (7), or to die during an actite care admission (8). The etiology of malnutrition in LTCFs is complex. Contributing factors include the admission of malnourished older adults from the commtmity (9) and acute care facilities (ACFs) (10), and the development of malnutrition within LTCFs because of inadeqtiate dietary intakes (11). Validated malnutrition screening tools are available to detect malnutrition in hospitalized older adults (3,12,13); however, use of these tools is discretionary and thus a consistent approach to measuring the prevalence of malnutrition may
Canadian Journal of" Dietetic Pnictice and Rcscaicll - Vol 70 No 1, Spring 2009

be lacking. Pre\ioi.ts work has identified that malnutrition is frequently overlooked in acute care admissions (14). T'he first International Classification of Diseiises (ICD) was developed in tlie early 1900s. Now in its tenth revision, it is the most widely used classification of diseiises (15). The ICD system is used to assign a numeric code for the most responsible diagnosis (MRD) provided at the end of the health care episode; this MRD is the piimai-y reiison for admission and tteatment (16,17). This standard approach to disease classification and entimeration hits applications beyond classifying morbidity and mortality data for statistical analyses. These diverse applications include health systems research and policy development, epidemiolog)', and health care reimbursement (18). In Canada, and specifically Ontario, the ICD is tised in ACFs to track disease prevalence and hospital outcome (18).

PERSPECTIVES IN PRACTICE PERSPECTIVES POUR LA PRATIQUE

PURPOSE Little research has been done to determine if the ICD system could be used as a tool to monitor the prevalence of malnutrition in hospitalized older adults. In this exploratory study, we examined the frequency of malnutrition MRDs in Ontario LTCF residents admitted to hospital. As residents of LTCFs have a high prevalence of malnutrition, limiting the analysis to this group could be expected to reveal trends in die use of ICD to track malnutrition in acute care. Tf i<i tiTTlF' METHODS An aggregate data set was obtained from the Canadian Institute for Health Information (CIHI) ICD-9 discharge abstract database that contained MRD U C statistics for protein-calorie malnutrition (PCM) for 1996 through 2000 for Ontario. The data are total counts of all LTCF discharges to acute care hospitals per year, and may include multiple admissions for the same individuals. Data included three MRD classifications of PCM, three MRD sub^ilassifications of PCM, and a single summary statistic for all other "non-malnutiition" MRDs for all Ontario LTCF residents aged 65 years and older transferred to an ACF. Within the ICD system, disease codes may be used without additional classification to specify a health condition; others require further indexing. The codes for kwashiorkor (code 260), nutritional mai-asmus (code 261), and otiier severe PCM (code 262) may be used to specify a health condition. However, ICD code 263 (for other and unspecified PCM) is classified as "non-specific" and has sub-classifications used to specify a health condition: 263.0 for malnutrition of a moderate

degree, 263.1 for malnutrition of a mild degi-ee, and 263.8 for other PCM (16,17). To further understand and describe the sample, aggi egate statistics were also requested by health condition, including gender, mean age by gender, mean length of stay, and discharge status (i.e., alive or dead). Ontario LTCF provincial summary data acquired from the Ontario Ministry of Health and Long-Tenn Care, and not available in CIHI databases, were used to provide context to the hospital usage data. The provincial summary data included die total number of LTCF residents and the case-mix measure, which is a provincial summary statistic of tlie complexity of resident care required per year for each of the yeare ^ggg ^^ gOOO (19-23). There were too few cases witliin each MRD to do any trend analyses for length of stay or mortality by malnutrition diagnosis. The project was approved by die University of Guelph Research Ethics Advisory Board. RESULTS For 1996 to 2000, there was a 1.8% increase in the proportion of patients transfen ed from LTCFs for acute care admissions, which indicates a relative increase in use of die acute care system by long-term care residents. Approximately one in six hospital admissions of LTCF residents ended in death. At the same time, the case-mix measure for all LTCFs in Ontario increased by 6.6% (19-25) (Table 1), which indicates that residents of facilities are frailer and in need of more intensive professional care. Gender and age differences were noted in the LTCF residents transfen^ed to hospitals; more women (66.9% of admissions) than men

Table 1
Number of Ontarians living in long-term care facilities, complexity of care, transfers to hospital, and hospital deaths, 1996 to 2000 Year Living in facilities (n) Residents Hospital Admissions^ Deaths^ (n) (%) (n) (%) Ontario LTCF case-mix measure^

1996 1997 1998 1999 2000

55,784 55,845 55,825 55,882 55,969

22,396 21,658 21,574 23,390 23,164

40.1 38.8 38.6 41.9 41.4

3779 3651 3657 3760 3706

16.9 16.9 17.0 16.0 16.0

79.83 80.99 82.12 83.30 85.07

LTCF: long-term care facility; n=nuinber Data source; CIHI ICD-9 discharge abstract database (total number of separations; data may inchide more than one admission for tlie sanie individual) '>Data sotirce: CIHI ICD-9 discharge abstract database (the ntimber and proportion of Ontario LTCF admissions to hospital that resulted in death) <^Data source: Ontario Ministiy of Health and Long-Term Care (19-23). Annually, each Ontario LTCF resident is assigned a level of care category for acttial nursing and personal care, ranging from light (level one) to hea\y care (level seven). For each LTCF, a case-mix measure is calculated for all I'esidenus and expressed ntimerically to facilitate comparison among other LTCFs. Case-mix measures for all LTCFs are tised to calctilate a provincial average.

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Table 2
Acute care admissions and deaths for Ontario long-term care facilit)' residents aged 65 and older with malnutrition as the most responsible diagnoses, by fiscal year ICD-9 nutritional deficiencies classification codes Frequency of admissions and deaths byfiscalyear'' 1996 1997 1998 1999 2000 AD AD AD AD AD

260 Kwashiorkor 261 Nutritional marasmus 262 Other severe malnutrition 263 Malnutrition 263.0 Malnutrition to a moderate degree 263.1 Malnutrition to a mild degree 263.8 Other severe protein-calorie malnutrition

0 <5 <5 0 <5 0

0 0 0 0 0 0

0 0 <5 0 <5 < 5

<5 0 0

0 0 < 5 <5 0 0 0 0 0 0 0 0

0 <5 <5 0 0 0

0 0 0 0 0 0

0 0 0 0 <5 0 0 0 0 0 <5 0

0 0 0

A=admission; D=deatli; lCD-9=lnteniational Classification of Diseases, ninih revision; LTCF=long-term care facility ''CIHI ICD-9 discharge abstract database: CIHI does not release acttial values for International Classification of Disease (ICD) codes witli fewer than five ca.ses.

were admitted to hospital, and for tbe years studied, all residents with malnutrition MRD were women aged 80 or older. Fewer than five LTCF residents were diagnosed within any one of the six ICD MRD malnutrition classifications for 1996 to 2000 (Table 2). DISCUSSION These data indicate that hospital admissions are common, and yet fewer than 20 residents a year were diagnosed with some fonn of PCM according to the ICD codes. These data represent tlie total number of separations, which means that the data may include more than one admission for the same individual; nevertheless, the recognition of malnutrition in frail institutionalized elderly people admitted to hospital is grossly under-represented, according to knowledge about the level of malnutrition estimated to occur in LTCFs. A condition such as malnutrition must be recognized before tieatment can be given that could reduce mortality (24). As one in six admissions resulted in death, identification of malnutiition amenable to intervention may be a way to redtice this adverse outcome and the health care costs associated with it (5,25-27). The importance of recognizing malnutrition in hospitalized older adults was established more than 30 years ago (28), but continues to be a difficult problem to manage in acute care settings (14,29). This study suggests that, for older adults admitted from LTCFs to hospitals, important gaps exist between the recognition of malnutrition as a health condition, doctimentation of malnutrition, and abstraction of the diagnosis from the health care record so that die ICD coding classification reflects the correct diagnosis and/or ti-eatment. Several potential reasons may explain the gap between tbe expected prevalence of malnutrition in tbis patient pop)Canadian Journal of Dicletic Practice and Research-Vol 70 iNo 1, Spring 2009

uladon and tbe use of die ICD codes for ti^acking malnutrition. First, malnutiidon may not be perceived as an MRD. Physicians are limited to selecting one healtli condidon for the MRD; however, PCM may be a complicating diagnosis (30). Potentially, malnuidon may be xiewed as an outcome rather than a specific bealdi condidon (31); of greater concern is the possibility diat it is considered a nomial feattire of old age witbin LTCF residents. Healtb care record pei"sonnel or physicians may be tinaware of or unfamiliar with die ICD nutridon deficiencies category, with PCM codes or definidons, or with use of reference standards in comparison with body weigbt. In addition, the ICD definidons for malnutridon have changed. For example, the ICD-9 malnutiidon definidons referenced pediatiic reference standards targeted at detecdng malnutridon syndromes in children in less developed counies; these definidons may not be relevant in developed countries for the diagnosis of malnuDidon in hospitalized older adults (16-17,32). Currendy, die Canadian ICD-10-CA definidon tises body weight expressed as standard de\iadons from die mean of a reference standard (33). Severe malnutiidon is defined as three or more standard de\iadons below die reference standard. If weigbt measures are not axfailable, then clinical evidence may be used for the diagnoses. In Canada, body mass index (BMI) has been idendfied as the preferred method for determining body weight appropriateness, but there is concern over the appropriate cut-points for those over age 65 yeare (34). Trend analyses of clinical diagnoses such as malnutridon, for which die ICD definidons have changed, may not be meaningful. Consistent with the current study findings are those from a recent Manitoba sttidy, in wliich the authors invesdgated the recognidon of malnutridon in hospitalized padents by medical house staff; 69% of padents were

PERSPECTIVES IN PRACTICE P E R S P E C T I V E S POUR LA PRATIQUE

identified by a nutritional assessment to have moderate to severe malnutrition, but only 2% of the malnourished patients had a reference to nutritional status in the hospital record (14). Although there are many plausible explanations for the identified gap, it is clear that with the current use of ICD, the diagnosis^and thus impactof malnutrition on health outcomes is not being sufficiently tracked in acute care. The first steps toward treating malnutrition in this setting are defining it, identifying it, and then accurately recording its occurrence. With subsequent abstraction of malnutrition diagnoses from the medical record and careful tracking, data can inform needed shifts in policy and practice to provide better intervention for older adults in acute care. There are limitations to this type of study design. Aggregate data are not patient-specific, and we were limited to descriptive analyses. In addition, the nutritional status of the LTCF residents transferred to hospital is unknown, and the data are based on the extrapolation that older adults from LTCFs admitted to hospitals are more undernourished than has been shown by the ICD coding. The LTCF data provide only numbers of acute care admissions and deaths. We do not know how many of the admissions in a given year were repeat visits by the same LTCF residents. Although other research suggests that malnutrition continues to be unrecognized by hospital physicians (14), only Ontario hospital data were analyzed as we had access to this province's LTCF separation data to provide context to the CIHI data. Conclusions cannot, therefore, be generalized to other provinces or other countries. RELEVANCE TO PRACTICE Today much research is focused on the identification of "best clinical practices" to prevent or ameliorate malnutrition in older adults in home care, long-term care, chronic care, and hospital settings. For example, to prevent the development of malnutrition, malnutrition risk screening protocols have been developed to detect modifiable risk factors (12,3537). Oral nutritional supplements (8,38) and communitybased meal services (39) have been used successfully to augment dietary intake in older adults identified as being at malnutrition risk. Enhanced LTCF menus, individualized to the needs of residents at high malnutrition risk (2,40), and dietitian time (2) have been demonstrated to improve nutrient intake (40) and weight status (2). Malnutrition can be prevented and treated, but it must first be identified. As the complexity of medical care increases and the population ages, training medical staff to recognize and document malnutrition will have greater importance. Validated malnutrition screening tools do exist for older adults admitted to hospitals (3,12,13); however, a standard approach to assessing and documenting malnutrition within tlie health care record is required and would assist health care data abstraction. For example, scoring BMI and weight status at discharge is an option for facilitating malnutrition diagnoses coding. Because there is no gold standard to assess nutritional status, the diagnosis of malnutrition is a challenge. Currentiy, the ICD codes do not take into consideration the fact that
40

dietary intake is an important component of an assessment to make a nutritional status diagnosis. A necessary first step is convening a panel of experts to review the existing ICD malnutrition definitions. This research highlights the need to use the ICD system as it was originally intended to be used: for the systematic and accurate classification of human disease. With over 100 years of use and ten revisions, it is time for dietitians to collaborate with the CIHI to focus on using the ICD system effectively for evidence-based client care, nutritional epidemiology, health care policy development, and cost analyses. Acknowtedgements This research was supported by the Canadian-Instittite for Health Information Graduate Student Data Access Program (GSDAP). Parts of this material were based on data and information provided by the Canadian Institute for Health Information. However, the analyses, concltisions, opinions, and statements expressed herein are those of the authors, and not necessarily those of the Canadian Institute for Health Information. References
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