Using mobile health (mHealth) to tackle malnutrition

Disease-related malnutrition is a global and growing health care problem which costs billions of dollars every year. In Metro South, published research has shown malnutrition to be a significant economic and operational burden to hospitals, with malnourished patients experiencing increased frequency of emergency hospitalisation, longer durations of hospital stay, earlier readmissions and poorer survival. Subsequently, the cost to the healthcare system to manage malnourished patients is double that of non-malnourished patients. The majority of malnutrition is treatable with nutrition support and is associated with improved patient outcomes (e.g. quality of life, survival), reduced health care use and health care costs. Best practice nutritional care is proactive, coordinated and continuous. However, although the hospital setting is an opportune time to identify patients who are malnourished or at risk of malnutrition, at a time when patients are at their most unwell, the nutritional advice provided by dietitians can be forgotten. In addition, discharge summaries with clear direction around ongoing nutritional management are often poorly completed and coordinated. As a result, routine nutritional care is often reactive, uncoordinated and intermittent.

There is a Brisbane health technology startup which is developing mobile health (mHealth) software specifically designed to support dietitians, health care professionals, patients as well as their wider support network (e.g. family, carers) in the coordination of best practice nutritional care across the entire health care continuum (i.e. from the hospital to the home/residential aged care facility). The software addresses known gaps in the coordination of nutritional care and helps leverage the significant nutritional expertise of dietitians across all health and social care settings. It aims to improve the communication between all health care providers from hospital and health services (Metro South HHS), primary health care services (Brisbane South PHN), acute and community nutrition and dietetics services, general practitioners, practice nurses, social workers and carers. The interactive software puts the patient and their support network at its centre, with easy access to nutrition care plans provided by expert dietitians, reminders around prescribed nutrition products and regimens (oral nutrition supplements, enteral tube feeding, parenteral nutrition), push notifications to encourage and capture adherence and links to education and supportive materials. 

We believe all patients should have access to best practice nutritional care and careful, co-designed software has the ability to ensure nutritional care is less fragmented and more seamless as patients move through their health care journey. It has the potential to not only improve adherence to prescribed nutritional interventions and reduce waste, but prevent unsafe gaps in nutritional care leading to improved patient outcomes and reduced healthcare use.

Why the contribution is important

Disease-related malnutrition costs governments around the world billions of dollars to manage every year. Across European countries disease-related malnutrition is estimated to cost €170 billion euros per year. Although data on the total cost of malnutrition to the Australian healthcare is lacking, the Australasian Nutrition Care Day Survey conducted across 56 hospitals in Australia and New Zealand reported 41% on inpatients to be at risk of malnutrition. This has considerable implications for the healthcare system as malnourished patients are hospitalised more often, have prolonged durations of hospital stay and are more likely to be readmitted early (<30 days). In Queensland, research conducted at the Princess Alexandra Hospital, Brisbane found that malnutrition presents a significant economic and operational burden to hospitals and is associated with poorer survival. Malnourished patients had significantly higher 1-year mortality, were more likely to require emergency hospitalisation, experience hospital stays almost twice the duration of non-malnourished patients, and healthcare costs were almost double. In addition, recently published research from The Prince Charles Hospital, Brisbane found malnutrition and morbid obesity were significant predictors of pressure injury. Both malnutrition and pressure injuries have been highlighted by the Australian Commission on safety and Quality in Health Care as priority hospital-acquired complications, with patients with hospital-acquired malnutrition requiring 21.3 days extra at an additional cost per episode of $44,176 AUD. However, the causes of malnutrition are complex and not all hospital-acquired malnutrition is preventable.

Nutrition across the continuum of care

There have been considerable improvements in both the identification and treatment of malnutrition in hospital patients through strategies including high-energy, high-protein menus and snacks, scripted oral nutritional support (supplements as medicine) and changes to food service delivery (room service (Mater/TPCH)). In addition, recent programs have focused on systematised pathways integrated in routine clinical care to improve the detection of hospital malnutrition and its management. However, in order for these strategies to be most effective they need to be continued and coordinated beyond the acute setting and into the community. Recent Australian research exploring improved discharge planning and follow up in older malnourished elders (Hospital to Home Outreach for Malnourished Elders (HHOME)) found enhanced nutritional discharge planning and post-discharge dietetic follow up may reduce weight loss. However, the study highlighted several potential barriers to the coordination of nutritional care such as ‘no system to support the transfer of nutrition information to the community'. The HHOME study found that the duration of hospital admission during the implementation phase was only 6 days, highlighting the limited amount of time available in the acute setting to identify and initiate nutritional support. These findings were similar to those in patients with chronic obstructive pulmonary disease (COPD) at another Brisbane hospital (Princess Alexandra Hospital) which found 41% of patients diagnosed with malnutrition were on the ward for <1 week.

The pressure on Nutrition and Dietetics services to ensure malnutrition risk is identified, effective nutritional support is initiated, and appropriate coordination back to the community occurs is only likely to intensify against a backdrop of a growing, ageing, multi-morbid population. The effects of this are already being seen with the vast majority of OECD countries seeing the average duration of hospital stay consistently declining over the last thirty years. In Australia, it has seen the average length of acute hospital stay reduce from ~7.5 days in 1980 to ~4.5 days in 2015. This has several important implications on the delivery of safe and effective nutritional care, from the identification of malnutrition and nutritional risk, to the timely initiation of nutritional support, through to the coordination of nutritional care into the community. The magnitude of this challenge is even more considerable when you consider not all dietitians are tasked with the management of malnutrition but work across a diverse range of clinical specialties, many of which are also presenting a growing burden to healthcare services such as Metro South (e.g. renal disease, diabetes). In 2018, Queensland Health was tasked with managing a 2.3 million hospital admissions, with the number predicted to rise to 3.7 million by 2026, driven primarily by population growth. With an estimated 30% of patients admitted to hospital malnourished, and with malnourished patients more likely to be readmitted, it is estimated in excess of 1 million episodes of care per year will be associated with malnutrition by 2026. Therefore, any innovations that can support acute care dietitians in the coordination of care post-discharge will be increasingly valuable.

Breaking the malnutrition carousel

Whilst the majority of costs associated with malnutrition are attributed to the hospital setting (secondary care, HHSs), the vast majority of malnutrition at any one time exists in the community setting (primary care, PHNs). Therefore, although the hospital setting is the opportune time to identify nutritional risk, diagnose malnutrition and initiate nutritional support, malnutrition cannot be treated during the confines of an acute episode of care. Although further nutritional depletion can be attenuated with nutritional support, in order for a diagnosis resolution for malnutrition, the appropriate type and amount of nutritional support needs to be provided for the appropriate amount of time post-discharge. Provision of nutritional support in the community setting, when patients are less acutely unwell and more mobile, is likely to result in a greater response to nutrition interventions resulting in improved clinical and economic outcomes. This has been observed in malnourished patients with chronic obstructive pulmonary disease (COPD), where evidence for nutritional support in the hospital setting is limited beyond improving intake and attenuating nutritional losses. However, in the outpatient setting there is Level I evidence (NHMRC) showing nutritional support in stable (non-acutely unwell COPD outpatients) results in significant improvements in nutritional status, functional capacity and quality of life.

A recent economic analysis by the Southampton National Institute for Health Research Biomedical Research Centre on the behalf of the British Association of Parenteral and Enteral Nutrition found the potential cost savings from better implementation of the identification and management of malnutrition across the continuum of care in England could result in savings to the National Health Service of over £200 million per year. However, in order to realise these clinical and economic improvements, best practice nutritional care faces a number of challenges. Firstly, the need to improve the coordination of nutritional care from the hospital setting to the community. Data from UK, Scandinavia and the US suggests only 20% of malnourished patients leave hospital with a clearly documented nutritional care plan as part of a discharge summary. Secondly, how to provide ongoing support to outpatients and their family in the community setting.

Currently in Queensland, malnourished patients admitted to the large tertiary hospitals are likely to receive world-leading nutritional care, but coordination of nutritional care post-discharge remains a challenge and where it does occur additional challenges present themselves. Recent research completed within Metro South Hospital and Health Service, investigated the effectiveness of multi-modal oral nutritional support in treating malnutrition in outpatients with COPD. Nutrition support was effective, with patients gaining a significant amount of body weight and reporting improvements in quality of life that exceeded the minimal important clinical difference (i.e. a meaningful improvement to the patient). However, 70% of outpatients were unwilling or unable to attend their dietetic clinic appointment which then required a home visit and adherence to oral nutritional supplements (ONS) was only 50%. The fact that non-adherence to ONS was associated with a non-response to treatment (malnutrition went untreated) and 70% of outpatients required a home visit by the dietitian highlights the need for innovative solutions around both the delivery of care and supporting patients implementing management plans.

by PFCollins on May 24, 2019 at 02:36PM

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