1/29/20161 Identifying Malnutrition in the Adult Patient It Makes “Cents” Maria Browning, MS, RDN, CNSC

Objectives/Outline What is Malnutrition: breaking down the consensus statement Where does malnutrition fit: Value Based Purchasing, CMS and coding How does malnutrition make cents Next steps 1/29/20162

WHERE WE HAVE BEEN AND WHERE WE ARE NOW Malnutrition 1/29/20163

Defining Malnutrition Simply put malnutrition begins when food and nutrient intake are consistently inadequate Inadequate intake results in changes in weight, body composition, and physical function Malnutrition in hospitalized or chronically ill patients is often a combination of cachexia (disease related) and malnutrition (inadequate consumption of nutrients) as apposed to malnutrition alone Baker, et al., 2011

Consequences of Malnutrition Multicenter retrospective analysis showed pt’s with pre-existing malnutrition had increased risk of C-diff, surgical site infection, postoperative pneumonia, >5 fold higher risk of mediastinitis, and catheter associated UTI Immune suppression, delayed wound healing, pressure ulcer formation, functional losses leading to increased fall risk Longer hospital stays Baker, et al., 2011

Malnutrition: Where we have been Historically based on the serum proteins albumin and prealbumin Merck Manual guidelines followed by CMS Should malnutrition be a “never” event in hospitals? 1/29/20166

Merck Manual Table MeasurementNormal Mild Undernutrition Moderate Undernutrition Severe Undernutrition Normal weight (%) 90–11085–9075–85< 75 Body mass index (BMI) 19–24*18–18.916–17.9< 16 Serum albumin (g/dL) 3.5–5.03.1–3.42.4–3.0< 2.4 Serum transferrin (mg/dL) 220–400201–219150–200< 150 Total lymphocyte count (per µL) 2000– – –1500< 800 Delayed hypersensitivity index † 2210 *In the elderly, BMI < 21 may increase mortality risk. † Delayed hypersensitivity index uses a common antigen (eg, one derived from Candida sp or Trichophyton sp) to quantitate the amount of induration elicited by skin testing. Induration is graded: 0 =< 0.5 cm, 1 = 0.5–0.9 cm, 2 =≥ 1.0 cm. 7 Values Commonly Used to Grade the Severity of Protein-Energy Undernutrition

Malnutrition: Where we are now Malnutrition Consensus statement of 2012 Etiology based malnutrition diagnosis 6 independent criteria used to support malnutrition in the acute, chronic and social etiologies of malnutrition 1/29/20168

The Consensus Statement Purpose is to define malnutrition for adults in all settings Current approaches to diagnosis malnutrition vary widely and lack evidence A.N.D and A.S.P.E.N recommend a standardized set of diagnostic characteristics to be use to identify and document adult malnutrition White, et al., 2012

Etiology-Based Malnutrition Definitions

Characteristics of Malnutrition 1) Insufficient food and nutrient intake 2) Weight loss over time 3) Loss of muscle mass 4) Loss of fat mass 5) Fluid accumulation 6) Diminished functional status White, et al., 2012

Energy Intake and Weight Loss Review diet history Assess current intake Compare actual intake vs. requirements Trend measured weights Determine percent of weight loss over time Consideration of fluid balance alterations Body composition changes might mask weight loss White, et al., 2012

Physical Assessment Muscle mass evaluation –Temporalis, Pectoralis, Deltoids, Trapezius, Interosseous, Quadriceps Body fat evaluation –Temple, chest/ribs, arms, legs Malone, 2012

Fluid Accumulation On physical exam assess for edema –Generalized or localized fluid accumulation Edema can mask actual weight loss White, et al., 2012

Edema: Etiology Generalized Edema: –Heart Failure –Cirrhosis –Nephrotic Syndrome –Massive Fluid Resuscitation in Trauma Patients Clinically Evident on Exam Pitting Non-pitting

Functionality Hand Grip Strength –A diminished hand grip shows functional decline and is related to malnutrition –Currently it’s the only validated tool used to document function decline Other Functional Makers –Assess overall energy, strength, and endurance –Examples: ability to perform ADL’s, wean from mechanical ventilator White, et al., 2012

Malnourished? Each of the characteristics used to diagnosis malnutrition may be seen in patients who malnutrition is not the appropriate diagnosis White, et al., 2012

VALUE BASED PURCHASING Pay for performance, the reward and penalty of: 1/29/201618

Evolution of Value Based Purchasing 1/29/ *

Performance Impact on FY 2016 & FY *

Value Based Purchasing FY2017 Outcomes (3 measures) –AMI 30 day Mortality –HF 30 day Mortality –PN 30 day Mortality

Value Based Purchasing FY2017 Safety (7 measures) –Catheter associated urinary tract infection –Central line associated blood stream infection –Surgical site infection (colon, hysterectomy) –MRSA (methicillin resistant staph aureus) –C. difficile –Patient Safety Indicator PSI-90

PSI-90 Components PSI 06 Iatrogenic Pneumothorax Rate PSI 07 Central Venous Catheter-Related Blood Stream Infection RatePSI 07 Central Venous Catheter-Related Blood Stream Infection Rate PSI 08 Postoperative Hip Fracture RatePSI 08 Postoperative Hip Fracture Rate PSI 09 Perioperative Hemorrhage or Hematoma Rate PSI 10 Postoperative Physiologic and Metabolic Derangement Rate PSI 11 Postoperative Respiratory Failure RatePSI 11 Postoperative Respiratory Failure Rate PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis RatePSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate PSI 13 Postoperative Sepsis RatePSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Accidental Puncture or Laceration Rate 1/29/201623

Hospital Readmission Reduction Program FY2017 All cause readmission –AMI –HF –PN –COPD –Elective Hip Arthroplasty –Elective Knee Arthroplasty –Coronary Art Bypass Graft Up to 3% penalty! 1/29/ *

MALNUTRITION VARIABLES FOR AMI, HF, PNEUMONIA, COPD AND STROKE CMS 2015 Measure Updates: 1/29/201625

CMS 2015 Measure Updates 2015 Condition-Specific Measures Updates and Specifications Report –Hospital-Level 30-Day Risk-Standardized Mortality Measures –Hospital-Level 30-Day Risk Standardized Readmission Measures Charts from report are simplified to show top 5 results and nutrition related risk factors. 1/29/201626

Odds Ratio An odds ratio (OR) is a measure of association between an exposure and an outcome 1. The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure 1. 1/29/201627

Odds Ratio 1/29/ OR=1 Exposure does not affect the odds of the outcome OR>1 Exposure associated with higher odds of outcome OR<1 Exposure associated with lower odds of outcome

Mortality and AMI 1/29/ Anterior myocardial infarction (ICD-9 codes )2.23 2Metastatic cancer, acute leukemia and other severe cancers (CC 7-8)2.02 3Other location of myocardial infarction (ICD-9 codes )1.67 4Protein-calorie malnutrition (CC 21)1.66 5Pneumonia (CC ) Diabetes mellitus (DM) or DM complications except proliferative retinopathy (CC 15-20, 120) 1.1 Table – Adjusted OR for the AMI Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day mortality following AMI by Top Results: Other Nutrition Related Results:

Mortality and HF 1/29/ Protein-calorie malnutrition (CC 21) Metastatic cancer, acute leukemia and other severe cancers (CC 7-8) Chronic liver disease (CC 25-27) Dementia or other specified brain disorders (CC 49-50) Pneumonia (CC ) 1.32 Table – Adjusted OR for the HF Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30day mortality in HF patients by Top Results: Other Nutrition Related Results: 18 Diabetes mellitus (DM) or DM complications except proliferative retinopathy (CC 15-20, 120) 0.98

Mortality and Pneumonia 1/29/ Table – Adjusted OR for the Pneumonia Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day mortality in Pneumonia by Top Results: Other Nutrition Related Results: 1 Metastatic cancer, acute leukemia, and other severe cancers (CC 7-8) Protein-calorie malnutrition (CC 21) Dementia or other specified brain disorders (CC 49-50) Chronic liver disease (CC 25-27) Cardio-respiratory failure or shock (CC 79) Iron deficiency or other unspecified anemias and blood disease (CC 47) 1.18

Mortality and COPD 1/29/ Table – Adjusted OR for the COPD Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day mortality in COPD by Top Results: Other Nutrition Related Results: 8 Iron deficiency or other unspecified anemias and blood disease (CC 47) Diabetes mellitus (DM) or DM complications (CC 15-20, ) Metastatic cancer or acute leukemia (CC 7)2.37 2Protein-calorie malnutrition (CC 21)2.12 3Lung, upper digestive tract, and other severe cancers (CC 8)1.83 4Cardio-respiratory failure or shock (CC 79)1.45 5Decubitus ulcer or chronic skin ulcer (CC )1.35

Mortality and Stroke 1/29/ Table – Adjusted OR for the Stroke Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day mortality after Stroke by Top Results: Other Nutrition Related Results: 1 Metastatic cancer, acute leukemia and other severe cancers (CC 7-8) Protein-calorie malnutrition (CC 21) Specified arrhythmias (CC 92) Quadriplegia, other extensive paralysis (CC 67-69) Pneumonia (CC ) Iron deficiency or other unspecified anemias and blood disease (CC 47) 1.2

Readmission and AMI 1/29/ Table – Adjusted OR for the AMI Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day readmission due to AMI by Top Results: Other Nutrition Related Results: 1 Metastatic cancer, acute leukemia and other severe cancers (CC 7-8) Protein-calorie malnutrition (CC 21) Specified arrhythmias (CC 92) Quadriplegia, other extensive paralysis (CC 67-69) Pneumonia (CC ) Iron deficiency or other unspecified anemias and blood disease (CC 47) 1.2

Readmission and HF 1/29/ Table – Adjusted OR for the HF Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Iron deficiency anemia increases the risk of 30 day readmission due to HF by Top Results: Other Nutrition Related Results: 1 Renal failure (CC 131) Severe hematological disorders (CC 44) Metastatic cancer or acute leukemia (CC 7) Chronic obstructive pulmonary disease (COPD) (CC 108) Congestive heart failure (CC 80) Iron deficiency or other unspecified anemias and blood disease (CC 47) Diabetes mellitus (DM) or DM complications (CC 15-20, ) Protein-calorie malnutrition (CC 21) 1.08

Readmission and Pneumonia 1/29/ Table – Adjusted OR for the Pneumonia Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Iron deficiency anemia increases the risk of 30 day readmission due to Pneumonia by Top Results: Other Nutrition Related Results: 1 Metastatic cancer or acute leukemia (CC 7) Severe hematological disorders (CC 44) Chronic obstructive pulmonary disease (COPD) (CC 108) Iron deficiency or other unspecified anemias and blood disease (CC 47) Lung, upper digestive tract, and other severe cancers (CC 8) Disorders of fluid/electrolyte/acid-base (CC 22-23) Protein-calorie malnutrition (CC 21) Diabetes mellitus (DM) or DM complications (CC 15-19, ) 1.08

Readmission and COPD 1/29/ Table – Adjusted OR for the COPD Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of disorders of fluid/electrolyte/acid-balance increases the risk of readmission due to COPD by Top Results: Other Nutrition Related Results: 1 Metastatic cancer or acute leukemia (CC 7) Cardio-respiratory failure or shock (CC 79) Lung, upper digestive tract, and other severe cancers (CC 8) Congestive heart failure (CC 80) Severe hematological disorders (CC 44) Disorders of fluid/electrolyte/acid-base (CC 22-23) Protein-calorie malnutrition (CC 21) Diabetes mellitus (DM) or DM complications (CC 15-20, ) 1.05

Readmission and Stroke 1/29/ Table – Adjusted OR for the Stroke Hierarchical Logistic Regression Model from 07/ /2014 Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day readmission due to Stroke by Top Results: Other Nutrition Related Results: 1 Metastatic cancer or acute leukemia (CC 7) End-stage renal disease or dialysis (CC ) Protein-calorie malnutrition (CC 21) Iron deficiency or other unspecified anemias and blood disease (CC 47) Severe hematological disorders (CC 44) Diabetes mellitus (DM) or DM complications (CC 15-20, ) Disorders of fluid/electrolyte/acid-base (CC 22-23) 1.12

WHAT IS THE VALUE? Coding and Clinical Documentation 1/29/201639

1/29/ Performance Index Severity Adjusted Data Observed mortality Expected mortality from severity adjusted DRGs = 1; as good as the next guy -  <1; preferred provider – significantly better  >1; excessive mortality; find another provider -  Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing = 1

1/29/ /29/ CDIP Metrics A quality Clinical Documentation Improvement Program will influence the following metrics:  Severity of Illness (SOI) & Risk of Mortality (ROM) – these metrics range from level 1 (minor) to level 4 (extreme) SOI – looks at the co-morbid illnesses of the patients ROM – the mortality likelihood based on the present diseases  Mortality Index – ratio of the actual mortality/ the expected mortality. The lower the metric the better performer. If this metric is over 1, then it perceives that the facility is providing a substandard quality of care. Accurate and complete physician documentation will allow for precise coding and assignment of the SOI and ROM levels which will result in representing the true acuity of the patient population. The SOI and ROM are utilized in calculating the facilities Mortality Index which is widely used for quality outcomes benchmarking.

1/29/ /29/ CDIP Metrics, cont… SOI (Severity of Illness) ROM (Risk of Mortality) MI (Mortality Index) Documentation Supported Higher Level of Acuity Documentation Supported Higher Risk of Mortality Better Performer Higher Quality of Care

1/29/ /29/2016 Is There a Diagnosis? 82 yo WF shaking chills, fevers, altered mental status, decr UO, T = 103, P = 124, R = 34, BP = 70/40 persistent despite 1 L NS, on Dobutrex, pO 2 = 78 on non- rebreather, pH = 7.18, pCO 2 = 105, WBC = 17,500, left shift, BUN = 78, Cr = 5.4, CXR – RUL infiltrate, start Cefipime, Clinda, Tx to ICU. May have to intubate – full resusc.

1/29/ /29/2016 Which better reflects SOI? Assessment/Plan 82 YO F patient presented to ER with Fever of unknown origin, shaking chills, hypotension, azotemia, elevated Creatinine, respiratory insufficiency, and respiratory acidosis Will transfer to ICU, continue Dopamine and monitor respiratory status for possible worsening of her hypoxemia/insufficiency and initiate Cefipime, Clinda for pulmonary infiltrates. CC time 1hr 45 minutes John Smith MD Assessment/Plan 82 YO F patient presented to ER with 1. Septic Shock, 2. Acute Respiratory Failure, 3. Acute Renal Failure, 4. Probable Aspiration pneumonia Will transfer to ICU, continue Dopamine and monitor respiratory status for possible worsening of her Ac Resp Failure and initiate Cefapime/clindamycin for possible …… aspiration pneumonia (?organism, etiology) CC time 1hr 45 minutes John Smith MD

1/29/ /29/2016 So What’s the Difference? Principal DiagnosisChills and FeverSevere Sepsis Secondary Diagnoses Hypotension Respiratory acidosis Renal insufficiency Altered mental status Lung infiltrates Septic Shock Acute Respiratory Failure Acute Renal Failure (AKI) Metabolic Encephalopathy Aspiration Pneumonia Medicare MS-DRG864 Fever w/o CC/MCC871 Septicemia or severe Sepsis w/o MV 96+ hrs w/ MCC APR-DRG722 Fever720 Septicemia & Disseminated infection APR-DRG Severity of Illness1 – Minor4 – Extreme APR-DRG Risk of Mortality1 – Minor4 – Extreme Medicare MS-DRG Rel Wt APR DRG Relative Weight National Mortality Rate (APR Adjusted) 0.04%62.02%

1/29/ /29/2016 Case Example Assessment/Plan 79 YO F pt presented to ER w/ –Decompensated Systolic HF –AFib, –CAD, –DM, –Malnutrition - Unspecified LOS = 3 days Assessment/Plan 79 YO F pt presented to ER w/ Decompensated Systolic HF, AFib, CAD, DM, Malnutrition – Alb 1.9 BMI under 19 LOS = 3 days Medicare MS-DRG 292 – Heart Failure & Shock w/CC 291 – Heart Failure & Shock w/ MCC Severity of Illness2 – Moderate3 – Major Risk of Mortality2 – Moderate3 – Major Average LOS3.1 days5.9 days Medicare MS-DRG Relative Weight

WHAT MAKES “CENTS” Putting it all together 1/29/201647

Malnutrition and the Big Picture Aligned with hospital score card to meet quality standards Significant variable in risk adjust mortality and to some extent readmission risk Malnutrition contributes to actual coding a reimbursement Potential prevention of never events like wounds that are not reimbursable Prevention of other infections (CAUTI, C-diff) 1/29/201648

The Cost of Malnutrition August 2015 Data from and MH 1/29/ MalnutritionNo malnutritionTotals Patients VDC2,864,1365,104,7857,968,921 Cost per patient$18,968$9,132$11,224 2Xs the COST!

Future Directions Collect data to better understand acuity variables Uses current data to advocate for nutrition and dietitians in the hospital Create better processes to ensure adequate nutrition 1/29/201650

Special Thanks Ann Cotton, Emily Myatt, Allison Sattison, Audrey Dubord, Lena Wilson and Carla Zacchondi IAND 1/29/201651

Thank You! 1/29/201652