Original articleMalnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality☆
Introduction
Malnutrition is prevalent in the hospital setting with 20-50% of patients identified as malnourished at admission.1, 2 Poor nutrition has been adversely associated with a range of clinical, functional and economic outcomes.1, 3, 4 Malnourished patients have been shown to have a length of hospital stay 1.5–1.7 times longer than well-nourished patients.3, 4 They have also been shown to have a three-fold increase in mortality over a 12-month period post discharge.3
The prevalence of inpatient malnutrition and its related outcomes are likely to vary with different populations and health care settings. Yet there are few studies reporting prevalence of malnutrition in Asian hospitals and these have largely focused on older adults.5, 6, 7 The true prevalence of malnutrition in a Singapore acute-care hospital setting has not been clearly established. A previous study done in a large acute-care hospital in Singapore, found the “prevalence” to be 15% using Subjective Global Assessment (SGA).8 However, this figure is likely to be an underestimate as only patients screened to be at risk of malnutrition using the Malnutrition Screening Tool9 were assessed using SGA. Furthermore, patients were selected from four discipline-specific wards and hence may not be representative of all hospital patients.
Few studies have prospectively examined the long term clinical outcomes of malnutrition3 and consideration of the confounding effect of disease or diagnosis-related groups (DRG) is rare.10 Even fewer studies have investigated mortality outcomes using data from national death registers.3 Furthermore, most studies evaluating the prognostic significance of malnutrition have focused on Caucasian populations, whilst studies in Asian populations are scarce.1, 3, 4
The aim of this study was to comprehensively determine the prevalence of malnutrition and its impact on length of hospital stay, readmission, 3-year mortality and cost of hospitalization in patients newly admitted to an acute-care tertiary hospital in Singapore, across different DRG.
Section snippets
Study participants and study design
The study participants were patients newly admitted to National University Hospital (NUH), which is a 987-bed acute tertiary hospital, with a comprehensive range of medical and surgical specialties. Its catchment includes the western region of Singapore as well as complicated clinical cases that require specialist tertiary care from all over the country. To ensure that study subjects were as representative of the institution’s patient profile as possible, consecutive patients newly admitted to
Demographics of participants
A total of 1079 patients fulfilled the inclusion criteria and were eligible to participate in the study. From these, 818 (76%) patients participated in the study, 11 declined to participate and 250 were discharged within 48 hours of admission before SGA could be completed. The demographic profiles of the participants and of the hospital population are described in Table 1. The study sample was older than the hospital population (difference = 2.6 years, CI 1.48–3.58) but there was no difference in
Discussion
This study is amongst the first to examine the impact of malnutrition on length of hospital stay, readmission, hospitalization cost and mortality in a large sample representative of patients admitted to a major Singaporean tertiary hospital. In addition, few studies have controlled for the confounding effect of diagnosis on malnutrition outcomes or used national death register data to determine mortality outcomes. After controlling for the potential confounders of age, gender, ethnicity and
Conclusions
Malnutrition is evident in up to one third of the patients admitted to a Singapore tertiary hospital and leads to substantial increases in length of hospital stay, readmission rate, mortality and hospitalization cost when compared with well-nourished patients of similar diagnosis. As such, this study provides clear evidence that the adverse outcomes of malnutrition are not just a consequence of the disease process. Given the prevalence of malnutrition and its poor short and longer term
Statement of authorship
SLL conceptualized, designed and conducted the study, interpreted the data and wrote the manuscript. KCBO, WCL and MF provided significant advice on the design of the study and assisted in writing the manuscript. YHC performed statistical analysis and interpreted the data. LD interpreted the data, provided significant advice on the design of the study and assisted in writing the manuscript. All authors have made substantial contributions and approved the final manuscript.
Conflict of interest
None of the authors had any conflict of interest related to the authorship of the submitted paper.
Acknowledgements
The recruitment phase of this study was supported by the National Healthcare Group Small Innovative Grant (NHG-SIG).
We thank Ms Tan Ai Vee (Singapore Ministry of Health), Ms Cherie Tong (National University Hospital) and Ms Serene Wong (National University Hospital) for contributing part of the data collection and Dr Merrilyn Banks (Royal Brisbane & Women’s Hospital) for her advice on DRG. We also thank Mr. Dennie Hsu from National University Hospital for his unwavering support for this study.
References (34)
- et al.
Prognostic impact of disease-related malnutrition
Clin Nutr
(2008) - et al.
Assessing the prevalence of malnutrition with the Mini Nutritional Assessment (MNA) in a nationally representative sample of elderly Taiwanese
J Nutr Health Aging
(2008) - et al.
Malnutrition in the elderly and its relationship with other geriatric syndromes
Clin Nutr
(2010) - et al.
Development of a valid and reliable malnutrition screening tool for adult acute hospital patients
Nutrition
(1999) - et al.
Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service
J Am Diet Assoc
(1997) Nutritional assessment
Nutrition
(2000)Nutrition and health economics
Nutrition
(2006)- et al.
Nutritional status among adult patients admitted to an university-affiliated hospital in Spain at the time of genoma
Clin Nutr
(2004) - et al.
Geriatric Nutritional Risk Index and overall-cause mortality prediction in institutionalised elderly: a 3-year survival analysis
Clin Nutr
(2008) - et al.
Prevalence of the notification of malnutrition in the departments of internal medicine and its prognostic implications
Clin Nutr
(2011)
Improving malnutrition documentation enhances reimbursement
J Am Diet Assoc
Implications of malnutrition and diagnosis-related groups (DRGs)
J Am Diet Assoc
The economic impact of disease-related malnutrition at hospital admission
Clin Nutr
Nutritional assessment and management in hospitalised patients: implication for DRG-based reimbursement and health care quality
Clin Nutr
Diagnosis and treatment of (disease-related) in-hospital malnutrition: the performance of medical and nursing staff
Clin Nutr
Incidence and recognition of malnutrition in hospital
BMJ
Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals
Intern Med J
Cited by (653)
Sarcopenia does not affect liver regeneration and postoperative course after a major hepatectomy. A prospective study on 125 patients using CT volumetry and HIDA scintigraphy
2024, Clinics and Research in Hepatology and GastroenterologyNutritional status and nutritional intervention of older inpatients in China
2024, Journal of Nutrition, Health and AgingThe Updated Global Malnutrition Composite Score Clinical Quality Measure: Its Relevance to Improving Inpatient Clinical Outcomes and Health Equity
2024, Journal of the Academy of Nutrition and DieteticsSex-related differences in the impact of nutritional status on in-hospital mortality in acute coronary syndrome: A retrospective cohort study
2023, Nutrition, Metabolism and Cardiovascular Diseases
- ☆
Institution where the study was conducted, National University Hospital, Singapore.
- h
Tel.: +65 67726699.
- i
Tel.: +65 65163698.
- j
Tel.: +65 90604563.
- k
Tel.: +61 07 3240 5588.
- l
Tel.: +61 07 3138 6139.