10yearsofscreening Didweachieve

thegoals?
Screeningtools:doesonesizefitsall?
ESPENCongressBarcelona2012
M. Van Bokhorst (Netherlands)
Screening Tools:
does one size fit all?
Marian A.E. van Bokhorst de van der Schueren
3
Purposes of screening
Defining nutritional status
Predicting outcome
Predicting responsiveness
to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA, MUST
4
5
Systematic Review
Pubmed, Embase, Cinahl, searched on February 2, 2012
Keywords on:
Screening / assessment
Malnutrition
Setting: hospitals
Limits: adults, humans
Filter for validation studies
Languages: English, French, German, Spanish, Portuguese
6
Pub Med: 3667 Cinahl: 1776 Embase: 3606
After checking for duplicates: 7357
Included for further investigation: 279
Excluded based on abstracts: 7078
Exluded based on full text: 192
Additional 7 references from manual
searches of the reference lists and
review articles
Total number of studies: 94
Total number of screening tools: 39
Total 9049
7
Study characteristics
Inpatients: 37 studies
32 studies on validity of a screening tool vs. a reference
standard or vs. outcome
5 studies on validity of a screening tool, whereby
malnourished patients were given nutritional support
Outpatients: 2 studies
8
Exlusion criteria
Tools not expressing clinimetric assessment (i.e. validity, reproducibility), but
only defining a percentage of malnutrition (no validation study)
Tools that were developed but never cross validated in another population
Studies < 25 patients
Modified versions, e.g. Taiwanese modification of tool xx
Tools exclusively consisting of lab values (in the first question), e.g.
Prognostic Nutritional Index/CONUT/INFONUT
Circle reasoning to validate
9
Circle reasoning
Tool A:
Question A1
Question A2
Tools B:
Question B1
Question B2
Question B3
Question B4
Tool C:
Question C1
Question C2
Question C3
Question A1
Question A2
Question B1
Question B2
Question B3
Question B4
Question C1
Question C2
Question C3
Tools to be validated Gold Standard
10
Circle reasoning?
SF-MNA to MNA
(Rubenstein, J . Gerontol. 2001)
PG- SGA to SGA
(Ottery, Semin. Oncol. 1994)
Excellent validity to the reference
standard
Applicability of the short form vs.
the long form
Full MNA
Short
form
11
Gold Standard?
No gold standard, no expression of criterion validity
Another tool / assessment: semi-gold standard
(construct validity)
Why?
the new tool can never be better than the original one
you should have serious reasons for not using the original
tool, .e.g. too time consuming / too invasive
12
Semi-gold standard
SGA validated against tool NRS-2002
1
se 85%, sp 69%, PPV 85%, NPV 69%
NRS-2002 validated against SGA
2
se 61%, sp 76% , PPV 65%, NPV 76%
1. Martins et al, J . of Nutr. for the Elderly (2005) 25, 5-21
2. Kyle, Clinical Nutrition (2006) 25, 409417
NRS-2002 SGA
13
Gold standards applied
55
15
14
9
7
3
2 2
1 1
0
10
20
30
40
50
60
Outcome (LOS,
complications, death)
Nutr assessment /
anthropometry
Assessment professional
SGA
MNA
MUST
pre-alb
NRI
NRS-2002
responsiveness to nutr
support
NRS, alb, MNA-SF, PG-SGA,
MIS, each 1 study
14
Purposes of screening
Defining nutritional status
Predicting outcome
Predicting responsiveness
to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA, MUST
15
Use of screening tools
Defining nutritional status
Predicting outcome
Predicting responsiveness
to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA,
MUST
16
Defining nutritional status
Predicting outcome
Predicting responsiveness
to nutritional support
NRS-2002
SGA, PNI, GNRI
SNAQ, NRS, NRI, MNA,
MUST
Age
MUST
17
Mess!
18
Structuring (1)
Predictive validity of different tools on outcome
LOS
(postoperative) complications
mortality
19
Structuring
Good Good/fair Fair Poor ??
Sensitivity /
Specificity
Se AND
Sp >
80%
Se OR SP
<80%, but both
>50%
Se
OR
Sp <
50%
Odds Ratio
/ Hazard
Ratio
> 3 2-3 < 2
Kappa > 0.6 0.4-0.6 < 0.4
AUC > 80 60-80 < 60
Correlation
Coefficient
> 0.70 0.40-0.70 < 0.40
P value < 0.05 and
n < 200 *
> 0.05 < 0.05 and
n > 200 **
* no indication of effect size? ** true effect or sample size effect
20
Inpatients ~ predicting outcome
Study including 705 patients, studying 6 different outcomes
Good Fair Poor
SGA-B - death - moderate or severe
compl
- severe compl or VLLOS or
death
- severe compl and
VLLOS and death
- severe compl
- VLLOS
SGA-C - death
- severe compl or
VLLOS or death
- VLLOS
- moderate or severe
compl
- severe compl and
VLLOS and death
- severe compl
NRS-2002 - death - moderate or severe
compl
- severe compl and VLLOS
and death
- severe compl
- severe compl or
VLLOS or death
- VLLOS
Raslan et al, Clinical Nutrition 30 (2011) 49-53
21
Inpatients ~ Predicting outcome
Good Good/fair? Fair Poor ??
SGA * (n=9),
1 study studying 6 outcomes for SGA B
and 6 for SGA C
6 3 8 3
MUST (7 studies) 2 2 1 1 1
NRS-2002 (5 studies)
1 study studying 6 outcomes
1 5 2 3
NRI (5 studies)
1 study studying 2 outcomes
1 2 3
PG-SGA (2 studies) 1 1
MST (2 studies) 1 1
MNA, MNA-SF, Birmingham NR
(all 1 study)
2 1
No instrument superior in predicting outcome
* designed to predict outcome
MUST reasonable?
22
Geriatrics ~ Predicting outcome
Good Good/fair? Fair Poor ??
MNA * (9 studies) 1 2 3 3
SGA (4 studies) 1 3
MNA-SF (3 studies) 1 1 1
MUST (3 studies) 2 1
NRI (3 studies) 1 2
NRS-2002 (2 studies) 1 1
Birmingham NR, PG-SGA,
NUFFE, Rapid Screen (all 1
study)
1 2 1
None of the instruments has good predictive validity regarding outcome
* Originally designed for determining nutritional status in the elderly
23
Surgical patients~ Predicting outcome
Good Good/fair? Fair Poor ??
SGA (6 studies)
1 study studying 2 outcomes
1 1 2 1 2
NRS-2002 (1 study)
1 study studying 2 outcomes
1 1
NRS (2 studies) 1 1
NRI, MUST, MCRS, ANS,
nutrition risk classification, MNA,
MST (all 1 study)
1 2 3 1
No instrument scores superior in predicting outcome.
NRS-2002 only 1 study with good/fair results
24
HD / renal ~ Predicting outcome
Good Fair Poor ?? Conflicting
MIS (3 studies)
1 study studying 2
outcomes
2 1 1 study/2 outcomes
- poor for LOS
- ? for mortality
SGA (4 studies) 1 2 1 study good/fair
1 study/2 outcomes:
- poor for hospital
days
- good for mortality
MUST, MST,
objective score
haemodialysis (all 1
study)
1
(obj.score
)
1 1
MIS reasonable in predicting outcome of HD/renal patients
Objective Score of Nutrition on Dialysis: good in predicting mortality,
however needs confirmation in more studies
25
Predicting outcome
Most tools, most studies: fair or poor predictive validity
No single superior tool
Sometimes positive on predicting LOS, not mortality; in another
study the other way around
Many studies difficult to interpret because only reporting in p-
values
Responsiveness of nutrition therapy to these tools understudied
26
Structuring (2)
Comparison of different tools within one study, one
population, same outcome measure
No bias due to study population or outcome parameter
27
One population, validity of
tool to anthropometry / assessment
MST fair all inpatients Neelemaat, J Clin Nurs 2011
SNAQ fair
MUST good
NRS-2002 good
MST fair elderly >60 Neelemaat, J Clin Nurs 2011
SNAQ fair
MUST good
NRS-2002 good
MNA-SF poor
NRS fair hosp <65 Corish, J Hum Nutr Diet 2004
NRI poor
NRS good hosp >65 Corish, J Hum Nutr Diet 2004
NRI good
MIS fair haemodial Kalantar-Zahed, Am J Kidn Disease 2001
SGA poor
28
One population, validity of
tool to assessment by a professional
MNA good geriatric Visvanathan, Age and Ageing 2004
Rapid screen poor
Simple screening tool 1 fair acute care
elderly
Laporte, J Nutr Health Aging 2001
Simple screening tool 2 fair
Nutrition Screening tool fair inpatients Elmore, J ADA 1994
Nutrition Screening
equation
poor
Who is performing poorly?
29
One population, validity of tool to SGA
MUST fair renal inpatients Lawson, J Ren Nutr 2012
MST poor
NRS-2002 good surgical Almeida, Clin Nutr 2012
MUST good
NRI poor
NRS-2002 fair newly admitted Kyle, Clin Nutr 2006
MUST fair
NRI poor
Pitfall: new tool can never be better than the reference tool
30
One population, validity of tool to MNA
MEONF-II fair elderly Westergren, BMC Nursing 2011
NRS-2002 poor
INSYST-I good inpatients Tamman, J Hum Nutr Diet 2009
INSYST-II fair
Pitfall: new tool can never be better than the reference tool
31
Conclusion (1)
One size does NOT fit all!
Know what you want to measure:
Nutritional status?
Outcome?
Responsiveness to nutritional intervention?
Know which population you want to measure in
Then choose your tool
32
Recommendations
Dos:
studies applying >1 tool in 1 population, 1 outcome measure
effects of nutritional intervention in patients at risk
outpatients
Donts:
develop new tools
33
Co-workers
Ilse J ansma
Riekie de Vet
Patricia Guaitoli