Advertisement

NOTICE: We are experiencing technical issues with Academy members trying to log into the JAND site using Academy member login credentials. We are working to resolve the issue as soon as possible. Alternatively, if you are an Academy member, you can access the JAND site by registering for an Elsevier account and claiming access using the links at the top of the JAND site. Email us at [email protected] for assistance. Thanks for your patience!

Quality Improvement as the Foundation for Health Care Advancement

Published:August 22, 2019DOI:https://doi.org/10.1016/j.jand.2019.05.026

      Abstract

      The rising cost of health care continues to be a key driver of the growing national debt. Improving the nation’s health requires a dedicated and holistic advancement of access to quality and affordable patient-centered health care, as well as a strong focus on the core elements of prevention, including nutrition. Programs must be put in place, such as the Malnutrition Quality Improvement Initiative (MQii), to identify and address the root causes of malnutrition. Registered dietitian nutritionists have an important role to lead malnutrition quality improvement efforts in their organizations to promote better patient health outcomes, keep health care costs affordable, and protect Medicare. It is a unique time where there is an opportunity to achieve meaningful change in malnutrition care, and working together to implement quality improvement programs can ensure the health and vitality of current and future generations of Americans.

      Funding/Support

      Publication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

      Keywords

      Statement of Potential Conflict of Interest: See page S17.
      As a nation, there is much to be proud of, from leading technologies to life-saving scientific discoveries. Yet, the rising cost of health care continues to be a key driver of our growing national debt, limiting opportunities for other areas of investment that are important for our citizens’ and our country’s long-term prosperity and growth. In fiscal year 2017, 31.4% of all federal spending was for health programs.
      US Office of Management and Budget. Historical tables. Table 15.1—Total outlays for health programs: 1962-2023.
      With total health care spending projected to continue to rise to be nearly one-fifth of the economy by 2027, never before has there been such a need for a health care system to deliver better-quality care at a lower cost. Malnutrition contributed to 2.2 million, or 8%, of nonmaternal and non-neonatal inpatient stays, in 2016, demonstrating the need for increased attention to the problem across all health care and community sectors.
      • Barrett M.L.
      • Bailey M.K.
      • Owens P.L.
      Non-maternal and non-neonatal inpatient stays in the United States involving malnutrition, 2016.
      Improving the nation’s health requires a dedicated and holistic advancement of access to quality and affordable patient-centered health care, as well as a strong focus on the core elements of prevention, including nutrition.

      Focusing on Those at Greatest Risk

      Malnutrition—both undernutrition and overnutrition—can lead to and exacerbate acute and chronic medical conditions, especially among older adults, who as estimated by the US Census Bureau, will exceed 20% of the US population by 2030.
      • United States Census Bureau
      2030 marks important demographic milestones for U.S. population.
      A 2017 Congressional Research Service report to Congress on Malnutrition in Older Adults
      • Dabrowska A.
      Congressional Research Service Memorandum. Malnutrition in older adults.
      cited one study that summarized that malnutrition affects as many as 60% of hospitalized older adult patients.
      • Sauer A.C.
      • Alish C.J.
      • Strausbaugh K.
      • West K.
      • Quatrara B.
      Nurses needed: Identifying malnutrition in hospitalized older adults.
      Programs such as the Malnutrition Quality Improvement Initiative (MQii), a project of the Academy of Nutrition and Dietetics (Academy), Avalere Health, and other stakeholders, must be put in place to identify and address the root causes of malnutrition, whether it is associated with disease, linked to food insecurity, or resulting from multiple social determinants. Helping seniors stay healthy and active is important to support their best quality of life and to promote patient engagement.
      Older adults, on average, spend more on health care than any other age group. It is estimated that the cost of disease-associated malnutrition for older adults is $51.3 billion annually.
      • Snider J.T.
      • Linthicum M.T.
      • Wu Y.
      • et al.
      Economic burden of community-based disease-associated malnutrition in the United States.
      Similar to other chronic diseases for which nutrition is a factor, viewing malnutrition through a health equity lens suggests a notable health disparity, with African Americans more than twice as likely to experience nutrition neglect and nearly 50% more likely to suffer from cachexia during in-patient hospital stays.
      • Barrett M.L.
      • Bailey M.K.
      • Owens P.L.
      Non-maternal and non-neonatal inpatient stays in the United States involving malnutrition, 2016.
      Focusing on older adults at greatest risk requires professionals to provide nutrition education and interventions that not only are culturally targeted and innovative, but include scientific evidence representative of diverse populations.
      • Satia J.Q.
      • Watters J.L.
      • Galanko J.A.
      Validation of an antioxidant nutrient questionnaire in whites and African Americans.

      Making a Commitment to Change

      The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) estimated that 30% of total US health care spending is used for unnecessary, ineffective, overpriced, and wasteful services.
      Institute of Medicine (IOM)
      Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
      Thus, it is not surprising that the Centers for Medicare and Medicaid Services has multiple programs focused on improving health care quality and value. Quality is directly linked to a health organization’s underlying processes of care, including malnutrition care. Quite simply, to achieve better health care quality, the current health systems need to change and that change needs to occur at multiple levels within and across organizations. Centers for Medicare and Medicaid Services has acknowledged that malnutrition care represents an important gap area.
      Hospital inpatient prospective payment system for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2018 rates CMS-1677-P, 82 Fed Reg 37990 (August 14, 2017).
      Yet, as identified in National Blueprint: Achieving Quality Malnutrition Care for Older Adults, malnutrition has not been integrated into public or private quality incentive programs.
      The Malnutrition Quality Collaborative
      National Blueprint: Achieving Quality Malnutrition Care for Older Adults.
      The MQii provides the framework for health care organizations to initiate change by evaluating what care is currently provided and how it is provided, and where there are gaps for malnutrition care improvement.

      Leveraging the Data

      When Congress passed the Health Information Technology for Economic and Clinical Health Act as part of the 2009 American Recovery and Reinvestment Act (https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html), providers were incentivized to implement electronic health records. Data is the cornerstone of quality improvement, and electronic health records hold the promise of yielding data to determine how well current systems are working, and what happens when changes are applied documenting successful performance on quality measures. Implementation of the malnutrition electronic clinical quality measures and collective assimilation of data from these measures lays the foundation for continued advocacy to integrate malnutrition screening and intervention into public and private quality incentive programs. Similarly, at the national level, data will be important for a forthcoming Government Accountability Office report requisitioned to determine if federally funded programs meet the nutritional needs of the older adults served.
      Defeat Malnutrition Today
      GAO Request Made on Nutritional Quality in Federal Programs for Older Adults.

      Educating the Health Care Interdisciplinary Team

      Interdisciplinary and integrated care was one of the hallmarks of the Patient Protection and Affordable Care Act (https://www.hhs.gov/healthcare/about-the-aca/index.html). Today’s health care organizations are transitioning toward an interdisciplinary team-based model of care, in which traditional health professionals work alongside community health workers or other providers, bringing together complementary skills toward the goal of improving patient outcomes. Similarly, quality improvement is a team process, and a malnutrition-focused quality improvement program provides the opportunity to support a more holistically-focused approach to patient care. Registered dietitian nutritionists can use the tools of the MQii to invest in educating and training their organization's health care workforce to better identify and intervene for malnutrition. In addition, the resources included and outcomes data from the MQii can be effective in communicating how malnutrition impacts health care costs and quality with hospital leaders and executives.
      The number of Medicare enrollees is expected to increase from 57 million in 2017 to 74 million by 2027. Registered dietitian nutritionists have an important role to lead malnutrition quality improvement efforts in their organizations to promote better patient health outcomes, keep health care costs affordable, and protect Medicare. There is also an opportunity for national advocacy. In October 2018, over 1,400 credentialed nutrition and dietetics practitioners attended the Academy’s largest-ever Public Policy Workshop to encourage members of Congress to include the diagnosis and treatment of malnutrition as a component of high-quality health care. During a Capitol Hill rally and visits to Congressional offices, Academy members emphasized the essential roles of credentialed nutrition and dietetics practitioners in comprehensive malnutrition care.
      • Russell M.
      Priority: Prevent, identify, treat malnutrition.
      It is a unique time where there is an opportunity to achieve meaningful change in malnutrition care. Working together to implement quality improvement programs can ensure the health and vitality of current and future generations of Americans.

      Acknowledgements

      We thank Catherine D’Andrea RDN, LDN, Mujahed Khan, MBA, RDN, LDN, and Mary Beth, Arensberg PhD, RDN, for their critical review of the manuscript.

      Author Contributions

      J. Blankenship and R. B. Blancato developed the first draft of the manuscript with additional contributions from R. Kelly. All authors reviewed and commented on subsequent drafts of the manuscript.

      References

      1. US Office of Management and Budget. Historical tables. Table 15.1—Total outlays for health programs: 1962-2023.
        • Centers for Medicare and Medicaid Services
        National health expenditure data. NHE fact sheet.
        (Updated February 20, 2019. Accessed July 11, 2019)
        • Barrett M.L.
        • Bailey M.K.
        • Owens P.L.
        Non-maternal and non-neonatal inpatient stays in the United States involving malnutrition, 2016.
        (Published August 30, 2018. Accessed July 11, 2019)
        • United States Census Bureau
        2030 marks important demographic milestones for U.S. population.
        (Published September 6, 2018. Accessed July 11, 2019)
        • Dabrowska A.
        Congressional Research Service Memorandum. Malnutrition in older adults.
        (Published March 8, 2017. Accessed July 11, 2019)
        • Sauer A.C.
        • Alish C.J.
        • Strausbaugh K.
        • West K.
        • Quatrara B.
        Nurses needed: Identifying malnutrition in hospitalized older adults.
        NursingPlus Open. 2016; 2: 21-25
        • Snider J.T.
        • Linthicum M.T.
        • Wu Y.
        • et al.
        Economic burden of community-based disease-associated malnutrition in the United States.
        JPEN J Parenter Enteral Nutr. 2014; 38: 77s-85s
        • Satia J.Q.
        • Watters J.L.
        • Galanko J.A.
        Validation of an antioxidant nutrient questionnaire in whites and African Americans.
        J Am Diet Assoc. 2009; 109: 502-508
        • Institute of Medicine (IOM)
        Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
        The National Academies Press, Washington, DC2013
      2. Hospital inpatient prospective payment system for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2018 rates CMS-1677-P, 82 Fed Reg 37990 (August 14, 2017).
        • The Malnutrition Quality Collaborative
        National Blueprint: Achieving Quality Malnutrition Care for Older Adults.
        Avalere and Defeat Malnutrition Today, Washington, DC2017
        • Defeat Malnutrition Today
        GAO Request Made on Nutritional Quality in Federal Programs for Older Adults.
        • Centers for Medicare and Medicaid Services
        National Health Expenditure Data. Projected.
        (Updated February 26, 2019. Accessed July 11, 2019)
        • Russell M.
        Priority: Prevent, identify, treat malnutrition.
        J Acad Nutr Diet. 2019; 119: 11

      Biography

      J. Blankenship is vice president, Policy Initiatives and Advocacy, Academy of Nutrition and Dietetics, Washington, DC.
      R. B. Blancato is national coordinator, Defeat Malnutrition Today, Washington, DC.
      R. Kelly is a member of the US House of Representatives (Illinois-2) and chair, Congressional Black Caucus Health Braintrust, Washington, DC.