February 2017- Question #3
The presence of malnutrition, especially in the form of cancer cachexia, increases the risk of hospital readmission and mortality. Using the evidence-based guidelines presented in the AND/ASPEN consensus statement and the continuing education article, how would you convince a physician to also document a malnutrition diagnosis in an oncology patient with laryngeal cancer? How would you respond if he references albumin as a marker of protein status?
posted by Unknown @ 4:46 PM
30 comments
30 Comments:
Documenting malnutrition is not only beneficial for the physician seeing this pt but is benefitial for the hospital. At DMH I have had the chance to work with the coders for insurance. While the process was being explained it amazed me the amount of money saved from coding patients as malnutrition and focusing on their needs to keep them from readmitting into the hospital. If the physician is a physician that works with albumin I would simply explain to the physician how up to date medical nutrition therapy is not including albumin as the only form of evidence and explain why and the different kinds.
It is important to address malnutrition status to assure the patient is given adequate care. First, in this example, laryngeal cancer is within the group of Head & Neck-- one of the cancers that puts patients at highest nutritional risk due to CT/RT in the head/neck region which greatly increases symptoms of taste changes, etc. Additionally, Head & Neck patients are at increased risk for needing Tube feeding related to surgery in that region. Thus, I would explain all these risk factors to the physician. In regards to using albumin as a marker for protein status I would inform the physician that albumin is not always a clear indicator for malnutrition as the value can be greatly altered by other factors, such as stress, and that we have significant research indicating other markers are more accurate at determining a patients nutritional status.
Malnutrition seen in hospitalized patients is often a combination of cachexia (disease-related) and malnutrition related (inadequate consumption of nutrients). This can be due to reduced intake of nutrients, decreased absorption, or a combination of both. Having doctors diagnose malnutrition can help not only the patient receive adequate care which is priority, but also reduce length of stay over time. While patients may need a longer hospitalization the first time they are admitted, it can prevent them from being readmitted. This can save a lot of dollars in the long run. Noel, I like the point you made regarding the need to look a little farther about the patient with laryngeal cancer. While they are already at a risk for malnutrition as they have cancer and the therapy can affect their energy consumption, they also have cancer in the head and neck category. This puts an additional concern due to possible nutrition support.
When talking with health professionals regarding albumin, I would mention the evidence-based research that concludes serum albumin not a useful marker for protein status, as this value is affected by a number of factors, most common including dehydration, stress, inflammation.
When discussing the use of acute phase proteins such as serum albumin as indicators of malnutrition with the physician mentioning the multiple influencers of this lab value would be required, as described by Noel. Further, I could share the these lab values have been found to not consistently or predictable change with weight loss, calorie restriction, or nitrogen balance (more validated indicators of malnutrition risk) according to AND research. Also, it would be beneficial to mention, albumin or pre-albumin would not make accurate indicators of malnutrition treatment/recovery in states of inflammation.
A patient with laryngeal cancer could be alternatively documented for malnutrition risk be criteria of %intake of energy/protein needs, or likely lack there of; measureable weight loss through EMR; perceivable loss of subcutaneous fat, muscle mass; or reduction of grip strength.
In my clinical experience, it became evident that more people are respecting malnutrition as a diagnosis and supporting it's documentation to achieve reimbursement. Communication among the healthcare team is key to assuring documentation is in agreement. If I discovered a laryngeal patient showed signs of malnutrition, I would contact the physician to let him/her know what I've found and request that the physician look into the case and hopefully confirm my diagnosis. From what I have learned, unless the physician documents malnutrition, it can be difficult to receive reimbursement. Many physicians still consider albumin an indicator of nutrition status. Requesting that the physician read the RD note explaining weight loss, loss of appetite, muscle wasting and fat depletion in a short period of time may allow the physician to understand that malnutrition is about more than just albumin levels. The RD may also explain that albumin is no longer considered a reliable marker of nutrition status as it is an acute phase responder so may fluctuate with stress levels common among all hospitalized patients. Ideally, communicating these established malnutrition diagnosis facts would help achieve consistent documentation and physical understanding of malnutrition.
Justine, I think you made a great point about brining the more important areas to light (loss of appetite, muscle wasting, fat depletion, weight loss) when discussing malnutrition in patients. I think this would be a good idea and would really highlight the real meaning of malnutrition.
As malnutrition is such a common concern in hospital patients, documenting malnutrition status can be a vital part to ensuring them the care they need as well as providing adequate funding and resources to give that care. Likely, with a patient suffering from cancer cachexia, they are also experiencing weight loss as well as lean tissue loss. If this patient is experiencing at least a 5% weight loss within a month, and at least mild muscle mass loss, this patient can be identified as malnourished according to the JAND. Additionally, other pieces such as changes in ability to perform ADLs, fluid retention, and subcutaneous fat loss can also bolster up the malnutrition diagnosis. Evidence based literature can be utilized to support these findings and their relevance to malnutrition status, and the literature can also counter the MDs suggestion to look at albumin. As albumin is no longer considered an accurate or relevant marker of protein status, the RD might discuss with the MD how that is no longer the standard for malnutrition diagnosis. Continuing to share resources and information about recommended malnutrition identification guidelines will be beneficial to aid the MDs understanding and use of malnutrition diagnoses. Continued communication between RD and MD will assist in making malnutrition guidelines clear and beneficial for patients.
We have discussed malnutrition diagnosis and associated lab values quite a bit in our current MNT course with guest speakers Robin Rinker and Angela Malinowki from Bromenn. Like many mentioned it is no doubt very important to assess and monitor nutritional status in cancer patients, especially those with cachexia, to increase the chances of recovery and to prevent complications, elongated hospital stays and readmissions. These are all points I would reiterate to the MDs. It is sometimes a struggle to communicate with MDs about malnutrition concerns and to be on the same page regarding diagnosis of status. Like Lauren mentioned sharing resources and information regarding current malnutrition diagnosis guidelines and practices can help bridge the gap in understanding and in the methods of practice between MDs and RDs. Robin too talked about the importance of coding for malnutrition like Moriah mentioned for both the patient and the hospital and these are both aspects that MDs and RDs both need to understand. As RDs we must be knowledgeable and adamant about assessing all the malnutrition markers identified in the AND/ASPEN guidelines and then also communicating with MDs so that they understand and are aware of the current most evidence-based practices. Robin also mentioned that the RDs at Bromenn worked to create some guidelines or communication documents to share with the MDs about changing practices in malnutrition assessment and diagnosis, such as nutrition-focused physical exams, and I think this is a good method to inform MDs and strengthen the overall collaboration between MDs and RDs.
As for using albumin as a marker for malnutrition I would explain to the MD that albumin levels may change for a variety of other reasons besides those relating to malnutrition or inadequate protein status, such as in inflammatory states or stress. I would explain that the most recent research supports this and then communicate with the MD about the other, more reliable markers of nutritional status that are currently being used.
I agree with Lauren that evidence-based literature should be utilized to emphasize the importance of documenting a malnutrition diagnosis and for citing the growing evidence that albumin is not an accurate marker. I think providing the MD with as much evidence from the patient as well as the literature is vital. I like Justine’s point that communication among the entire healthcare team is key to assuring documentation. Again, the more evidence, especially from different disciplinary perspectives, the greater the chance a malnutrition diagnosis would be documented. Nikki makes a fantastic point on how having the MD diagnose malnutrition can help reduce length of stay on top of receiving proper nutrition care. Perhaps emphasizing the MD’s role and how it could positively affect their practice—without coaxing or bribing them!—would help. I think being able to properly explain how receiving the malnutrition diagnosis would benefit the patient and whole healthcare team is important.
Everyone has mentioned the use of evidence-based research to rationalize with physicians, especially in regards to albumin and its role as a negative acute stress responder (vs. protein-energy indicator). This is a very important aspect of dietetics, and the field as a whole has worked to build a practice grounded in education and research. With physicians, it is useful to be able to effectively explain your rationale concisely with as your source of credibility. Organizations like ASPEN are well-respected, so it can be useful to cite their research as part of your explanation. Be confident!
As some of you have mentioned, financial implications of malnutrition are becoming a driving factor of consistent documentation of medical diagnoses of malnutrition. Hospitals can now be reimbursed for malnutrition, and correct identification and treatment of malnutrition can decrease readmissions and complications (which means money savings in the long-run!).
Another aspect that may help to build credibility is to discuss malnutrition from a metabolic standpoint. How would you explain the metabolic process of cancer (either to a physician or other medical staff) in order to better explain malnutrition? Think energy/macronutrient usage!
2. In terms of metabolic state in cancer patients, often times they are in a hypermetabolic state. As the body tries to keep up with treatments, heal from possible surgeries, and fight off infections with a suppressed immune system energy is burned very quickly. This means that many cancer patients may have increased energy needs that are difficult to achieve when fatigue and loss of appetite occur as well. These factors together put the patient at higher risk for malnutrition because may be difficult to meet energy needs of the hypermetabolic state which could result in weight loss, muscle wasting, and fat loss. Relating to the malnutrition diagnosis in the laryngeal cancer patient, malnutrition may be occurring as evidenced by muscle wasting and energy intakes significantly less than energy needs. The inflammatory state associated with cancer and illnesses in general is likely to cause a low albumin level. While a patient may have low albumin and malnutrition, low albumin alone is not enough to diagnose malnutrition. In clinical rotations right now, occasionally doctors diagnose PCM exclusively based on low albumin. In some of these cases, our nutrition assessments uncover other evidence of malnutrition that supports the initial diagnosis. In other cases, we assess patients and find indicators of malnutrition, document malnutrition, and have the documentation verified by the coders and doctors because of how we document weight loss, poor intakes, muscle wasting or fat loss. Using ASPEN guidelines as a reference and supportive tool in diagnosing malnutrition is an excellent way to establish credibility for the diagnosis.
The presence of malnutrition, especially in the form of cancer cachexia, increases the risk of hospital readmission and mortality. Using the evidence-based guidelines presented in the AND/ASPEN consensus statement and the continuing education article, how would you convince a physician to also document a malnutrition diagnosis in an oncology patient with laryngeal cancer? How would you respond if he references albumin as a marker of protein status?
I agree with what everyone has said about the financial benefits of diagnosing malnutrition. Not only that, the patients will have better odds of recovering if the malnutrition is addressed early on. Patients with cancers near the head and neck, such as this patient, have the highest risk of developing malnutrition. Close monitoring will be necessary to identify if the patient is beginning to experience the symptoms. That being said, this could be a transition point in discussing the value of albumin in determining malnutrition risk. It is important not to discredit the physician but suggest that in addition to monitoring albumin, a physical assessment and the use of a MST will be great tools in determining the patient's needs.
As part of a malnutrition assessment, I would complete a Nutrition-Focused Physical Assessment. Though this assessment, I should be able to tell if the patient is experiencing muscle wasting. With laryngeal cancer, the patient may not be able to eat very well, if at all. Thus, if the patient is not on enteral/parenteral nutrition and has not been eating, it is very likely that they are malnourished.
If the doctor references albumin as a marker of protein status, I would explain that albumin is not necessarily an accurate measure of protein status, and as such, it’s important to look for other markers of malnutrition as well. I would then list the other markers I had found which indicate malnutrition.
As part of my nutrition assessment note I would use the AND/ASPEN guidelines as part of my nutritional diagnosis of malnutrition. Then I would need to communicate my findings to the physician, requesting he/she read my assessment and findings of malnutrition. As for referencing albumin as a marker for protein status, I think referencing the lab value as an indicator of malnutrition depends on the policies of the organization where you and the physician are working. Emerging research may indicate that albumin is not a reliable marker for malnutrition because it fluctuates with stress. But, albumin is still the lab value that is used at my clinical rotation facility as part of determining if a patient has malnutrition.
As Moriah mentioned, I would explain to the physician that addressing malnutrition now can save the hospital a significant amount of money as well as improve the patient's quality of life. I would further elaborate that there is substantial evidence that proper nutrition decreases length of hospital stays and lowers readmittance rates, and I would try to have an article or two printed to provide as a reference. I think Noel made an excellent point about Head & Neck cancer patients being more likely to need tube feeding, and I would explain this to the physician as well.
If a physician were to cite albumin as a nutritional marker, I would again refer to the recent literature showing albumin to be too sensitive to inflammation to be a reliable marker (and have a print-out available if requested). Furthermore, I would elaborate that a laryngeal cancer patient is likely chronically inflamed, thus more methods are needed to ascertain nutritional status. I would also use the patient's weight history as evidence of malnutrition. For example, a patient losing 10% of his/her body weight in a span of 6 months is a sign of malnutrition.
As many of you stated, albumin is not the best marker of malnutrition. Finding evidence in multiple areas I the best way to provide evidence of malnutrition. Nutrition Focused Physical Assessments is one form of evidence to document malnutrition as a diagnosis, but also having additional evidence makes a strong case, such as recent weight loss and food recalls. Also, having a good relationship with staff and doctors can make this process much easier. I have found during my rotations building relationships and trust with nurses and doctors can really speed up the process of recommendations and diagnoses. Obviously, this comes with time, but having these relationships with fellow staff members can ultimately improve patient care and can make the conversation of diagnosing a patient with malnutrition go much faster - with the appropriate evidence of course.
Tessa, I think you made a great point that Elyse touched on as well, the importance of the MD-RD relationship. While yes, we certainly want to bring in our expertise and the most up-to-date evidenced-based practices as ASPEN publishes them, we also need to understand that the physician world and mind-set can be different from ours. Yes, we work together as part of a team and both have the patient’s best interest and often the same goals in mind, but there will always be varying opinions and more than one way to go about things. I think we can view this as an advantage however, as more viewpoints and conversations about differing opinions may have the power to spark new ideas and courses of action. I am looking forward to having the opportunity to interact with physicians during rotations and to see and experience this dynamic first-hand.
From the guest speakers we have had the past month, I have learned that documenting malnutrition is important for the hospital to get reimbursed by insurance companies. I think it is also important for patients to be properly diagnosed with malnutrition so they are able to get the specialized care and attention they need to become nutritionally healthy again. Like others have mentioned I would like at markers for malnutrition such as energy intake, weight loss, nutrition focused physical exam findings, fluid accumulation, and grip strength to determine if the patient does indeed have malnutrition. If they do, then I would use evidenced-base literature findings to discuss with the doctor why the patient is actually malnourished and not use the albumin value for my conclusion. This is honestly something I know I will have trouble with as a new RD but hopefully I will become more confident in rotations.
Like many of you mentioned, evidenced-based literature will help you make a strong case when convincing a physician to document malnutrition. It also may be in your best interest to keep the physicians you work with updated on the current literature and the current Nutrition Physical Assessments that help you to determine if a patient is malnourished. This way, you can educate the MD’s while showing them firsthand how you are putting the literature into practice.
In regards to albumin, I would explain that the JAND no longer considers this to be an efficient way to assess malnutrition. This is due to the sensitivity of albumin in times of stress, trauma, hydration, etc. in which albumin levels are easily skewed. Instead, I would explain that malnutrition should focus more on physical findings as evidenced by weight loss, muscle/subcutaneous fat loss, diminished ADL’s, and fluid accumulation.
I really appreciate that Justine mentioned that from her clinical experience she is seeing that more people are respecting the diagnosis of malnutrition. As I mentioned in a pervious post, I think the NFPA is now a critical aspect of clinical dietetics, just as imperative as documenting nutrition needs and intake. During our guest speakers in class, we learned that albumin should no longer be used to assess protein status. Again, evidence-based research is key to supporting this concept. I think that not being able to directly diagnosis malnutrition as an RD poses some challenges for us. As experts of malnutrition, I can still see it being difficult to get physicians and nurses to agree with our opinions. Being able to confidently confront a physician or nurse with our observations from assessments will impact the diagnosis of malnutrition. I believe that since oncology patients are at risk for cancer cachexia, the assessment and diagnosis of malnutrition should be a routine part of a physician’s care for cancer patients.
As mentioned by many others, I would talk to the MD about the importance of accurately diagnosing malnutrition as that can change the pt's plan of care. I would definitely discuss the financial implications. Money is a motivator! I think the MD would appreciate knowing how the proper diagnosis can save the hospital a lot of money, and it can also cut back on readmission rates...another way for the hospital to get money! I really appreciate what Holly said about speaking to the MD with confidence. Sure, sometimes other disciplinaries may think little less of RDs, but if we came in with that confidence and the facts this will only boost our career.
For the Albumin, I would talk to the MD about all of the research that shows it is not an accurate measure of malnutrition. This is an outdated way of diagnosing. I would present the facts from research, and as Nikki said, I would make sure to inform the MD of other things that can lower Albumin such as inflammation and IV fluids.
Holly and Kirsten started mentioning the differences in energy and macronutrient needs for a patient with cancer. I think utilizing our knowledge of cancer and metabolism would be a great way to start discussing the patients needs and potential malnutrition status with the doctor by noting why they are hypermetabolic. Whether the patient is post-op, stressed, or experiencing trauma, the reality of cancer is that the patient has cells that are likely turning over and multiplying at a very quick rate. Creation and growth of cells requires energy and nutrients, and with a patient's body doing this at an accelerated rate, they are then more at risk for being undernourished. Cancer cells typically utilize glucose and glutamine at a higher rate than average, so those may also be nutrients at higher risk. I think by talking about the disease state on this level, the MD can easily see where you are coming from with your concerns for malnutrition, and you can likely continue this conversation away from albumin content, and more towards relevant measures.
As several of you have mentioned, we don’t want to get the doctor on board with our malnutrition diagnosis for any other reason than the fact that it will equip us to provide our pt with the best intervention possible. (Though the money can motivate as others have said). The continuing education article stresses the importance of early and aggressive intervention, as this approach is understandably linked to better pt outcomes. When determining a malnutrition diagnosis, I would definitely start with the ASPEN guidelines. In cancer patients, I am sure it is not too much of a stretch to find support under two of the criteria, such as insufficient energy intake, unintentional weight loss, decreased grip strength, etc. Additional “back-up” according to the article includes nutrition impact symptoms, markers of inflammation (elevated C-reactive PRO), and additional signs of muscle or fat wasting. Delving more into the literature on cachexia, I am learning just how nasty it is. Since it “cannot fully be reversed by conventional nutrition support and leads to progressive functional impairment” (as it is metabolizing precious, functional PRO), it is important to halt the process and not let it go any longer, such as precachexia to cachexia to refractory cachexia (life expectancy of less than three months).
As Justine mentioned, communication among the healthcare team is key to assuring documentation is in agreement. This was something I recently encountered during my clinical rotation when during rounds a physician asked his resident why the patient's albumin was so low. The resident mentioned "poor nutrition," and the physician agreed. My preceptor spoke up and communicated her thoughts on how albumin is not always a reliable indicator and how the patient was receiving a lot of IVF which is more likely the case for the low lab value. Witnessing this discussion just shows we as RD's need to feel comfortable bringing new research into conversation with physicians and the entire medical team.
In regards to Holly's inquiry about discussing malnutrition from an energy/macronutrient usage standpoint, I'm on board with Lauren. Perhaps explaining the patient's state through more metabolic means would emphasize the importance of proper nutrition to the MD. The MD might not be focusing on nutrition, but rather the overall state of the patient. With a more in-depth conversation, it is likely that they would see how nutrition is connected (to everything!) and therefore important to be addressed.
To address many of the comments made, I agree that is great to get extra money for the malnutrition diagnosis but the most important aspect is the patient's overall health. As Jamey, Lauren, and a few others mentioned, addressing the nutritional concerns of the patient will help to remedy or treat other conditions the patient is experiencing. This will help reduce the rate of readmission or further treatment. This cycles back to the money in which reduced readmission rates will increase reimbursement to the hospital. It's a win/win.
Noel, I am curious to know how the physician reacted when your preceptor stated her thoughts about albumin? Communication is extremely important in the healthcare field in order for the entire medical team to be on the same page. I understand the importance of speaking up to educate others about all the knowledge we have that makes qualified RDs. After witnessing how to go about that confrontation, I know that I would confidently be able to speak up, but does doing so ever step on anyone's toes? The care of the patient is top priority so I would assume that many people are open to new ideas and suggestions, but since I have not had much experience yet, I wonder if that is always the case.
Kandice, I can share you experience that albumin remains a commonly used indicator for malnutrition when combined with concurring evidence of weight loss of low BMI. In such incidences it may not be within the RD's interest or ability to contest such policy at the single facility level having to rely on the policies of a larger network of health centers. However, when possible, RD's or a facilities department may supply best evidence for diagnosing malnutrition to policy boards for potential reform. These processes may be lengthy and difficult due to the involvement of multiple facilities.
Kandice and Rachel make a great point that although we as future dietitians see past the use of low albumin values to diagnose malnutrition, it really comes down to the facility and its network's policies. Despite the literature, some have not yet shifted their diagnostic tools- and some doctors will still habitually look to that albumin value anyway. My approach in a situation like that would be, as Kandice said, to utilize the ASPEN guidelines in determining malnutrition. If those criteria are there, I can be assured of my diagnosis, no matter what the albumin level may be. If it is depressed, the physician most likely agrees with my determination of malnutrition. On the other hand, if it is not impacted in a way that the doctor believes it should and does not diagnose malnutrition, this would definitely be the time to step up and speak up for the patient to receive the proper diagnosis according to their signs and symptoms (nutrition-focused physical exam, decreased intake, decreased strength, etc). I love Noel's story and the way her preceptor is advocating for the correct interpretation of albumin, therefore advocating for proper diagnoses.
Justine and Noel, I think you both made a couple of great points. Communication among the healthcare team is key to providing effective care. As RDs we assess patients’ nutritional status, often being the lead person recognizing and charting malnutrition and it is our responsibility to pass along our findings to physicians. Noel your experience witnessing your preceptor speak up and communicate about the unreliability of albumin in nutrition diagnosis is something we all as RDs need to feel confident in conveying our expertise.
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