Décima Lección Jesús Culebras. Nutrición clínica: de la superespecialización a la atención comunitaria / X Jesús Culebras Lecture. Clinical nutrition: from super specialization to community care

La nutrición clínica ha evolucionado en nuestro país desde la superespecialización de la nutrición parenteral (NPT) en la Unidad de Cuidados Intensivos (UCI) hasta lo que supone la atención comunitaria de salud. En sus inicios, la NPT se utilizaba en una mínima parte de pacientes hospitalizados. El desarrollo de la nutrición enteral (NE) supuso una ampliación de los beneficiados por lograr un correcto aporte nutricional. Al involucrarnos en el código de dietas, la responsabilidad se extendió a toda la población hospitalizada. Las técnicas de nutrición artificial se extendieron posteriormente al domicilio del paciente y se consolidó con la inclusión de la nutrición enteral domiciliaria (NED) en la cartera de servicios del Sistema Nacional de Salud (SNS). Para mejorar la prevención de la desnutrición, tras el estudio PREDYCES surgieron el Consenso Multidisciplinar y posteriormente la Alianza Más Nutridos, con los que el campo de la nutrición clínica se amplió a la Atención Primaria y a las residencias. El último escalón es la atención comunitaria de salud, una estrategia que se sustenta en el concepto de que la salud es algo más que la ausencia de enfermedad junto a la necesidad de implicar a los ciudadanos en sus propias decisiones sobre su estilo de vida y sobre cómo afrontar los problemas de salud

Clinical nutrition has evolved in our country from the super-specialization of parenteral nutrition (PN) in the Intensive Care Unit (ICU) up to the community care of health. In the beginning, PN was used in a minimum percentage of hospitalized patients; the development of the enteral nutrition (EN) meant an extension of the beneficiaries to achieve a correct nutritional contribution. By getting involved in the diet code the responsibility was extended to the entire hospitalized population. Artificial nutrition techniques were subsequently extended to the patient's home and consolidated with the inclusion of the home enteral nutrition (HEN) in the Spanish National Health Service (SNS) portfolio. To improve the prevention of malnutrition, after the PREDYCES study, the Multidisciplinary Consensus emerged and later the Alianza Más Nutridos was developed, in which the field of clinical nutrition was extended to Primary Care and nursing homes. The last step is community health care, a strategy that is based on the concept that health is more than the absence of disease along with the need to involve citizens in their own decisions about their lifestyle and how to address health problems

[X Jesús Culebras Lecture. Clinical nutrition: from super specialization to community care]. / Décima Lección Jesús Culebras. Nutrición clínica: de la superespecialización a la atención comunitaria.

INTRODUCTION: Clinical nutrition has evolved in our country from the super-specialization of parenteral nutrition (PN) in the Intensive Care Unit (ICU) up to the community care of health. In the beginning, PN was used in a minimum percentage of hospitalized patients; the development of the enteral nutrition (EN) meant an extension of the beneficiaries to achieve a correct nutritional contribution. By getting involved in the diet code the responsibility was extended to the entire hospitalized population. Artificial nutrition techniques were subsequently extended to the patient's home and consolidated with the inclusion of the home enteral nutrition (HEN) in the Spanish National Health Service (SNS) portfolio. To improve the prevention of malnutrition, after the PREDYCES study, the Multidisciplinary Consensus emerged and later the Alianza Más Nutridos was developed, in which the field of clinical nutrition was extended to Primary Care and nursing homes. The last step is community health care, a strategy that is based on the concept that health is more than the absence of disease along with the need to involve citizens in their own decisions about their lifestyle and how to address health problems.

INTRODUCCIÓN: La nutrición clínica ha evolucionado en nuestro país desde la superespecialización de la nutrición parenteral (NPT) en la Unidad de Cuidados Intensivos (UCI) hasta lo que supone la atención comunitaria de salud. En sus inicios, la NPT se utilizaba en una mínima parte de pacientes hospitalizados. El desarrollo de la nutrición enteral (NE) supuso una ampliación de los beneficiados por lograr un correcto aporte nutricional. Al involucrarnos en el código de dietas, la responsabilidad se extendió a toda la población hospitalizada. Las técnicas de nutrición artificial se extendieron posteriormente al domicilio del paciente y se consolidó con la inclusión de la nutrición enteral domiciliaria (NED) en la cartera de servicios del Sistema Nacional de Salud (SNS). Para mejorar la prevención de la desnutrición, tras el estudio PREDYCES surgieron el Consenso Multidisciplinar y posteriormente la Alianza Más Nutridos, con los que el campo de la nutrición clínica se amplió a la Atención Primaria y a las residencias. El último escalón es la atención comunitaria de salud, una estrategia que se sustenta en el concepto de que la salud es algo más que la ausencia de enfermedad junto a la necesidad de implicar a los ciudadanos en sus propias decisiones sobre su estilo de vida y sobre cómo afrontar los problemas de salud.

Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES® study.

PURPOSE: In oncology patients, hospital malnutrition is associated with a greater risk of morbidity and mortality. The objective of this study was to determine the prevalence of nutritional risk and the clinical and economic consequences of hospital malnutrition in oncology patients hospitalised in Spanish centres. METHODS: This was an observational, cross-sectional, multicentre study. The prevalence of nutritional risk was determined using the Nutrition Risk Screening(®)-2002 (NRS(®)-2002). RESULTS: Four hundred one oncology patients were included; 33.9% (136/401) were at nutritional risk (NRS(®)-2002 ≥ 3) at admission and 36.4% (135/371) at discharge. On average, patients at nutritional risk were more elderly and had lower weights, body mass indices and arm and calf circumferences, as well as lower serum albumin levels than patients not at risk. Mean duration of hospitalisation and healthcare costs were greater in patients at nutritional risk at discharge (12.1 days; 95% confidence interval (CI) 10.83-13.39) than in well-nourished patients (8.6 days; 95% CI 7.86-9.40). Only a third of the patients at risk of malnutrition at discharge had received any kind of nutritional support. CONCLUSIONS: This study shows that hospital malnutrition is a prevalent and undertreated condition in oncology patients that is associated with longer hospital stays and increased healthcare costs.

PREVALENCE AND COSTS OF MALNUTRITION IN HOSPITALIZED DYSPHAGIC PATIENTS: A SUBANALYSIS OF THE PREDYCES STUDY.

INTRODUCTION: dysphagia and malnutrition are conditions that frequently appear together in hospitalized patients. OBJECTIVES: the main purpose of this study was to analyze the prevalence of malnutrition in patients with dysphagia included in the PREDyCES study as well as to determine its clinical and economic consequences. METHODS: this is a substudy of an observational, cross-sectional study conducted in 31 sites all over Spain. RESULTS: 352 dysphagic patients were included. 45.7% of patients presented with malnutrition (NRS-2002 ≥ 3) at admission and 42.2% at discharge. In elderly patients (≥ 70 years old) prevalence of malnutrition was even higher: 54.6% at admission and 57.5% at discharge. Also, prevalence of malnutrition was higher in urgent admissions versus those scheduled (45.7% vs 33.3%; p < 0.05) and when admitted to small hospitals vs. large hospitals (62.8% vs 43.9%; p < 0.001). In-hospital length of stay was higher in malnourished patients compared to those well-nourished (11.5 ± 7.1 days vs. 8.8 ± 6.05 days; p < 0.001), and in malnourished patients a tendency towards increase related-costs was also observed, even though it was not statistically significant (8 004 ± 5 854 € vs. 6 967 ± 5 630 €; p = 0.11). Length of stay was also higher in elderly patients (≥ 70 y/o) vs adults (< 70 y/o). 25% of dysphagic patients and 34.6% of malnourished patients with dysphagia received nutritional support during hospitalization. DISCUSSION: these results confirm that in patients with dysphagia, malnutrition is a prevalent and under recognized condition, that also relates to prolonged hospitalizations.

Introducción: la disfagia y la desnutrición son condiciones que con frecuencia aparecen juntas en los pacientes hospitalizados. Objetivos: el objetivo principal de este estudio fue analizar la prevalencia de desnutrición en pacientes con disfagia incluidos en el estudio PREDyCES®, así como para determinar sus consecuencias clínicas y económicas. Métodos: se trata de un subestudio de un estudio observacional, transversal realizado en 31 hospitales de toda España. Resultados: se incluyeron 352 pacientes con disfagia. El 45,7% de los pacientes presentaron desnutrición (NRS®-2002 ≥ 3) al ingreso y el 42,2% al alta. En pacientes de edad avanzada (≥ 70 años) la prevalencia de la desnutrición fue aún mayor: 54,6% al ingreso y el 57,5% al alta. Además, la prevalencia de la desnutrición fue mayor en los ingresos urgentes frente a las programados (45,7% vs 33,3%; p.

Prevalence and costs of malnutrition in hospitalized dysphagic patients: a subanalysis of the PREDyCES® study / Prevalencia y costes de la desnutrición en pacientes hospitalizados con disfagia: un subanálisis del estudio Predyces®

Introduction: dysphagia and malnutrition are conditions that frequently appear together in hospitalized patients. Objectives: the main purpose of this study was to analyze the prevalence of malnutrition in patients with dysphagia included in the PREDyCES® study as well as to determine its clinical and economic consequences. Methods: this is a substudy of an observational, cross-sectional study conducted in 31 sites all over Spain. Results: 352 dysphagic patients were included. 45.7% of patients presented with malnutrition (NRS®-2002 ≥ 3) at admission and 42.2% at discharge. In elderly patients (≥ 70 years old) prevalence of malnutrition was even higher: 54.6% at admission and 57.5% at discharge. Also, prevalence of malnutrition was higher in urgent admissions versus those scheduled (45.7% vs 33.3%; p < 0.05) and when admitted to small hospitals vs. large hospitals (62.8% vs 43.9%; p < 0.001). In-hospital length of stay was higher in malnourished patients compared to those well-nourished (11.5 ± 7.1 days vs. 8.8 ± 6.05 days; p < 0.001), and in malnourished patients a tendency towards increase related-costs was also observed, even though it was not statistically significant (8 004 ± 5 854 Euros vs. 6 967 ± 5 630 Euros; p = 0.11). Length of stay was also higher in elderly patients (≥ 70 y/o) vs adults (< 70 y/o). 25% of dysphagic patients and 34.6% of malnourished patients with dysphagia received nutritional support during hospitalization. Discussion: these results confirm that in patients with dysphagia, malnutrition is a prevalent and under recognized condition, that also relates to prolonged hospitalizations (AU)

Introducción: la disfagia y la desnutrición son condiciones que con frecuencia aparecen juntas en los pacientes hospitalizados. Objetivos: el objetivo principal de este estudio fue analizar la prevalencia de desnutrición en pacientes con disfagia incluidos en el estudio PREDyCES®, así como para determinar sus consecuencias clínicas y económicas. Métodos: se trata de un subestudio de un estudio observacional, transversal realizado en 31 hospitales de toda España. Resultados: se incluyeron 352 pacientes con disfagia. El 45,7% de los pacientes presentaron desnutrición (NRS®-2002 ≥ 3) al ingreso y el 42,2% al alta. En pacientes de edad avanzada (≥ 70 años) la prevalencia de la desnutrición fue aún mayor: 54,6% al ingreso y el 57,5% al alta. Además, la prevalencia de la desnutrición fue mayor en los ingresos urgentes frente a las programados (45,7% vs 33,3%; p <0,05) y en los ingresados en hospitales pequeños frente a los hospitales grandes (62,8% vs 43,9%; p <0,001). La estancia hospitalaria fue mayor en los pacientes desnutridos en comparación con los bien nutridos (11,5 ± 7,1 días frente a 8,8 ± 6,05 días, p <0,001). En pacientes con desnutrición también se observó una tendencia al incremento de costes relacionados, aunque no fue estadísticamente significativa (8 004 ± 5 854 Euros frente a 6 967 ± 5 630 Euros; p = 0,11). La duración de la estancia también fue más prologada en los pacientes de edad avanzada (≥ 70 y / o) vs adultos (<70 y / o). El 25% de los pacientes con disfagia y el 34,6% de los pacientes desnutridos con disfagia recibieron soporte nutricional durante la hospitalización. Conclusión: estos resultados confirman que en los pacientes con disfagia, la desnutrición es una condición frecuente y poco reconocida, que también está relacionada con la prolongación de la hospitalización (AU)

PREDyCES study: The cost of hospital malnutrition in Spain.

OBJECTIVES: The aim of this study was to analyze the economic effects of hospital malnutrition and the cost of longer hospital stays according to the Prevalence of Hospital Malnutrition and Associated Costs in Spain (PREDyCES) study data. METHODS: This was a nested case-control study in a prospective cohort of patients (n = 114) who were at nutritional risk at admission and controls (n = 354) who were not at risk at admission. The total cost of hospital stay was the cost of the bed plus the cost of drugs administered during the stay. Hospital costs were extrapolated to Spanish National Health System admissions for 2009. RESULTS: The mean hospital length of stay for patients at risk (cases) was significantly longer (11.5 ± 7.5 versus 8.5 ± 5.8 d; P < 0.001) than for the controls. The cost of patients at risk at admission was significantly higher than that of those not at risk (€8590 ± €6127 versus €7085 ± €5625; P = 0.015). The most significant difference in the cost of the hospital stay was observed between controls at nutritional risk at discharge and controls who remained not at risk throughout the hospital stay (€13 013 ± €9086 versus €6665 ± €5091; P < 0.001). Extrapolation of the study findings to Spanish National Health System hospital admissions showed that the potential cost of hospital malnutrition in Spain was at least €1.143 billion per year. CONCLUSION: Hospital malnutrition in Spain is associated with substantial costs, suggesting the need to establish procedures for screening, diagnosing, and treating malnutrition.