How Nutritional Deficiencies Impact Health Economics in the Hospital Setting

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Nestlé Health Science.  Here’s your host, Dr. Mary Katherine Cheeley. 

Dr. Cheeley:
Welcome to Clinician’s Roundtable on ReachMD. I’m Dr. Mary Katherine Cheeley, and joining me to investigate the impacts of nutritional deficiencies on health economics in the hospital setting is Shelby Yaceczko. Ms. Yaceczko is an advanced practice registered dietician nutritionist and also an Assistant Clinical Professor in the Department of Nutrition at the University of the Pacific in Sacramento, California. Ms. Yaceczko, thanks for being here today.

Ms. Yaceczko:
Thank you so much for having me.

Dr. Cheeley:
Let’s jump straight in. So can you give us some background on nutritional deficiencies most commonly seen in the hospital setting? And what kind of complications come from these?

Ms. Yaceczko:
Yes, absolutely. So protein-calorie malnutrition is definitely the most common nutrition deficiency that we see in the hospital setting. We see it documented upwards of one-third of patients in developed countries on hospital admission present with protein calorie malnutrition. This number even goes up to roughly 70 to 75 percent when you go back to the literature in patients who are in higher-level care settings or critical care settings in some geographic areas. So looking at some of malnutrition and as it relates to clinical outcomes, we know that malnourished patients have 3.4 times higher in-hospital deaths than those without malnutrition and roughly a 1.9 longer hospital length of stay, with 2 times higher discharge rates to long-term care facilities or rehab units and 1.4 times higher needs for home healthcare services. So really nothing good comes from protein-calorie malnutrition, and this is a disease process we really need to do a better job at recognizing and intervening on.

Dr. Cheeley:
So what do we need to know about the relationship between nutritional complications and health economics in the hospital?

Ms. Yaceczko:
So the burden of malnutrition across the globe is really unacceptably high, as I just mentioned. There is this kind of vital and intertwined relationship existing between nutritional status, human capital, and economic standing. The ultimate goal of really providing medical nutrition therapy or nutrition interventions is to positively impact clinical outcomes for patient care, including enhanced survival, using our evidence-based nutrition strategies. A considerable amount of research we keep seeing published over and over demonstrates that people living in or near poverty have disproportionately worse health outcomes and less access to healthcare than those who do not. So we look at neighborhoods, for example. So neighborhoods with poor or low-income residents often have fewer resources that promote health, such as access to full-service grocery stores offering affordable and nutritious foods, recreational facilities or parks that encourage physical activity in residents, and individuals have environmental threats that can potentially harm their health, like poor air or water quality and poor housing conditions, compared to those with higher income neighborhoods. In general, 1 out of 3 chronically ill adults is unable to afford medicine, food, or both, and I think that’s a really profound number. Not surprisingly, research shows that household food insecurity is a strong predictor of higher healthcare utilization and thus increased healthcare costs.

Dr. Cheeley:
Those are all things that I also feel deeply. I work in indigent healthcare, and those are things that every day we see the exact same things. We see our patients who don’t have access to healthy food and therefore have poor disease state management. So I’m loving that we’re having this conversation today. But with all that in mind, how can early nutritional care impact health economics in the hospital specifically?

Ms. Yaceczko:
Yeah. That’s a great question. So medical nutrition therapy is the services that are provided by a registered dietician and nutritionists in the United States. So allowing access to medical nutrition therapy in the hospital setting, which really should be and is a human right, would allow for this early intervention, screening resources, and appropriate resource support and utilization upon discharge to allow us to focus a bit more on healthcare being more preventative rather than reactive to an already diagnosed health condition, so shifting this mindset to how do we capture individuals who are at highest risk of needing nutrition support and intervention and providing resource support early on rather than being reactive to.

Dr. Cheeley:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m Dr. Mary Katherine Cheeley, and I’m speaking with Shelby Yaceczko about nutritional deficiencies, health economics, and their impact on care in the hospital. 

Let’s turn our attention to patient-centric nutritional care. What kind of role could this approach have on a patient’s quality of life?

Ms. Yaceczko:
So I love patient-centric care, and for those of you unfamiliar with this topic, patient-centered care really considers the patient’s whole self, if you will. So we’re looking at the unique needs, preferences, personal values, the psychosocial situation that’s really at heart of the decisions related to the healthcare of the individual. So patients really do strongly desire to have individualized nutrition care and medical intervention with greater involvement in their total care decisions across the continuum. This whole concept of patient-centric care can be very meaningful as decisions regarding nutrition therapy, especially those in our more complex patient state case such as individuals diagnosed with late-stage cancers, can influence their morbidity and mortality as well as the patient’s quality of life. So patient-centric care is associated with improved decision-making, patient-provider communication, as well as enhanced quality of life for patients. So the question is why aren’t we using this more and considering this as a best practice for our patients? This is, I want to note, a relatively new area in the literature. So when you start doing a deep dive, you do notice there is further research needed to really determine the association between patient-centered care and quality of life outcomes specific to the areas and subspecialties of nutrition therapy.

Dr. Cheeley:
What does this patient-centered nutritional care look like? Is it done while the patient is in the hospital? Is it done at the clinic visits? Is it community-based?

Ms. Yaceczko:
Yeah. So in my opinion, it starts with the full continuum of care. So it’s identifying, again, kind of what are the patient’s values, what are their personal goals and preferences, how does that tie back to their cultural beliefs, their family values, and what kind of the whole picture, what their psychosocial situation is, and that is really the heart of what decisions are going to be made around their healthcare journey, so taking that and using that as our foundation and moving that forward to the inpatient hospitalization as well as out upon discharge into the community to make sure that we have this patient-centered approach around their nutritional care and intervention.

Dr. Cheeley:
And then who’s a part of the team? What about the care coordination for the patient or a multidisciplinary care team structure?

Ms. Yaceczko:
Yeah. So within a hospital, we’ve moved from this kind of authoritarian where there was one particular person that was really the main person in charge of care, and we’ve moved to looking at care teams as being like a team sport, so everyone’s playing a little bit of a different role, and there may be a quarterback in charge. So these are what’s known as our multidisciplinary teams, and it’s really defined as cooperation between different specialized professionals in healthcare and with the overarching goal of improving treatment efficacy as well as patient care clinical outcomes. So the multidisciplinary team approach really allows for focus on supportive interventions, so different specialty areas and ancillary staff, such as physical and occupational therapy, speech language pathologists, registered dietician/nutritionists, and case managers and social workers typically involved to help support these discharge plannings, but really the goal of these multidisciplinary teams are to maximize a patient’s quality of life and to ensure that patients have the appropriate resource and education support so they feel ready for hospital discharge and have a plan in place so that way they don’t get home and realize that x, y, and z is missing in their care plan.

Dr. Cheeley:
I think I would love to see a model and a world where patients, before they’re discharged, would have – and maybe this exists, you can educate me – where they have kind of almost like this team that comes to the bedside. It’s a pharmacist, which I’m a pharmacist so I’m a little bit partial to that, it’s a dietician, it’s the social worker, to help them be successful at home because there’s so many things that we can do in the hospital, but then if we’re not translating that back to the outpatient setting, then they just end up kind of coming back.

Ms. Yaceczko:
Absolutely, and I think we’re starting to see more of these models pop up, which I’m a huge supporter of personally. One of the spaces we see in the nutrition realm are these nutrition support teams, which are very multidisciplinary in nature. We typically have a nurse practitioner or APP, we have a physician who’s typically a gastroenterologist or potentially a general surgeon on the case, a pharmacist, as well as a registered dietitian/nutritionist, and these nutrition support teams, depending on the models, tend to follow patients both on the inpatient and outpatient setting to create a more closed continuum of care working with case managers and social workers to ensure that discharge needs are met and patients have the appropriate support services they need upon discharge, to not be readmitted into the hospital and to improve their quality of life, and that way they can feel more educated and comfortable in their care goals.

Dr. Cheeley:
Before we close, can you share some tips and best practices for engaging patients in the decision-making process?

Ms. Yaceczko:
Sure. So the reality is there’s really no single right healthcare decision because choices about treatment, medical tests, and health issues, they always come with pros and cons, right? So that has to be considered, but shared decision-making occurs when a healthcare provider or clinician and patient are working together in synergy to make a healthcare decision that is right and best for the patient at their current status and what their current values and goals are. So shared decision-making helps providers and patients agree on a healthcare plan, and we know that when patients participate in decision-making and they really understand what they need to do, they’re more likely to follow through with that plan. So some of the main benefits I see personally with shared decision-making is that it allows patients to feel more informed about their health and truly understand their health condition as well as recognize the need to make decisions around their health, so we’ve all probably been there when we lay out different options or decisions for a patient, and they may be struggling a bit to come to a conclusion that makes sense for them, and then you have to step back and realize was this kind of on the healthcare side or the healthcare provider’s side where we could’ve done a better job of providing education and informing the patient along the way so they feel more confident and comfortable in making a decision to not delay potential treatment options or interventions.

Dr. Cheeley:
Are there any kind of final thoughts that you want to leave us with?

Ms. Yaceczko:
I do strongly believe that nutrition is a human right and that everyone should have access to food as well as the right access to healthcare, so continue spreading the word and looking at your patients from a holistic perspective, considering things like their socioeconomic status, their nutritional background, their personal goals, values, and cultural preferences because all of these things play a role into their clinical outcomes and what’s going to be most important to them.

Dr. Cheeley:
I couldn’t agree more. I will reiterate exactly what you said as well. Everyone has the right to food, and everyone has the right to health. I would love to thank my guest, Shelby Yaceczko, for joining me to discuss the unique burdens of nutritional deficiencies on health economics in the hospital space. Ms. Yaceczko, it was so great having you on the program today.

Ms. Yaceczko:
Thanks so much for having me. It was such a blast.

Announcer:
This episode of Clinician’s Roundtable was sponsored by Nestlé Health Science. To access this and other episodes in this series, visit ReachMD.com/Clinician’s Roundtable, where you can Be Part of the Knowledge. Thanks for listening!