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article in press clinical nutrition 2005 24 75 82 http intl elsevierhealth com journals clnu original article development and validation of a hospital screening tool for malnutrition the short nutritional ...

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                                                  ARTICLE IN PRESS
             Clinical Nutrition (2005) 24,75–82
                                                                               http://intl.elsevierhealth.com/journals/clnu
             ORIGINAL ARTICLE
             Development and validation of a hospital screening
             tool for malnutrition: the short nutritional
             assessment questionnaire (SNAQr)
                                 a,                   b                     c                       a
             H.M. Kruizenga          , J.C. Seidell , H.C.W. de Vet , N.J. Wierdsma ,
             M.A.E. van Bokhorst–de van der Schuerena
             aDepartment of Dietetics,VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam,
             The Netherlands
             bDepartment of Internal Medicine, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
             cEMGO Institute, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
             Received 13 November 2003; accepted 15 July 2004
               KEYWORDS                   Summary   Objective: For the early detection and treatment of malnourished
               Hospital                   hospital patients no valid screening instrument for the Dutch language exists.
               malnutrition;              Calculation of percentage weight loss and body mass index (BMI) by the nurse at
               Screening;                 admission to the hospital appeared to be not feasible. Therefore, the short,
                    r                     nutritional assessment questionnaire (SNAQr
               SNAQ ;                                                           ), was developed.
               Validation;                  Research,designandmethods:Twohundredandninetyonepatientsonthemixed
               Development                internal and surgery/oncology wards of the VU University medical center were
                                          screened on nutritional status and classified as well nourished (o5% weight loss in
                                          the last 6 months and BMI418.5), moderately malnourished (5–10% weight loss in
                                          the last 6 months and BMI418.5) or severely malnourished (410% weight loss in the
                                          last 6 months or 45% in the last month or BMIo18.5). All patients were asked 26
                                          questions related to eating and drinking difficulties, defecation, condition and pain.
                                          Odds ratio, binary and multinomial logistic regression were used to determine the
                                          set of questions that best predicts the nutritional status. Based on the regression
                                          coefficient a score was composed to detect moderately (X2 points) and severely
                                          (X3points) malnourished patients. The validity, the nurse–nurse reproducibility and
                                          nurse–dietitian reproducibility was tested in another but similar population of 297
                                          patients.
                                            Results: The questions ‘Did you lose weight unintentionally?’. ‘Did you experience
                                          a decreased appetite over the last month?’ and ‘Did you use supplemental drinks or
                                          tube feeding over the last month?’ were most predictive of malnutrition. The
                                          instrument proved to be valid and reproducible.
              Corresponding author. Tel.: +31-20-444-3410; fax: +31-20-4444-143.
               E-mail address: h.kruizenga@vumc.nl (H.M. Kruizenga).
             0261-5614/$-see front matter r 2004 Elsevier Ltd. All rights reserved.
             doi:10.1016/j.clnu.2004.07.015
                                                     ARTICLE IN PRESS
             76                                                                                   H.M. Kruizenga et al.
                                               Conclusion: SNAQr is an easy, short, valid and reproducible questionnaire for
                                            early detection of hospital malnutrition.
                                            r2004Elsevier Ltd. All rights reserved.
             Introduction                                           questionnaire divides hospital patients into three
                                                                    groups: well nourished, moderately malnourished
             Malnutrition is a state of nutrition in which a        and severely malnourished. Using this question-
             deficiency or excess or imbalance of energy,            naire, malnourished patients are recognized at
             protein and other nutrients, causes measurable         admission and referred to dietitian in an early
             adverse effects on tissue or body form (body shape,    stage. This article describes the process of the
             size and composition), function, and clinical out-     development of the so called short nutritional
             come.1 This broad definition implies that malnutri-     assessment questionnaire (SNAQr). In addition, it
             tion may arise from a wide range of conditions that    reports the results of the diagnostic value and
             differ in severity and cause. In Western countries,    reproducibility of the SNAQr.
             undernutrition is considered to be only a minor
             problem compared with that of overweight.
                In hospital settings however, there is growing      Research design and methods
             awareness that undernutrition may play an impor-
             tant role in the course of the treatment of patients.  The development of the SNAQr is based on the
             The body mass index (BMI) (weight/length2
                                                        ) can be    results of nutritional status data and characteristics
             used to provide an approximate guide to the            of 291 patients (population A). The validity of the
             probability of chronic undernutrition. One of the      SNAQristested in a similar population (population
             most commonly used cut-off values to define this        B) (cross validation). The reproducibility of the
             kind of malnutrition is a BMIo18.5.1–4 This index      SNAQr is also tested in population B.
             does, however, usually not give information about
             the unintentional recent weight change that is         Questionnaire development study
             often accompanying underlying disease. Several         (population A)
             clinical studies have demonstrated that recent
             involuntary weight loss 410% in 6 months is a good
             indicator of more acute undernutrition.1,5–8           Subjects
                In 2001, the Dutch Dietetic Association con-        Twohundredandninetyonepatients,admittedtoa
             ducted a national screening on disease related         mixed internal ward (internal medicine, gastro-
             malnutrition in 6150 hospital patients at 56           enterology, dermatology, nephrology) and a mixed
             different locations.9 Based on the generally accep-    surgical ward (general surgery and surgical oncol-
             table definitions of malnutrition, disease related      ogy) of the VU University medical center in the
             malnutrition was defined as 410% involuntary            period of April until October 2002, were included in
             weight loss 1,5–8 or BMI o18.5.1–3 In this study,      the study. Patients who were not able to give
             about 25% of the hospital patients appeared to be      informed consent, could not be weighed or were
             malnourished. Only 50% of the malnourished pa-         younger than 18 years of age were excluded from
             tients were recognised by the nursing and medical      the study. The study-design was approved by the
             staff.9                                                medical ethical commission of the VU University
                In an ideal situation the physician or the nurse    medical center.
             calculates the BMI and the percentage of involun-
             tary weight loss over the last months at the first day  Nutritional status
             of patients’ admission to the hospital. With this      On the day of the admission to the hospital, all
             information the physician and/or the nurse can         patients were weighed on the same calibrated
             decide which patients are malnourished and should      scale (SECA 880) and their height was asked for.
             be referred to a dietitian. In practice nurses or      When patients did not know their height, it was
             physicians do not have time to calculate indices of    measured (SECA 220). Patients were asked whether
             nutritional status. Thus, hospital malnutrition often  they had lost weight unintentionally over the last
             remains unidentified. Therefore, our team devel-        month and the last 6 months. Patients were
             oped a short questionnaire that can be integrated      considered severely malnourished if one or more
             in the nurses’ intake of the patient at admission to   of the following conditions were present: a BMI
             the hospital and costs less than 5min time. This               1–4
                                                                    o18.5,     unintentional weight loss of more than
                                                         ARTICLE IN PRESS
              Development and validation of a hospital screening tool for malnutrition:                                     77
              5% in the last month or more than 10% in the last 6        malnourished, a is the constant and b , b , b and
                                                                                                                 1   2   3
              months. Patients were considered moderately                bx represent the regression coefficients of the
              malnourished when they had lost 5–10% of their             questions x ,x,x and x .
                                                                                    1   2   3       x
                                                                1,5–8
              weight unintentionally in the last 6 months.                 To make the new questionnaire to a screening
              Based on the most commonly accepted standards              tool which is practical, the regression coefficients
              from the literature, this definition of nutritional         associated with the questions were transformed
              status was used as the ‘‘objective standard of             into a simple score that can be added up to obtain
              malnutrition’’ against which the questions from the        an aggregate score (in this case: the coefficients of
              questionnaire were validated.                              the model are multiplied by 4/7 and rounded to the
                                                                         nearest integer, resulting in a score, ranging from 0
              Questionnaire                                              to 7 (Table 3). The cut-off points for the scores
              Onthedayofadmissiontothehospital,allpatients               belonging to ‘moderately malnourished’ and ‘se-
              completed a detailed questionnaire on symptoms             verely malnourished’ were determined by reading
              and risk factors of malnutrition. The questionnaire        the optimal cut-off point in the ROC-curve. All
              consisted of 26 nutrition-related questions (Table 2)      analyses were performed with the SPSS software
              adopted from the quality of life questionnaires            package, version 9.0.
              EORTC-C30andEORTCH&N35,10andfromcomplex
              screening instruments which are too complex and
              time-consuming for the daily hospital situation            Questionnaire validation study
              (Nutricia Nutritional Screening List, Mini Nutritional     (population B)
              Assessment,11 Subjective Global Assessment).12
              The questionnaire was completed with questions             For the validation study a new group of 297
              of experts (dietitians, nutritionists) who also unan-      patients, admitted to the same wards of the VU
              imously approved the questionnaire.                        University medical center in the period of February
                                                                         until June 2003, was included. Patients who were
              Analysis                                                   not able to give informed consent, could not be
              To select symptoms and risk factors that could be          weighedorwereyoungerthan18yearsofagewere
              used to identify subjects with malnutrition, selec-        excluded from the study.
              tion of questions predictive of malnutrition was             Upon admission to the hospital the nurse filled
              performed in three phases to finally make up a              out the newly developed screening tool, the
              short and simple questionnaire, the SNAQr.                 SNAQr, for every patient. Patients who were
                First, the odds ratio was calculated for each            classified as moderately or severely malnourished
              question of the questionnaire with the presence or         following the SNAQr-score (X2 points) received
              absence of malnutrition as dependent variable. All         energy- and protein-enriched meals and twice a
              questions with a statistically significant odds ratio       day a nutritious snack. Patients who were classified
              (Po0:05) were included in the next phase.                  as severely malnourished (X3 points) received,
                Second, logistic regression was carried out with         besides the energy- and protein-enriched meals
              the presence or absence of malnutrition as depen-          and snacks, treatment by a dietitian (who was
              dent variable and with questions with a significant         not involved in the study). The dietitian scored
              odds ratio as independent variables. The questions         the referrals based on the SNAQr-score as
              associated with malnutrition at a significance level        ‘very necessary’, ‘moderately necessary’ or ‘not
              of Po0:05 in a backward stepwise procedure were            necessary’.
              selected for the next phase of the analysis.                 The measurements and the definition of the
                Third, multinomial logistic regression was carried       nutritional status were identical to the procedure
              out with severe malnutrition, moderate malnutri-           of the first phase of the study.
              tion and no malnutrition as the dependent variable           The validity of the SNAQr in population B is
              and the questions from phase two as the indepen-           expressed in the sensitivity, specificity and the
              dent variables using Po0:05 as selection criterion.        negative and positive predictive value. To measure
              This model contained all the finally selected items         thecross-validity of the SNAQr a receiver–operator
              together.                                                  characteristic (ROC) curve was constructed to
                The probability of a patient being malnourished          present the relationship of the SNAQr-score with
              can be predicted by the following regression               the definition of malnutrition. ROC curves char-
              equation, in which the categorization is based on          acterise the relationship between the true positive
              a continuous function of P between 0 and 1:P(mal-          rate (sensitivity) and the false positive rate (1-
              nourished)=1+e–(a+b x +b x +b x +b x )1        where      specificity). The specificity of a test is the prob-
                                    1 1   2 2  3 3   x x
              P(malnourished) represents the probability of being        ability (0–100%) that the SNAQr score is o2 points
                                                      ARTICLE IN PRESS
             78                                                                                     H.M. Kruizenga et al.
                Table1    Characteristics of the well nourished and the moderately/severely malnourished patients of population
                A and B.
                                  Population A                               Population B
                                  Moderately/    Well          Whole group   Moderately/   Well           Whole group
                                  severely       nourished                   severely      nourished
                                  malnourished                               malnourished
                N (%)             93 (32%)       198 (68%)     291           98 (33%)      199 (67%)      297
                Internal ward/    62/31 (67%)    99/99 (50%)   161/130 (55%) 63/35 (64%)   79/120 (40%)   144/155 (49%)
                surgical and
                oncological ward
                (N) (% internal)
                Sex (men/women) 38/55 (41%)      80/118 (40%)  118/173 (41%) 36/62 (37%)   81/118 (41%)   117/180 (39%)
                (% men)
                Age (years)       62.2718.3      56.6718.0     58.4718.3     62.2719.0     60.0716.5      60.6717.3
                BMI (kg/m2
                          )       22.174.7       26.375.1      25.075.4      22.475.0      25.874.1       24.774.6
             for well nourished patients. The sensitivity is the     questions showed statistically significant odds
             probability (0–100%) that the SNAQr score is X2         ratios. From these, 7 remained in the binary logistic
             points for moderately malnourished patients and         regression analyses of the second phase. The third
             X3points for severely malnourished patients. The        and last phase of multinomial logistic regression,
             area under the curve (AUC) quantifies the validity       based on a significant Wald-test, resulted in the
             of the SNAQr: the greater the area under the            final selection of the four questions for the SNAQr
             curve, the better the performance of the SNAQr.It       (Table 3). These were ‘‘Did you lose weight
             varies between 0.5, when the SNAQr is no better         unintentionally? More than 6kg in the last 6 months
             than the chance in correctly categorising the two       (3 points) or more than 3kg in the last month’’ (2
             groups, and 1.0, when its sensitivity and specificity    points), ‘‘Did you experience a decreased appetite
             are perfect.                                            over the last month?’’ (1 point), ‘‘Did you use
                To measure the inter observer agreement of the       supplemental drinks or tube feeding over the last
             SNAQr, it was filled out for 47 patient by two           month?’’ (1 point).
             nurses and for another 47 patients by a nurse and a        Patients witho2 points were classified as well
             dietitian. The inter observer agreement was tested      nourished. Patients with 2 points were classified as
             with the kappa (k) and the 95% confidence interval       moderately malnourished and patients with X3
             (CI) (k71.96 SE).13                                     points were classified as severely malnourished.
                                                                     Questionnaire validation study
             Results                                                 (population B)
             Questionnaire development study                         Following the objective criteria of malnutrition
             (population A)                                          (reference standard) in population B (N=297) 78
                                                                     patients (26%) were severely malnourished and 19
             Subjects                                                patients (6%) were moderately malnourished De-
             Of the 291 patients that participated in this study,    mographic data were similar in population A and B
             76 patients (26%) were severely malnourished and        (Table 1).
             17 patients (6%) were moderately malnourished,
             according to the previously described definition of      Validity and cross-validity of the SNAQr
             malnutrition. The characteristics of population A       The validity and the cross-validity of the SNAQr is
             and B, including parameters of nutritional status       shown in Table 4 for the two cut-off points. In
             are presented in Table 1.                               population B, both sensitivity and specificity proved
                                                                     to be more than 75% for both cut-off points. The
             Selection of the questions for the SNAQr                ROC-curve (Fig. 1a) of the moderately and severely
             The selection of the SNAQ-questions is described in     malnourished patients (cut-off point X2) shows an
             Table 2. In the first phase of the selection 17          area under the curve of 0.85 (95% CI 0.79–0.90;
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...Article in press clinical nutrition http intl elsevierhealth com journals clnu original development and validation of a hospital screening tool for malnutrition the short nutritional assessment questionnaire snaqr b c h m kruizenga j seidell w de vet n wierdsma e van bokhorst der schuerena adepartment dietetics vu university medical center p o box mb amsterdam netherlands bdepartment internal medicine cemgo institute received november accepted july keywords summary objective early detection treatment malnourished patients no valid instrument dutch language exists calculation percentage weight loss body mass index bmi by nurse at admission to appeared be not feasible therefore r snaq was developed research designandmethods twohundredandninetyonepatientsonthemixed surgery oncology wards were screened on status classied as well nourished last months moderately or severely month bmio all asked questions related eating drinking difculties defecation condition pain odds ratio binary multinom...

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