screening tools: does one size fits all? - espen.org · 10 years of screening ‐did we achieve the...
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10 years of screening ‐ Did we achieve the goals?
Screening tools: does one size fits all?
ESPEN Congress Barcelona 2012
M. Van Bokhorst (Netherlands)
Screening Tools:does one size fit all?
Marian A.E. van Bokhorst – de van der Schueren
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Purposes of screening
Defining nutritional status
Predicting outcome
Predicting responsiveness to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA, MUST
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Systematic Review
• Pubmed, Embase, Cinahl, searched on February 2, 2012
• Keywords on: – Screening / assessment– Malnutrition– Setting: hospitals– Limits: adults, humans– ‘Filter’ for validation studies
• Languages: English, French, German, Spanish, Portuguese
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Pub Med: 3667 Cinahl: 1776Embase: 3606
After checking for duplicates: 7357
Included for further investigation: 279
Excluded based on abstracts: 7078
Exluded based on full text: 192
Additional 7 references from manual searches of the reference lists and review articles
Total number of studies: 94
Total number of screening tools: 39
Total 9049
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Study characteristics
Inpatients: 37 studies
• 32 studies on validity of a screening tool vs. a reference standard or vs. outcome
• 5 studies on validity of a screening tool, whereby malnourished patients were given nutritional support
Outpatients: 2 studies
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Exlusion criteria• Tools not expressing clinimetric assessment (i.e. validity, reproducibility), but
only defining a percentage of malnutrition (no validation study)
• Tools that were developed but never cross validated in another population
• Studies < 25 patients
• Modified versions, e.g. Taiwanese modification of tool xx
• Tools exclusively consisting of lab values (in the first question), e.g. Prognostic Nutritional Index/CONUT/INFONUT
• Circle reasoning to validate
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Circle reasoning
• Tool A:– Question A1– Question A2
• Tools B:– Question B1– Question B2– Question B3– Question B4
• Tool C:– Question C1– Question C2– Question C3
– Question A1– Question A2
– Question B1– Question B2– Question B3– Question B4
– Question C1– Question C2– Question C3
Tools to be validated Gold Standard
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Circle reasoning?
• SF-MNA to MNA (Rubenstein, J. Gerontol. 2001)
• PG- SGA to SGA(Ottery, Semin. Oncol. 1994)
►► Excellent validity to the reference standard
►► Applicability of the short form vs. the long form Full MNA
Short form
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Gold Standard?
• No gold standard, no expression of criterion validity
• Another tool / assessment: semi-gold standard(construct validity)
• Why?
– the new tool can never be better than the original one– you should have serious reasons for not using the original
tool, .e.g. too time consuming / too invasive
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Semi-gold standard
• SGA validated against tool NRS-20021
se 85%, sp 69%, PPV 85%, NPV 69%
• NRS-2002 validated against SGA2
se 61%, sp 76% , PPV 65%, NPV 76%
1. Martins et al, J. of Nutr. for the Elderly (2005) 25, 5-212. Kyle, Clinical Nutrition (2006) 25, 409–417
NRS-2002 SGA
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Gold standards applied
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15 14
97
3 2 2 1 10
10
20
30
40
50
60 Outcome (LOS,complications, death)Nutr assessment /anthropometryAssessment professional
SGA
MNA
MUST
pre-alb
NRI
NRS-2002
responsiveness to nutrsupportNRS, alb, MNA-SF, PG-SGA,MIS, each 1 study
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Purposes of screening
Defining nutritional status
Predicting outcome
Predicting responsiveness to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA, MUST
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Use of screening tools
Defining nutritional status
Predicting outcome
Predicting responsiveness to nutritional support
NRS-2002
SGA, PNI, GNRI, MUST
SNAQ, NRS, NRI, MNA, MUST
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Defining nutritional status
Predicting outcome
Predicting responsiveness to nutritional support
NRS-2002
SGA, PNI, GNRI
SNAQ, NRS, NRI, MNA, MUST
Age
MUST
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Mess!
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Structuring (1)
• Predictive validity of different tools on outcome
– LOS– (postoperative) complications– mortality
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StructuringGood Good/fair Fair Poor ??
Sensitivity /Specificity
Se AND Sp > 80%
Se OR SP <80%, but both >50%
Se OR Sp < 50%
Odds Ratio / Hazard Ratio
> 3 2-3 < 2
Kappa > 0.6 0.4-0.6 < 0.4
AUC > 80 60-80 < 60
Correlation Coefficient
> 0.70 0.40-0.70 < 0.40
P value < 0.05 and n < 200 *
> 0.05 < 0.05 andn > 200 **
* no indication of effect size? ** true effect or sample size effect
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Inpatients ~ predicting outcome• Study including 705 patients, studying 6 different outcomes
Good Fair Poor
SGA-B - death - moderate or severe compl- severe compl or VLLOS or death
- severe compl and VLLOS and death- severe compl- VLLOS
SGA-C - death- severe compl or VLLOS or death- VLLOS
- moderate or severe compl
- severe compl and VLLOS and death- severe compl
NRS-2002 - death - moderate or severe compl- severe compl and VLLOS and death- severe compl
- severe compl or VLLOS or death- VLLOS
Raslan et al, Clinical Nutrition 30 (2011) 49-53
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Inpatients ~ Predicting outcomeGood Good/fair? Fair Poor ??
SGA * (n=9), 1 study studying 6 outcomes for SGA B and 6 for SGA C
6 3 8 3
MUST (7 studies) 2 2 1 1 1
NRS-2002 (5 studies)1 study studying 6 outcomes
1 5 2 3
NRI (5 studies)1 study studying 2 outcomes
1 2 3
PG-SGA (2 studies) 1 1
MST (2 studies) 1 1
MNA, MNA-SF, Birmingham NR(all 1 study)
2 1
No instrument superior in predicting outcome* designed to predict outcomeMUST reasonable?
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Geriatrics ~ Predicting outcomeGood Good/fair? Fair Poor ??
MNA * (9 studies) 1 2 3 3
SGA (4 studies) 1 3
MNA-SF (3 studies) 1 1 1
MUST (3 studies) 2 1
NRI (3 studies) 1 2
NRS-2002 (2 studies) 1 1
Birmingham NR, PG-SGA, NUFFE, Rapid Screen (all 1 study)
1 2 1
None of the instruments has good predictive validity regarding outcome * Originally designed for determining nutritional status in the elderly
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Surgical patients~ Predicting outcomeGood Good/fair? Fair Poor ??
SGA (6 studies)1 study studying 2 outcomes
1 1 2 1 2
NRS-2002 (1 study)1 study studying 2 outcomes
1 1
NRS (2 studies) 1 1
NRI, MUST, MCRS, ANS, nutrition risk classification, MNA, MST (all 1 study)
1 2 3 1
No instrument scores superior in predicting outcome.
NRS-2002 only 1 study with good/fair results
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HD / renal ~ Predicting outcomeGood Fair Poor ?? Conflicting
MIS (3 studies)1 study studying 2 outcomes
2 1 1 study/2 outcomes- poor for LOS- ? for mortality
SGA (4 studies) 1 2 1 study good/fair1 study/2 outcomes:- poor for hospital days - good for mortality
MUST, MST, objective score haemodialysis (all 1 study)
1 (obj.score…)
1 1
MIS reasonable in predicting outcome of HD/renal patients
Objective Score of Nutrition on Dialysis: good in predicting mortality, however needs confirmation in more studies
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Predicting outcome
• Most tools, most studies: fair or poor predictive validity
• No single superior tool
• Sometimes positive on predicting LOS, not mortality; in another study the other way around
• Many studies difficult to interpret because only reporting in p-values
• Responsiveness of nutrition therapy to these tools understudied
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Structuring (2)
• Comparison of different tools within one study, one population, same outcome measure
• No bias due to study population or outcome parameter
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One population, validity of tool to anthropometry / assessment
MST fair all inpatients Neelemaat, J Clin Nurs 2011
SNAQ fair
MUST good
NRS-2002 good
MST fair elderly > 60 Neelemaat, J Clin Nurs 2011
SNAQ fair
MUST good
NRS-2002 good
MNA-SF poor
NRS fair hosp < 65 Corish, J Hum Nutr Diet 2004
NRI poor
NRS good hosp > 65 Corish, J Hum Nutr Diet 2004
NRI good
MIS fair haemodial Kalantar-Zahed, Am J Kidn Disease 2001
SGA poor
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One population, validity of tool to assessment by a professional
MNA good geriatric Visvanathan, Age and Ageing 2004
Rapid screen poor
Simple screening tool 1 fair acute care elderly
Laporte, J Nutr Health Aging 2001
Simple screening tool 2 fair
Nutrition Screening tool fair inpatients Elmore, JADA 1994
Nutrition Screening equation
poor
Who is performing poorly?
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One population, validity of tool to SGA
MUST fair renal inpatients Lawson, J Ren Nutr 2012
MST poor
NRS-2002 good surgical Almeida, Clin Nutr 2012
MUST good
NRI poor
NRS-2002 fair newly admitted Kyle, Clin Nutr 2006
MUST fair
NRI poor
Pitfall: new tool can never be better than the reference tool
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One population, validity of tool to MNA
MEONF-II fair elderly Westergren, BMC Nursing 2011
NRS-2002 poor
INSYST-I good inpatients Tamman, J Hum Nutr Diet 2009
INSYST-II fair
Pitfall: new tool can never be better than the reference tool
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Conclusion (1)
• One size does NOT fit all!
– Know what you want to measure:– Nutritional status?– Outcome?– Responsiveness to nutritional intervention?
– Know which population you want to measure in
• Then choose your tool
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Recommendations
• Do’s:
– studies applying >1 tool in 1 population, 1 outcome measure
– effects of nutritional intervention in patients at risk
– outpatients
• Don’ts:
– develop new tools
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Co-workers
• Ilse Jansma
• Riekie de Vet
• Patricia Guaitoli