IBD Malnutrition Screening Model Shows Promise

Inflammatory bowel disease (IBD) researchers reported success with a new model to address gaps in the screening and management of malnutrition in IBD patients.

The IBD-Nutrition Care Pathway (IBD-NCP) pilot-tested components within IBD Qorus, a collaborative learning initiative between patients and healthcare providers sponsored by the Crohn’s and Colitis Foundation, aimed at improving care.

The pathway quickly screened more than 2,000 IBD patients using the existing Qorus infrastructure and did assessments of both patients and providers with regard to specific care pathway components, according to Jason K. Hou, MD, of the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, both in Houston, and colleagues.

Malnutrition rates are 40% to 85% in hospitalized IBD patients and 20% to 50% in their ambulatory counterparts, they wrote in Clinical Gastroenterology and Hepatology. In addition, large cohort studies and meta-analyses have shown malnourished inpatients have increased inpatient mortality, more frequent and lengthier hospitalizations, and an increased risk of nosocomial infections.

Yet gastroenterologists generally do a less than stellar job of screening their IBD patients for nutritional deficiencies despite the associated adverse outcomes.

“We haven’t, as a whole healthcare system, been great about implementing good screening processes,” co-author Caroline Hwang, MD, of the Keck School of Medicine at the University of Southern California in Los Angeles, previously told MedPage Today. “And that includes IBD which, given that it is a chronic GI condition, is something we should have been able to do early on. But we actually haven’t, and part of that is that physicians really aren’t well trained in nutrition and don’t get great medical information regarding nutrition.”

The pilot study was tested at five academic and three private-practice sites located across the country that participated in IBD Qorus. These sites represented a broad spectrum of practice types based on IBD specialty practice, academic affiliation, practice size, and geography. Quantitative and qualitative feedback was obtained during and after pilot testing of components of the IBD-NCP.

The authors explained that one of the major challenges to studying the impact of malnutrition in IBD is the lack of standardized nutritional screening programs for IBD. A variety of malnutrition screening instruments have been validated for use in the acute care setting, including the Malnutrition Universal Screening Tool (MUST) and the Malnutrition Screening Tool (MS).

In the current study, participating patients were consecutively screened for the IBD-NCP using a modified version of MUST (mMUST), which was adapted to suit outpatients and address IBD symptom activity specifically. In mMUST, assessment is based on BMI, calculated from self-reported height and weight, percentage of self-reported weight loss in the past 6 months, and an acute disease effect subscore. Four stages make up the IBD-NCP: screening, assessment, intervention, and follow-up.

Pilot testing screened 2,388 patients, with 92% completing the full survey. Of those screened, 1,758 provided feedback on the process, with 93% reporting that mMUST was easily completed, and 44% considering nutritional screening relevant to their care.

Of patients who completed mMUST, 72% were considered at low risk (mMUST=0), 10% at medium risk (mMUST=1), and 18% at high risk (mMUST≥2). For the purposes of the IBD-NCP, all patients at medium and high risk were considered at-risk for malnutrition and were recommended for further nutritional evaluation, including with a registered dietitian.

However, multiple barriers to referral emerged. For example, many providers did not have access to registered dietitian services, particularly ones with IBD-specific dietary counseling experience. In addition, providers were often unable to follow dietitians’ recommendations since they were unfamiliar with the test and therapies they recommended.

Several patient barriers to dietitian referral were also identified, including lack of insurance coverage for dietitian counseling services, and lack of interest in some patients in dietitian referral. To address these impediments, the IBD-NCP was modified to specifically evaluate and provide patient and provider instruction for specific domains of malnutrition, which are most relevant to IBD patients and can be feasibly performed by GI providers. These included symptoms impairing oral intake, food-avoidant behaviors, and micronutrient deficiencies.

“IBD Qorus has the potential to continue to serve as a platform to test the IBD-NCP as well as other care pathways in development,” according to Hou and colleagues. They said they anticipated obstacles to following up those at risk for malnutrition, so “Dashboard-based population management tools currently under development within IBD Qorus will be tested specifically to address these barriers.”

“The IBD-NCP provides a clinically feasible way to screen for and manage malnutrition in patients with IBD and will require further testing to demonstrate improvement in clinical outcomes,” the authors stated.