eCQM Title | Global Malnutrition Composite Score |
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eCQM Identifier (Measure Authoring Tool) | 986 | eCQM Version Number | 1.9.000 |
NQF Number | 3592e | GUID | bff5e631-bcd1-4e4b-af54-9d93cd19c835 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | Academy of Nutrition and Dietetics | ||
Measure Developer | Avalere Health | ||
Endorsed By | National Quality Forum | ||
Description |
This measure assesses the percentage of hospitalizations for adults aged 65 years and older prior to the start of the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalizations where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed. |
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Copyright |
(C) Academy of Nutrition and Dietetics 2022 Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. CPT (R) contained in the Measure specifications is copyright 2004-2021 by the American Medical Association. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. ICD-10 copyright 2021 World Health Organization. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2021. International Health Terminology Standards Development Organization. All Rights Reserved. |
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Disclaimer |
This measure and the specifications are subject to further revisions. This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, copyright is indicated by (C) or [C], registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]. |
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Measure Scoring | Continuous Variable | ||
Measure Type | Intermediate Clinical Outcome | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
This measure is constructed as an arithmetic average of the four equally weighted measure populations. A single measure population is used to calculate the Total Components Measure Score and the Total Components Measure Score as Percentage. Measure Observation 1 = Encounters with Malnutrition Risk Screening / Initial Population Measure Observation 2 = Encounters with Malnutrition Assessment / Encounters with Malnutrition Screening At Risk Result Measure Observation 3 = Encounters with Malnutrition Diagnosis / Encounters with Nutrition Assessment Result of Moderate or Severe Malnourishment Measure Observation 4 = Encounters with Nutrition Care Plan / Encounters with Nutrition Assessment Result of Moderate or Severe Malnourishment Measure Observation Total Components Measure Score = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") Measure Observation Total Components Measure Score as Percentage = 100 * ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") / "Total Components Measure Score Eligible Denominators" Total Malnutrition Components Score Eligible Denominators equals: 1, if Malnutrition Risk Screening was performed and a Malnutrition Screening At Risk Result was not identified OR 2, if Malnutrition Assessment was performed and a Nutrition Assessment Result of Moderate or Severe Malnourishment was not identified OR 4, if Malnutrition Screening was not performed OR Malnutrition Screening At Risk Result was identified AND a Nutrition Assessment was not performed OR a Nutrition Assessment Result of Moderate or Severe Malnourishment was identified |
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Rationale |
The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at-risk of malnutrition in order to form the basis for an appropriate nutrition intervention; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers. The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough physical assessment by registered dietitian nutritionists (RDN). The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician. The four component measures individually will only provide a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely nursing malnutrition risk screening and hand off to RDNs for appropriate nutritional assessment for patients at-risk of malnutrition during the current hospitalization. For patients identified with a moderate or severe malnutrition status from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professionals and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stay, and complications, as well as improved quality of life after hospitalization. |
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Clinical Recommendation Statement |
American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (2011) This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk of malnutrition is the first step in nutrition care as nutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Nutrition assessment is suggested for all patients who are identified to be at malnutrition risk by nutrition screening. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition support intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition support intervention in patients identified assessment as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition intervention in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. |
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Improvement Notation |
Higher score indicates better quality of care. |
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Reference |
Reference Type: CITATION Reference Text: 'Mueller, C., Compher, C., Druyan, M.E., & the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. (2011). A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. Journal of Parenteral and Enteral Nutrition, 35(1), 16-24. https://doi.org/10.1177/0148607110389335' |
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Reference |
Reference Type: CITATION Reference Text: 'Silver, H.J., Pratt, K.J., Bruno, M., Lynch, J., Mitchell, K., & McCauley, S.M. (2018). Effectiveness of the Malnutrition Quality Improvement Initiative on Practitioner Malnutrition Knowledge and Screening, Diagnosis, and Timeliness of Malnutrition-Related Care Provided to Older Adults Admitted to a Tertiary Care Facility: A Pilot Study. Journal of the Academy of Nutrition and Dietetics, 118(1), 101-109. https://doi.org/10.1016/j.jand.2017.08.111' |
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Reference |
Reference Type: CITATION Reference Text: 'Hudson, L., Chittams, J., Griffith, C., & Compher, C. (2018). Malnutrition Identified by Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Is Associated With More 30-Day Readmissions, Greater Hospital Mortality, and Longer Hospital Stays: A Retrospective Analysis of Nutrition Assessment Data in a Major Medical Center. JPEN Journal of Parenteral and Enteral Nutrition, 42(5), 892-897. https://doi.org/10.1002/jpen.1021' |
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Reference |
Reference Type: CITATION Reference Text: 'Sriram, K,, Sulo, S., VanDerBosch, G., Partridge, J., Feldstein, J., Hegazi, R.A., & Summerfelt, W.T. (2017). A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN Journal of Parenteral and Enteral Nutrition, 41(3), 384-391. https://doi.org/10.1177/0148607116681468' |
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Reference |
Reference Type: CITATION Reference Text: 'Milne, A.C., Potter, J., Vivanti, A., Avenell, A., and Cochrane Metabolic and Endocrine Disorders Group. (2009). Protein and energy supplementation in elderly people at risk from malnutrition. The Cochrane Database of Systematic Reviews, 2009(2), CD003288. https://dx.doi.org/10.1002%2F14651858.CD003288.pub3' |
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Reference |
Reference Type: CITATION Reference Text: 'Lew, C.C., Yandell, R., Fraser, R.J., Chua, A.P., Chong, M.F., & Miller, M. (2016). Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review. JPEN Journal of Parenteral And Enteral Nutrition, 41(5), 744-758. https://doi.org/10.1177/0148607115625638'Reference Text: 'Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clinical nutrition (Edinburgh, Scotland). 2013;32(5):737-745.' |
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Reference |
Reference Type: CITATION Reference Text: 'Corkins, M.R., Guenter, P., Dimaria-ghalili, R.A., Jensen, G.L., Malone, A., Miller, S., Patel, V., Plogsted, S., Resnick, H.E., & American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). (2014). Malnutrition diagnoses in hospitalized patients: United States, 2010. Journal of Parenteral and Enteral Nutrition, 38(2), 186-95. https://doi.org/10.1177/0148607113512154' |
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Reference |
Reference Type: CITATION Reference Text: 'Kruizenga. H., van Keeken, S., Weijs, P., Bastiaanse, L., Beijer, S., Huisman-de Waal, G., Jager-Wittenaar, H.J., Jonkers-Schuitema, C., Klos, M., Remijnse-Meester, W., Witteman, & B., Thijs, A. (2016). Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer. The American Journal of Clinical Nutrition, 103(4), 1026-1032. https://doi.org/10.3945/ajcn.115.126615' |
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Reference |
Reference Type: CITATION Reference Text: 'Meehan, A., Loose, C., Bell, J., Partridge, J., Nelson, J., & Goates, S. (2016). Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs. Journal of Nursing Care Quality, 31(3), 217-223. https://doi.org/10.1097/ncq.0000000000000177' |
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Reference |
Reference Type: CITATION Reference Text: 'Doley, J., Phillips, W., Talaber, J. & Leger-LeBlanc, G. (2018). Early Implementation of Malnutrition Clinical Quality Metrics to Identify Institutional Performance Improvement Needs. Journal of the Academy of Nutrition and Dietetics, 114(4), 547-552. https://doi.org/10.1016/j.jand.2018.02.020' |
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Reference |
Reference Type: CITATION Reference Text: 'White, Jane V. et al. (2012). Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). Journal of the Academy of Nutrition and Dietetics, Volume 112, Issue 5, 730 - 738' |
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Definition |
None |
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Guidance |
The measure is constructed as an arithmetic average of four equally weighted component measures expressed as a percentage. The four measure populations used to calculate the Total Components Measure Score may differ. Component Measure 1: Inpatient hospitalizations for patients with a current screening for malnutrition risk performed at the time of admission. Component Measure 2: Inpatient hospitalizations for patients with a current assessment for malnutrition performed from an "at risk" finding in a current malnutrition screening. Component Measure 3: Inpatient hospitalizations for patients with a current malnutrition diagnosed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. Component Measure 4: Inpatient hospitalizations for patients with a current nutrition care plan performed as a result of a "moderate" or "severe" malnutrition status from a current malnutrition assessment. The activities of the four component numerators do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the measurement period. |
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Measure Population |
Initial Population |
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Measure Population Exclusions |
None |
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Measure Observations |
This is a continuous variable measure. There are six measure observations for this measure. This measure is constructed as an arithmetic average of the four equally weighted component measures. A single measure population is used to calculate the Total Components Measure Score and the Total Components Measure Score as Percentage. Measure Observation 1 = Encounters with Malnutrition Risk Screening / Initial Population Measure Observation 2 = Encounters with Malnutrition Assessment / Encounters with Malnutrition Screening At Risk Result Measure Observation 3 = Encounters with Malnutrition Diagnosis / Encounters with Nutrition Assessment Result of Moderate or Severe Malnourishment Measure Observation 4 = Encounters with Nutrition Care Plan / Encounters with Nutrition Assessment Result of Moderate or Severe Malnourishment Measure Observation Total Components Measure Score = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") Measure Observation Total Components Measure Score as Percentage = 100 * ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") / "Total Components Measure Score Eligible Denominators" Total Malnutrition Components Score Eligible Denominators equals: 1, if Malnutrition Risk Screening was performed and a Malnutrition Screening At Risk Result was not identified OR 2, if Malnutrition Assessment was performed and a Nutrition Assessment Result of Moderate or Severe Malnourishment was not identified OR 4, if Malnutrition Screening was not performed OR Malnutrition Screening At Risk Result was identified AND a Nutrition Assessment was not performed OR a Nutrition Assessment Result of Moderate or Severe Malnourishment was identified |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
"Global Malnutrition Encounter"
"Initial Population"
None
None
Sum ( if ( "Encounter with Malnutrition Risk Screening" contains Encounter ) then 1 else 0 )
"Global Malnutrition Encounter"
"Initial Population"
None
None
Sum ( if ( ( "Encounter with Malnutrition Screening At Risk Result" contains Encounter ) and ( "Encounter with Malnutrition Assessment" contains Encounter ) ) then 1 else 0 )
"Global Malnutrition Encounter"
"Initial Population"
None
None
Sum ( if ( ( "Encounter with Nutrition Assessment Malnourishment Result" contains Encounter ) and ( "Encounter with Malnutrition Diagnosis" contains Encounter ) ) then 1 else 0 )
"Global Malnutrition Encounter"
"Initial Population"
None
None
Sum ( if ( ( "Encounter with Nutrition Care Plan" contains Encounter ) and ( "Encounter with Nutrition Assessment Malnourishment Result" contains Encounter ) ) then 1 else 0 )
"Global Malnutrition Encounter"
"Initial Population"
None
None
Count ( Sum({ "Measure Observation 1"(Encounter), "Measure Observation 2"(Encounter), "Measure Observation 3"(Encounter), "Measure Observation 4"(Encounter)}) )
"Global Malnutrition Encounter"
"Initial Population"
None
None
Average ( 100 * ( "Measure Observation TotalMalnutritionComponentsScore"(Encounter)/ "TotalMalnutritionComponentsScore Eligible Denominators"(Encounter)) )
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with ["Assessment, Performed": "Malnutrition Assessment"] MalnutritionAssessment such that MalnutritionAssessment.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with ["Diagnosis": "Malnutrition Diagnosis"] MalnutritionDiagnosis such that MalnutritionDiagnosis.prevalencePeriod starts during GlobalMalnutritionEncounter.relevantPeriod
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with ["Assessment, Performed": "Malnutrition Risk Screening"] MalnutritionRiskScreening such that MalnutritionRiskScreening.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with ["Assessment, Performed": "Malnutrition Screening At Risk Result"] MalnutritionScreeningResult such that MalnutritionScreeningResult.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with "Nutrition Assessment Result of Moderate or Severe Malnourishment" AssessmentResultMalnourishment such that AssessmentResultMalnourishment.relevantDatetime during GlobalMalnutritionEncounter.relevantPeriod
"Global Malnutrition Encounter" GlobalMalnutritionEncounter with ["Intervention, Performed": "Nutrition Care Plan"] NutritionCarePlan such that NutritionCarePlan.authorDatetime during GlobalMalnutritionEncounter.relevantPeriod
["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter where InpatientEncounter.relevantPeriod during day of "Measurement Period" and duration in hours of InpatientEncounter.relevantPeriod >= 24 and AgeInYearsAt(date from start of "Measurement Period")>= 65
"Global Malnutrition Encounter"
"Initial Population"
["Assessment, Performed": "Malnutrition Assessment"] AssessmentResultMalnourishment where ( AssessmentResultMalnourishment.result in "Nutritional Status Moderately Malnourished" or AssessmentResultMalnourishment.result in "Nutritional Status Severely Malnourished" )
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
if ( "Encounter with Malnutrition Risk Screening" contains Encounter ) then 1 else 0
if ( ( "Encounter with Malnutrition Screening At Risk Result" contains Encounter ) and ( "Encounter with Malnutrition Assessment" contains Encounter ) ) then 1 else 0
if ( ( "Encounter with Nutrition Assessment Malnourishment Result" contains Encounter ) and ( "Encounter with Malnutrition Diagnosis" contains Encounter ) ) then 1 else 0
if ( ( "Encounter with Nutrition Care Plan" contains Encounter ) and ( "Encounter with Nutrition Assessment Malnourishment Result" contains Encounter ) ) then 1 else 0
Sum({ "Measure Observation 1"(Encounter), "Measure Observation 2"(Encounter), "Measure Observation 3"(Encounter), "Measure Observation 4"(Encounter)})
100 * ( "Measure Observation TotalMalnutritionComponentsScore"(Encounter)/ "TotalMalnutritionComponentsScore Eligible Denominators"(Encounter))
if ( ( "Encounter with Malnutrition Risk Screening" contains Encounter ) and not ( ( "Encounter with Nutrition Assessment Malnourishment Result" contains Encounter ) or ( "Encounter with Malnutrition Diagnosis" contains Encounter ) or ( "Encounter with Nutrition Care Plan" contains Encounter ) ) ) then if not ( ( "Encounter with Malnutrition Screening At Risk Result" contains Encounter ) and ( "Encounter with Malnutrition Assessment" contains Encounter ) ) then 1 else if ( "Encounter with Malnutrition Assessment" contains Encounter ) then 2 else 4 else 4
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
This is a continuous variable measure. There are six measure observations for this measure. See "Measure Observations" above for details. |
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