Global Malnutrition Composite Score

This measure assesses the percentage of hospitalizations for adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization 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 or for a hospital dietitian referral order, 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.

(C) Academy of Nutrition and Dietetics 2023 

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. 

LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.  

ICD-10 copyright 2022 World Health Organization. 

This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2022. International Health Terminology Standards Development Organisation. All Rights Reserved.

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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This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations. A single measure population is used to calculate the "TotalMalnutritionComponentsScore" and "TotalMalnutritionCompositeScore as Percentage". The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater. 

"Measure Observation 1" = "Encounters with Malnutrition Risk Screening and Identified Result"

"Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed with a current identified "Malnutrition Screening Not At Risk Result" or current identified "Malnutrition Screening At Risk Result". 

"Measure Observation 2" = "Encounters with Nutrition Assessment and Identified Status" 

"Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was  performed with a current identified "Nutrition Assessment Status Not or Mildly Malnourished", "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished".

For "Measure Observation 1" and "Measure Observation 2", only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment".

"Measure Observation 3" = "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies hospital encounters where a current "Malnutrition Diagnosis" was documented.

"Measure Observation 4" = "Encounters with Nutrition Care Plan" 

"Measure Observation 4" identifies hospital encounters where a current "Nutrition Care Plan" was performed. 

"Population 5 Measure Observation TotalMalnutritionComponentsScore" = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4")  
 
"Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations:
-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. 
-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.

"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" = 100 * ("Measure Observation TotalMalnutritionComponentsScore" divided by "Measure Observation TotalMalnutritionCompositeScore Eligible Denominators")

"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations:
-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. 
-For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: 
-If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1.
-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2. 

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:
-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. 
-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. 
-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.
-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

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 or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (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.

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (A.S.P.E.N., 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 interventions 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.

Higher score indicates better quality of care

Reference Type: CITATION

Reference Text: 'Agarwal, E., Ferguson, M., Banks, M., Batterham, M., Bauer, Capra, S., & Isenring, E. (2013). 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). 32(5):737-745.'

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. JPEN, 38(2), 186-95. https://doi.org/10.1177/0148607113512154'

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'

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. Journal of Parenteral and Enteral Nutrition (JPEN), 42(5), 892-897. https://doi.org/10.1002/jpen.1021'

Reference Type: CITATION

Reference Text: 'Jimenez, E. Y., Long, J. M., Lamers-Johnson, E., Kelley, K., Abram, J. K., & Steiber, A. (2021). Academy of Nutrition and Dietetics Nutrition Research Network: Rationale and protocol for a study to validate the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition consensus-derived diagnostic indicators for adult and pediatric malnutrition and to determine optimal registered dietitian nutritionist staffing in acute care hospital settings. Journal of the Academy of Nutrition and Dietetics, 122(3), 630-639. https://doi.org/10.1016/j.jand.2021.03.017'

Reference Type: CITATION

Reference Text: 'Kruizenga. H., van Keeken, S., Weijs, P., Bastiaanse, L., Beijer, S., Huisman-de Waal, G., Jager-Wittenaar, H., 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'

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, 41(5), 744-758. https://doi.org/10.1177/0148607115625638'

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'

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'

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 on nutrition screening, assessment, and intervention in adults: Journal of Parenteral and Enteral Nutrition, 35(1), 16-24. https://doi.org/10.1177/0148607110389335'

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'

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'

Reference Type: CITATION

Reference Text: 'White, J., Guenter, P., Gordon, J., Malone, A., Schofield, M., Academy Malnutrition Work Group, A.S.P.E.N. Malnutrition Task Force, & A.S.P.E.N. Board of Directors (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, 112(5), 730-738.'

Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from the nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening is performed by a nursing professional, Registered Dietitian (RD), or Registered Dietitian Nutritionist (RDN).  

Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. 

Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s). For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician/eligible clinician based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. 

Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations and interventions that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, and is documented by the RD or RDN.

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater.

Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed.

Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed from a "Malnutrition Screening At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization. 

For Component Measure 1 and Component Measure 2, only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment".

Component Measure 3: Inpatient hospitalizations for patients with a current  documented "Malnutrition Diagnosis" as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current "Nutrition Assessment Status Severely Malnourished". 

Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current “Nutrition Assessment Status Severely Malnourished”. 

"Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations
-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. 
-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.
 
"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations:
-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. 
-For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: 
-If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1.
-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2. 

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:
-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. 
-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. 
-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.
-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

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.

TBD

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 inpatient encounter

Equals Initial Population

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This is a continuous variable measure. There are six measure observations for this measure.

This measure is constructed of four clinically eligible components aggregated as an arithmetic average of eligible hospitalizations. A single measure population is used to calculate the "TotalMalnutritionComponentsScore" and "TotalMalnutritionCompositeScore as Percentage". The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater.

"Measure Observation 1" = "Encounters with Malnutrition Risk Screening and Identified Result" 

"Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed with a current identified "Malnutrition Screening Not At Risk Result" or current "Malnutrition Screening At Risk Result". 

"Measure Observation 2" = "Encounter with Nutrition Assessment and Identified Status" 

"Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed with a current identified "Nutrition Assessment Status Not or Mildly Malnourished", "Nutrition Assessment Status Moderately Malnourished", or "Nutrition Assessment Status Severely Malnourished".

"Measure Observation 3" = "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies hospital encounters where a current "Malnutrition Diagnosis" was documented.

“Measure Observation 4” = “Encounters with Nutrition Care Plan”

"Measure Observation 4" identifies hospital encounters where a current "Nutrition Care Plan" was performed. 

"Population 5 Measure Observation TotalMalnutritionComponentsScore" = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4")

"Population 5 Measure Observation "TotalMalnutritionComponentsScore" Calculations
-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. 
-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.
 
"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" = 100 * ("TotalMalnutritionComponentsScore" divided by "TotalMalnutritionCompositeScore Eligible Denominators"). 

Population 6 Measure Observation "TotalMalnutritionCompositeScore as Percentage" Calculations:
-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. 
-For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: 
-If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1.
-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the “TotalMalnutritionCompositeScore Eligible Denominators” are 2. 

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:
-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. 
-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. 
-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.
-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

This is a continuous variable measure. There are six measure observations for this measure. See "Measure Observations" above for details.