Global Malnutrition Composite Score

This measure assesses the percentage of hospitalizations of 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 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 (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.

Copyright (C) Academy of Nutrition and Dietetics 2024

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 2004-2023 Regenstrief Institute, Inc. 

ICD-10 copyright 2023 World Health Organization.

This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2023. 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].

None

None

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations. 

A single measure population, or eligible hospitalization, is used to calculate the "Total Malnutrition Components Score" and "Total Malnutrition Composite Score as Percentage". The initial population are inpatient 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" is "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 Finding of Not At Risk Result" or current identified "Malnutrition Screening Finding of At Risk Result" documented. It also identifies a hospital encounter where there is a Hospital Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not.

"Measure Observation 2" is "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 Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished" OR "Nutrition Assessment Status Finding of Severely Malnourished" documented.

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

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

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

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

" Measure Observation 5 Total Malnutrition Components Score" equals ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4")  
 
" Measure Observation 5 Total Malnutrition Components Score" Calculations:
-For each hospitalization, Measure Observation 5 represents the sum of Measure Observations 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4.

" Measure Observation 6 Total Malnutrition Composite Score as Percentage" equals “Measure Observation 5 Total Malnutrition Components Score” divided by the “Measure Observation Total Malnutrition Composite Score Eligible Occurrences”, then multiplied by 100. 

" Measure Observation 6 Total Malnutrition Composite Score as Percentage" Calculations:
-For each hospitalization, Measure Observation 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences, multiplied by 100. Possible values may result in 0, 50, 75, or 100 per hospitalization. 

"Total Malnutrition Composite Score Eligible Occurrences" always equals 4 except in the following instances: 
-The "Total Malnutrition Composite Score Eligible Occurrences" is 1 if
---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered
- The "Total Malnutrition Composite Score Eligible Occurrences" is 2
---If a "Nutrition Assessment" was performed and a "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished" was identified
--- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was ordered OR a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed.

-For the reporting facility, the Aggregate Operator 'Count' includes the number of eligible hospitalizations during the measurement period.
-For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Composite Score as Percentage" across all eligible hospitalizations during the measurement period.

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 for 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 (Academy of Nutrition and Dietetics, 2017).

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 assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutritional status utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible provider as defined by CMS. The four measure observations individually will only provide a fraction of the necessary information on quality of care for patients at risk for or with 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 malnutrition risk screening and hand off to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with a moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/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 associated nutrition interventions. 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 stays, and complications, as well as improved quality of life after hospitalization (Sriram, 2017).

American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, et al., 2011).

This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. 

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 intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plants in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans 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: 'Mueller, C., Compher, C., Druyan, M.E., & the ASPEN Board of Directors. (2011). ASPEN 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: '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: 'Academy of Nutrition and Dietetics. The Nutrition Care Process Model. Published 2017. Accessed June 12, 2023. https://www.ncpro.org/pubs/2020-encpt-en/ncp-model'

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 nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. 

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), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS 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, interventions, and monitoring and evaluation plans 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, along with a plan for monitoring and evaluation, 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. 

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 among individuals 65 years of age and older at the start of the inpatient encounter. 

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

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

None

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 "Total Malnutrition Components Score" and "Total Malnutrition Composite Score as Percentage". 

Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Hospital Dietitian Referral. 

"Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Hospital Dietitian Referral" 

"Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies a hospitalization where there is a Hospital Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not.

Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization. 

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

"Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished".

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

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

"Measure Observation 3" identifies hospital encounters where a "Malnutrition Diagnosis" was active during the hospitalization (including preceding observation or emergency department encounters).

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

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

"Measure Observation 4" identifies hospital encounters where a "Nutrition Care Plan" was performed or authored during the hospitalization (including preceding observation or emergency department encounters). 

"Population 5 Measure Observation Total Malnutrition Components Score" Calculations
-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4.
 
"Population 5 Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4")

"Population 6 Measure Observation Total Malnutrition Composite Score 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 occurrences. 

"Population 6 Measure Observation Total Malnutrition Composite Score as Percentage" is 100 multiplied by ("Total Malnutrition Components Score" divided by "Total Malnutrition Composite Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent. 

"Total Malnutrition Composite Score Eligible Occurrences" is always 4 except in the following instances:
-The "Total Malnutrition Composite Score Eligible Occurrences" is 1 if
---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered.
- The "Total Malnutrition Composite Score Eligible Occurrences" are 2
---If a "Nutrition Assessment" was performed and a "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished" was identified
--- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was ordered OR a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed

-For the reporting facility, the Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.
-For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Composite Score as Percentage" across all eligible hospitalizations during the measurement period.

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.