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