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Part II Nutrition Assessment, Consequences, and Implications

reasons for 30-day readmission were gastrointestinal problems/complications (27.6%), surgical infections (22.1%), and failure to thrive/malnutrition (10.4%) (32).

An additional factor to consider when addressing hospital readmissions is the care older adults receive both during and after hospitalization. A recent commen- tary by Harlan Krumholz, MD, SM, published in the New England Journal of Medicine states that to promote a successful recovery after hospitalization, health care professionals need to focus on not only the admitting diagnosis but also the effects of that hospital- ization on the individual’s body function. At discharge, older adults’ physiological systems are often impaired, their reserves are depleted, and their body cannot effec- tively defend itself, a phenomenon Krumholz refers to as post- hospital syndrome. This syndrome occurs as a result of hospitalization for an acute illness along with other factors, such as sleep deprivation, decreased cog- nitive function, pain and discomfort, and poor nutrition (see Box 20.2). Krumholz suggests that the health care team implement interventions to improve the health status of these individuals after hospital discharge, including promoting good nutrition and addressing nutritional deficiencies (33).

BOX 20.2 Posthospital Syndrome Associated Causes

● Sleep deprivation ● Pain and discomfort

● Decline in mental functioning ● Poor nutrition

Source: Data are from reference 33.

RESEARCH ON THE IMPACT OF NUTRITION INTERVENTION ON REDUCING HOSPITAL READMISSIONS

Many studies have shown that nutrition intervention, including diet education, coordinated nutrition care, oral nutritional supplements (ONS), and enteral feeding, can help decrease readmission rates, therefore helping to decrease costs and improve quality of care. The majority of the research has been conducted in hospitalized elderly and/or malnourished patients. Diet education for those with AMI and CHF can improve outcomes and improve diet adherence (34). Studies have demonstrated that cardiac rehabilitation and heart failure programs that include diet

counseling and cooking classes significantly reduce hospital readmissions (35-38). Research has also examined the impact of coordinated nutritional care on readmissions. Holyday et al examined the impact of a malnutrition care plan that included modifica- tion of hospital meals, prescription of an ONS, meal assistance, and diet education versus standard of care in hospitalized patients in acute aged care. They found no difference between the groups on one- and six-month readmission frequency but did find a trend toward reduced readmission rates for the malnour- ished individuals (39).

Several studies have examined the impact of ONS use during and after hospitalization on read- mission rates in various populations (40-44). Gariballa et al evaluated the impact of ONS in acutely ill older hospital patients who were random- ized to receive either a normal hospital diet plus ONS or a normal hospital diet plus a placebo daily for six weeks. After six months, the proportion of older adults readmitted to the hospital was signifi- cantly lower in individuals receiving ONS (29%) compared with those in the placebo group (40%; P < .05) (40). Norman et al examined the effect of a three-month posthospital nutrition intervention with high-protein ONS in malnourished older adults with gastrointestinal (GI) disorders. Individuals were ran- domized to receive either ONS with dietary counsel- ing or only dietary counseling for three months. This study demonstrated that those receiving ONS in addition to dietary counseling have significantly fewer readmissions (n = 10) than those receiving dietary counseling alone (n = 20; p = 0.041) (41). Recent systematic reviews and meta-analyses have also confirmed the link between nutrition intervention with ONS and readmissions. Cawood et al showed that intervention with high-protein ONS compared to stan- dard care reduced overall readmissions by 30% (42). Similar findings have been published more recently by Stratton et al, where ONS was shown to significantly reduce hospital readmissions, particularly in older adult populations, with economic implications for health care. This review examined six randomized controlled trials involving 852 patients and demonstrated a 41% reduction in readmission risk with ONS compared with routine care (odds ratio [OR]: 0.59, 95% CI 0.43–0.80, P = 0.001) (43). Additionally, a series of health economic outcomes research studies have highlighted the benefits of ONS in the hospital setting (44-46). The first was an 11-year retrospective study using the Premier Research Database, which contains diagnostic and billing infor- mation on 44 million adult inpatient episodes. Using a matched sample of ONS use and non-ONS use