Original articleScreening malnutrition in hospital outpatients. Can the SNAQ malnutrition screening tool also be applied to this population?
Introduction
Disease-related malnutrition is a widespread problem in nearly all health care settings. Prevalence of disease-related malnutrition is reported to vary from 25–40% in hospital inpatients to 15–25% in home care units and 20–25% in nursing homes.1, 2, 3, 4, 5, 6, 7 To the best of our knowledge, very little data is available on the prevalence of disease-related malnutrition in a general hospital outpatient population. Wilson found a malnutrition prevalence of 7–11%, depending on age.8 A recent study on the prevalence of disease-related malnutrition (based on Body Mass Index (BMI) and percentage of unintentional weight loss) in our own general outpatient population revealed a malnutrition percentage of 7% (VU University Medical Centre in Amsterdam, The Netherlands).9
Disease-related malnutrition may be harmful to patients. Studies have reported increased postoperative complications,10, 11, 12 decreased quality of life,13 decreased wound healing14 and increased mortality and morbidity.15 These harmful effects lead to an increased length of hospital stay and so higher hospital costs.16, 17, 18, 19, 20
In order to diminish the negative consequences of disease-related malnutrition it is of paramount importance to recognize malnourished patients at an early stage of their medical treatment. The time available to set out an optimal nutritional treatment plan during hospital stay is limited because the length of hospital stays decreases. Patients will optimally benefit from nutritional treatment if this has already been initiated in the outpatient setting. Therefore, early recognition of malnutrition in the outpatient clinic is essential.15
Several studies have pointed out that medical and nursing staff recognizing of disease-related malnutrition is often inadequate.16, 21 Also in our own general outpatient population only 15% of the malnourished patients received nutritional treatment.9 These findings emphasize the need for an appropriate screening tool for the early detection of malnourished patients. Although without any doubt screening tools are already being used in the outpatient setting, diagnostic accuracies for these tools have not been reported.
A malnutrition screening tool for the hospital outpatients in clinical practice should be quick, easy and ready to apply and to interpret. An example of such a tool is the Short Nutritional Assessment Questionnaire (SNAQ). The SNAQ (Fig. 1), consisting of three questions, has been validated for the hospital inpatient population against low BMI and/or unintentionally weight loss. The SNAQ has been proven to be a valid and reproducible screening tool for determining the risk of malnutrition of hospitalized patients.22 The recognition of disease-related malnutrition may improve from 50% to 80% by using this malnutrition screening tool. Implementation of this screening tool, accompanied by a treatment plan, has been proven to be both effective and cost effective.16
Diagnostic accuracies of the SNAQ for the hospital outpatient population are missing. Therefore, the first objective of this study was to determine whether the three SNAQ questions most predictive of malnutrition in the hospital inpatient setting were also most predictive of malnutrition in the hospital outpatient setting. The second objective was to measure the diagnostic accuracy of this SNAQ malnutrition screening tool in the outpatient population.
Section snippets
Patients and methods
This study was performed in three steps. First, the development of the SNAQ outpatient malnutrition screening tool was performed by selecting the optimal set of questions most predictive of malnutrition in a preoperative outpatient population. Second, the diagnostic accuracy of this screening tool was calculated in the same preoperative population. Finally, the diagnostic accuracy of this screening tool was calculated in a general outpatient population.
The study design was in accordance with
Development of the SNAQ in the preoperative population
In this sub-study 1107 patients were included. One hundred and nine patients (10%) were excluded because of the following reasons: the investigator did not succeed to contact the patient by telephone within a period of five working days (n = 50), the telephone number could not be traced (n = 31), the patient did not consent to participate (n = 25) or the patient was unable to speak due to oral or throat related conditions (n = 3). Another 19 patients (2%) were excluded (after inclusion), in whom no
Discussion
The SNAQ malnutrition screening tool was found to be a reliable tool for malnutrition risk screening in a general outpatient population. In preoperative patients the prevalence of moderate malnutrition was 9% and the prevalence of severe malnutrition was 8%. In the general outpatient population, 7% was moderately malnourished and 5% was severely malnourished. The diagnostic accuracy of the SNAQ malnutrition screening tool in these outpatient populations was determined: sensitivity was 53–67%
Conclusion
The SNAQ malnutrition screening tool in its original form can be applied for the general hospital outpatient population as well. The recognition and treatment of malnourished patients may improve from 15% before screening to 53–67% after implementing the SNAQ malnutrition screening tool. Deciding to screen only in high malnutrition risk departments may improve recognition up to even 71%.
Since calculating BMI and percent unintentional weight loss of each patient is no daily routine, the SNAQ
Conflict of interest statement
This project was financially supported equally by both Abbott BV and Nutricia Nederland BV. There was no conflict of interest.
Acknowledgements
The authors of this article would like to thank the nursing and medical staff on the preoperative outpatient clinic for handing out SNAQ questionnaires. We also would like to thank Esther van 't Riet en Annemarie Brummelman, students, for their help with the practical part of this study. F.N. and H.M.K. were responsible for the study design, data collection, analysis, and writing the manuscript (guarantor). H.C.W.dV., J.C.S. and M.A.E.vB. participated in developing the study design, the
References (26)
- et al.
Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation
Clinical Nutrition
(1999) - et al.
Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group
Clinical Nutrition
(2000) - et al.
Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition
Clinical Nutrition
(2003) - et al.
Hospital malnutrition: the Brazilian National Survey (IBRANUTRI): A study of 4000 patients
Nutrition
(2001) - et al.
Prevalence and causes of undernutrition in medical outpatients
American Journal of Medicine
(1998) - et al.
Van Bokhorst-de van der Schueren MAE. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients
American Journal of Clinical Nutrition
(2005) - et al.
Nutritional assessment: lean body mass depletion at hospital admission is associated with an increased length of stay
American Journal of Clinical Nutrition
(2004) Lean body mass depletion is associated with an increased length of hospital stay
American Journal of Clinical Nutrition
(2004)- et al.
van Bokhorst-de van der Schueren MA. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ)
Clinical Nutrition
(2005) - et al.
Screening of nutritional status in The Netherlands
Clinical Nutrition
(2003)
Undernutrition in hospitals
British Journal of Nutrition
Existence, causes and consequences of disease related malnutrition in the hospital and the community, and clinical and financial benefits of nutritional intervention
Clinical Nutrition
Still hungry in hospital: identifying malnutrition in acute hospital admissions
QJM
Cited by (82)
Nutritional Aspects of Wound Care
2024, Clinics in Geriatric MedicineShort Nutritional Assessment Questionnaire as a predictor of undernutrition in cancer patients receiving outpatient chemotherapy: A retrospective study
2021, European Journal of Oncology NursingCitation Excerpt :The number of cancer outpatients is also increasing annually (Ministry of Health, Labour and Welfare, 2017). Patients with cancer receiving outpatient chemotherapy are often undernourished due to adverse events such as loss of appetite, stomatitis, malaise, changes in taste perception, pain, constipation, diarrhea, nausea, fever, and vomiting (Neelemaat et al., 2008; Pressoir et al., 2010; Tanaka et al., 2018). Undernourishment in patients with cancer results in impaired immunity, weight loss, and poor performance status, and these factors may compromise the planned treatment regimens (Ramsey et al., 2020; Álvaro Sanz et al., 2020; Tumas, 2020).
Malnutrition screening in head and neck cancer patients with oropharyngeal dysphagia
2021, Clinical Nutrition ESPENCitation Excerpt :The scores range from 0 to 100, with 0 being extremely impaired and 100 standing for ‘normal swallow’. To determine risk of malnutrition, the validated Dutch version of the Short Nutritional Assessment Questionnaire (SNAQ) was used [15,23]. The SNAQ is a screening tool used to evaluate the risk of malnutrition.
Pressure Injuries Among Critical Care Patients
2020, Critical Care Nursing Clinics of North AmericaAdult Malnutrition (Undernutrition) Screening: An Evidence Analysis Center Systematic Review
2020, Journal of the Academy of Nutrition and Dietetics