Malnutrition is a widespread problem in hospitalized patients, which significantly impacts clinical outcomes, quality of life, and healthcare costs. Despite its well-documented consequences, it remains underdiagnosed and inadequately managed in many healthcare settings. Even with recent progress, key challenges remain, including inconsistent use of standardized nutritional screening tools and practices, insufficient professional training, and resource limitations. A multidisciplinary approach involving physicians, dietitians, nurses, and pharmacists is crucial for early detection, timely intervention, and prevention of malnutrition-related complications. The sustainability of a multidisciplinary model requires overcoming logistical and financial barriers, including the integration of technology for real-time monitoring, standardized screening protocols, and specific professional training. Regional initiatives, such as the establishment of the Clinical Nutrition Network of Lombardy (Italy), reported and discussed in this article, have made strides in improving nutritional care by promoting scientific networking and standardized practices across hospitals. This approach may not only improve patient outcomes but also reduce long-term healthcare costs by shortening hospital stays and preventing readmissions. For this model to be effective and sustainable, collaboration among healthcare providers, policymakers, and researchers is essential to promote an integrated, cost-effective approach to managing nutritional risk throughout the continuum of care.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).

Multidisciplinary nutrition teams can help guide the use of parenteral nutrition (PN), thereby reducing infectious risk, morbidity, and associated costs. Starting in 2007 at Harborview Medical Center, weekly multidisciplinary meetings were established to review all patients receiving PN. This study reports on observed changes in utilization from 2005-2010.

All patients who received PN from 2005-2010 were followed prospectively. Clinical data and PN utilization data were recorded. Patients were grouped into cohorts based on exposure to weekly multidisciplinary nutrition team meetings (from 2005-2007 and from 2008-2010). Patients were also stratified by location, primary service, and ultimate disposition.

In total, 794 patients were included. After initiation of multidisciplinary nutrition meetings, the rate of patients who started PN decreased by 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63-0.84). A reduction in the number of patients receiving PN was observed in both the intensive care unit (ICU) and on the acute care floor (RR, 0.64; 95% CI, 0.53-0.77 and RR, 0.80; 95% CI, 0.64-0.99, respectively). The rate of patients with short-duration PN use (PN duration of <5 days) declined by 30% in the ICU (RR, 0.70; 95% CI, 0.51-0.97) and by 27% on acute care floors (RR, 0.73; 95% CI, 0.51-1.03).

Weekly multidisciplinary review of patients receiving PN was associated with reductions in the number of patients started on PN, total days that patients received PN, and number of patients who had short-duration (<5 days) PN use.

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

The controlling nutritional status (CONUT) score (CS), a simple score for assessing nutritional status, is calculated using laboratory data, including serum albumin concentration. Although dye-binding assays such as the bromocresol green (BCG) and modified bromocresol purple (mBCP) methods are widely used for albumin measurement, acute-phase proteins interfere with the BCG method.

We aimed to determine whether the choice of albumin assay affects assessment of nutritional status using CONUT scores (CSs).

We measured serum albumin concentrations by the BCG (ALBBCG) and mBCP (ALBmBCP) methods in 44 malnourished inpatients, 27 of whom underwent nutritional intervention, and compared them to 30 age-matched healthy volunteers. In treated patients, CSs were calculated by ALBBCG (CS-BCG) and ALBmBCP (CS-mBCP).

C-reactive protein (CRP) concentrations were positively correlated with the difference between ALBBCG and ALBmBCP in malnourished inpatients (r = 0.59, p < 0.001). CS-BCG was always lower than CS-mBCP (lower CS indicates superior nutritional status) in treated patients with persistently high CRP levels. However, in patients whose CRP decreased gradually, this difference diminished over the clinical course. CS-BCG and CS-mBCP were similar throughout their courses in patients with normal CRP concentrations. Adding haptoglobin to the human albumin solutions increased ALBBCG in a dose-dependent manner.

The choice of albumin assay affected the assessment of nutritional status using CSs in patients with inflammation. We recommend that the modified BCP assay be used to assess nutritional status, particularly in patients with inflammation.

The present review exposes why considering primary endpoints such as cost-effectiveness and quality of life in wasting disease research is critical for promoting medical nutrition therapy.

Despite growing evidence that nutritional support improves patients' clinical outcome, its use is not widely considered as a routine by most healthcare professionals. Many factors, depending on physicians, patients and institutions, could explain such a resistance to implement nutritional therapy in routine care. One of these factors is the lack of indisputable evidence that nutritional intervention improves patients' quality of life and is cost-effective.

In today's resource-constrained environment, disease management strategies are judged in terms of not only clinical efficacy and safety but also patient satisfaction and economic dimensions. The demonstration of a positive costs/saving ratio is crucial to obtain the political backing of health administrators and sustain further investment in research. Moreover, improving patients' quality of life promotes their capacity to cope with psychological distress, increases their tolerance and response to treatments, and enhances the global image of the healthcare system. In wasting diseases research, there is a need for well designed clinical trials from which cost-utility performance of nutritional interventions could be assessed in order to convince all the stakeholders and to get support from clinicians and patients themselves.

Enteral nutrition (EN) is the preferred method of nutrition support in hospitalized patients but only 50-90% of the required calories are actually delivered. In order to identify where our nutrition support team (NST) should focus its activity, we prospectively evaluated the level of coverage of energy and protein needs during the first 5 days of EN in intensive care unit (ICU) and non-ICU patients and the relationship of energy and protein coverage with serum albumin, transthryretin, insulin-like growth factor-1 (IGF-1) and C-reactive protein (CRP).

Subjects (n=183) who required nutrition support and received EN were prospectively recruited. Calorie prescription was 20 and 25, 25 and 30 kcal/kg BW for women and men 60 years and <60 years, respectively. Protein needs were estimated as 1.2g protein/kg BW. Logistic regression analysis was used to estimate odds ratios (OR) for energy and protein delivery 66.6% and <66.6% and albumin, transthryretin, IGF-1 (low vs. normal) and CRP (high vs. normal) in ventilated vs. non-ventilated patients.

Significantly more mechanically ventilated than non-ventilated patients received <66.6% of energy (71% vs. 48%) and protein (96% vs. 65%). The ventilated patients were more likely to be energy (OR 2.1, CI 1.1-4.0) and protein (OR 15.7, CI 4.9-50.8) underfed than non-ventilated patients. There was a significant association on day 5 between low protein delivery and low albumin (OR 2.9, CI 1.3-6.5), low transthyretin (OR 3.0, CI 1.4-6.5), low IGF-1 (OR 2.8, CI 1.2-6.7) and high CRP (OR 3.5, CI 1.6-7.8).

The energy and protein needs of hospitalized patients are not met during the first 5 days of EN. Ventilated patients are more likely to be energy and protein underfed than non-ventilated patients and to have low plasma protein level. These findings support our decision to intensify EN monitoring by our NST in ventilated patients to optimize their nutritional coverage.

We sought to review the economics literature on enteral nutrition (EN) and oral nutrition supplements (ONS) against the background of an ongoing clinical guideline development.

We searched the Health Economic Evaluations Database, the NHS Economic Evaluation Database, and the Cochrane Database of Systematic Reviews.

Enteral vs parenteral nutrition was found to be the most common comparison undertaken. The randomized trial evidence suggests that, in some groups of patients, EN is better in terms of clinical endpoints and/or length of hospital stay. This should translate into a lower mean cost for EN, given the reduced daily cost. These studies should be treated with caution because of their small sample size and poor quality. Costing was often crude and poorly reported, tending to focus on the narrow costs of the nutrition supplements. Only 1 study of a nutrition supplement in the community setting was found.

There is some evidence to indicate economic advantages of enteral over parenteral nutrition and of immune-enhancing supplements relative to control diet. There is a lack of well-designed studies taking a broad view of relevant comparators, costs, and outcomes. The cost-effectiveness of different forms of nutrition in different patient groups remains to be established.

Current nutritional care provision to 1905 patients hospitalized in 12 Cuban hospitals is presented in this article, diagnosed after conducting the Hospital Nutrition Survey (HNS), as part of the activities comprising the Cuban Study of Hospital Malnutrition (Elan-Cuba). The obtained HNS results were contrasted with standards regarding the nutritional assessment of hospitalized patient, the diagnosis of nutritional disorders occurring in the patient, and the identification of patients in need of nutritional intervention. The Elan-Cuba Study returned a 41.2% malnutrition rate [Barreto Penié J, Cuban Group for the Study of Hospital Malnutrition. State of malnutrition in Cuban hospitals. Nutrition 2005;21:487-97]. However, malnutrition was recorded as an independent diagnosis in only 0.4% of the surveyed clinical charts. It could not be shown that medical care teams were systematically applying any of the techniques and procedures recommended for the assessment of the nutritional status of hospitalized patients. In the best of the cases, only 40.6% of the surveyed patients had their height and weight recorded in their clinical charts at admission, 9.0% of those with more than 15 days of hospitalization had a prospective value of weight, and less than 20.0% of them had their serum albumin levels and/or their counts of Lymphocytes annotated on their clinical charts. Although 10.9% of the surveyed patients (median of the subcategories values; range: 3.5-41.2%) fulfilled an indication for nutritional intervention, support (enteral and/or parenteral) was only provided to less than 15.0% of them, with the exception made of patients on NPO, of whom 32.3% received either of the two modes of artificial nutrition listed above. It is to be noticed that none of the patients with chronic organic failure were on nutritional support at the time of the survey. The current nutritional care provision to the hospitalized patient might explain the increased rates of hospital malnutrition documented in the Elan-Cuba Study, and should lead to the design and urgent implementation of nutritional and metabolic intervention programs in the surveyed hospitals, given the deleterious effects of nutritional disorders upon the ultimate results of the medical and surgical actions, and the quality and costs of medical care.

This review will discuss the financial cost of the decisions taken regarding the nutritional therapy of hospitalized patients compared with those treated at home. To facilitate comprehension, the authors present a concise introduction to the general concepts of economic health studies, including a glossary of technical terms.

From a revision of the literature, economic aspects are underscored involving the cost of malnutrition, the maintenance of work in a nutritional support team, the use of nutritional therapy in home-care programmes, and in the use of nutritional therapy as a prophylactic action against surgical complications.

Hospital malnutrition burdens the system financially by provoking a higher rate of surgical complications, mortality and longer hospital stays. Investment in nutritional therapy provides economic returns. The cost of the creation and maintenance of the nutritional support team is easily offset by the resources generated by the team itself. Nutritional therapy in home-care is highly advantageous. In Brazilian trials, groups of surgical patients receiving nutritional therapy within the integrated hospital-home model demonstrated a cost 2.6 times less than the conventional group (exclusively intra-hospital treatment). The adoption of preoperative immunomodulatory nutritional therapy in patients undergoing elective surgery as a prophylactic against postoperative surgical complications presented a 2.24 times reduction in the total treatment cost. The search for the ideal model of nutritional therapy is based on the binomial of quality and cost. The prescription of nutritional therapy has a favourable impact on financial and resource-generating aspects of the institution, when practised by properly trained groups.

Evaluation. Contrary to the Anglo-American region, very little is known in Germany on the structure and organisation of nutrition support teams (NST).

Prospective investigation of the structure and organisation of German NST, using standardised interview questionnaires.

Hospitals with more than 250 beds in Germany.

German NST (n=47).

Face-to-face interview in 1999, using a standardised questionnaire.

From a total of 2000 German hospitals, NST have been established at 47 hospitals (2.3%). Most NST are affiliated to a large university hospital or an academic teaching hospital. In general, the NST are not independently operating units but are affiliated to a special discipline, and were in operation for an average of 8 y. The NST cared for a median of 65 outpatients annually. At the university hospitals in average, 477 in-patients were treated per year, at the teaching hospitals 400 and at all other hospitals 179. The work of the NST centred on enteral nutrition. A total of 47% of the physicians, 19% of the nurses and 19% of the dietitians in the NST held a nutrition-specific additional qualification. A total of 2% of the physicians, 68% of the nurses and 77% of the dietitians are exclusively responsible for the NST. More than 70% of the financing of the personnel was secured through third-party funds.

In Germany, neither uniform nor comprehensive patient care by NST existed in 1999. More than 50% of all NST members do not hold a nutrition-specific additional qualification. Frequently, besides their tasks in the team, the NST staff also carries out other clinical functions. Contrary to the American NST, the German NST are not interdisciplinary operating units but are primarily financed through third-party funds of the industry.

Interdisciplinary nutrition-support teams (NSTs) can improve the efficacy of clinical nutrition. The purpose of this survey was to investigate the prevalence, and structure of German NSTs.

Hospitals in Germany with more that 250 beds were screened for the existence of NSTs. Eligible NSTs were interviewed about structural characteristics, administration of clinical nutrition and quality control in a face-to-face manner using a standardised questionnaire.

A total of 47 NSTs existed in Germany revealing a prevalence of 5.6%. Their main activities were creating nutritional regimens (100%), education (98%) and monitoring nutrition therapy (96%). Twenty-two of NST-physicians (50%) had a specific education as compared to 20.9% NST-nurses and 24% NST-dietitians. Only 12.7% of physicians and 17% of dieticians in comparison to 55.3% of nurses received funding support. Improvement of clinical nutrition by means of increased use of enteral nutrition and special diets was indicated by 72%, 23%, respectively. Some NSTs indicated a reduction of complications (38.3%) and cost-saving (34%) since their establishment.

There is a low prevalence of interdisciplinary NSTs in Germany. Standards of practice, development of guidelines in clinical nutrition and better documentation in NSTs are necessary. Special efforts should be aimed at education of NST members and financing of teams.

The aims of this study were to prospectively analyze the 1-month mortality and long-term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment.

Between 1990 and 1996, 417 patients, aged 64 +/- 25 years, were discharged on HEN and followed up until December 31, 1998, when outcome was assessed, which allowed us to determine survival probabilities and conditions associated with survival.

The mean duration of HEN was 242 +/- 494 days, with a 24- to 103-month follow-up. Probabilities of being alive at 1 month, 1 year, and 5 years were 80%, 41.7%, and 25%, respectively. Factors associated with death were dementia, neurologic disease, head and neck cancer, AIDS, and age over 70 years. A total of 5.5% of patients remained dependent on HEN, 32.6% resumed full oral nutrition, 20.2% of patients died during the first month on HEN, and 35% died after more than 1 month on HEN (219 +/- 257 days). A total of 6.7% of patients stopped HEN for other reasons.

HEN provides well-tolerated long-term nutritional support in many patients. However, because of their likelihood of being old and the nature of the underlying disease, these patients as a group tend to have a modest prognosis. This calls for the determination of more accurate selection criteria, and the measurement of the impact of HEN on quality of life.

At the present time when interprofessional collaboration in practice is reaching new levels of interest related to health care system changes in both the UK and the US, a key question being raised is: What are the outcomes and costs of interprofessional collaborative models of care? The purposes of this paper are to: (a) summarize past research efforts, primarily in the US, to examine whether interprofessional collaboration improves the outcomes of care, (b) articulate the continuing conceptual and methodological challenges associated with efforts to examine this relationship, (c) present more recent research in the US in which investigators have overcome some of the conceptual and methodological barriers to this type of research, and (d) identify gaps in knowledge and areas for future research on the relationship between collaborative models of care and care outcomes.

To assess whether health-care related economic evaluations labeled as "cost benefit analyses" (CBA) meet a contemporary definition of CBA methodology and to assess the prevalence of methods used for assigning monetary units to health outcomes.

Medline, Current Contents, and HSTAR databases and reference lists of review articles, 1991-1995.

Economic analyses labeled as CBAs were included. Agreement on study selection was assessed. STUDY EVALUATION: CBA studies were classified according to standard definitions of economic analytical techniques. For those valuing health outcomes in monetary units (bona fide CBAs), the method of valuation was classified.

53% of 95 studies were reclassified as cost comparisons because health outcomes were not appraised. Among the 32% considered bona fide CBAs, the human capital approach was employed to value health states in monetary units in 70%. Contingent valuation methods were employed infrequently (13%).

Studies labeled as CBAs in the health-care literature often offer only partial program evaluation. Decisions based only on resource costs are unlikely to improve efficiency in resource allocation. Among bona fide CBAs, the human capital approach was most commonly used to valuing health, despite its limitations. The results of health-care related CBAs should be interpreted with extreme caution.

Thirty patients with parenteral nutrition were studied in order to evaluate if they could be given enteral nutrition instead. Based upon absolute and relative contraindications for enteral nutrition, we calculated that 80% of the patients were possible candidates for enteral nutrition. Long-term use of parenteral nutrition may cause complications. Besides metabolic and other advantages when enteral nutrition is used, economical gains are also important. We have calculated an estimated annual net profit of US$ 357,000 in our hospital, if enteral instead of parenteral feeding is used in patients suitable for the former type of feeding. This implies that it is really cost-beneficial to consider enteral nutrition in hospitalized patients. Although parenteral nutrition will continue to have its place in the management of different occasions, increased use of enteral nutrition may result in improved patient outcomes and improved cost-effectiveness.

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care.

After more than two decades of nutritional awareness, we designed a prospective study to determine whether malnutrition is still a significant issue in hospitalized patients. Patients admitted to an intensive care unit (ICU) were divided into well-nourished and malnourished groups, according to their nutritional status as assessed by serum albumin level and weight/height ratio. Severity of illness, as assessed by the Therapeutic Intervention Scoring System (TISS), was used to further stratify the study population. All patients were followed clinically until discharge or death and their outcome recorded. Of 129 patients studied, 43% were malnourished. Length of hospital stay (p = n.s.), incidence of complications (p < 0.01), and number of patients not discharged from hospital (p < 0.05) were greater in the malnourished patients than in the well-nourished. In patients with less severe degrees of illness, the existence of malnutrition led to a worse outcome than in sicker patients. To further assess the clinical setting in which hospital-related malnutrition develops or is exacerbated, postoperative patients admitted to the ICU (n = 66) were also studied in a nutritional survey; the results of this survey indicate that: (a) the incidence of malnutrition in the surgical population is similar to that in the whole study population, and (b) hospital-related malnutrition in surgical patients mainly develops during their preoperative stay in general wards. Whereas our conclusion that patients' outcome is adversely affected by a poor nutritional status is not new or startling, malnutrition continues to be a persistent problem in hospitalized patients, which can be readily identified using simple and easily available indices and, furthermore, readily treated.