Effectiveness of an integrated nutritional care program for malnourished patients: A retrospective quasi-experimental study at Chomthong Hospital

Abstract

Malnutrition affects approximately 20–50% of newly admitted inpatients but is often under-diagnosed or inadequately managed, leading to unfavorable clinical outcomes and higher care costs. Key barriers include complex care processes, limited personnel, suboptimal screening/assessment tools, and insufficient awareness. This study evaluated an integrated Nutrition Care program that embeds screening/assessment workflows into routine care, links data to the Hospital Information System (HIS), and uses data-analytics tools (Python/R, QlikView, and AI-assisted analytics). The objective of this study is to assess the impact of the Chomthong Nutrition Care program on clinical outcomes (in-hospital mortality, 30-day readmission, complications), operational outcomes (screening and assessment coverage), and financial indicators (adjusted relative weight [adjRw], unit cost) at Chomthong Hospital, Chiang Mai. We conducted a retrospective quasi-experimental analysis using a difference-in-differences (DiD) design. Adult inpatient episodes (age ≥18 years) were compared between the pre-implementation period (September 2024–February 2025; n=3,165) and the post-implementation period (March–August 2025; n=2,973). The intervention was defined as documented nutrition screening. Models adjusted for age, sex, payer type, ward, specialty, comorbidity, and calendar month. Sensitivity analyses included inverse probability of treatment weighting (IPTW) and post-period comparisons by NAF severity. The results showed that post-implementation, nutrition screening coverage increased to 92.3%. The adjusted complication rate decreased significantly (-18.6 percentage points; p=.001), while mortality and readmission showed no significant change. Length of stay increased (RR=1.51; p<.001), whereas adjRw (RR=0.64; p<.001) and cost (RR=0.90; p=.009) showed modest declines. Within the post period, patients classified as NAF C had higher readmission (+14.3 pp; p<.001) and longer LOS (RR=1.28; p=.004) compared with NAF A. In conclusion, implementation of the Chomthong Nutrition Care program improved access to nutrition services and significantly reduced complications, with no detectable effect on mortality or readmission. Financially, costs declined and adjRw decreased. Moderate and severe nutritional risk (NAF B/C) predicted adverse outcomes. Integrating nutrition screening with data-analytics tools is a feasible and valuable approach to enhance nutrition care quality in resource-limited hospitals.

References

Hudson, L. M. (2021). Disease-associated undernutrition in Southeast Asia: A retrospective study in Vietnamese hospitalized adults. Clinical Nutrition.

Yin, L., et al. (2024). Investigation on Nutrition Status and Clinical Outcome of Common Cancers (INSCOC). Clinical Oncology Journal.

Kyle, U. G., et al. (2005). Prevalence of malnutrition at hospital admission: A body composition study. Clinical Nutrition, 24(6), 1027–1035.

Meijers, J. M., et al. (2010). Malnutrition in Dutch healthcare: Prevalence and quality indicators. Nutrition, 26(11–12), 1189–1196.

Crowe, T. C. (2024). Artificial Intelligence in Malnutrition: A Systematic Literature Review. Advances in Nutrition, 15(9), 100264.

American Society for Parenteral and Enteral Nutrition (ASPEN). (2012). Consensus statement: Characteristics recommended for the identification and documentation of adult malnutrition.

Gandy, J. (2019). Manual of Dietetic Practice (6th ed.). Wiley-Blackwell.

Compher, C. (2023). Barriers and enablers of malnutrition screening in hospitals: A U.S. perspective. Journal of Nutrition in Clinical Practice.

Janssen, S. M. W., Bouzembrak, Y., & Tekinerdogan, B. (2021). A fusion decision system to identify and grade malnutrition in cancer patients. Clinical Nutrition, 40(8), 4958–4970.

Liangyu, Y., et al. (2024). Machine learning-based risk stratification for malnutrition in hospital settings. Journal of Medical Systems.

Cederholm, T., et al. (2017). ESPEN guidelines on definitions and terminology of clinical nutrition. Clinical Nutrition, 36(1), 49–64.

Wang, M., et al. (2023). Clinical Decision Support Systems for Malnutrition Screening: A Systematic Review. BMC Medical Informatics and Decision Making.

Pongchaiyakul, C., et al. (2023). Development of a QlikView dashboard for nutrition workflow monitoring. Thai Journal of Clinical Nutrition.

Ruangrit, P., et al. (2024). Utilizing R and Python in hospital nutrition analytics: A case study. Proceedings of Thai Health Informatics Conference.

Saengthong, K., et al. (2024). Comparing manual and automated nutrition screening in regional Thai hospitals. Chiang Mai Medical Journal.

Correia, M. I., & Waitzberg, D. L. (2003). The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition, 22(3), 235–239.

Dent E, Hoogendijk EO, Visvanathan R, Wright ORL. Malnutrition Screening and Assessment in Hospitalised Older People: a Review. J Nutr Health Aging. 2019;23(5):431-441. doi: 10.1007/s12603-019-1176-z. PMID: 31021360; PMCID: PMC12280429.

Y.-C. Lin, R. Hagen, B. D. Powers, S. P. Dineen, J. Milano, E. Hume, O. Sprow, S. Diaz-Carraway, J. B. Permuth, J. Deneve, A. Alishahi Tabriz, and K. Turner, “Digital Health Intervention to Reduce Malnutrition Among Individuals With Gastrointestinal Cancer Receiving Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy: Feasibility, Acceptability, and Usability Trial,” JMIR Cancer, vol. 11, p. e67108, 2025.

H. van den Berg, G. G. J. Huisman-de Waal, H. Vermeulen, and M. A. E. de van der Schueren, “Effects of nursing nutrition interventions on outcomes in malnourished hospital inpatients and nursing home residents: A systematic review,” Int. J. Nurs. Stud., vol. 117, p. 103896, 2021.

Reber, K. Norman, O. Endrich, P. Schuetz, A. Frei, and Z. Stanga, “Economic Challenges in Nutritional Management,” J. Clin. Med., vol. 8, no. 7, p. 1005, Jul. 2019.

Huang, M. D. Banks, P. M. Sowa, and J. D. Bauer, “A Cost–Consequence Analysis of Nutritional Interventions Used in Hospital Settings for Older Adults with or at Risk of Malnutrition,” Healthcare, vol. 12, no. 10, Art. no. 1041, May 2024.

Khalatbari-Soltani and P. Marques-Vidal, “Impact of nutritional risk screening in hospitalized patients on management, outcome and costs: A retrospective study,” Clin. Nutr., vol. 35, no. 6, pp. 1340–1346, Dec. 2016.

Khalatbari-Soltani and P. Marques-Vidal, “The economic cost of hospital malnutrition in Europe; a narrative review,” Clin. Nutr. ESPEN, vol. 9, no. 3, pp. e139–e145, Jun. 2015.

A. Cano-Torres et al., “Impact of nutritional intervention on length of hospital stay and mortality among hospitalized patients with malnutrition: A clinical randomized controlled trial,” J. Am. Coll. Nutr., vol. 36, no. 3, pp. 160–165, Mar. 2017.