February 24, 2017

A Surgeon’s Perspective on Malnutrition

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What does a doctor or other provider know about clinical documentation and integrity? What does a surgeon know? Why is it important? How do surgeons get to where they need to be, and how do we help our surgeons get there?

Malnutrition, generally interpreted as undernutrition (although strictly speaking, overnutrition is also malnutrition), is a common co-morbidity in surgical patients. While it may be due to a dietary deficiency (iron, iodine, or vitamin), most commonly it is due to a protein-calorie issue, now referred to as protein-energy deficit. It may be secondary to cancer, organ failure, transplantation, trauma, psychiatric disease, complications of other medical and surgical treatments, age, institutionalization, or disability. Kwashiorker, marasmus, and marasmic kwashiorkor are the classic medical conditions of undernutrition from lack of food due to poverty. Malnutrition is important as it pertains to surgery because it can impede immunity and increase the risk of infection, delay wound healing, weaken muscles, and lead to other complications such as pneumonia, immobility, pressure ulcers, venous thromboembolism, injury from falls, etc. These patients require more human and infrastructural resources.

Accurate documentation of malnutrition, allowing accurate coding of this condition, like for many other co-morbid conditions, can lead to better understanding and delineation of each patient’s problems and facilitate making a choice for helpful therapies. It allows reproducible descriptions of the true severity of illness and risk of mortality in a given patient. It reliably depicts less-expected outcomes in a manner that makes the ratio of observed outcomes to expected outcomes favorable in publicly reported metrics. Finally, it contributes to rendering the case-mix index of a hospital more favorable. So malnutrition serves as an excellent example of the value of good communication between coders, clinical documentation improvement specialists (CDIS), physician advisors, and the surgeons (and other physicians) providing patient care.

When patients come to us doctors, we must assume responsibility for their care regardless of their general physical and mental health. Even the calmest, most even-keeled and confident of us has at least a twinge of discomfort and anguish when we see from the foot of the bed so-called “poor protoplasm” and a laundry list of co-morbidities. This is especially aggravating in this era of decreasing reimbursement and expanding outcomes metrics, when we often feel we can only be “hurt”by such patients. However, by carefully describing the patient and carefully categorizing the various conditions contributing to their baseline health status, not only can we generate an appropriate list of problems to address, thereby giving the patient a better chance at a good outcome – for example, pre-operative dietary supplements, enteral tube feeds, or parenteral nutrition may be given for a week or two pre-op to enhance a patient’s nutritional status – but we can actually get paid for it, enhance our case-mix index, and improve our outcome metrics. Sicker patients will have worse expected outcomes, so the observed to expected (O:E) ratio will be higher, which is better.

In my surgical practice, I might see a young athlete with an inguinal hernia, an older adult with a recurrent inguinal hernia, or a cirrhotic with intractable ascites, portal hypertension, hepatic encephalopathy, acute-on-chronic renal insufficiency, thrombocytopenia, insulin-dependent diabetes, anemia, morbid obesity, malnutrition, and an inguinal hernia. There is no doubt to anyone that the first case should be straightforward and uncomplicated. The second one, because it is a redo, may be harder, take more time, and be more difficult to fix, with tissues that have already been damaged by an initial hernia followed by an operation to repair it and then its subsequent failure. The third one has a potential risk of death and a definite risk of intra-operative and post-operative complications. The procedure, inguinal herniorrhaphy, is in fact technically exactly the same, but the expected outcomes are different. Every little bit of documentation that can be captured more accurately reflects the patient’s true condition, and can more accurately predict the expected outcome.

Let’s take the three patients above and look at the documentation and coding of nutritional status – or stated differently, the documentation and coding of malnutrition in these patients. The young athlete with an inguinal hernia should be well-nourished and have a successful routine procedure as an outpatient. There is no malnutrition. The older adult with a recurrent hernia but who is otherwise healthy may have a higher reimbursement, severity of illness (SOI), and risk of mortality (ROM) score due to age and the recurrent nature of the hernia. However, with respect to nutrition, the patient is nourished and there is no malnutrition to document. The cirrhotic patient with ascites, chronic renal insufficiency, and hepatic encephalopathy clearly has comorbid conditions (CCs and MCCs) that will lead to higher reimbursement, SOI, and ROM, but this patient is also likely to have malnutrition of some kind. However, nothing that can be coded as malnutrition, whether mild, moderate, or severe (or protein-calorie malnutrition) has been discussed or documented. We all have an image of the patient, but the presence of malnutrition and the degree to which the patient has it cannot be inferred.

We often glibly use terms like “failure to thrive,” “emaciated,” “cachexia,” or “anorexia.” These are not codable and do not contribute to any billing or outcome metric. But is it mild, moderate, or severe malnutrition, protein-calorie malnutrition (now called protein energy malnutrition), or just protein deficiency or calorie deficiency or what? This is all Greek to the specialist or generalist who isn’t in the field of nutrition.

So how do surgeons get it right and give the right supporting documentation to allow for the listing of the diagnosis as “mild malnutrition” or “severe protein-calorie malnutrition?” The easiest measure of nutrition for most surgeons to remember is albumin, since it was engrained in training. However, if associated with inflammation or liver disease, infection, nephrotic syndrome, or fluid imbalance, it will be inaccurate and will not be helpful for documentation.

More helpful are clear guidelines:

  • Protein deficiency: low albumin and peripheral edema but weight maintained
  • Calorie-deficiency: More than20 percent below usual weight or significant weight loss present; obvious muscle wasting but normal albumin
  • Protein-calorie deficient: More than 20 percent below usual weight; albumin less than 2.9 Gm/dL; obvious muscle wasting
  • Mild malnutrition: albumin 2.9-3.4 Gm/dL; weight 80-89 percent ideal body weight or 85-95 percent usual body weight
  • Moderate malnutrition: albumin 2.5-2.9 Gm/dL; weight 70-79 percent IBW or 75-84 percent usual body weight
  • Severe malnutrition: worse than that

But like every other surgeon, I won’t remember this tomorrow unless it is reinforced.
The easiest thing for a surgeon or any physician to do in a hospital setting is order and review the assessment of a dietician. This is their profession; they are there to guide and support the provider with their expert knowledge. Use them!

Every doctor would agree that when discussing a patient’s cancer, one should use the appropriate staging system to communicate clearly the extent of disease. Every researcher would agree that for a scholarly journal article to be interpretable and merit publication, correct use of specific definitions must be used. We are taught this in medical school and training and in our daily interaction with other doctors. Clinical documentation, which is used for coded data and big data in healthcare (that is, what is used to describe the clinical problem of a patient and their underlying health from one setting or location to another in a different hospital or state in a database), should be no different, and in fact it isn’t. And the expectation is that we, as professionals of the highest academic degree, use precise, interpretable terms with clear, indisputable definitions – as in any other part of our professional life.

Doctors want to be authorities on as much about medical science and knowledge as they can. So a coder, CDIS or physician advisor who provides a doctor with “the facts” in an easy-to-digest, retainable manner will succeed at raising that doctor’s documentation completeness and accuracy. The suggestion is often made “doctor, just say what your expert professional assessment is, and if it’s mild or severe, just say that.” This reinforces to the disbelieving, non-compliant doctor the misconception that this is all vague meaningless garbage. Doctors cannot carry a thousand laminated cards around. They want it in their head. A direct discussion with an email with a PDF attachment that can be placed on their desktop for reference is one technique. Another is to have short, one-page summaries (like a pilot’s checklist, with information obtainable at a glance) on the hospital intranet readily accessible to the doctor as note-writing is occurring. Lunch-and-learns, meet-and-greets, and emails that are hard to find again do not allow repeated reference and retention by rote. Have one process of query notification, and ensure that every provider knows how they are being notified and that a notification really is noticeable to them. I have seen some electronic medical records (EMRs) where it appears in the inbox like a lab result, patient inquiry, or staff communication, so it is right where they are looking multiple times throughout every day. I have seen others where none of the doctors know the query comes through the EMR and it is mixed in with other unimportant, inconsequential communications. If you shrug your shoulders and say “they were all educated during on-boarding or orientation,” stop! Poll the entire staff, and do this repeatedly till you know they know what’s going on. It’s the late-appearing query with a nasty threatening email or phone call from the boss that creates angst, anger, and opposition.

They also don’t like to be embarrassed or have their status or privileges threatened. Inform a doctor in real time, as soon as possible, after an opportunity is identified. It is when the provider or attending gets a notice that they have 24 hours to write an addendum in the chart or they will lose their privileges, a very serious problem, that they become upset.

Making this list not only helps us address each and every condition and treat them appropriately for what they are, thereby making our patient healthier and a better candidate for procedures, but we can bill for it – and since they will do better if we pay attention to detail, their observed outcome may be considerably better than their expected outcome. On the flip side, if we don’t describe our patient correctly and the sick ones look like an athlete, we get burned across the board.

They may prove to be a diamond in the rough, or a feather in our cap.
Charles Winans, MD

Charles Winans, MD, is a staff surgeon at Ashtabula County Medical Center, a Cleveland Clinic affiliate hospital.