Adaptation of nutritional risk screening tools may better predict response to nutritional treatment. A secondary analysis of the randomized controlled trial EFFORT

BACKGROUND:Nutritional screening tools have proven valuable for predicting clinical outcomes but have failed to determine which patients would be most likely to benefit from nourishment interventions. The Nutritional Risk Screening 2002 (NRS) and the Mini Nutritional Assessment (MNA) are two of these tools, which are based on both nutritional parameters and parameters reflecting disease severity. OBJECTIVE:We hypothesized that adaptation of nutritional risk scores, by removing parameters reflecting disease severity, would improve their predictive value regarding response to a nutritional intervention while providing similar prognostic information regarding mortality at short- and long-term. METHODS:We re-analyzed data of 2,028 patients included in the Swiss-wide multicenter, randomized controlled Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-day all-cause mortality. RESULTS:While stratifying patients by high compared with low NRS score showed no difference in response to nutritional support, patients with high adapted NRS showed substantial benefit, while patients with low adapted NRS showed no survival benefit (adjusted hazard ratio (HR) 0.55 [95% CI 0.37 to 0.80], compared with 1.17 [95%CI 0.70-1.93], a finding that was significant in an interaction analysis (coefficient 0.48, [95%CI 0.25-0.94], p=0.031). A similar effect regarding treatment response was found when stratifying patients based on MNA vs. the adapted MNA. Regarding the prognostic performance, both original scores were slightly superior in predicting mortality compared to the adapted scores. CONCLUSION:Adapting the NRS and MNA by including nutritional parameters only improved their ability to predict response to a nutrition intervention, but slightly reduces their overall prognostic performance. Scores dependent on disease severity may best be considered prognostic scores, while nutritional risk scores not including parameters reflecting disease severity may indeed improve a more personalized treatment approach for nourishment interventions. CLINICAL TRIAL REGISTRATION:Clinicaltrials.gov as NCT02517476 (registered 7 August 2015).