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How the malnutrition story came together

How many of California’s Medicare patients are malnourished? 

Do some hospitals report more malnutrition among seniors than others?

California Watch used public records to compare how frequently California hospitals diagnose malnutrition among older patients when their care is paid for by the federal Medicare system.

Our findings are based on a computer-assisted analysis of public data from a state agency, the Office of Statewide Health Planning and Development. The data contains information about every patient who was discharged from a state-licensed hospital in 2009, the most recent data available. It details each patient’s health problems – reporting as many as 25 different diagnoses, coded according to the World Health Organization’s ICD-9 system.  

The data also provides some demographic information, while concealing personal identifiers. The 2009 data set contained 3,985,166 records. We zeroed in on patients age 65 or older whose care was billed to Medicare and who were treated at a major acute care, or general, hospital. We also focused on cases where patients sought care for serious medical conditions, rather than substance abuse treatment, psychiatric care or physical rehabilitation.

Excluded were hospitals that treated fewer than 500 patients per year, because their rates might be distorted. Also excluded were long-term acute-care facilities, because their patients’ health problems differ from those encountered at acute care hospitals. Finally, the analysis excluded managed-care hospitals, including those of the Kaiser Permanente system, because of fundamental differences in the way they are reimbursed for treating Medicare patients. 

In the end, our analysis included a subset of 769,202 patients at 254 hospitals. 

Using SAS data analysis software, California Watch examined the records of every patient fitting the criteria we identified. The ICD-9 system lists 38 different codes for malnutrition diagnoses – everything from kwashiorkor, a Third World nutritional disorder, to vitamin A deficiency. 

A patient with one or more of these 38 codes entered by the hospital was counted as a malnutrition case. 

The analysis then calculated the percentage of malnutrition cases among the total number of cases at each hospital, as well as the percentage of cases that had different degrees of malnutrition, including a separate count of cases coded as kwashiorkor.  

The analysis found that hospitals in the Prime Healthcare Services chain reported that 25 percent of their Medicare patients age 65 and older were malnourished. The state average for hospitalized seniors was 7.5 percent. Two Prime hospitals also reported high rates of kwashiorkor.

Our results were similar to those reported in two other studies. 

In October, the Service Employees International Union, which has clashed with Prime over pay and staffing issues, provided authorities with a private statistical study of federal Medicare data, a spokesman said. It showed high malnutrition and kwashiorkor rates at Prime hospitals. Later, the union said it paid the state health department to do a custom computer study of state health data. That study also showed high malnutrition and kwashiorkor rates at Prime, the union said. But California Watch relied on its own statistical analysis for this report.

In December, California Watch provided Prime officials with a description of our methodology and a copy of the entire state data set in computer form, inviting a critique of our findings. 

Hospitals are eligible to receive bonus payments for treating patients with certain ailments or diseases. There are hundreds of medical complications that qualify for enhanced payments from Medicare. Three types of severe malnutrition, including kwashiorkor, are classified as “major complications,” and get the biggest boost, while 35 other forms of malnutrition are termed “complications” and get a more modest payment enhancement.

In e-mails, Prime officials insisted that their malnutrition diagnoses were accurate and that the chain was not assigning the diagnosis to obtain enhanced payments from Medicare.

Prime officials also accused the union of manipulating data to wrongly implicate the company in Medicare fraud. That’s part of a “campaign of misinformation and extortion” to leverage labor contracts, the company has charged. 

The officials otherwise didn’t comment on California Watch’s methodology, study or findings.

Prime provided California Watch with letters from the Health Services Advisory Group, a Medicare contractor that monitors billing. The letters challenge Prime’s decision to bill for two cases of kwashiorkor, noting that the condition  “is extremely rare if seen at all” in the American adult. Both cases, on re-review, say the bill is acceptable but cite no explanation. Prime did not provide information about hundreds of other kwashiorkor cases, and the Health Services Advisory Group did not return calls from California Watch. Its letter to Prime says the information about billing disputes is confidential.



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propraetor's picture

I worked as an Administrator in Training for a large Long Term Care hospital chain. I just want to comment based on my own observations about a few things where this story may have some (I say that cautiously) some statistics which may be accurate. First, Let me comment that the level of car that Seniors receive in most Long Term Care Facilities (other than patients in Acute Care/Skilled Nursing level locations), is terribly lacking. Often times, many Seniors have low to no appetite due to factors such as depression, being in a strange environment and onset dementia. As a result, unless they happen to have the Care from a VERY compassionate CNA who helps feed them every meal, simply they often fail to eat "hospital food". And the quality of food provided is often as described in the article as "...lacking in protein..." The contention that the Spokesperson for Prime gave, "...Prime is a leader in early diagnosis and treatment of malnutrition and suggested that other hospitals aren’t as diligent. The disparity in malnutrition rates “means there are patients going undiagnosed and untreated” at other hospitals, he said in an interview..." May have a great deal of validity. From my personal observations, Directors of Nursing were constantly hyper-vigilant about a condition they described as "...failure to thrive..." Simply put, the patients lost tremendous amounts of weight in very short time frames and they always put their heads in the sand about the problem. Mind you, they documented the Hell out of the malnourishment and often used a system of percentages of each meal the Senior ate. But come on, anyone who has ever been around a child under 5 knows that a human will eat certain items (such as desserts) and leave their vegetables, etc. untouched. Seniors are worse in that many of us are used to listening to THEM tell us what to do and not the other way around. A young doctor who was assigned to a 133 bed hospital once speculated during a meeting that medical tests (Albumin levels) of several patients she had been assigned to treat were coming back well below 2.0 (2.0 is level of protein in the blood at a given moment most of those African starvation pictures depicts). She noted that those patients who smoked (the ONLY enjoyment many patients have) showed a much lower rate and were more difficult to try and help. What happened was typical --- everyone was very encouraging and checked on the patients, the menu improved as far as more meats, fish and protein shakes --- for about a week and then all went back to normal until most patients passed away. My point is, Seniors living independently or with lower levels of Assisted Care do not make very good nutritional choices in that scenario. With the economy going bad, prices on everything going up and Seniors on a fixed income, most Seniors who have Chronic Diseases (diabetes, kidney failure, dementia) usually have some degree of malnutrition going on WHEN THEY ARE FIRST ADMITTED TO HOSPITALS. That being said though, Owners/Operators of Long Term and other Hospitals are trying to run a BUSINESS and I have no doubt that well over HALF the exaggeration reported in this article IS VALID AND JUSTIFIED. That being said, State of California Hospital Survey Inspectors have dozens of things they can criticize a Facility for. It could be someone focused on Malnutrition as an overcompensation for some other deficiency the Hospitals are known to have. -I WAS THERE AND SAW IT

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It was an amazing article thank you for the info.

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