www.journalpulmonology.org
ORIGINAL
ARTICLE
Undernutrition
risk
at
hospital
admission
and
length
of
stay
among
pulmonology
inpatients
I.
Maia
a,∗,
S.
Xará
b,
D.
Vaz
c,
T.
Shiang
c,
T.F.
Amaral
d,eaEPIUnit-InstitutodeSaúdePública,UniversidadedoPorto,RuadasTaipas,n◦135,4050-600Porto,Portugal
bServic¸odeNutric¸ãoeDietética,CentroHospitalardeVilaNovadeGaia/Espinho,RuaConceic¸ãoFernandes,4434-502VilaNova
deGaia,Portugal
cServic¸odePneumologia,CentroHospitalardeVilaNovadeGaia/Espinho,RuaConceic¸ãoFernandes,4434-502VilaNovade
Gaia,Portugal
dFaculdadedeCiênciasdaNutric¸ãoeAlimentac¸ão,UniversidadedoPorto,RuaDr.RobertoFrias,4200-465Porto,Portugal eUISPA-IDMEC,FaculdadedeEngenharia,UniversidadedoPorto,RuaDr.RobertoFrias,4200-465Porto,Portugal
Received17August2017;accepted13January2018
KEYWORDS Malnutrition; Nutritionalstatus; Respiratorymedicine; Lengthofstay Abstract
Background: There isalackofevidence regardingtheassociationbetween the
undernutri-tionriskathospitaladmissionwithadverseclinicaloutcomesamongstpulmonologyinpatients. Theaimofthisstudywastoquantifytheassociationbetweenundernutritionriskathospital admissionandtimetodischargealive.
Methods:A retrospective cohort study includingpatients consecutively admitted to a
pul-monology unitwasconducted.Undernutritionriskathospitaladmissionwasidentifiedusing the Malnutrition Universal Screening Tool. Survival analyses (Kaplan---Meier curves and Cox regression)werecarriedout.
Results:Thesamplewascomposedof683patients.Patientswhopresentedhigh
undernutri-tion riskonhospitaladmissionhadalongerlengthofhospitalstay(approximately50%were discharged to home after 14 days of hospitalization). In the multivariable Cox regression, highundernutritionrisk wasshown tobeindependently associatedwithalowerprobability ofdischargealiveovertime(adjustedhazardratio=0.70;95%confidenceinterval:0.55---0.90).
Conclusions: Pulmonologyinpatientswithhighundernutritionriskhavealongerlengthof
hos-pitalstayandhadalowerprobabilityofbeingdischargedtohome.Inparticular,lungcancer patients had alower probabilityofbeing discharged tohome, which corroborates aworse prognosisforthesepatients.
©2018SociedadePortuguesadePneumologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Abbreviations: CI,confidenceinterval;COPD,chronicobstructivepulmonarydisease;HR,hazardratio;IQR,interquartilerange;LC, lungcancer;LOS, lengthofhospitalstay;MUST,MalnutritionUniversal ScreeningTool;NRS-2002,NutritionalRiskScreening----2002;SD, standarddeviation.
∗Correspondingauthor.
E-mailaddress:isabel.maia@ispup.up.pt(I.Maia). https://doi.org/10.1016/j.pulmoe.2018.01.004
2531-0437/©2018SociedadePortuguesadePneumologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Ahighproportionofpulmonology inpatientsareat under-nutritionriskor areundernourisheddespite theincreasing awarenessofitsburden.1---4Beingmale,4older,5sideeffects
of treatments or drugs as well as eating and swallowing difficulties6havealreadybeenshowntoberelatedto
under-nutrition risk in hospitalized patients presenting a wide range of diagnoses. However, data regarding the factors associatedwithundernutritionriskonhospitaladmissionin pulmonologyinpatientsisstillrequired.
Pulmonology patients, such aschronic obstructive pul-monary disease (COPD) or lung cancer (LC) patients, frequentlyexperiencedbreathingdifficultiesthatcancause lossof appetiteanddecreasednutritionalintake.7---9
More-over,thestateofinflammationofthosepatientscontributes tobodymassdepletion,7,8highlightingpulmonologypatients
aspronetobeatundernutritionrisk.
Undernutrition revealed to be associated with a pro-longedlength of hospitalstay (LOS) and increasedrisk of morbidityandmortalityinavariedsampleof hospitalized patients.10Ithasalsobeenshown,inmixedinpatients
sam-ples,thatundernutritioncontributestoincreasedcostsfor healthcare6,11andsocialservicesprovision.12
Among pulmonology patients, undernutrition has been linkedtopoorprognosisandrecurrenthospitalization.2,13---15
However, knowledge regarding the association of under-nutrition with increased LOS and worse prognosis in pulmonology department inpatients was obtained from bivariablecomparative analysis6,16,17 or logistic regression
models,12,15whichdidnottakeintoaccountallthe
param-etersthatmayberelatedtoLOSanddischargedestination. Somestudiesthatincludedpulmonology patientsreported the use of survival analysis. However, patients were all analyzed in a single group without stratified analysis for pulmonology patients10,18 or the analysiswas relatedtoa
particulargroupofpulmonarydiseasepatients.2,13,14Infact,
evidenceregardingthe nutritionalfactorsassociated with LOSanddischargedestinationamongpulmonology depart-ment inpatients is scarce, which reinforces the need for furtherresearch.
Increasing knowledge regarding the consequences of undernutrition among pulmonology patients would be of major relevance. Predicting LOS is relevant for hospital managementsinceitwouldallowhospitalstoorganizetheir resourcesaccordingly.Moreover,itisessentialforthe devel-opmentofamoreeffectivehealthcareplan.19 Shortening
LOSwouldalsoreducehealthcare costs.Additionally,the earlyidentificationofpatients’healthstatusandthe imple-mentationofanadequatetreatmentwouldreducetherisk ofnosocomialinfectionsandcouldleadtoanimprovement inpatients’qualityoflife.20
Several tools have been developed toassess undernu-trition risk. Nonetheless,there is current knowledge that undernutritionscreeningtoolsdifferintheirperformance,21
andthereisnogold standard definedforidentification of undernutritionrisk17andnoconsensusaboutthemost
appro-priatetool for undernutritionscreening neitherfor hospi-talizedpatientsnorspecificallyforpulmonologyinpatients. Actually,arecentsystematicreviewandmeta-analysishas revealedalackofstandardizedmethodstoassess undernu-tritionriskandundernutritioninpulmonologyinpatients.22
The Malnutrition Universal Screening Tool (MUST) was developed by the British Association for Parenteral and EnteralNutritionandwasvalidatedinahospitalsetting.23,24
Therefore,thisstudy aimedtoquantifytheassociation ofundernutritionriskevaluatedusingtheMUSTathospital admissionwithtimetodischargealive.
Methods
Studydesignandparticipants
A retrospective cohort study was performed in the Pul-monologyDepartmentofthe‘‘CentroHospitalarVilaNova deGaia/Espinho’’.Patientsovereighteenyearsofagewho were consecutivelyadmitted tothis department between February2013andMay2014wereconsideredforinclusionin thestudy.Informationonpatients’eligibilitywasgathered fromclinicalfiles.
Theexclusioncriteriaweretheabsenceofinformation about undernutrition risk evaluation due to discharge or deathbeforetheevaluation(n=106),theincapacityofthe patienttoprovideinformation(n=6)ortheunavailabilityof performundernutritionrisk evaluationinisolatedpatients duetoaninfectiouscondition(n=4).
Giventhehighnumberofhospitalreadmissions,thefirst admissionduring thestudy periodwasconsidered for this study,exceptforcaseswhereinformationregarding under-nutritionriskevaluationwasmissing.The follow-upperiod correspondedtotheLOS,whichisthenumberofdaysfrom hospitaladmissionuntiltheendofthehospitalstay.
ThestudyprotocolwasapprovedbytheHospitalEthical Committee(number35/2015)andbytheInstitution Admin-istrationBoard(number3859;49/2015).Allinformationwas obtainedaccordingtotherecommendationsofthe Declara-tionofHelsinki.
Datacollection
Dataonsocio-demographiccharacteristics(sex,age,marital statusandworkingstatus),onclinicalcharacteristics (diag-nosis,LOSanddischargedestination)andonundernutrition riskevaluationwereobtainedfromthepatient’sclinicalfile. Socio-demographicandotherclinicalparameters
Marital status was defined as married (married or civil partnership), single, widowed or divorced. Working sta-tus was categorized as (1) employed, (2) unemployed or economically inactive,(3) retiredand (4)housewives and students.
The diagnoses presented by the patients at hospi-tal admission were categorized into nine categories: LC, asthma, pneumonia, pneumothorax, tuberculosis, COPD, empyema,bronchiectasisand‘‘otherreasons’’.Indiagnoses suchasCOPDandLC,thepatientswerealsocategorizedby theirhistologicaltypeandstage,andonlybystageinCOPD patients,wheneverthisinformationwasavailable.
Thedischargedestinationwasconsideredas‘‘discharged to home’’, ‘‘transferred to continuing care unit’’, ‘‘transferred to another hospital’’, ‘‘discharge against medicaladvice’’or‘‘death’’.
Undernutritionriskevaluation
Inthedepartmentunderstudy,patient’sundernutritionrisk wasassessedusingMUST,whichis appliedinthefirst72h after hospital admission,23,25 as a established procedure.
MUSThasshowngoodvalidity,24,26isquickandeasytoapply
andhasan excellentreproducibilitybetween users.24 The
MUSToverallundernutritionriskfinalscorecorrespondsto thesumofthescoresobtainedineachparameter,ranking thepatientsintolow(0),moderate(1)orhigh undernutri-tionrisk(≥2).
Anthropometricdata(heightandweight)wascollected applying standard procedures,27 using a Seca®
scale with an incorporated stadiometer. When it was impossible to obtain these parameters, reported weight and height or mid-upperarmcircumferencewasusedasanalternativeto estimatebodymassindex,asrecommended.23The
percent-ageofweightloss,usedtocalculatethefinalscoreofthe MUST,wascalculatedconsidering theweightregisteredin themedicalrecordsortheweightreportedbythepatient.23
Theundernutritionriskevaluationwasperformedbytrained nutritionists,whichcontributetointraandinter-interviewer agreement.
Dataanalysis
Categorical variables were described asabsolute and rel-ativefrequencies. Continuous variablesweredescribed as meanandstandarddeviation(SD)ifnormaldistributedoras medianandinterquartilerange(IQR)ifdistributeddifferent fromnormal.ProportionswerecomparedusingChi-square test.Continuousvariableswerecomparedacrosscategories ofundernutritionriskusingANOVAorKruskal---Wallistest,as appropriate.
Survival analysis was also conducted, and the Kaplan---Meier method was used to estimate the cumu-lative probability of being discharged alive over time, according to undernutrition risk at hospital admission and diagnosis. Patients who were transferred to another hospitalortoacontinuingcareunit(n=16),thosewhodied duringhospitalization(n=62)orthosewhoweredischarged against medical advice (n=7) were censored at the time ofthoseevents. LOSwascensoredat 30days28 (n=48).A
higher probability of discharge-free survival represents a lowerprobabilityofhospitaldischargeatacertaintime.
Cox proportional hazard regression modelswere fitted to estimate the hazard ratios (HR) and respective 95% confidenceintervals(CI).AkaikeInformationCriterionwas usedtoevaluatethefitofthemodel.Inthemultivariable Cox proportional hazard regression the following varia-bleswereconsidered:sex,age(continuous),undernutrition risk (categorical: low, moderate and high undernutrition risk),maritalstatus(marriedvs.notmarried(including sin-gle, widowed and divorced)), working status (employed, unemployed(includingboth categoriesofunemployedand housewivesand students)and retired)and diagnosis (cat-egorical: LC, COPD, pneumonia, bronchiectasis and other diagnoses).
Statistical analysis wascarried out using SPSS (version 23.0;IBM-SPSS,Inc.).Theadoptedsignificancelevelwas5%.
Results
This sample was composed of 683 patients, of which the majority weremen (67.2%)with amean (SD)age of 63.2 (16.3)years.Among thestudied sample, 16.5% and18.3% ofthepatientspresentedmoderateandhighundernutrition risk,respectively(34.8%ofundernutritionrisk).
Ahigherproportionofmenwereobservedamong mod-erate and high undernutrition risk categories (p=0.001). Acrossthegradientofundernutritionrisk(lowtohigh under-nutritionrisk), therewas adecrease in the proportionof marriedparticipants and an increaseof the proportionof singleindividuals(p=0.009).Also,an increasein the pro-portionofunemployedindividualswasobservedinthehigh undernutritionriskcategory(p<0.001)(Table1).
There are significant differences concerning LOS and dischargedestinationaccording toundernutritionrisk cat-egories. Patientswith high undernutritionrisk had longer LOS (p=0.006) andamong those,it was verifieda higher proportionof patients who were not dischargedto home (p=0.030),comparedwiththeothergroups.
Inthesurvivalanalysis,we observedthatpatientswith highundernutritionriskonadmissionhadhigher probabil-ityofremaining inthe hospitalat acertainpoint in time (p<0.001;Fig.1a).Similarly,LCpatientshadlower proba-bilityofhospitaldischarge(p<0.001).Kaplan---Meiercurves for COPD,pneumonia, bronchiectasis andother diagnoses seemedtobeoverlapped(Fig.1b).Patientswithhigh under-nutritionriskhadalongerLOS,withapproximately50%of patientsdischargedtohomeonlyafter14daysof hospital-ization(p<0.001;Fig.1a).Ontheotherhand,patientswith low andmoderate undernutritionrisk were discharged to homeafteramedianof10and13days,respectively.
ThroughCoxregression,weverifiedthatthepresenceof highundernutritionriskathospitaladmissionwasassociated withadecreasingprobabilityofdischargealiveover time, regardlessofsex,age,diagnosis, maritalstatusand work-ingstatus(adjustedHR=0.70;95%CI:0.55---0.90)(Table2). Lungcancerpatientswerealsoshowntohavealower prob-abilityofbeingdischargedtohome.
Discussion
Inthe present study,approximatelyone in threepatients admitted to this pulmonology department was at under-nutritionrisk.Ourresultsrevealedthatundernutritionrisk assessedbyMUSTisassociatedwithbothLOSanddischarge destinationamongpulmonologyinpatients.
The prevalence of undernutrition risk found in the presentanalysisissimilartopreviousresults(33.8%)of inpa-tientsfromthesamedepartmentwherethisstudyhasbeen conducted.29 However, higher frequencies have also been
reported in other settings.4,30 A recent study conducted
in Norway among respiratory diseases patients using the NutritionalRiskScreening----2002(NRS-2002)showedahigher prevalence of undernutrition risk (43.5%).30 In another
study carried out in a Chinese pulmonology unit, also usingNRS-2002, 55.9% of patients were at undernutrition risk.4Theseresultsrevealahigh,althoughvariable,
preva-lence of undernutrition risk among these patients across different settings, geographical areas and using different
Table1 Samplecharacterizationaccordingtoundernutritionriskcategoriesonhospitaladmission.
Lowrisk Moderaterisk Highrisk p
Age(years)a Mean(SD) 63.4(15.6) 63.6(16.1) 62.0(18.5) 0.656 <65 209(47.0) 55(48.7) 61(48.8) 0.907 ≥65 236(53.0) 58(51.3) 64(51.2) Sexa 0.001 Women 168(37.8) 25(22.1) 31(24.8) Men 277(62.2) 88(77.9) 94(75.2)
Maritalstatusa,b 0.009
Married 282(74.4) 61(59.8) 69(59.5)
Single 34(9.0) 13(12.7) 21(18.1)
Widowed 45(11.9) 18(17.6) 17(14.7)
Divorced 18(4.7) 10(9.8) 9(7.8)
Workingstatusa,c <0.001
Employed 65(15.6) 16(14.5) 3(2.4)
Unemployed 37(8.9) 11(10.0) 19(15.4)
Retired 279(66.7) 76(69.1) 80(65.0)
Housewivesandstudents 37(8.9) 7(6.4) 21(17.1)
Diagnosisa 0.173 Lungcancer 68(15.3) 22(19.5) 24(19.2) NSCLCIa/Ib/IIa/IIb/IIIa 6(8.8) 1(4.5) 1(4.2) NSCLCIIIb/IV 46(67.6) 17(77.3) 16(66.7) SCLCIa/Ib/IIa/IIb/IIIa 0(0.0) 1(4.5) 0(0.0) SCLCIIIb/IV 10(14.7) 0(0.0) 5(20.8) Othersd 6(8.8) 3(13.6) 2(8.3) COPD 88(19.8) 20(17.7) 20(16.0) A/B 10(11.4) 2(10.0) 0(0.0) C/D 74(84.1) 18(90.0) 18(90.0) Otherse 4(4.5) 0(0.0) 2(10.0) Pneumonia 123(27.6) 24(21.2) 29(23.2) Bronchiectasis 16(3.6) 7(6.2) 12(9.6) Others 150(33.7) 40(35.4) 40(32.0) Asthma 52(34.7) 3(7.5) 3(7.5) Pneumothorax 22(14.7) 10(25.0) 13(32.5) Tuberculosis 8(5.3) 4(10.0) 9(22.5) Empyema 12(8.0) 7(17.5) 3(7.5) Othersf 56(37.3) 16(40.0) 12(30.0)
LOS(days)(median(IQR)) 10.0(8.0) 12.0(10.0) 13.0(14.0) 0.006
Dischargedestinationa 0.030
Home 400(89.9) 96(85.0) 102(81.6)
Nottohome 45(10.1) 17(15.0) 23(18.4)
Death 31(68.9) 14(82.4) 17(73.9)
Transference 8(17.8) 3(17.6) 5(21.7)
Dischargeagainstmedicaladvice 6(13.3) 0(0.0) 1(4.3)
BMI:bodymassindex;CI:confidenceinterval;COPD:chronicobstructivepulmonarydisease;IQR:interquartilerange;LOS:lengthof hospitalstay;MUST:MalnutritionUniversal ScreeningTool;NSCLC:non-smallcelllungcancer;OR:oddsratio;SCLC:smallcelllung cancer;SD:standarddeviation.
an(%). b n=597. c n=651.
d Pulmonarymasswithoutconfirmationofdiagnosis(n=2),sarcomatoidcarcinoma(n=1),sarcoma(n=1),largecellscarcinoma(n=1), carcinomawithoutstaging(n=2),non-Hodgkin’slymphoma(n=1),lungcarcinoma(n=1),malignantmesothelioma(n=1),largecell neuroendocrinecarcinoma(n=1).
e COPDpatientswithoutfunctionalstudy(n=6).
f Respiratoryfailure(n=25),haemoptysis(n=11),tracheobronchitis(n=10),pulmonaryembolism(n=9),bronchitis(n=4),respiratory infection(n=3),pleuraleffusion(n=5), bronchospasm(n=4),pulmonary fibrosis(n=2),pulmonaryhypertension(n=2),pulmonary silicosis(n=2),sarcoidosis(n=1),bronchospasmresistanttotherapy(n=1),splenicbiopsy(n=1),trachealstenosis(n=1),alveolar proteinosis(n=1),respiratoryacidosis(n=1),pulmonaryaspergillosis(n=1).
a
b
1,0 0,8 0,6 0,4 0 5 10 15 20 25 30 0 5 10 15 20 25 30Time (days) Time (days)
0,2 Discharge-free sur viv al Discharge-free sur viv al 0,0 1,0 0,8 0,6 0,4 0,2 0,0 p<0.001 p<0.001
Undernutrition Risk Diagnosis
Lung cancer Pneumonia COPD Bronchiectasis Others Low risk Moderate risk High risk
Figure1 Kaplan---Meierestimatesofdischarge-freesurvivalofpulmonologyinpatientsaccordingtoundernutritionrisk(a)and diagnosis(b).Highervaluesofdischarge-freesurvivalrepresentalowerprobabilityofhospitaldischargeatacertaintimepoint; in-hospitaldeaths,transfersanddischargeagainstmedicaladvicewerecensoredattimeofthoseevents.Lengthofhospitalstay wascensoredat30days.
Table2 UndernutritionriskidentifiedbyMalnutrition Uni-versalScreeningToolanddischargeovertime.
CrudeHR(95%CI) AdjustedHR(95%CI)a
Sex Women 1 1 Men 0.83(0.70---0.98) 0.94(0.77---1.13) Age(years) 0.98(0.98---0.99) 0.98(0.97---0.99) Maritalstatus Married 1 1 Notmarried 1.02(0.85---1.23) 1.04(0.86---1.26) Workingstatus Employed 1 1 Notemployed 1.01(0.76---1.35) 1.09(0.79---1.50) Retired 0.74(0.58---0.95) 1.31(0.96---1.79) Diagnosis Lungcancer 0.50(0.38---0.65) 0.52(0.39---0.70) COPD 1.01(0.80---1.26) 1.11(0.85---1.44) Pneumonia 0.92(0.75---1.13) 0.97(0.77---1.21) Bronchiectasis 0.89(0.61---1.30) 1.02(0.69---1.51) Othersb 1 1 Undernutritionrisk Low 1 1 Moderate 0.79(0.63---0.98) 0.81(0.63---1.02) High 0.69(0.55---0.85) 0.70(0.55---0.90)
CI:confidence interval;COPD:chronic obstructivepulmonary disease;HR:hazardratio.
a Adjustedbysex,age(continuous),undernutritionrisk, mar-italstatus,workingstatusanddiagnosis.
b Asthma,pneumothorax,tuberculosis,empyema,others (res-piratory failure, haemoptysis, tracheobronchitis, pulmonary embolism, bronchitis, respiratory infection, pleural effusion, bronchospasm, pulmonary fibrosis, pulmonary hypertension, pulmonarysilicosis,sarcoidosis,bronchospasmresistantto ther-apy, splenic biopsy, tracheal stenosis, alveolar proteinosis, respiratoryacidosis,pulmonaryaspergillosis).
undernutritionscreeningtools.Similarlytoarecent system-aticreview,MUSTrevealedtohavegoodpredictivevalidity forbothLOSandmortalityamongadultinpatients.21
According to our results, the probability of discharge aliveovertimedecreasedwiththepresenceofhigh under-nutrition risk on admission. This is in agreement with previous studies, involving inpatients from a wide vari-etyofmedicalwards31 andpulmonologyinpatients.2,10,13,18
The association of undernutritionwith in-hospital mortal-itywasreportedamongacutecarepatientswithrespiratory diseases.10 Survivalanalyses, performed among
tuberculo-sispatients2,13 usingeitherMUSTorMalnutritionScreening
Tool, revealed that patients withhigh undernutrition risk hadalowerprobabilityofsurvival.Thisreinforcesour find-ings,sincealowerprobabilityofbeingdischargedtohome amongpatientsathighundernutritionriskwasfound.
Furthermore, through Cox analysis, it was shown that highundernutritionriskmaintaineditsassociationwithtime todischarge,evenafteradjustingforsex,age,marital sta-tus, working status and diagnosis. LC patients were less likelytobedischargedaliveover time.Thesefindings are similar to those previously reported in non-small cell LC outpatients,in whom the presence of undernutrition was associatedwithloweroverallsurvival.14
This is a relevant study on the association of under-nutrition risk with adverse clinical outcomes amongst pulmonology department inpatients. To the best of our knowledge,evidenceinpulmonologyinpatientsisscarceand ithasbeenmainlyfocused onspecificpatientsgroupsand theuseofdifferentscreeningtoolsmakesitdifficulttomake comparisons.Inthemajorityofstudiessurvivalanalysiswas notcarried out,6,12,15---17 andits use can be regarded asa
studystrength.
The concurrent validity of MUST at hospital level was previouslystudied.24 MUSTwasshowntobeareliableand
usefultoolforpredictingadverseoutcomesintuberculosis patients13andalsoinlinewithresultsfrominpatientsfrom
awidespectrumofmedicalwards.26,31---33
Thisstudyaimedtoevaluatetheassociationbetweenthe nutritionalparametersassessedonhospitaladmissionand timetodischargealive.
As patients with increaseddisease severity would cer-tainlybethosewiththegreatestneedofhospitalization34
and as the undernutrition risk increases with disease severity,35 the inclusion of this information would be
valuablefor forthcoming studies,sinceit wasunavailable forthepresentstudy.Furthermore,educationlevelwould be relevant for socio-demographic characterization36 and
becausethisinformationwasunavailable,thepossibilityof confoundingcannotbediscardedasitwasreportedthatless educatedpatientsaremorelikelytobeundernourished.37It
isnoteworthythatinsomecasesinformationonweightwas reportedbypatients;thus,ourresultscouldbeinfluenced byrecallbias.
Additionally, selection bias could occur since patients were selected from a tertiary hospital. Nonetheless, our findingscouldbegeneralizedtopulmonologyinpatientswith identicalcharacteristicsasthoseincludedinthisstudy.
Themajorstrengthsofthisstudyweretheevaluationof alargeandvariedsampleof patientsfromapulmonology departmentandfromthesamegeographicalarea,allowing thegeneralizabilityoftheseresultsforpatientswithsimilar characteristics.
The findings of this study support the need of early nutritional screening and assessment and consequently implementationofnutritionalsupport. Furtherstudies are stillrequiredtostudyspecificdiagnosesinordertoimprove nutritionalstatusofhospitalizedpatients.Inourstudywe onlyuseddataonundernutritionscreening,thusitwillbe alsorelevanttousedataonthediagnosisofundernutrition infuturestudies.
Conclusions
Thisstudyrevealsthatpatientsat highundernutritionrisk havelongerLOSandalowerprobabilityofbeingdischarged to home, regardless of sex, age, marital status, working statusanddiagnosis.Lungcancerpatientshadlower prob-abilityofbeingdischargedtohome,whichcorroboratesa worseprognosisforthesepatients.Hospitalsshouldfollow theguidelinesfor nutritionalscreening andassessment as earlynutritionalinterventionscanimprovenutritional sta-tusandthereforeimproveclinicaloutcomes.
Conflicts
of
interest
Theauthorshavenoconflictsofinteresttodeclare.
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