Clearly defined value-based medicine emphasizes the quality and cost-effectiveness of medical care, which is increasingly essential to achieve long-term sustainability in healthcare delivery.1–3 Basically, a value-based system is grounded in 3 principles: the goal is value for patients, care delivery is organized around medical conditions and care cycles, and results are measured.4 Therefore, approaches, such as value-based purchasing and precision medicine, for reducing the incidence of hospital-acquired conditions and hospital readmissions represent initial reforms.5 Improving the value of health care is the positive-sum competition: better care for patients, excellent reward for physicians, and contained cost for health administrations. Importantly, enabling health and effective care could deservedly earn professional satisfaction and reduce current pressure on administrative control of medicine.6 In the public health sector today, health care systems and caregivers face a double burden of disease and have to balance the care for both acute and chronic conditions.7 As reflected in the recent consensus of malnutrition, it can be either a contributor cause or a consequence of disease conditions,8–10 which indicates a hidden but costly component of medical care.2,11 Here, we propose a strategy for reform that is value-based and nutrition-led. To coordinate health care during and beyond hospitalization, the awareness of nutrition and best-practice nutritional interventions should be aligned in treatment strategies that ought to be well-performed by hospital executives and bedside clinicians.12 Value-based nutrition provides a path for innovation that recognizes the role of nutrition therapy at the heart of the medical care. To promote nutrition care and develop training programs, the overarching theme is to refine value-based nutrition strategies. Patient-centered care, personalized medicine, and precision medicine lay the foundation of value-based medicine. Here, a strategic framework was proposed for implementing value-based nutrition: Patient-centered nutrition: establish hunger-free hospitals (HFHs), change the perception of nutrition intervention, and refine it as the first-line therapy. Personalized nutrition: boost multidisciplinary teams for nutritional screening, diagnosis, and treatment. Precision nutrition: increase the development of nutritional biomarkers and formulas and enhance the evaluation of nutrition therapy and follow-ups. HFH: malnutrition accounts for a large and hidden component of medical costs Disease-related malnutrition ranges from 30% to 50% of hospital patients and is notably higher in long-term care patients.13 In certain diseases and conditions, such as congestive heart failure, chronic obstructive pulmonary disease, cancers, surgery or critical illness, as well as in elderly patients, the consequences of malnutrition are dire and costly, along with longer lengths of hospital stay and higher costs of medical care.5,14 Policies, nursing, and allied medical training programs must find place in their curricula to enhance awareness of nutrition and increase knowledge of best-practice interventions. The HFH, as a nutrition care delivery program, focuses on providing high-quality nutrition intervention and ensuring that patients obtain easy access to safe, affordable, nourishing meals during hospitalization. It is a multilevel approach involving professionals in clinical settings, staff in the catering system, patients, and family members. The key approaches related to efficient HFH implementation are the following (Fig. 1): Standardize bedside nutritional preparations, such as routine nutrition assessment, diagnosis, and treatment for individualized patients. Design solutions to improve nutritional treatment and promote nutrition science into standardized clinical nutrition. Develop nutrition support teams (NSTs) and reinforce hospital catering services. Measure health outcomes and cost, recognize nutrition therapy as the first-line therapy. Expand nutritional committee and enhance hospital administration management. Figure 1:: Strategic framework for value-based nutrition implementation in HFH. HFH, hunger-free hospital.NST-a cross-disciplinary collaboration can promote personalized nutrition practice The percentage of NSTs has remained consistently around mid-40% in US hospitals; however, their existence still requires further justification.15 What can NSTs do to promote personalized nutrition practice? Value-based care requires not only patient-centered reconstruction of a functional life but also a meaningful life, which involves four aspects: physical, psychological, social, and spiritual.16 However, in a value-based environment, understanding what the purchaser is seeking (beneficial cost and quality outcomes) will promote the development of NST programs and activities. Previous research has indicated that nutritional support is a vital cost-saving tool, whereas other treatments are scaled back due to financial considerations.2 Therefore, several factors have contributed to the NST, following the acronym “ACT” (accountability, communication, and teamwork),17 but the emphasis on cost and quality expectations should be further noted in the current value-based system. It is encouraged to strengthen the integrated nutritional treatment in time, space, course, content, and extension.12 The joint efforts of hospitals, communities, and families are required to coordinate disease prevention, treatment, and rehabilitation to implement whole nutritional management during the treatment period, the home period, and even the hospice period. Nutrition diagnosis: the first step toward personalized nutrition care Nutritional screening, as the first phase to identify patients at risk of malnutrition, was strongly recommended to be performed within the first 24–48 hours of hospital admission and at regular intervals thereafter. Subsequently, a detailed nutritional assessment that requires skilled specialists could be further applied for malnutrition diagnosis based on multiple parameters. According to the performance of Nutritional Risk Screening 2002 (NRS 2002) and Patient-Generated Subjective Global Assessment (PG-SGA), a national-wide observational cohort study performed at the Inpatient Oncology Unit in China was registered as the Investigation on Nutrition Status and its Clinical Outcome of Common Cancers (INSCOC) project in 2013.18–20 From the large-scale practice of nutrition assessment, it is confirmed that nutritional status should be referred to as the fifth basic vital sign (in addition to temperature, pulse, respiration, and blood pressure, which are the 4 classic basic vital signs), particularly for patients with cancer, for whom it has a vital near-term predictive value for clinical outcome.21 The admission diagnosis of inpatients strongly recommends a binary diagnosis of primary disease and nutritional status. Timely and regular nutrition interventions based on malnutrition biomarkers improve precision nutrition Value-based nutrition requires timely evaluation and regular follow-up of patient outcomes. Nutrition support in the traditional sense focuses on the changes in patient weight and albumin. For severely malnourished patients, 4-dimensional analysis should be performed to understand their energy expenditure, stress status, inflammation level, and metabolism16 for more precise nutritional interventions. Currently, translational research based on the pathophysiology of malnutrition is the innovation to develop effective interventions. Once the diagnosis of malnutrition has been confirmed, a defined individual nutritional goal, including energy expenditure and requirement, protein intake, and micronutrient supplementation, can be estimated with a validated formula or calorimetry.22 While energy requirements are measured, a nutritional plan should be provided with an initial adoption of the oral diet plan or escalated to enteral and parenteral feeding to meet disease-specific demands. In line with evidence-based medicine, a wide consensus regarding the beneficial effects of energy, special formulas, and immunonutrients (eg, omega-3 fatty acids, arginine, nucleotides, and glutamine), which are recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), should be further verified in diverse medical conditions for precision nutrition.23,24 For instance, individuals with a mutant genotype were reported to exhibit a higher risk of stroke; however, they could particularly benefit from folic acid supplementation, according to the China Stroke Primary Prevention Trial (CSPPT), which represents a promising pipeline for precision nutrition.7 Diverse nutritional formula: heterogeneity for precision nutrition support The population-targeted dietary options recommended by dieticians are very promising, as therapeutic eating plans with multiple considerable restrictions and increasing dietary options exhibit incredible potential to improve personalized oral nutritional treatment to match individuals’ preferences, lifestyles, values, and global health status.25 For enteral and parenteral nutrition, a standard polymeric formula should be used routinely in most patients; however, some distinct nutrient profiles or immune-modulating formulas, such as arginine, vitamins, and fish oil, should be reserved for special medical settings, including major surgery, chronic disease, and cancers, with clear outcome-beneficial evidence.26–28 Guideline update: better evaluation of nutritional treatment Essential roles of nutrition currently recognized in treatments of global chronic disease and improvement of outcomes are founded on a standardized evidence-based approach to the development of nutritional guidelines.29 The evaluation and follow-up of the effects of nutritional therapy emphasize the 4Ps, namely, predictive, preventive, personalized, and participatory.30 In terms of the evaluation of malnutrition, the Global Leadership Initiative on Malnutrition (GLIM) proposed specific consensuses with 3 phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and 2 etiological criteria (reduced food intake or assimilation and increased inflammation or disease burden), which have been verified in many cohorts worldwide.22,31–33 Nevertheless, there is still a need to understand whether the tool or the criteria are appropriate for the patient population (eg, age, sex, region, and medical condition) and setting of interests (eg, institute, hospital, physician, or community setting). A scientific view to guide precision nutrition will be derived from large-scale clinical trials and prospectively cohort studies, as well as targeted, well-designed metabolism-related basic studies.34 Furthermore, malnutrition biomarkers indicating worsening nutrition-related outcomes due to the merging influences of poor dietary intake, acute/chronic disease, and advancing age should be prospectively validated. Additionally, malnutrition quality measures and nutrition-focused quality improvement programs by nurses should be encouraged to promote health outcomes and move them to a value-based care model.35 Last, the health effects and cost of ongoing nutritional therapy in patients who have been discharged from hospital should also be scrutinized under studies of careful consideration. Generally, in conclusion, value-based nutrition can bring essential impacts to medical care: overall improvement of disease outcomes and savings in medical costs. The hallmarks of value-based nutrition are patient-centered nutrition (HFHs), personalized nutrition (multidisciplinary teams for nutritional screening, diagnosis, and treatment), and precision nutrition (the development of nutritional biomarkers and formulas and evaluation of nutrition therapy and follow-ups). To provide examples for implementation of these concepts, to start from current standard care with outlook for increasingly precise approaches and rigorous methodology, and to move toward disease-specific biomarkers and nutritional treatment. We are contributing actively to the health administration for increasing emphasis on clinical nutrition and giving nutritional treatment full play in value-based system. Funding This work was supported by the National Key Research and Development Program to Prof. Hanping Shi (No. 2022YFC2009600), and the Beijing Municipal Science and Technology Commission Program to Prof. Hanping Shi (SCW2018-06). Conflicts of interest None.
Tang et al. (Thu,) studied this question.