Transmural Nutritional Support 

Approximately 25-40% of patients admitted to hospitals are malnourished. Disease related undernutrition is known to have adverse health consequences: reduction of muscle mass, respiratory function and immune function, impaired wound healing and higher care complexity. This results in increased morbidity and mortality, lengthened stay in hospital and increasing costs of health care. In the Netherlands the general policy is to discharge hospital patients as soon as possible. This implies a shorter hospital stay than in earlier years. Given the decreasing length of hospital stay, the problem of disease related undernutrition is shifting to the outpatient clinic and the community. Although the effectiveness and costeffectiveness of nutrition intervention of hospital patients has been proven, the effectiveness and cost-effectiveness of prolonged intervention (after discharge from hospital) remains to be studied. 

To generate evidence of the cost-effectiveness of oral nutritional support for malnourished elderly patients admitted to hospital and discharged to home, compared to usual care 

The study will be performed as a randomised controlled clinical trial (RCT)
Hospitalized patients of 60 years and over, admitted to the wards of mixed internal medicine with a BMI<20 and/or involuntary weight loss >10% and/or SNAQ malnutrition score ≥3 (= malnourished), will be randomized to receive either standardized oral nutritional support (600 kcal/day) or usual care, from admission until three months after discharge. 100 Control and 100 intervention patients are needed in order to detect a clinically relevant difference of 20% in functional and nutritional status or a difference in complication rates of 40% (control) vs. 20% (intervention).
Primary outcome measures are changes in ADL, physical activity, functional limitations, muscle strength and quality of life between admission and at 3 months after discharge; length of hospital stay, number of re-admissions to hospital, complication rate, medication use, visits to general practitioner
Secondary outcome measures are changes in body weight and composition between admission and at 3 months after discharge. For the economic evaluation cost-effectiveness ratios and cost-utility ratios will be calculated with bootstrapping according to the bias corrected percentile method.
Multivariate techniques will be applied to test differences between the intervention and control group, regression analysis to test the relative contribution of the intervention on the outcome parameters 

ir. F. Neelemaat, PhD student
dr. M.A.E. van Bokhorst – de van der Schueren, senior investigator
prof. Dr. S.A. Danner
Drs. A. Thijs
Prof. Dr. J.C. Seidell
Prof. Dr. M.W. van Tulder
Prof. Dr. P. Lips
Prof. Dr. W. Stalman
Dr. Ir. P.D. Bezemer