Things We Do For No Reason: Prealbumin Testing to Diagnose Malnutrition in the Hospitalized Patient

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 34-year-old man is admitted for a complicated urinary tract infection related to a chronic in-dwelling Foley catheter. The patient suffered a spinal cord injury at the C4/C5 level as a result of a motor vehicle accident 10 years ago and is confined to a motorized wheelchair. He is an engineer and lives independently but has caregivers. His body mass index (BMI) is 18.5 kg/m², and he reports his weight has been stable. He has slight muscle atrophy of the biceps, triceps, interosseous muscles, and quadriceps. The patient reports that he eats well, has no chronic conditions, and has not had any gastrointestinal symptoms (eg, anorexia, nausea, diarrhea) over the last six months. You consider whether to order a serum prealbumin test to assess for possible malnutrition.

The presence of malnutrition in hospitalized patients is widely recognized as an independent predictor of hospital mortality.¹ According to the American Society for Parenteral and Enteral Nutrition (ASPEN), malnutrition is defined as “an acute, subacute or chronic state of nutrition, in which varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.”² In one large European study, patients screening positive for being at risk of malnutrition had a 12-fold increase in hospital mortality.¹

Inpatient malnutrition is remarkably underdocumented. Studies using chart reviews have found a prevalence of malnutrition in hospitalized patients of between 20% and 50%, and only 3% of hospital discharges are associated with a diagnostic code for malnutrition.^3–5 Appropriate diagnosis and documentation of malnutrition is important given the profound prognostic and management implications of a malnutrition diagnosis. Appropriate documentation benefits health systems as malnutrition documentation increases expected mortality, thereby improving the observed-to-expected mortality ratio.

Serum prealbumin testing is widely available and frequently ordered in the inpatient setting. In a query we performed of the large aggregate Cerner Electronic Health Record database, HealthFacts, which includes data from inpatient encounters for approximately 700 United States hospitals, prealbumin tests were ordered 129,152 times in 2015. This activity corresponds to estimated total charges of $2,562,375 based on the 2015 clinical laboratory fee schedule.⁶