Screen and TREAt for Malnutrition (STREAM) Programme

Background. 12-13% of older people living at home are at risk of malnutrition. Those most likely to benefit from MST have appetite or weight loss, are more often unwell with multiple chronic conditions, and have more hospital admissions. NICE called for research on the effectiveness of MST in primary care. Aim. To assess Malnutrition screen and treat policies (MST) in a free-living older age primary care population at risk of malnutrition Objective: To develop, test and assess the effectiveness and cost-effectiveness of interventions to support staff and participants for MST in primary care. Research plan: Workstream 1 (WS1): Intervention development. We will update existing reviews on trials of screening and of nutritional interventions and review qualitative studies. Theoretical modelling will systematically identify key target behaviours for health professionals and patients, and the psychological, social and environmental factors influencing these behaviours, using theoretical frameworks for understanding influences on the relevant behaviours of patients and health professionals. The intervention planning process will enable selection of appropriate theory-based behaviour change techniques and practical strategies to promote implementation of the intervention. We will explore key issues for MST policies in 1:1 interviews among 20-25 primary care staff and 20-25 patients. This information will be used to create web/computer/printed materials to help staff and patients understand the importance of nutritional care and screening, provide practical support in using the validated Malnutrition Universal Screening Tool (MUST), and in guiding management. Having drafted the materials, we will interview people about the acceptability and useabiliy of the materials, modify them and retest them again. We will then perform a feasibility trial of screening and of nutritional intervention (18-30 months) aiming to identify approximately 80 patients at high nutritional risk from screening to document recruitment and attrition rates (over 6 months);web usage (training undertaken, care recommended etc); and feasibility and acceptability of trial procedures (method of recruitment, randomisation, questionnaires etc). WS2.Main trial. 4900 participants will complete a baseline questionnaire and then practices will be randomised to one of three groups. 1) Brief Intervention practices: Screening and dietary modification We will use the package developed in WS1 to train practice staff to screen patients both opportunistically - patients are picked up when they see their nurse or GP – or by invitation to a nurse run screening clinic, or a home visit if housebound. Individuals identified during screening ( MUST positive) will be given dietary advice (frequent snacks, food fortification, a balanced diet, etc) and follow-up. This is likely to be the least expensive and most easily rolled out model, but will probably provide less absolute benefit for individuals and so may not be the most cost-effective. 2) Stepped care practices: Screening and stepped care approach intervention with ONS. As in 1 but with the additional use of ONS (Oral liquid Nutritional Supplementation) twice daily. Initially this will only be given in addition to the basic dietetic advice for 2 week periods during inter-current illnesses (a mirror of many effective short intervention ONS studies in hospitals). If no satisfactory maintenance of weight occurs then a longer course of ONS twice daily will be given following review after 3 months. If no improvement then occurs at 6 months, a further 3 month course of regular ONS will be given with referral for review by community dieticians. This may be the most effective strategy for individuals but will require significantly more resource input. 3) Control practices. Participants will complete survey questions and follow-up only WS3 will determine the cost-