CAJ | 학술논문

评价一种筛查工具的预测有效性(validity),需观察经该工具筛查阳性的患者接受治疗后,能否改善临床结局.尤其在临床营养中,仅基于观察性研究所获得的工具,其筛查阳性结果不足以反映对不良结局的预测.因为在许多疾病过程中,营养不足和并发症常常相伴而行,且营养不足未必是导致这些并发症的因素.因此,开发一种可供医院和其他诊疗机构使用的、具备良好有效性的营养风险筛查工具绝非易事,因为迄今为止仅有很少的随机对照研究(RCT)是基于与结局相关的营养筛查而纳入患者的.另外,针对患者诊疗质量管理以及针对营养制剂报销制度的政策均依据营养风险筛查.过去10～20年也出台了几种筛查工具,而到底该选用何种工具存在较大困惑.笔者指出,“营养风险筛查2002”(NRS 2002)是有效性最佳的筛查工具,理由如下:(1)包括了所有被广泛认同的疾病相关营养不足的评分指标,及因营养不足未经治疗而导致并发症的风险.该评分系统既包括了营养状况评分,如体重指数(BMI)、近期体重下降和近期摄食量减少.(2)将上述指标纳入数值评分系统.(3)其有效性已在观察性结局研究、系统文献分析、随机对照研究和大规模前瞻性队列研究中获得证实.笔者就NRS 2002的预测有效性与其他筛查或评定工具进行比较,着重评价其在癌症患者和老年住院患者中的应用价值.并在新近国际共识的框架下,就疾病相关营养不足的诊断进行论证.
평개일충사사공구적예측유효성(validity),수관찰경해공구사사양성적환자접수치료후,능부개선림상결국.우기재림상영양중,부기우관찰성연구소획득적공구,기사사양성결과불족이반영대불량결국적예측.인위재허다질병과정중,영양불족화병발증상상상반이행,차영양불족미필시도치저사병발증적인소.인차,개발일충가공의원화기타진료궤구사용적、구비량호유효성적영양풍험사사공구절비역사,인위흘금위지부유흔소적수궤대조연구(RCT)시기우여결국상관적영양사사이납입환자적.령외,침대환자진료질량관리이급침대영양제제보소제도적정책균의거영양풍험사사.과거10～20년야출태료궤충사사공구,이도저해선용하충공구존재교대곤혹.필자지출,“영양풍험사사2002”(NRS 2002)시유효성최가적사사공구,이유여하:(1)포괄료소유피엄범인동적질병상관영양불족적평분지표,급인영양불족미경치료이도치병발증적풍험.해평분계통기포괄료영양상황평분,여체중지수(BMI)、근기체중하강화근기섭식량감소.(2)장상술지표납입수치평분계통.(3)기유효성이재관찰성결국연구、계통문헌분석、수궤대조연구화대규모전첨성대렬연구중획득증실.필자취NRS 2002적예측유효성여기타사사혹평정공구진행비교,착중평개기재암증환자화노년주원환자중적응용개치.병재신근국제공식적광가하,취질병상관영양불족적진단진행론증.
Predictive validity of a screening tool requires that clinical outcome improves when those screened positive are treated according to the result of the screening.Particularly in clinical nutrition,predictive validity only in the form of observation studies showing adverse outcome in those screened positive is insufficient since malnutrition and complications go hand in hand in many disease processes without malnutrition necessarily being the intermediate cause of the complication.It is therefore not a simple task to develop a well validated screening tool for nutritional risk in hospitals and other care settings,since very few randomized controlled trials are available in which patients were included on the basis of outcome by nutritional screening.On the other hand,regulations for quality management of patient care and rules for reimbursement of nutritional products require screening to be in place.The result is the development of several screening tools in the last 10-20 years and a great deal of confusion about which tool to use.In this editorial it is argued that Nutritional Risk Screening 2002 (NRS 2002) is the best validated screening tool since (1) it includes all the widely accepted components of disease related malnutrition,or rather risk of developing complications due to untreated malnutrition:a score for nutritional status including BMI,recent weight loss and recent food intake in combination with an estimate of possibly increased nutritional requirements,(2) it links these components to a numerical scoring system and (3) it has been validated in observational outcome studies,by a systematic literature analysis,in randomized controlled trials and in large scale prospective cohort studies.The predictive validity of NRS 2002 is discussed in relation to other screening or assessment tools with specific comments on its use in cancer patients and in hospitalized elderly.It is discussed within the framework of the recent international consensus on etiology and diagnosis of disease-related malnutrition.