Title: Screen and TREAt for Malnutrition (STREAM) Programme
Funder: Department of Health and Social Care

Abstract: 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 &ndash; 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-effectiveness of MST pathways and explore the consequences of screening using modelling approaches. Dissemination Our findings will be disseminated through: open access journals; professional publications; social media; stakeholder events; PPI collaborators; NICE. If appropriate the web-based intervention can be disseminated widely, at low cost to NHS patients, through appropriate partnerships or licensing arrangements. PPI Jessima Hunter and Bernard Gudgin and the charity AgeUK will be involved at all stages of the research, and have been active in developing the protocol; PPI collaborators are part of the trial management team and have full collaborator status. Management and Governance The Programme Manager will be in daily contact with MS, PL, LM and LYar as appropriate. Each WS will be coordinated by designated leads (WS1 MS, LM and LYar, WS2 PL and MS, WS3 LYao), and there will be regular team meetings for each WS and for the whole Programme team quarterly. Southern Health will host, and the University of Southampton sponsor the study; the research will be subject to NHS ethics and Research Management and Governance arrangements, and overseen by a PSC and a DMEC as necessary. Benefits to patients and the NHS Potential benefits are improved quality of life, reduced infections, reduced hospital admissions and reduced health and social care costs for a fast-growing section of the population who currently are not well served.

Lay abstract: Aim. To assess whether the 12-13% of older patients living at home who are at risk of malnutrition can benefit from screening for malnutrition. Background. People living at home at risk of malnutrition have more illnesses and hospital admissions, so screening for and treating malnutrition could potentially improve health. Methods Workstream1 (WS1) We will interview 20-25 primary care staff and 20-25 patients about their views of malnutrition and how best to manage it, and will review the evidence for screening and treatment from previous studies. We will then create online and printed materials to help staff and patients understand the importance of nutritional care and screening, show them how to use the Malnutrition Universal Screening Tool (MUST), and guide management. We will interview staff and patients about whether these materials and will make any changes needed to improve them. WS2. Participants will be invited by general practices based on their computerised electronic records. Almost 5000 patients who agree to take part in the study will be asked to complete a questionnaire on their quality of life and appetite. They will then be allocated to one of three groups based on their GP practice (practices will be allocated by random numbers to one group). Group 1. Brief Intervention: Screening and dietary modification. Staff will be trained to screen patients who seem at risk of malnutrition when they see their nurse or GP &ndash; or by invitation to a screening clinic (or at home if housebound). Patients confirmed by screening as having problems with low weight will be given advice on how to improve their diet, for example fortifying foods, and will have a follow-up session. Group 2: Stepped care (increasing care as necessary). Patients in this group will receive the same screening and advice as group 1, but will also be prescribed an Oral Liquid Nutritional Supplementation(ONS), which is a liquid form of nutritional supplement, to take twice daily for 2 weeks whenever they are ill and lose their appetite. These patients will have follow-up at 3 months, and if they have lost weight will be prescribed ONS to take twice daily for 3 months. They will have another follow-up at 6 months and if they have lost weight will be prescribed ONS for another 3 months and referred for review by community dieticians. Group 3. Control practices. Participants do not receive an intervention but complete survey questions and measures of quality of life and weight change over 18 months.WS3 will assess the costs and benefits of screening and treatment. Patient and Public Involvement. Two individuals and the charity AgeUK are involved throughout the research.

Research activity codes: 3.3 NUTRITION AND CHEMOPREVENTION;3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE;CANCER AND NEOPLASMS