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From the Editor

From The Editor: Are People Starving In Your Waiting Room?

What scares me the most about the following story is the fact that I did not pay attention to the problem until a few years ago, when we began developing quality measures for wound care practitioners. Now that I am paying attention, I’m horrified by both what I see and the thought of what I’ve probably missed in the past. Last month, in the course of a single day in the outpatient wound center, I saw three women who were starving — literally starving — based on objective criteria. Two of them were wearing makeup and jewelry (we do live in the South), and all of them have loving families and strong support systems. The first patient had a body mass index (BMI) of only 17.3; the second, a BMI of only 16.1. (Keep in mind that a BMI below 18.5 is considered low, so these women met the definition of severe malnutrition.) I saw many people with a BMI below 18 when I volunteered at a clinic in Haiti, however, that’s about the poorest country in the world. These ladies live in one of the most affluent communities in the United States. The woman whose BMI is severely low (only 16)   also has a below-knee amputation that is falling apart. Both of these severely underweight women have numerous symptoms of malnutrition, including brittle nails, dry skin, low blood pressure, thinning hair, and temporal wasting. They also asked for blankets to keep warm.

The third woman had a BMI of 19, which is within the normal range of 18.5-24.9. How could I know that she was starving even though her BMI was normal? Her malnutrition was obvious based on the amount of swelling she exhibited practically everywhere. She presented with peau d’orange, changes in both legs and one arm, and a tense abdomen full of ascites. It’s true she has a history of congestive heart failure, but she’s still living independently, driving her own car, and going to the grocery store. Her typical day’s menu includes cinnamon toast for breakfast, soup for lunch, and cookies for a snack. For dinner, she is “not hungry.” In other words, she eats almost no protein and takes no vitamins. She sleeps during the day and is up all night, so she is almost never outside during the day (an issue that affects vitamin D metabolism). She was referred to me because a leg wound from minor trauma wouldn’t heal. I spent the majority of my day not talking about what these ladies need to place on their wounds, but rather what they should be eating. We talked about specific foods that would provide more protein and calories, and discussed L-arginine supplementation, vitamin D, zinc, and other nutrients. These stories are not rare. We need to do a better job of identifying nutritional problems among our patients and help them to get healthy. This means “Doing the Right Thing” for patients who are living with chronic wounds and ulcers. If you are a physician, nurse practitioner (NP), or podiatrist who is subject to the Merit-Based Incentive Payment System (MIPS) and who works in a hospital-based outpatient wound center, I have good news for you: If you haven’t done anything about MIPS participation for 2018 you can still keep from losing 5% of your Medicare Part B payments. Last year, the U.S. Wound Registry (USWR) approached the Centers for Medicare & Medicaid Services (CMS) about creating a new clinical practice improvement activity (CPIA) category for improving the collection of patient-reported data, such as patient-reported nutritional screening. CMS agreed and assigned this a relatively rare “high value” rating. That means that in 2018, all NPs (regardless of practice site) and physicians practicing in hospital-based centers can obtain 40 points in the CPIA subcategory by demonstrating activities such as the collection of patient-reported nutritional screening.

I recommend the Mini Nutritional Assessment (MNA®) by Nestlé, a tool that has been previously discussed in Today’s Wound Clinic.1 The MNA is a validated nutritional screening-and-assessment tool that can identify geriatric patients aged 65 and older who are malnourished or at risk of malnutrition. The MNA was developed nearly 20 years ago and is the best validated nutritional screening tool for the elderly, based on published data. Originally comprised of 18 questions, the current MNA consists of only six questions that streamline the screening process.2 A very important caveat about the CPIA is that, unlike quality measures, which must be reported for the entire year, CPIAs (at least in 2018) may be performed over a 90-day period. Unfortunately, the final 90 days of the 2018 reporting period began in October. However, you might just be able to implement a nutritional screening CPIA in time to get credit for the whole 90 days, if you start immediately, and save yourself from losing 5% of your Part B payments. There is more information available through the USWR.3

Caroline E. Fife is chief medical officer at Intellicure Inc., The Woodlands, TX; executive director of the USWR; and medical director of the CHI St. Luke's Wound Care Clinic - The Woodlands.


1. Nestlé health science & nestlé nutrition institute: Q&A. TWC. 2016. Epub. Accessed online: 

2. MNA mini nutritional assessment. Nestlé Nutrition Institute. 2018. Accessed online:

3. Clinical practice improvement activity (CPIA) projects. USWR. 2018. Accessed online:

From the Editor
Caroline E. Fife, MD, FAAFP, CWS, FUHM
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