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General Topics: Albumin and Prealbumin
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10/28/10 12:23 PM | Edit ReplyReply   |    Albumin and Prealbumin
RD0111
62 Posts

Registered Dietitian

How often do you order Albumin and Prealbumin labs?

10/28/10 02:25 PM | Edit ReplyReply   |    labs
GRD
1001 Posts

Registered Dietitian

oops double post

[Edited by GlassgeraniumRD on 10/28/10 02:33 PM]

10/28/10 02:34 PM | Edit ReplyReply   |    labs
GRD
1001 Posts

Registered Dietitian

I don't. They are markers of morbidity and mortality, not nutrition status markers. They are negative acute phase proteins and are also skewed due a multitude of reasons, one (or more) of which probably brought the patient to the facility in the first place. So what are they going to tell me that I don't already know/am not already addressing?

11/05/10 12:47 AM | Edit ReplyReply   |    RE: Albumin and Prealbumin
DNS1920
212 Posts

Registered Dietitian


    Posted by RD0111:
    How often do you order Albumin and Prealbumin labs?

I would save the patient money and not order them. They are markers for morbidity and mortality. They are negative acute markers so they go down when someone is sick. You could use the prealbumin with a c reactive protein to show that there is inflammation so the prealbumin being low is a result of illness until the CRP becomes normal, but there really is no research to support that so that is why I would save the patient money and not order them. You know the patient is sick. They will both increase when the illness resolves. Hope that helps.

11/06/10 10:56 AM | Edit ReplyReply   |    RE: Albumin and Prealbumin
SZT
615 Posts

Registered Dietitian


    Posted by DNS1920:

      Posted by RD0111:
      How often do you order Albumin and Prealbumin labs?

    I would save the patient money and not order them. .

You're not saving the pt money (unless they're self-pay of course, in which case, yes). Medicare does pay (actually more than the actual cost of the test in most cases). And an ALB or PAB can be used by the MD to diagnose malnutrition which can increase reimbursement for the hospital.

That being said, I don't order it on everybody. If the result of the test isn't going to change my POC (and we already have a malnutrition dx etc..) then I won't bother. But sometimes it can help to justify a big jump in pro provision (when taken into account w/other factors), and it is good for trending. I do like to have it for my nutrition support pts, as I am the one dictating the pro provision (unlike in a general PO pt, who for the most part is only going to eat what they want). In those cases, I try to have as much info as possible to base my recommendations on and to help assess the adequacy of my provision.

11/06/10 01:33 PM | Edit ReplyReply   |    ordering
GRD
1001 Posts

Registered Dietitian

Quote: "You're not saving the pt money (unless they're self-pay of course, in which case, yes). Medicare does pay (actually more than the actual cost of the test in most cases). And an ALB or PAB can be used by the MD to diagnose malnutrition which can increase reimbursement for the hospital."

But see...in the long run, it IS costing someone to run unnecessary tests - the taxpayers who fund Medicare/Medicaid or insurees who fund insurance policies through premiums. Imagine all the $$$ that could be saved over the course of a single year if all these unnecessary tests stopped being ordered - but that's the subject of another post...

Anyway, why does one need a PAB to justify increased protein? A multitude of reasons call for higher protein, I'm sure one can easily justify that without adding an uncessary - e.g. s/p trauma, O.R., wounds, etc. Refer to the PES statement guidelines for "increased nutrient need", all sorts of reasons there.

I still stand behind not ordering them, because the tests aren't going to tell me anything I don't already know, either from other lab tests done, anthropometric data, physical exam, etc. plus they are NOT nutrition markers.

11/06/10 05:50 PM | Edit ReplyReply   |    RE: ordering
SZT
615 Posts

Registered Dietitian


    Posted by GRD:
    Quote: "You're not saving the pt money (unless they're self-pay of course, in which case, yes). Medicare does pay (actually more than the actual cost of the test in most cases). And an ALB or PAB can be used by the MD to diagnose malnutrition which can increase reimbursement for the hospital."

    But see...in the long run, it IS costing someone to run unnecessary tests - the taxpayers who fund Medicare/Medicaid or insurees who fund insurance policies through premiums. Imagine all the $$$ that could be saved over the course of a single year if all these unnecessary tests stopped being ordered - but that's the subject of another post...

    Anyway, why does one need a PAB to justify increased protein? A multitude of reasons call for higher protein, I'm sure one can easily justify that without adding an uncessary - e.g. s/p trauma, O.R., wounds, etc. Refer to the PES statement guidelines for "increased nutrient need", all sorts of reasons there.

    I still stand behind not ordering them, because the tests aren't going to tell me anything I don't already know, either from other lab tests done, anthropometric data, physical exam, etc. plus they are NOT nutrition markers.


Yes, but if you ARE treating malnutrition, and the hospital is incurring that cost, shouldn't they receive reimbursment?! And for most, a PAB or ALB is used to diagnose. I can't write malnutrition in a chart - that's diagnosing, but I can request tests, write indicators, etc... that can lead to a diagnosis. As dietitians, we need to be knowledgable of how we can help hospital to create revenue (legitimate) and increase our value. Unfortunately hopsitals can't bill insurance companies for what we do, but we do provide a service. And to be clear, I wasn't advocating running PAB on all patients, just where it could affect my POC or outcomes. Sometimes doctors need to see concrete numbers to get on board. And I maintain that it can be useful for trending. JMO.

11/10/10 11:54 AM | Edit ReplyReply   |    RE: Albumin and Prealbumin
DNS1920
212 Posts

Registered Dietitian


    Posted by SZT:

      Posted by DNS1920:

        Posted by RD0111:
        How often do you order Albumin and Prealbumin labs?

      I would save the patient money and not order them. .

    You're not saving the pt money (unless they're self-pay of course, in which case, yes). Medicare does pay (actually more than the actual cost of the test in most cases). And an ALB or PAB can be used by the MD to diagnose malnutrition which can increase reimbursement for the hospital.

    That being said, I don't order it on everybody. If the result of the test isn't going to change my POC (and we already have a malnutrition dx etc..) then I won't bother. But sometimes it can help to justify a big jump in pro provision (when taken into account w/other factors), and it is good for trending. I do like to have it for my nutrition support pts, as I am the one dictating the pro provision (unlike in a general PO pt, who for the most part is only going to eat what they want). In those cases, I try to have as much info as possible to base my recommendations on and to help assess the adequacy of my provision.


It can save the patient money because unless they are a Medicare HMO they have to pay an out of pocket amount. Also all patients are not Medicare patients and insurance patients do pay a percentage of the bill. Just because a doctor writes the diagnosis of malnutrition it does not mean the hospital will be paid for it. Hospitals are paid by Medicare based on DRG's (diagnosis related groups). If the patient is admitted for a hip fracture the DRG is about 3 days. The hospital is paid a flat rate based on the DRG. If you discharge the patient sooner than 3 days, or do not order additional tests other than what is required to fix the hip the hospital makes money. The only time the additional diagnosis would assist is if the patient is what they call an outlier. That means the patient has had major complications and the cost of care has been extremely high. So for a patient that had a hip repaired they would have to go into respiratory failure, require a ventilator and be unweanable to usually meet the outlier status so the hospital would be reimbursed above the DRG rate. All other patients would continue to pay a percentage of the agreed upon costs. The hospital can charge $130,000, but that does not mean they will get paid that amount. The insurance companies have agreed upon rates in their contracts that the hospital must abide by. The hospital discounts the amount by the contract amount and then the patient is charged the percentage their company requires they pay. Medicare/Medicaid patients that are HMO patients are not charged for the test, but every working person is charged in the form of taxes. Please since we know it is not a nutritional marker, if the patient is not going to meet the outlier status for Medicare/Medicaid,save us all the money.

11/11/10 08:44 AM | Edit ReplyReply   |    RE: Albumin and Prealbumin
SZT
615 Posts

Registered Dietitian


    Posted by DNS1920:

      Posted by SZT:

        Posted by DNS1920:

          Posted by RD0111:
          How often do you order Albumin and Prealbumin labs?

        I would save the patient money and not order them. .

      You're not saving the pt money (unless they're self-pay of course, in which case, yes). Medicare does pay (actually more than the actual cost of the test in most cases). And an ALB or PAB can be used by the MD to diagnose malnutrition which can increase reimbursement for the hospital.

      That being said, I don't order it on everybody. If the result of the test isn't going to change my POC (and we already have a malnutrition dx etc..) then I won't bother. But sometimes it can help to justify a big jump in pro provision (when taken into account w/other factors), and it is good for trending. I do like to have it for my nutrition support pts, as I am the one dictating the pro provision (unlike in a general PO pt, who for the most part is only going to eat what they want). In those cases, I try to have as much info as possible to base my recommendations on and to help assess the adequacy of my provision.


    It can save the patient money because unless they are a Medicare HMO they have to pay an out of pocket amount. Also all patients are not Medicare patients and insurance patients do pay a percentage of the bill. Just because a doctor writes the diagnosis of malnutrition it does not mean the hospital will be paid for it. Hospitals are paid by Medicare based on DRG's (diagnosis related groups). If the patient is admitted for a hip fracture the DRG is about 3 days. The hospital is paid a flat rate based on the DRG. If you discharge the patient sooner than 3 days, or do not order additional tests other than what is required to fix the hip the hospital makes money. The only time the additional diagnosis would assist is if the patient is what they call an outlier. That means the patient has had major complications and the cost of care has been extremely high. So for a patient that had a hip repaired they would have to go into respiratory failure, require a ventilator and be unweanable to usually meet the outlier status so the hospital would be reimbursed above the DRG rate. All other patients would continue to pay a percentage of the agreed upon costs. The hospital can charge $130,000, but that does not mean they will get paid that amount. The insurance companies have agreed upon rates in their contracts that the hospital must abide by. The hospital discounts the amount by the contract amount and then the patient is charged the percentage their company requires they pay. Medicare/Medicaid patients that are HMO patients are not charged for the test, but every working person is charged in the form of taxes. Please since we know it is not a nutritional marker, if the patient is not going to meet the outlier status for Medicare/Medicaid,save us all the money.


It is my understanding, and that of my hospitals as well - that there are up to 5 allowable DRGs. And most people (unless self pay) pay either a flat rate (ie $150 per stay) or have an annual deductable ($5000). Some do pay a percentage, but since PAB when ordered with other labs ie BMP is less than $5 in our lab. I don't think my requesting it 2 or 3 times during a 2 week stay is going to break anyone's bank. And I reiterate that many docs will not dx malnutrition on admission unless they have numbers to back it up. Our (RD) notes often provide the info that doctors (or our DRG management person) use to code for diagnoses. And again, having a PAB can affect my POC.

And let me state, that I am not the only one who uses PAB in the course of practice. I have attended many conferences where trending PAB has been advocated in the course of MNT. If you don't feel comfortable with it, fine. But in SOME instances I do find it helpful.

11/26/10 07:46 PM | Edit ReplyReply   |    Alb PAB
sophie45
84 Posts
Kansas City MO
Registered Dietitian

I did not work long in the hospitals to get into the lab orders, but work in LTC in which residents come in severely malnourished. Hospitals seem to have a As an RD, I know when someone's illness/condition depletes the body of protein; however, the initial protocols for labs are in place at time of admission, and I apply MNT after assessing the whole person w/med dx. I will talk to the dr to tell him what I think I can do for the person and he agrees. All residents get initial lab work done, possibly unlike a hospital. If the alb/pab are low, I utilize medical nutrition therapy as intended according to RD scope of practice to provide intervention to help provide extra protein through food, Juven (if wounds), suppl and powders, if tolerated. It usually works and I see wounds healing, and others gaining wt and overall doing better; but if a critical resident w/wounds/amputee, renal, etc. continues to struggle w/protein losses, I will order a second pab some time later to assess if my interventions are working to prove to dr/nsg/family we may need different interventions or to show that I am continuing to provide services and dr is also overseeing patient's progress. Unlike the hospital, I have the advantage of seeing patients every week to look at their progress. If you have a very good working relationship with the LTC doctors, you will have more authority to do what our scope of practice/MNT guidelines suggest based on evidence. We are always looking for evidence; however, I do understand about tax dollars and unlike hospitals, nutritional labs are routine as most residents come in malnourished. Patient care needs to be top priority for us as we provide MNT as a professional health provider, although I see hospital RD's more challenged with nutritional labs. I know the CRP labs are not routinely ordered in LTC, so I would like to get more information from perhaps Becky Dorner and Associates to see how to best utilize that lab to try instead of albumin.

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