Q&A: GLIM FAQs
Q: How do these new Global Leadership Initiative on Malnutrition (GLIM) guidelines compare to the guidelines CMS refers to during audits?
A: CMS does not publish any clinical diagnostic “guidelines.” Many auditors apply their own, typically arbitrary criteria and may assert something like that but such assertions do not actually come from CMS.
Q: Should we educate providers about the American Society for Parenteral and Enteral Nutrition (ASPEN), or do we teach them to use GLIM, given that CMS endorses neither of them? ASPEN has been around for a while, so the dieticians and providers are already familiar with it—and so are the auditors.
A: Since there has not been enough time yet for nutrition societies to consider endorsement of GLIM, provider education would be premature at this time. In the U.S., a lot will depend on what ASPEN and the Academy of Nutrition decide to do. CDI programs and their nutrition services should start conversations now. I would suggest alerting medical staff leadership about GLIM and explain what you and nutrition services are doing about it. Be on the lookout for recommendations from ASPEN and the Academy of Nutrition.
Q: How does GLIM view those patients who have a normal or elevated body mass index (BMI) and malnutrition?
A: GLIM really doesn’t address this problem except to comment vaguely: “The experience from the current U.S. population is that people are often overweight or obese and would need to lose substantial weight before low BMI designation would occur.”
In this country, elevated BMI by no means excludes a diagnosis of malnutrition, but GLIM would define malnutrition in those people by either of the other two phenotypic criteria (weight loss parameters seem very reasonable in this setting; evaluating reduced muscle mass could be problematic in obesity). Since the BMI criterion really needs a “clinical modification” as we pointed out on ACDIS Radio, perhaps ASPEN/the Academy could suggest a reasonable solution to this problem as a part of that.
Q: We frequently receive denials if weight loss and < EEN are the only two criteria listed. How can we defend against these denials and what treatment is needed to qualify for severe malnutrition? Is supplementation alone enough?
A: Based on ASPEN criteria, those two are certainly enough unless the unfavorable decision is based on the absence of some traditional concepts and expectations. An appeal should point out the documentation confirming the ASPEN definition attaching a copy of the table of criteria with pertinent elements highlighted. The response ought to include a rebuttal of unjustified requirements the auditor seems to be imposing.
Treatment is another problem all together. A patient with severe malnutrition ought to be treated aggressively. “Aggressive” is a subjective term, but I believe a reasonable medical professional would expect, at a minimum, supervised, multiple daily oral supplements to a nutritious diet. Just providing nutrition education, encouragement, and recommending 1-2 supplements a day won’t suffice for a severely malnourished patient, although some nutritionists may argue that is does.
Q: How does GLIM compare with the World Health Organization’s (WHO) statements and criteria?
A: I am unaware of any WHO adult malnutrition guidelines or definitions, only pediatric. GLIM addresses only adults and ASPEN has entirely separate pediatric definitions/criteria quite different from adults. Pediatric malnutrition is described in detail by the CDI Pocket Guide. WHO does have some informational content available, but the main source is from 1999 and certainly outdated at this point.
Editor’s note: Richard Pinson, MD, FACP, CCS, answered these questions after the October 24, 2018, episode of ACDIS Radio. Pinson is the co-author of the CDI Pocket Guide and the Outpatient CDI Pocket Guide: Focusing on HCCs. He and Cynthia Tang, RHIA, CCS, principals at Pinson and Tang, LLC. Contact him at rpinson@pinsonandtang.com. To read the article from Pinson and Tang in the November/December CDI Journal on GLIM, click here.