The Norwegian Directorate of Health recommends Malnutrition Screening Tool (MST) for all adults

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Introduction
The Norwegian Directorate of Health has the authority and mandate to develop national guidelines and other normative standards aimed at improving the health care services, to ensure good quality, give guidance on the right priorities, and to prevent unwanted variation in the health care services. The National guideline for prevention and treatment of malnutrition was first published in 2009, and a revised version was launched in 2022 (1). The aim of the guideline is that malnourished patients and patients at risk of malnutrition are identified and receive targeted nutritional treatment and follow-up, so that malnutrition and its consequences can be prevented and treated. The main recommendation is both legally justified and professionally grounded, and states that the risk of malnutrition should be evaluated in all patients (≥18 years) in an institution, in municipal or specialist health care services, patients/users who receive health care services at home or practical assistance in food and food care, as well as in high-risk groups in the general practitioner service, outpatient clinics, and day activity services.
According to national quality indicators, malnutrition screening is inadequate among older adults in the primary health and care service in Norway (2-4). In 2009, the Norwegian Directorate of Health recommended five different malnutrition screening tools. The use of various screening tools complicates the comparison of both clinical evaluations and research results on malnutrition, may lead to miscommunication between health care providers and levels of health care, and ultimately pose a risk to patient safety. Furthermore, the use of various screening tools serves as a barrier for monitoring malnutrition. Thus, one major objective for the guideline revision was a standardization and harmonization of the screening practice for malnutrition in adults across health care settings and diagnoses or conditions. The goal was to use evidence-based practice to decide upon one malnutrition screening tool to be recommended for all adults.

Materials and Methods
The Norwegian Directorate of Health appointed a working group for the revision of the guideline. It The working group identified and sorted screening tool criteria into three categories; 1) overall criteria, 2) criteria within generalizability, and 3) properties of the tool, and ranked the criteria by use of a 5-point Likert-type scale for importance for the screening tool to be recommended, ranging from 1= not important to 5= very important (Table 1). Each ranking was based on a consensus reached by discussion in the group.

Results
The working group ranked the criteria and properties of the malnutrition screening tools ( Table 1). The results of the systematic literature review (REF systematic review), the working group's prioritization of generalizability criteria, and the overall ranking of the screening tools, are summarized in Table 2. The working group decided that validity was the most important among the overall criteria (Table 1), given that the quality of evidence was satisfactory. Among the criteria for generalizability, a low complexity of the tool was rated as most important. Of the properties of the tools, the working group came to the consensus that a tool's ability to register changes in food intake and weight loss were more important than registration a body mass index (BMI) score (Table 1).

J o u r n a l P r e -p r o o f
When summarizing the results, the working group prioritized the tools in the following order: 1: MST, 2: MUST, 3: NRS-2002, and 4: MNA (Table 2).

Discussion
Based on GRADE, DECIDE and the working group consensus, the Norwegian Directorate of Health recommends use of MST (7) for screening for malnutrition among all adults regardless of age (≥ 18 years), setting, or diagnosis or condition.
In addition to the scientific evidence (in this case the systematic review of validity and reliability), clinical experiences and the users' perspectives should be considered. A crucial step towards reaching a onetool-consensus was to pursuit an objective weighting of the screening tool criteria based on clinical experiences and the user's' perspectives. When the group was reconciled on the importance of each criterion, it was easier for everyone to contribute to the discussion and come to an overall agreement.
MST and MUST were ranked higher than NRS-2002 and MNA due to better ratings for generalizability, and also for quality of evidence for MNA. The criterion that was ranked highest, with a 5 on the Likerttype scale, was complexity of the tool within the generalizability category. Overall, the higher priority was given to MST based on the working group's high priority of changes in food intake and complexity of the tool.
The recommendation of one screening tool was the major change in the revised guideline. Even so, the guideline was updated and transformed into an online format (Norwegian only) (1). In addition to the systematic review, the revision of the guideline was based on the British National Institute for Health and Care Excellence (NICE) guideline on nutrition support for adults (8), and the Swedish guidelines for prevention and treatment of malnutrition (9).

Concluding statement by the Norwegian Directorate of Health
The Norwegian Directorate of Health recommends use of MST for screening for malnutrition among all adults (≥ 18 years), across all health care settings, and diagnoses or conditions in Norway.
Use of MST across all levels of health care settings is expected to monitor and even out differences in health care services for malnourished patients and patients at risk of malnutrition, and to provide a seamless communication of malnutrition screening status along the patient pathway. The overall goal is to secure patient safety. PPV: Positive predictive value; NPV: Negative predictive value; BMI: Body mass index *If otherwise equal, sensitivity should weight more than specificity **Provided that the quality of evidence is satisfactory, sensitivity and specificity weigh more than the quality of evidence