P1252428562nqEOW

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Health Economics and ONS
Carole Glencorse Head of Nutritional Services
Abbott Nutrition
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Happy
21st
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What is Health Economics?

• Assessment of the most efficient use of
  available resources, defined in terms of costs
  and outcomes

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Rationale for Health Economics
Resources are scarce
Demand is infinite and changing

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Which treatments to choose?
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Elements of Health Economic Analysis
How does the illness/treatment affect ?
How a patient feels or functions
Patients ability to work
Patients use of healthcare services
Healthcare resource use
Quality of Life
Productivity
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Types of Health Economic Analysis

• Budget impact (costing) analysis
• Net financial impact to the healthcare system of
  treatments
• Resource utilisation analysis
• Comparisons of different treatments in terms of
  their resource requirements
• Economic Evaluation
• Comparisons of different treatments in terms of
  both their costs and consequences
• Cost-Effectiveness/ Cost-Utility Analysis

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Measuring Costs
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Why is HE relevant to nutrition?

• Locally
• Trusts
• PCTs

• Nationally
• NICE
• ACBS?

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NICE and RCTs

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Nutrition support in adults oral supplements,
enteral parenteral feeding

• NICE aims to make recommendations for good
  practice based on the available clinical and
  cost-effectiveness data

Ref NICE, First Draft, May 2005
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ONS Conclusions

• Pooled results showed a statistically significant
  improvement in weight as well as a statistically
  significant reduction in complications in
  supplemented patients
• It is also likely that ONS reduce mortality by
  about 10
• ONS group favoured where functional benefits
  recorded
• LOS not significant

Ref NICE, Section 7.4
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ONS Conclusions

• The use of ONS in malnourished hospital
  populations improves energy intake and weight
  gain when compared to no action, dietary advice
  alone or additional snacks.
• Economic modelling suggests that ONS are probably
  cost-effective in treating malnourished hospital
  patients (lt20,000 per QALY gained)

Ref NICE, Section 7.6
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Summary

• Overall, it appears that ONS are beneficial in
  improving some health outcomes if used in
  malnourished patients
• Lack of HE data on the effect of dietary advice,
  food fortification and the use of ONS
• Underpowered studies
• Heterogeneous populations
• Outcomes not reported

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Pre and Post-operative use of ONS

• RCT comparing the use of ONS in patients
  undergoing lower GI surgery
• Cost
• Clinical effects
• Randomised to receive
• No ONS
• ONS pre- and post-operatively
• Pre-operative ONS only
• Post-operative ONS only

Ref Smedley F et al. Br J Surg 200491983-990
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Results

• Patients receiving pre-op ONS gained weight
  pre-op and lost significantly less weight
  post-op (plt0.05) than those receiving no ONS or
  post-op ONS only
• Morbidity reduced with post-op ONS regardless of
  BMI (plt0.05)
• Cost was 300 (15) less per patient episode in
  the groups receiving ONS

Ref Smedley F et al. Br J Surg 200491983-990
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Conclusion

• ONS has no disadvantages, has clinical benefits
  and is cost-effective
• ONS should be given to all patients undergoing
  major lower GI surgery, regardless of nutritional
  status

Ref Smedley F et al. Br J Surg 200491983-990
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Database Interrogation and Economic Modelling
Alternative Sources of HE Data
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Enteral Feeding in the Community A study of HE
Outcomes

• GPRD database used to identify patients receiving
  ONS in 2000 and 2001
• A matched control population was also identified
• Analysis of the main HE outcomes was made

Ref Edington, Glencorse, Knight et al, 2004
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Sample Size

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Results Prescribing Patterns

• Only 10 of patients receiving ONS have a weight
  and height recorded
• Only 5 of all prescriptions were for ONS
• 6.1 where BMIlt20kg/m2
• 0.9 where BMIgt30kg/m2
• Costs of ONS are low

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Results - BMI
BMI (kg/m2) Cases (n252) Controls (n252)
15 to lt20 38.5 10.3
20 to lt 25 39.7 27.8
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Results GP Visits / Admissions

• Patients on ONS had fewer GP visits / hospital
  admissions than controls
• Where BMI lt20kg/m2, trend to more hospital
  admissions
• Those with normal BMI had fewer GP visits per
  annum
• Those with BMI gt30kg/m2 for both control/cases
  had more GP visits

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Conclusions 1

• Of those patients receiving one or more
  prescription for ONS, only 10 had weight and
  height recorded
• ONS seem to be appropriately prescribed based on
  BMI, but may be underused through lack of patient
  identification

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Conclusions 2

• Normally nourished cost less than over or
  underweight individuals
• Trend towards reduced use of healthcare resources
  in those receiving ONS
• Cost of prescribing ONS low and only small
  proportion of overall spend

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Discussion

• Reflects real life
• Provides trend results
• Limitations of database study
• missing codes,
• unable to make direct links
• Benefit from prospective study

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Development of a Budget Impact Model for
Post-operative ONS

• Expert opinion
• assumptions on treatments pathways
• Current published data
• outcomes of intervention versus no intervention
• corroborates expert opinion
• Published episode costs
• real NHS costs

Ref Abbott Nutrition, Data on File, 2004
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Model

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Unit Costs Used in the Model

• Oral nutritional supplements
• 2 x 220ml cartons daily
• 7 days at contract prices in hospital
• 1 month at community price
• Cost of dietetic consultation
• Cost of complications - wound infection

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Impact of changing current practice to give all
patients ONS
Cost of current treatment 47ONS/53NF All ONS Net budget impact
Cost of ONS 14,161,674 30,131,221 15,969,547
Cost of complications 87,352,442 64,148,527 - 23,203,915
Total cost 101,514,116 94,279,748 - 7,234,368

- 7.13 reduction in total spending
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Impact of changing current practice to give all
patients NF
Cost of current treatment 47 ONS/53 NF All NF Net budget impact
Cost of ONS 14,161,674 0 - 14,161,674
Cost of complications 87,352,442 107,929,499 20,577,057
Total cost 101,514,116 107,929,499 6,415,383

6.32 increase in total spending
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Impact of giving ONS to 47 of assessed patients
(current practice)
All NF Current treatment 47 ONS/53 NF Net budget impact
Cost of ONS 0 14,161,674 14,161,674
Cost of complications 107,929,499 87,352,442 - 20,577,057
Total cost 107,929,499 101,514,116 - 6,415,383

- 5.94 reduction in total spending
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Conclusions

• The use of ONS is cost-effective
• Greater cost savings realised when all patients
  are treated
• Current practices in treating malnutrition not
  well defined
• Wide range of practices amongst experts
• Model may bias towards treatment

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Summary and Recommendations
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• HE data can be obtained from a number of sources
• Recommendation for further adequately powered
  RCTs with HE component
• Outcomes
• Quality of life
• Cost effectiveness

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• Oral Nutritional Supplements
• Cost effective
• Reduce morbidity and mortality
• Improve nutritional status
• Reduce LOS
• Safe
• Beneficial peri-operatively regardless of
  nutritional status

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Thank You!