Health Economics and ONS

1. Health Economics and ONS Carole Glencorse Head of Nutritional Services Abbott Nutrition

2. Happy 21st

3. What is Health Economics? Assessment of the most efficient use of available resources, defined in terms of costs and outcomes

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

5. Quality of Life Cost Effectiveness HealthcareDecision Making Affordability Efficacy & Safety Equity Politics Appropriateness Which treatments to choose?

6. Elements of Health Economic Analysis How does the illness/treatment affect…… ? How a patient feels or functions Patient’s ability to work Patient’s use of healthcare services Healthcare resource use Quality of Life Productivity

7. 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

8. Direct medical costs Direct non-medical costs Indirect costs Hospitalisation Days of hospitalisation Discharges Outpatient visits Outpatient clinic attendance Visit to GP Visit to paramedic Procedures and tests Tests (blood analysis, x-ray, ultrasound scans, etc) Surgical interventions Devices Medical devices (wheelchairs, hearing aids, pacemakers etc) Services Home care (hours or days) Nursing care (hours or days) Transportation Outpatient visits (taxi, ambulance, etc) Services Home help (hours or days) Meals on wheels Social assistance (hours or days) Devices & investments Adaptation to house or car Special kitchen and bathroom utensils Informal care Care by relatives (Sometimes considered as indirect cost) Sick leave Days or weeks Reduced productivity at work Percentage or hours Early retirement due to illness Years to normal retirement Premature death Years to normal retirement Measuring Costs

9. Locally Trusts PCTs Nationally NICE ACBS? Why is HE relevant to nutrition?

10. NICE and RCTs

11. 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

12. 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

13. 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 (<£20,000 per QALY gained) Ref: NICE, Section 7.6

14. 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

15. 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 2004;91:983-990

16. Results • Patients receiving pre-op ONS gained weight pre-op and lost significantly less weight post-op (p<0.05) than those receiving no ONS or post-op ONS only • Morbidity reduced with post-op ONS regardless of BMI (p<0.05) • Cost was £300 (15%) less per patient episode in the groups receiving ONS Ref: Smedley F et al. Br J Surg 2004;91:983-990

17. 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 2004;91:983-990

18. Database Interrogation and Economic Modelling – Alternative Sources of HE Data

19. 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

20. 9,815,484 total patients in the database 9,815,484 total patients in the database 2,940,002 patients having permanent registration 2,940,002 patients having permanent registration status and at least one day of up to standard status and at least one day of up to standard enrolment with a physician in 2000 or 2001 enrolment with a physician in 2000 or 2001 ≥ = 1 1 13,143 patients with 13,143 patients with enteral feed prescription in enteral feed prescription in 2000 or 2001 2000 or 2001 1,332 patients with a height measurement 1,332 patients with a height measurement ≥ = 18 years old and a weight reading within 18 years old and a weight reading within 6 months of the first enteral feed 6 months of the first enteral feed prescription prescription 472 patients having a matched control 472 patients with matched for age, gender, diagnosis and (age, gender, diagnosis) and a height and weight measurement. height and weight 252 patients receiving a sip feed. 252 matched patients received at least 1 Rx for ONS feeding difficulties & anorexia (n=101) Sample Size

21. 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 BMI<20kg/m2 • 0.9% where BMI>30kg/m2 • Costs of ONS are low

22. Results - BMI

23. Results – GP Visits / Admissions • Patients on ONS had fewer GP visits / hospital admissions than controls • Where BMI <20kg/m2, trend to more hospital admissions • Those with normal BMI had fewer GP visits per annum • Those with BMI >30kg/m2 for both control/cases had more GP visits

24. 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

25. 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

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

27. Development of a Budget Impact Model for Post-operative ONS • Expertopinion • 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

28. Model

29. 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

30. Impact of changing current practice to give all patients ONS - 7.13% reduction in total spending

31. Impact of changing current practice to give all patients NF 6.32% increase in total spending

32. Impact of giving ONS to 47% of assessed patients (current practice) - 5.94% reduction in total spending

33. 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

34. Summary and Recommendations

35. 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

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

37. Thank You!