Health Economics and ONS

Carole Glencorse

Head of Nutritional Services

Abbott Nutrition

What is Health Economics?

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

Rationale for Health Economics

Resources are scarce

Demand is infinite

and changing

Which treatments to choose?

HealthcareDecision Making

Quality of

Life

Efficacy

& Safety

EquityAppropriateness

Politics

Affordability

Cost

Effectiveness

Elements of Health Economic Analysis

How a patient feelsor functions

Patient’s ability to work

Patient’s use of

healthcare services

How does the illness/treatment affect…… ?

Quality of Life ProductivityHealthcare

resource use

Types of Health Economic Analysis

• Budget impact (costing) analysis Net financial impact to the healthcare system of

treatments

• Resource utilisation analysisComparisons of different treatments in terms of their

resource requirements

• Economic EvaluationComparisons of different treatments in terms of both

their costs and consequencesCost-Effectiveness/ Cost-Utility Analysis

Measuring Costs

Direct medical costs

Direct medical costs

Hospitalisation Days of hospitalisationDischarges

Outpatient visitsOutpatient clinic attendanceVisit to GPVisit to paramedic

Procedures and testsTests (blood analysis, x-ray, ultrasound scans, etc)Surgical interventions

DevicesMedical devices (wheelchairs, hearing aids, pacemakers etc)

ServicesHome care (hours or days)Nursing care (hours or days)

Direct non-medical costsDirect non-

medical costsIndirect costsIndirect costs

TransportationOutpatient visits (taxi, ambulance, etc)

ServicesHome help (hours or days)Meals on wheelsSocial assistance (hours or days)

Devices & investmentsAdaptation to house or carSpecial kitchen and bathroom utensils

Informal careCare by relatives (Sometimes considered as indirect cost)

Sick leaveDays or weeks

Reduced productivity at workPercentage or hours

Early retirement due to illnessYears to normal retirement

Premature death Years to normal retirement

Why is HE relevant to nutrition?

Locally• Trusts

• PCTs

Nationally• NICE

• ACBS?

NICE and RCTs

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

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

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

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

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

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

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

Database Interrogation and Economic Modelling –

Alternative Sources of HE Data

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

Sample Size

2,940,002 patients having permanent registration status and at least one day of up to standard enrolment with a physician in 2000 or 2001

13,143 patients with =1 enteral feed prescription in 2000 or 2001

1,332 patients with a height measurement = 18 years old and a weight reading within

6 months of the first enteral feed prescription

472 patients having a matched control (age, gender, diagnosis) and a

height and weight measurement.

9,815,484 total patients in the database

252 patients receiving a sip feed.

feeding difficulties & anorexia (n=101)

2,940,002 patients having permanent registration status and at least one day of up to standard enrolment with a physician in 2000 or 2001

13,143 patients with ≥1 enteral feed prescription in 2000 or 2001

1,332 patients with a height measurement ≥ 18 years old and a weight reading within

6 months of the first enteral feed prescription

472 patients with matched for age, gender, diagnosis and

height and weight

9,815,484 total patients in the database

252 matched patients received at least 1 Rx for ONS

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

Results - BMI

BMI

(kg/m2)

% Cases (n=252)

% Controls (n=252)

15 to <20 38.5 10.3

20 to < 25 39.7 27.8

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

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

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

Discussion

• Reflects real life• Provides trend results• Limitations of database study

– missing codes, – unable to make direct links

• Benefit from prospective study

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

Model

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

Impact of changing current practice to give all patients ONS

Cost of current treatment:

47%ONS/53%NF

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

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

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

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

Summary and Recommendations

• 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

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