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

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Presentation on theme: "Health Economics and ONS Carole Glencorse Head of Nutritional Services Abbott Nutrition."— Presentation transcript:

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

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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 Which treatments to choose? Healthcare Decision Making Quality of Life Efficacy & Safety Equity Appropriateness Politics Affordability Cost Effectiveness

6 Elements of Health Economic Analysis How a patient feels or functions Patients ability to work Patients use of healthcare services How does the illness/treatment affect…… ? Quality of LifeProductivity Healthcare resource use

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 Measuring Costs Direct medical 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) Direct non- medical costs Indirect costs 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

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

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:

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:

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:

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

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/m 2 –0.9% where BMI>30kg/m 2 Costs of ONS are low

22 Results - BMI BMI (kg/m 2 ) % Cases (n=252) % Controls (n=252) 15 to < to <

23 Results – GP Visits / Admissions Patients on ONS had fewer GP visits / hospital admissions than controls Where BMI <20kg/m 2, trend to more hospital admissions Those with normal BMI had fewer GP visits per annum Those with BMI >30kg/m 2 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 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

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 Cost of current treatment: 47%ONS/53%NF All ONSNet 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, % reduction in total spending

31 Impact of changing current practice to give all patients NF Cost of current treatment: 47% ONS/53% NF All NFNet 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, % increase in total spending

32 Impact of giving ONS to 47% of assessed patients (current practice) All NFCurrent treatment: 47% ONS/53% NF Net budget impact Cost of ONS£ 0£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, % 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

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