Presentation on theme: "Health Economics and ONS"— Presentation transcript:
1Health Economics and ONS Carole GlencorseHead of Nutritional ServicesAbbott Nutrition
2Happy21stHaving been a PEN Group committee member for 8 years it is a great honour to have been invited back to speak at the meeting today, and participate in last night’s celebrations!This morning I want to talk to you about health economics and present some of the data that is currently available. I would however like to set the scene by explaining what HE is and why this is relevant to us.
3What is Health Economics? Assessment of the most efficient use of available resources, defined in terms of costs and outcomesSo what is HE?HE can be defined as the most efficient use of available resources and may be defined in terms of both cost and outcome measures.
4Rationale for Health Economics Resources are scarceDemand is infinite and changingThe rationale for this is that resources are scarce and the demand is infinite and ever changing. It hence makes sense that resources are used where there will be the greatest perceived benefit.However, HE can only inform the choice made by the decision maker and can never provide all of the answers as a number of factors come into play in the decision making process.
5Which treatments to choose? Healthcare Decision MakingQuality ofLifeEfficacy& SafetyEquityAppropriatenessPoliticsAffordabilityCostEffectivenessThe decision maker must evaluate the choice of treatment taking into consideration all of the issues highlighted here.For example does the treatment in question offer quality of life benefits to the patient and if so are these more important that the cost effectiveness of the drug or equity of access to treatment – a cataract operation costs in the region of £500 and restoring sight will improve QoL, while a heart transplant costs £20,000 and will confer 10 years life gain. Do you spend the budget on improving the quality of life of 40 people by restoring their sight or by lengthening the lifespan of one individual by providing them with a new heart?Is this equitable, where does it sit in the political agenda…?
6Elements of Health Economic Analysis How does the illness/treatment affect…… ?How apatient feelsor functionsPatient’sabilityto workPatient’suse ofhealthcareservicesThere are 3 main elements to a health economic assessment:How does the illness/treatment affect how a patient feels or functions? I.e. QoLHow does the illness or treatment affect the patient’s ability to work? I.e. ProductivityHow does the illness/treatment affect the patient’s use of healthcare resources? I.e. medication, hospital admission rates, nursing time etcHealthcare resource useQuality of LifeProductivity
7Types of Health Economic Analysis Budget impact (costing) analysisNet financial impact to the healthcare system of treatmentsResource utilisation analysisComparisons of different treatments in terms of their resource requirementsEconomic EvaluationComparisons of different treatments in terms of both their costs and consequencesCost-Effectiveness/ Cost-Utility AnalysisThere are 3 main types of economic evaluation:Budget impact analysis – this is where the net impact of a treatment to the healthcare system is calculated – consider the eligible patient population – how many are currently receiving treatment – if more given the treatment would this prove to be more cost-effective? For example if you play the lottery once a month and don’t win anything, by playing every week would you offset the increased cost of buying tickets through increased profits secondary to wins.Resource utilisation analysis takes into account the overall cost of the treatment – drug treatment is only part of the cost. e.g. I could travel to London by train or by car. If I travel by train, my only expense is the cost of my ticket. If I drive, on the surface of it, it may seem cheaper as the cost of petrol is less than the train ticket, but what I also need to consider is the cost of the general wear and tear on my car and the potential depreciation if I add lots of miles.Economic evaluation allows comparison of the cost of treatment compared to the effectiveness I.e. how much do the extra benefits cost relative to the alternatives? You can think of this in terms of a world cup football match – travelling to the game, hotel accommodation and flights might cost £1500. If you go to the game and your team win 3-nil, you can think of the expense as £500 per goal, which you could perceive as good value for money. If your team loses or doesn’t score, then you may be more inclined to feel that this was a waste of £1500, and that the money could have been better spent elsewhere!
8Direct non-medical costs Measuring CostsDirect medical costsHospitalisationDays of hospitalisationDischargesOutpatient visitsOutpatient clinic attendanceVisit to GPVisit to paramedicProcedures and testsTests (blood analysis, x-ray, ultrasound scans, etc)Surgical interventionsDevicesMedical devices (wheelchairs, hearing aids, pacemakers etc)ServicesHome care (hours or days)Nursing care (hours or days)Direct non-medical costsIndirect costsTransportationOutpatient visits (taxi, ambulance, etc)Home help (hours or days)Meals on wheelsSocial assistance (hours or days)Devices & investmentsAdaptation to house or carSpecial kitchen and bathroom utensilsInformal careCare by relatives (Sometimes considered as indirect cost)Sick leaveDays or weeksReduced productivity at workPercentage or hoursEarly retirement due to illnessYears to normal retirementPremature deathWhen undertaking a cost analysis study it is important to remember both direct and indirect costs.Direct costs could include the cost of a test or procedure, or of transportation to and from hospital appointments……while indirect costs could include the time taken off work secondary to illness
9Why is HE relevant to nutrition? LocallyTrustsPCTsNationallyNICEACBS?So why is HE relevant to nutrition?At a local level there is an increasing need to justify the cost of ONS either within the Trust or to PCTs. Nutritional support is often perceived to be an expensive luxury – lack of awareness of incidence and consequences of malnutrition amongst GPs, appears in top 20 list of products prescribe – on their radar! Lack of understanding – something they can manage without? Goes back to limited budget and how to spend.Nationally - NICE guideline on adult nutrition support ongoing. NICE have a requirement to review economic data relating to interventions as well as looking at clinical benefit – will review later. ACBS currently sit within NICE secretariat, but it could be that in the future they will move further under the NICE umbrella – if this is the case, as well as supplying clinical data on with new product submissions, companies could also have to supply HE data.
10NICE and RCTsStart by reviewing data published in NICE guideline and in RCTs
11Ref: NICE, First Draft, May 2005 Nutrition support in adults: oral supplements, enteral & parenteral feedingNICE aims to make recommendations for good practice based on the available clinical and cost-effectiveness dataRef: NICE, First Draft, May 2005
12ONS ConclusionsPooled results showed a statistically significant improvement in weight as well as a statistically significant reduction in complications in supplemented patientsIt is also likely that ONS reduce mortality by about 10%ONS group favoured where functional benefits recordedLOS – not significantRef: NICE, Section 7.4
13ONS ConclusionsThe 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)QALY= A measure of health outcome, calculated by estimating the number of years of life gained from a treatment and weighting each year with a quality of life score between zero and one.Ref: NICE, Section 7.6
14SummaryOverall, it appears that ONS are beneficial in improving some health outcomes if used in malnourished patientsLack of HE data on the effect of dietary advice, food fortification and the use of ONSUnderpowered studiesHeterogeneous populationsOutcomes not reported
15Pre and Post-operative use of ONS RCT comparing the use of ONS in patients undergoing lower GI surgeryCostClinical effectsRandomised to receive:No ONSONS pre- and post-operativelyPre-operative ONS onlyPost-operative ONS onlyI’d like to highlight the following paper which is one of the few currently published that set out to look at both clinical course and cost of care.The abstract of this paper has been included in the NICE guideline, but not the full paper at this point in time.This RCT was conducted in 3 centres and patients undergoing lower GI surgery were randomised to receive no ONS, ONS pre-op only, ONS post-op only or ONS both pre and post op. Data on 152 patients was analysed for clinical effects and costRef: Smedley F et al. Br J Surg 2004;91:
16Ref: Smedley F et al. Br J Surg 2004;91:983-990 ResultsPatients 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 onlyMorbidity reduced with post-op ONS regardless of BMI (p<0.05)Cost was £300 (15%) less per patient episode in the groups receiving ONSPatients receiving pre-op ONS gained weight pre-op and lost significantly less weight post-op that those individuals receiving no supplements or supps post op onlyMinor complications were significantly reduced post-operatively regardless of BMI – not specifiedONS was demonstrated to be cost-effective across all groups receiving ONS and regardless of nutritional status – costs were based on consumables and staff timeRef: Smedley F et al. Br J Surg 2004;91:
17Ref: Smedley F et al. Br J Surg 2004;91:983-990 ConclusionONS has no disadvantages, has clinical benefits and is cost-effectiveONS should be given to all patients undergoing major lower GI surgery, regardless of nutritional statusThe results of this study are in contrast to several others where cost saving or the greatest cost benefits have only been demonstrated in malnourished individuals.While a cost saving of £300 per patient is not vast, extrapolation across all surgical patients in a Trust could lead to significant cost savingsRef: Smedley F et al. Br J Surg 2004;91:
18Database Interrogation and Economic Modelling – Alternative Sources of HE Data Given the lack of published data in RCTs, we have looked to alternative sources to provide HE data. I would now like to share with you examples of data provided via database interrogation and via a budget impact model
19Enteral Feeding in the Community: A study of HE Outcomes GPRD database used to identify patients receiving ONS in 2000 and 2001A matched control population was also identifiedAnalysis of the main HE outcomes was madeThe GPRD is the General Practice Research Database and collects anonomysed longitudinal patient data from contributing centres around the UK. These data include demographics (age, gender), diagnosis, prescriptions, referrals to hospital.The database was used to identify individuals who had received at least one prescription for ONS in 2000 or A matched control was also identified – same primary diagnosis, gender and age - weight and height recordedRef: Edington, Glencorse, Knight et al, 2004
20Sample Size = 1 2,940,002 patients having permanent registration status and at least one day of up to standardenrolment with a physician in 2000 or 200113,143 patients with=1enteral feed prescription in2000 or 20011,332 patients with a height measurement18 years old and a weight reading within6 months of the first enteral feedprescription472 patients having a matched control(age, gender, diagnosis) and aheight and weight measurement.9,815,484 total patients in the database252 patients receiving a sip feed.feeding difficulties& anorexia (n=101)≥472 patients with matched forage, gender, diagnosis andheight and weight252 matchedpatientsreceived at least1 Rx for ONSOf almost 10 million patients registered in the database, only 13,000 (0.4%) received a prescription for ONS in 2000 or 2001.Of these, only 1300 had a baseline height and weight recorded and a further weight recorded within 6 months of receiving the prescription for ONSOf these 1300 patients, it was only feasible to match 472 for age, sex, diagnosis and BMI (all diagnoses)Of these 252 patients received at least one prescription for ONS in 2000 or Only data for 2001 is presented.
21Results – Prescribing Patterns Only 10% of patients receiving ONS have a weight and height recordedOnly 5% of all prescriptions were for ONS6.1% where BMI<20kg/m20.9% where BMI>30kg/m2Costs of ONS are lowIt was established that only 10% of patients receiving ONS have a weight and height recorded.Overall, only 5% prescriptions were for ONS – hence makes up a small proportion of the overall budget – it would also seem that prescribing is appropriate with the majority being used in those with a BMI<20
22Results - BMI BMI (kg/m2) % Cases (n=252) % Controls (n=252) 15 to <2038.510.320 to < 2539.727.8When the patient population was reviewed by BMI, as may be expected, a higher number of individuals in the ONS group has low BMI compared to controls (38.5% of cases had a BMI<20 compared to 10.3% controls) (for BMI % cases vs 28% controls)
23Results – GP Visits / Admissions Patients on ONS had fewer GP visits / hospital admissions than controlsWhere BMI <20kg/m2, trend to more hospital admissionsThose with normal BMI had fewer GP visits per annumThose with BMI >30kg/m2 for both control/cases had more GP visitsWhere ONS were given, those individuals had fewer GP visits (15.7 v 18) and hospital admissions than the controlsThere was a trend towards more hospital admission with underweight individuals, BMI<20Normally nourished individuals had fewer visits to their GPs regardless of whether or not they were on ONSThose with BMI>30 had more GP visits regardless of whether they did or did not receive ONS
24Conclusions 1Of those patients receiving one or more prescription for ONS, only 10% had weight and height recordedONS seem to be appropriately prescribed based on BMI, but may be underused through lack of patient identificationIt can be concluded that only 10% of individuals receiving ONS have weight and height recorded – but it could be that many individuals who would benefit from ONS are not being identified and those receiving ONS are not being adequately monitored
25Conclusions 2Normally nourished cost less than over or underweight individualsTrend towards reduced use of healthcare resources in those receiving ONSCost of prescribing ONS low and only small proportion of overall spendThose individuals who have a BMI within the normal range seem to use fewer healthcare resources than either those who are malnourished or obeseAnd provision of ONS appears to further reduce the use of healthcare resourcesONS are relatively cheap and proportionately make up only 6% of the overall drugs budget
26Discussion Reflects real life Provides trend results Limitations of database studymissing codes,unable to make direct linksBenefit from prospective studyThis study has permitted us to draw conclusions based on real life treatment scenarios, but database studies can be limited by the accuracy of the data collected and inputted and also the inability to make direct links – can only report on trends. What this study has done is highlight areas for future prospective research
27Development of a Budget Impact Model for Post-operative ONS Expert opinionassumptions on treatments pathwaysCurrent published dataoutcomes of intervention versus no interventioncorroborates expert opinionPublished episode costsreal NHS costsWhere gaps in data exist, it is possible to develop cost effectiveness models for different treatment pathways.In this instance a model was developed to investigate the cost effectiveness of using ONS post-operatively. The model was developed using expert opinion to give guidance on the treatment options and pathways. This was corroborated using published data (Keele et al) and real NHS costs were used to populate the modelRef: Abbott Nutrition, Data on File, 2004
28ModelThe model illustrated here was developed as discussed previously.As can be seen……
29Unit Costs Used in the Model Oral nutritional supplements2 x 220ml cartons daily7 days at contract prices in hospital1 month at community priceCost of dietetic consultationCost of complications - wound infectionThe following treatment and cost assumptions were used in the model. Costs of lab tests were not included as it was felt that these would be done regardless of whether individuals were receiving ONS or not
30Impact of changing current practice to give all patients ONS Cost of current treatment: %ONS/53%NFAll ONSNet budget impactCost of ONS£14,161,674£30,131,221£15,969,547Cost of complications£87,352,442£64,148,527- £23,203,915Total cost£101,514,116£94,279,748- £7,234,368The cost of the current treatment option is estimated at £101mm, where 47% of patients receive ONS post-op.If gave all individucals undergoing ONS post-op, would have a net saving of £7mm (or 7.13%)- 7.13% reduction in total spending
31Impact of changing current practice to give all patients NF Cost of current treatment: 47% ONS/53% NFAll NFNet budget impactCost of ONS£14,161,674£ 0- £14,161,674Cost of complications£87,352,442£107,929,499£20,577,057Total cost£101,514,116£6,415,383Changing practice to give all patients normal food instead of ONS would incur additional costs of over £6mm (6.32%)6.32% increase in total spending
32Impact of giving ONS to 47% of assessed patients (current practice) All NFCurrent treatment: 47% ONS/53% NFNet budget impactCost of ONS£ 0£14,161,674Cost of complications£107,929,499£87,352,442- £20,577,057Total cost£101,514,116- £6,415,383While moving from giving all patients normal diet post-op to giving 47% ONS (in line with current treatment patterns) would realised a net cost saving of over £6mm (5.94%)- 5.94% reduction in total spending
33Conclusions The use of ONS is cost-effective Greater cost savings realised when all patients are treatedCurrent practices in treating malnutrition not well definedWide range of practices amongst “experts”Model may bias towards treatmentUsing this model, it can be concluded that using ONS post-operatively is cost effective, and greater cost savings are likely to be realised when more patients are fed – this is in agreement with the work carried out by Smedley et al that I have just presentedIt is fair to say that current practices in both the identification and treatment of malnutrition are not well defined, and there were a wide range of practices observed amongst the experts interviewedGiven that we used expert opinion to develop the model, this could have resulted in bias towards treatment with ONSFurther research is required to provide a more definitive guide