1. Avoiding Inappropriate Prescribing of Oral Nutritional Supplements in Primary Care Kim Malcolmson Kimberley.malcolmson@hhft.nhs.uk Tel: 01256 313232

2. Preamble - Figure dropping Malnutrition affects 5-10% of your Practice population UK associated health costs > £13 billion annually NICE identifies better nutritional care as the THIRD largest potential source of cost savings to the NHS Nutritional Supplements are clinically beneficial in treating malnutrition Therefore, if appropriate, oral nutritional supplements are very cost-effective National Institute for Health and Clinical Excellence (NICE). (2006) Guideline32

3. What are Oral Nutritional Supplements (ONS) - 1 Clinically beneficial in treating malnutrition National Institute for Health and Clinical Excellence (NICE). (2006) Guideline32 BNF: Enteral feeds Nutritional Supplement Specialised Formulas Feed supplements Feed additives Foods for special diets Nutritional supplements for metabolic diseases Milkshake type Fruit Juice type Crème and desserts Made up with milk No protein

5. Per 100ml Full Cream Milk (FCM) Fortified FCM 1kcal per ml 1.5 kcal per ml 2kcal per ml Kcal66110100150200 Prot (g) 3.37.545.610 Cost (£) 0.080.170.880.920.96 Ensure Fortimel Fresubin original Ensure Plus Fortisip Fresubin Ensure twocal Fortisip compact Fresubin 2kcal What are Oral Nutritional Supplements (ONS) - 2 Hampshire-wide: 12% saving potential when supplement <1.5Kcal/ml removed (£245K)

6. ONS Spend in Hampshire  Hampshire PCT: £2 Million spent this year (ePACT data) Furthermore:  One GP Practice, Basingstoke (20,000 registered):  Spent £14,760 on ONS (april-sep2011) eq. to £29,500/year for <60 patients  35% of prescriptions deemed inappropriate after dietetic review  ?10K savings, or 0.3WTE /11hrs a week band 6 dietitian  Aldershot practice (14,000 registered):  63% of patients on ONS deemed inappropriately so  57% of current prescription inappropriate  Potential savings £9,950 / year (56% of annual ONS spend of 17,466/y)

7. 4 steps to avoid inappropriate prescription

8. 1.Screening /Assessment is Key: Weight BMI Weight loss Cause 2.First Line should be dietary advice 3.≤ 300Kcal per day  little therapeutic benefit 4.Monitoring of prescriptions ONS<1.5Kcal/mls and ONS with only fat and/or sugar should only be prescribed with clear rationale

9. 4 Steps to avoid inappropriate prescribing - Step 1 1.Screening for malnutrition (MUST – validated tool) BMI < 18.5 > 10% Unintentional weight loss (last 3-6months) BMI 5% unintentional weight loss (last 3-6 months) Or Malnutrition Risk Little or no intake for > 5 days Poor absorptive capacity/high nutrient losses MUST: Malnutrition Universal Screening Tool, freely available on: http://www.bapen.org.uk/musttoolkit.html http://www.bapen.org.uk/musttoolkit.html

10. What is the ideal BMI range 18.5-22.5 18.5-29 20-25 22.5-29 What is the percentage weight loss of a normally 70kg man who lost 6kg 7.5 8.6 9.8 10.2 How many kg in 1 stone 5.2 6.3 7.1 8.4 %weight loss= weight loss/initial weightx100 Quiz time

11. 2.First Line: dietary advice Give high calorie/high protein advice + written information Diet sheet available on Pages4PrimaryCare: http://www.hampshire.nhs.uk/primary- care/gps/documents/cat_view/43-gps/173-prescribing/587-nutritionhttp://www.hampshire.nhs.uk/primary- care/gps/documents/cat_view/43-gps/173-prescribing/587-nutrition Suggest over the counter products such as Complan, Build-up, Nutrament and Nurishment Referal to appropriate support teams if needed by GP (social services, SALT, OT etc.) 4 Steps to avoid inappropriate prescribing - Step 2

15. Quiz Time: what is the common fact that links these They all have 300Kcal 1 Slice Toast with 1 Tbsp butter 1 Cup whole milk Calories: 312 2 oz Cheese 4 crackers Calories: 295 1 Cereal Bar 1 Cup 100% Fruit Juice Calories: 300

16. 3.Consider ONS twice a day / 600Kcal if: Food First approach is not feasible OR if Food first approach tried for 1 month with no progress Patient meets ACBS criteria Short bowel syndrome, Intractable malabsorption, Pre-operative preparation of patients who are malnourished, Proven inflammatory Bowel Disease, Following a gastrectomy, dysphagia, Disease related malnutrition, Continuous ambulatory peritoneal dialysis (CAPD) or Haemodialysis The following are Agreed / Specified: GOALS, DOSE, TIMING, DURATION 3 Steps to avoid inappropriate prescribing - Step 3

18. GOALS: Measurable goals Once goals are set its easier to measure progress DOSE: Prescribe at least bd or 600kcals/day To reach therapeutic dose TIMING: Not a meal replacement Advise to take between meals, sheet on P4PC DURATION: Avoid prescribing on repeat Monitor prescriptions are they having a positive effect do they need to be weaned down? If not do they need to be adjusted? 4.Monitoring

20. Prescribing supplements  ONS although similar are all slightly different  ONS play different roles for some people, the same ONS may be used for different reasons, if patient queries occur over products refer to GP or Dietitian advice  Advise to take between meals and not as meal replacement  Few patients will clinically require more than bd doses- large doses likely to reduce food  Check BNF to ensure products meet the needs of the patient i.e. allergies, religious restriction, diabetes

21. What to remember Screening /Assessment is Key: Weight BMI Weight loss First Line should be dietary advice 300Kcal or less per day is of little benefit Reviewing and monitoring of prescriptions is important ONS<1.5Kcal/mls and ONS with only fat and/or sugar should only be prescribed with clear rationale

22. So... The best way to achieve this is... Communication with GP’s Give out info when dispensing? Ability to weight patients More advice available for pharmacy to access How can we help you or you help us to achieve Avoiding Inappropriate Prescribing of Oral Nutritional Supplements in Primary Care?

24. North Hampshire Care Home ONS Audit Report Kimberley Malcolmson & Aude Cholet Prescribing support dietitians

25. Data collected 28 Nursing and Residential homes in North Hants area (Calleva) 2-3 hours per home (dependant on how many pts on ONS) 1100 Total occupied beds 100 Patients on supplements (9% of total)

26. Audit Standards 1.All residents on ONS should have a MUST score 2.All residents on ONS should meet at least one ACBS criteria 3.If ACBS criteria is disease related malnutrition, this should be established by a MUST score of 1 or more 4.All residents on ONS should have a clear nutrition care plan documented 5.All residents on ONS should be receiving fortified diet and/or extra snacks and/or nourishing drinks 6.All residents on ONS should be offered ONS as a supplement, not as a meal replacement unless strong rationale demonstrated 7.Residents on ONS should be offered ONS bd, or in excess of 400Kcal/d 8.All residents on ONS should have clear goals that ONS are hoped to achieve 9.ONS therapy goals should be monitored on at least a monthly basis

27. Results Individual Care Home report written and sent to medicine management team lead for GP practice(s) covering Care Home Recommendations made for supplements at that time based on nutritional and clinical assessment 3 Recommendations for prescriptions were for them to: Continue, or Stop, or Change (to meet therapeutic dose or avoid non recommended product)

28. Results MUST = Malnutrition Universal Screening Tool

29. Results 1 home recommended spend increased, 27 decreased 44% of prescriptions advised to be stopped (44 Patients) Total Daily cost of ONS before audit Total daily cost of ONS after audit Potential Saving per day Potential saving per year £240.43£125.35£115.08 (47.9%) £42,004

30. Conclusion Potential saving = 42 K a year i.e. 45 hours/week of Band 6 Dietitian/year Need for ongoing training and support for Screening (MUST) Food fortification Nutrition Care planning Training so far 63 people trained (4 sessions) ongoing process Improvement in patient nutritional care possible

31. Cost of Malnutrition Cost of malnutrition in the UK £13 billion annually NICE have identified malnutrition as the 4 th largest potential saving for the NHS Those that are malnourished are more likely to: Visit GPs Spend longer in hospitals More likely to be admitted to hospital Appropriate use of ONS has been shown to reduce these costs to the NHS

32. BAPEN report provision of ONS to malnourished patients reduces complications such as Infections and wound breakdown by 70% Mortality by 40% Better nutritional care for individuals at risk can result in substantial cost savings to the NHS Studies have shown improved nutritional care can reduce emergency admissions, infection risk, improve wound care and reduce their associated costs BAPEN, Malnutrition Matters Meeting Quality Standards in Nutritional Care 2010

33. ePact Data – % of Non preferred ONS North East cost of non preferred ONS £8,210 last 3 months =£32,840/year

34. ePact Data – Comparison