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

2. Happy
21st
Having 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.

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

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

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

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
There are 3 main elements to a health economic assessment:
How does the illness/treatment affect how a patient feels or functions? I.e. QoL
How does the illness or treatment affect the patient’s ability to work? I.e. Productivity
How does the illness/treatment affect the patient’s use of healthcare resources? I.e. medication, hospital admission rates, nursing time etc
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
There 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!

8. Direct non-medical costs
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)
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
When 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

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

10. NICE and RCTs
Start by reviewing data published in NICE guideline and in RCTs

11. Ref: NICE, First Draft, May 2005
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)
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

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
I’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 cost
Ref: Smedley F et al. Br J Surg 2004;91:

16. 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
Patients 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 only
Minor complications were significantly reduced post-operatively regardless of BMI – not specified
ONS was demonstrated to be cost-effective across all groups receiving ONS and regardless of nutritional status – costs were based on consumables and staff time
Ref: Smedley F et al. Br J Surg 2004;91:

17. 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
The 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 savings
Ref: Smedley F et al. Br J Surg 2004;91:

18. Database 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

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
The 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 recorded
Ref: Edington, Glencorse, Knight et al, 2004

20. Sample Size = 1 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) ≥
472 patients with matched for
age, gender, diagnosis and
height and weight
252 matched
patients
received at least
1 Rx for ONS
Of 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 ONS
Of 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.

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
It 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

22. 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
When 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)

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
Where ONS were given, those individuals had fewer GP visits (15.7 v 18) and hospital admissions than the controls
There was a trend towards more hospital admission with underweight individuals, BMI<20
Normally nourished individuals had fewer visits to their GPs regardless of whether or not they were on ONS
Those with BMI>30 had more GP visits regardless of whether they did or did not receive ONS

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
It 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

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
Those individuals who have a BMI within the normal range seem to use fewer healthcare resources than either those who are malnourished or obese
And provision of ONS appears to further reduce the use of healthcare resources
ONS are relatively cheap and proportionately make up only 6% of the overall drugs budget

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

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
Where 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 model
Ref: Abbott Nutrition, Data on File, 2004

28. Model
The model illustrated here was developed as discussed previously.
As can be seen……

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
The 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

30. Impact of changing current practice to give all patients ONS
Cost of current treatment: %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
The 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

31. 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
£6,415,383
Changing 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

32. 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
Cost of complications
£107,929,499
£87,352,442
- £20,577,057
Total cost
£101,514,116
- £6,415,383
While 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

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
Using 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 presented
It 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 interviewed
Given that we used expert opinion to develop the model, this could have resulted in bias towards treatment with ONS
Further research is required to provide a more definitive guide

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!