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Health Economics and ONS. Carole Glencorse Head of Nutritional Services Abbott Nutrition. Happy . 21st. 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.

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Health Economics and ONS

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Health Economics and ONS

Carole Glencorse

Head of Nutritional Services

Abbott Nutrition




what is health economics
What is Health Economics?

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

rationale for health economics
Rationale for Health Economics

Resources are scarce

Demand is infinite and changing

which treatments to choose

Quality of




HealthcareDecision Making



& Safety




Which treatments to choose?
elements of health economic analysis
Elements of Health Economic Analysis

How does the illness/treatment affect…… ?

How a

patient feels

or functions



to work


use of



Healthcare resource use

Quality of Life


types of health economic analysis
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
measuring costs

Direct medical costs

Direct non-medical costs

Indirect costs


Days of hospitalisation


Outpatient visits

Outpatient clinic attendance

Visit to GP

Visit to paramedic

Procedures and tests

Tests (blood analysis, x-ray, ultrasound scans, etc)

Surgical interventions


Medical devices (wheelchairs, hearing aids, pacemakers etc)


Home care (hours or days)

Nursing care (hours or days)


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

Years to normal retirement

Measuring Costs
why is he relevant to nutrition






Why is HE relevant to nutrition?
nutrition support in adults oral supplements enteral parenteral feeding
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
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 conclusions13
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

  • 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
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

  • 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

  • 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

enteral feeding in the community a study of he outcomes
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

9,815,484 total patients in the database

9,815,484 total patients in the database

2,940,002 patients having permanent registration

2,940,002 patients having permanent registration

status and at least one day of up to standard

status and at least one day of up to standard

enrolment with a physician in 2000 or 2001

enrolment with a physician in 2000 or 2001




13,143 patients with

13,143 patients with

enteral feed prescription in

enteral feed prescription in

2000 or 2001

2000 or 2001

1,332 patients with a height measurement

1,332 patients with a height measurement


18 years old and a weight reading within

18 years old and a weight reading within

6 months of the first enteral feed

6 months of the first enteral feed



472 patients having a matched control

472 patients with matched for

age, gender, diagnosis and

(age, gender, diagnosis) and a

height and weight measurement.

height and weight

252 patients receiving a sip feed.

252 matched


received at least

1 Rx for ONS

feeding difficulties

& anorexia (n=101)

Sample Size
results prescribing patterns
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 gp visits admissions
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
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
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
  • 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
Development of a Budget Impact Model for Post-operative ONS
  • Expertopinion
    • 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

unit costs used in the 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 giving ons to 47 of assessed patients current practice
Impact of giving ONS to 47% of assessed patients (current practice)

- 5.94% reduction in total spending

  • 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
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