Anne Marie Beck, June 2009

1. ECONOMIC CONSIDERATIONS FOR THE USE OF ORAL NUTRITIONAL THERAPY TO OLD (65+ Y) NURSING HOME RESIDENTS Anne Marie Beck, June 2009

2. Content • Danish recommendations • Purpose • Method, effect and population • Background • Interventions • Details (project 5) • Choice of model – decision tree • Assumptions • Direct costs and savings (project 5) • Sensitivity analysis (project 5) • Extra costs of interventions (project 1-8) • Direct costs and savings (project 1-8) • Uncertainties • Conclusion

3. Danish recommendations • Oral nutritional therapy is: offering an energy and protein dense menu with 50 E% from fat and 50 E% from in-between-meals, and/or oral nutritional supplements, or the provision of individual dietary advice by e.g. a clinical dietician, to persons on how to increase overall nutrient intake by the above • Oral nutritional therapy may primarily be offered to residents, where a benefit has been documented • Those in need of the therapy should be identified by screening • Key persons may be appointed Ref. Pedersen A., & Ovesen L. Danish Veterinary and Food Administration 2000.

4. Purpose • Cost-effectiveness analysis of a project *) which use a new technology, compliant with the Danish recommendations, in order to identify whether the new technology should replace the old existing technology *)within the framework of Better Care for Old People, see http://dtbu.sm.dk/Social.dk/global/nyheder/Nyheder/projekt_stoette/index.aspx?id=f4c5d643-1b69-4596-b259-87a38e72a661

5. Method, effect and population Cost-effectiveness analysis • Direct (extra) costs of intervention (= money granted from the framework of Better Care for Old People) • Cost measured as saved expenses due to prevention of weight loss • No discounting, since the results are expected to be evident almost immediately • Effect – no data Nursing home residents

6. Background • One third of old Danish nursing home residents suffer from undernutrition • Weight loss may have an impact on activities of daily living (ADL) and their need for health care staff assistance • Weight loss > 5 % and 10 %, may increase the cost of care for one resident (average increase 1,830 and 2,920 EURO per year) Ref. Beck A, & Ovesen L. Scand J Caring Sci 2002;16:86-90 Mamhidir A.G., et al. J Nutr Health & Aging 2006;10: 255-62; Suominen M., et al. EJCN 2005; 59:578-83

7. Background (cont.) • Oral nutritional therapy which improves the weight of the resident, even to a small extent, may translate into gain in muscle function or ADL Ref. Beck A., et al. AGG 2009; in press; Nijs K., et al. BMJ 2006; 33:1180-84 Bonnefoy M., et al. Br J Nutr 2003; 89:731-8

8. Background (cont.) • Old technology in practice • 27 % use screening • 7 % use an energy and protein dense menu • 5 % use in-between-meals and/or supplements • 7 % use a clinical dietician • 47 % have appointed key persons • 30 % of all cases gain weight (among those with BMI <18.5, 25 %; and among those with BMI <24, 37 %) Ref. Beck A,. et al. Nutrition 2008; 4:1073-80 Beck A., et al. Danish Food and Veterinary Research 2006

9. Interventions Note. Oral nutritional therapy organised in different new ways within the framework of Better Care for Old People. Red colour = compliant with the Danish recommendations

10. Interventions (cont)Note. Compliance = weight gain >1%. ND = No data. 1-8 is different models within the framework of Better Care for Old People. Old model is data from Beck A., et al. Nutrition 2008;4:1073-80. Red colour = compliant with the Danish recommendations

11. Details (project 5)Note. Project 5 is most compliant with the Danish recommendations

12. Choice of model - decision treeNote. New technology (project 5) within the framework of Better Care for Old People. Old technology is data from Beck A., et al. Nutrition 2008;4:1073-80

13. Assumptions • Time horizon: 12 months • Weight gain = Gain in muscle function or ADL • Compliance old technology as found in Beck et al. 2008 • Saved expenses based on an estimated increase in the average cost of care of 2,920 EURO/annum and 1,830 EURO/annum for residents who lose >10% and >5% in weight • Marginal effect: New minus old

14. Direct costs and savings (project 5)

15. Sensitivity analysis (project 5)Note. At different levels of compliance, corresponding to the levels achieved in projects 1,2,4,7. Red colour = Project 5

16. Sensitivity analysis (cont.) • The new model of oral nutritional therapy (project 5) do not longer result in cost savings, when less than about 50% of the residents achieve a weight gain

17. Extra costs of interventions (project 1-8)Note. Extra costs of nutritional therapy per resident (EURO/annum) and achieved compliance (%). Arrow = Old technology

18. Direct costs and savings (project 1-8)Red colour = Project 5

19. Direct costs and savings (cont.) • The new technology used in project 1, 6, 7 and 8 appears to be more expensive than the old technology • Project 3, 4 and 5 each applied for money primarily to employ nutritional expertise and purchase freedom (time) for staff education

20. Uncertainties • The majority of the projects applied for more money than they were granted. According to the status reports, this seldom resulted in a reduction in the activities planned. Hence the direct costs may, in practice, have been higher • Project 1 and 8 included all residents, including those where no benefit of oral nutritional therapy has been documented • In project 7, only 40 % of the estimated number in need of therapy, was referred • Three of the projects (3, 4 and 7) also involved oral nutritional therapy offered to home-care clients. It has not been possible to divide the total cost between, respectively, EURO used for home-care clients and EURO used for nursing home residents

21. Conclusion • It seems like money could be saved if a new technology of oral nutritional therapy, which comply with the Danish recommendations replace the old • Money spend on education of staff and employment of nutritional expertise appears to be well spend