Let s Talk about Nutrition: Communication Skills for Health Care Professionals Topic 39

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1 Let s Talk about Nutrition: Communication Skills for Health Care Professionals Topic 39 Module Nutrition Facts: Cost-effectiveness of Nutrition Support Prof. Maurizio Muscaritoli, MD Full Professor of Internal Medicine Department of Clinical Medicine Sapienza University of Rome, Rome, Italy Maria Ida Amabile, MD, PhD Research Fellow Department of Clinical Medicine Sapienza University of Rome, Rome, Italy Learning Objectives To understand the benefits of nutrition therapy; To understand the concept of nutrition support; To show the cost-effectiveness of nutrition therapy. Contents 1. Introduction 2. Effectiveness and efficacy of nutritional therapy 3. Cost and cost-effectiveness of nutritional therapy 4. Summary 5. References Key Messages Evidence is accumulating that nutritional therapy (NT) is cost-effective in both hospital and community settings; Having convinced physicians of the negative impact of disease related malnutrition on outcomes, the next challenge will be to adequately deliver knowledge about the cost-effectiveness of NT; Irrespective of its nature, NT should be part of structured and homogeneous Clinical Nutrition pathways. 1

2 1. Introduction Disease-related malnutrition has deleterious consequences on patients' outcomes and healthcare costs (1). Evidence indicates that postoperative complications, risk of falls, hospital-acquired infections, risk of death and costs of care are significantly higher in malnourished than in well-nourished patients (1-3). The evolving recognition of the importance of malnutrition as a cause, consequence, and complication of deterioration of many diseases has emphasized the need for a scientific evaluation of the effectiveness of nutritional therapy (1). An appropriate nutritional therapy is able to improve outcome through preventing or correcting malnutrition-related disorders (1). It has to be considered that the demonstration of improved outcome due to appropriate nutritional management is sometimes difficult, primarily due to the lack of standardized procedures regarding the definition of malnutrition, the diversity of populations studied, the endpoints and proposed nutritional interventions (the prescription of nutritional solutions for parenteral or enteral use, or of oral supplementation) as well as gaps between prescription and actual clinical practice (1,4). As a consequence, clinical nutrition pathways have been very sparsely implemented in comparison to those of other clinical medicine disciplines, their benefits have been largely underestimated in clinical practice, and medical nutrition is often seen as an additional cost (1). Feed M.E. is a malnutrition awareness and medical education (M.E.) programme developed by international leaders who are committed to increasing recognition of nutrition s role in improving health outcomes around the world (5). The programme highlights the facts that malnutrition is common and often unrecognized and undertreated, and how, during and after hospitalization, it leads to poor clinical outcomes and higher costs of care (extra care and longer hospital stay are needed to treat complications) (6). Nutrition care improves clinical outcomes and lowers health care costs, ameliorating nutrition status, muscle mass, strength, or performance, reducing health complications and risk of mortality, and so reducing length of stay, possible hospital readmissions, and the costs of care (economic benefits) (5). 2. Effectiveness and Efficacy of Nutritional Therapy It is known that poor nutritional status on discharge predicts hospital readmission within 30 days (7) and the importance of involving specialists in the field of nutrition is correctly emphasized (1). A published database study on patients affected by chronic obstructive pulmonary disease indicated that the use of oral nutritional supplement (ONS) was associated with a 13.1% decrease in the probability of 30-day readmission (8). This shows that it is possible to prove that nutritional support can have significant effects in reducing hospital readmission when large studies are performed in homogeneous disease groups. In addition, with length of stay for hospital patients becoming shorter, the opportunity to treat malnutrition in hospital is also reduced. This could represent a relevant confounding factor when assessing the role of inpatient nutritional therapy in preventing readmissions (1). More recently, Deutz et al. studied older malnourished adults hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease, and these patients were supported with standard care plus a supplement containing beta-hydroxybeta-methylbutyrate (HP-HMB) or a placebo supplement (9). Although no effects were observed in the 90-day post-discharge nonelective readmission rate, the HP-HMB supplemented group compared with the placebo 2

3 group showed decreased 90-day mortality and improved indices of nutritional status during the observation period (9). Zhang et al. evaluated the impact of nutrition support on clinical outcome among patients at nutritional risk and documented that nutrition support reduces the number of patients with one or more infectious complication(s) as well as the hospital length of stay (10). A recent Cochrane systematic review (1) of the literature was performed to answer the following key questions: 1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge?, 2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge?, 3) Is nutritional therapy costeffective / does it reduce costs in hospitalized patients?, and 4) Is nutritional therapy cost effective / does it reduce costs in outpatients?. This review highlights the clinical impact of malnutrition and the benefits deriving from its treatment, including a reduction in hospital readmission rates and costs (1). One clear finding is the cost-effectiveness of nutritional therapy, most evident from large, homogeneous studies. The results support the use of nutritional therapy to reduce healthcare costs (1). 3. Cost and Cost-effectiveness of Nutritional Therapy Interestingly, in recent years several authors have published on the topic of costeffectiveness of nutritional support (11, 12). A retrospective data analysis has been conducted to assess the association and causal impacts of ONS on health outcomes in hospitalized patients, focusing on 3 key outcomes: length of stay, episode cost, and probability of 30-day readmission (13). The authors documented that ONS patients had a statistically significant shorter length of stay - by 2.3 days - and decreased episode cost with respect to patients not supplemented with ONS. Moreover, restricting the matched sample to the episodes where patients were readmitted at some point, ONS patients had a reduced probability of early readmission (within 30 days) (14). Cereda et al. conducted an economic evaluation from a local healthcare system perspective in patients suffering from pressure ulcers. The use of a disease-specific oral nutritional formula not only resulted in better healing of pressure ulcers, but also reduced the costs of local pressure ulcers care from a healthcare system perspective (14). Similarly, Zhang et al. investigated the total costs of hospitalization and documented that these were comparable between the patients in their nutrition support cohort and those in the non-support cohort (10). The incremental cost-effectiveness analysis suggested that nutrition support costs prevented patients from having infectious complications (10). In this light, also, Zhong et al. evaluated the cost effectiveness of a specialized ONS in malnourished older hospitalized patients, showing that the investigative ONS costeffectively extended the lives of malnourished hospitalized patients (15). A recent meta-analysis by Elia et al. was undertaken according to recommended procedures to assess whether ONS administered in community and care home settings can produce cost savings and cost-effective outcomes (11). The meta-analysis documents that the use of standard ONS in the community, with or without additional use in hospital, produced an overall net cost saving favouring the ONS group, or a near neutral balance. These cost outcomes were associated with clinically relevant benefits such as improved quality of life, reduced infections, reduced minor post-operative complications, reduced falls, and functional limitations. Moreover, most cost analyses favoured the ONS group even when considered in subgroups according to nutritional status and age, study design, duration of intervention and setting. Overall, this comprehensive review suggested a cost effectiveness of nutritional support (on average ONS accounted for less than 5% of total 3

4 costs), indicating, nevertheless, the need for prospective studies designed to examine primary economic outcomes (11). In a subsequent meta-analysis, the cost and cost-effectiveness of using standard (nondisease specific) ONS administered only in the hospital setting were examined (12). This meta-analysis suggests that the use of ONS compared to no ONS or routine care can produce significant net cost savings. Study level analyses showed a significant overall cost saving, and a series of subgroup analyses according to malnutrition, age group, type of study and study design globally favoured the ONS group, although only some of these cost savings were significant. The cost savings were generally found to be associated with a range of favourable clinical outcomes, such as reduced complications, reduced mortality, and reduced length of hospital stay (earlier return to the familiar home environment) (12). The favourable cost and cost-effectiveness outcomes associated with the use of ONS in the hospital setting could have been predicted in part because the cost of ONS is small compared to total hospital costs (12). Both reviews (11, 12) also aimed to identify gaps in knowledge that need to be addressed to help guide clinical practice. In this light, given the high prevalence of malnutrition among in- and out-patient populations, these studies suggest that ONS use could help improve outcomes at relatively low cost to the healthcare system (13). At this moment, hospitals are facing pressures to find low-cost, highly effective therapy while maintaining quality of care. By increasing ONS use, hospitals can improve hospitalization outcomes and decrease healthcare spending. 4. Summary The consequences of malnutrition are serious, including increased complications (pressure ulcers, infections, falls), longer hospital stays, more frequent readmissions, increased costs of care, and higher risk of mortality. A relevant recent finding is that nutritional interventions for malnutrition provide economic benefits in terms of saving and costeffectiveness in hospitalized patients and they may be cost-effective in selected sub-groups of outpatients, even if the evidence is limited with smaller number of studies on this Topic. 4

5 5. References 1. Muscaritoli M, et al. Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology. Clin Nutr 2017;36: Fry DE, et al. Patient characteristics and the occurrence of never events. Arch Surg 2010;145: Freijer K, et al. The economic costs of disease related malnutrition. Clin Nutr 2013;32: Preiser JC, et al. ESPEN disease-specific guideline framework. Clin Nutr. 2011; Correia MI, et al. Evidence-Based Recommendations for Addressing Malnutrition in Health Care: An Updated Strategy From the feedm.e. Global Study Group. JAMDA 2014;15: Lim SL, et al. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31: Friedmann JM, et al. Predicting early nonelective hospital readmission in nutritionally compromised older adults. Am J Clin Nutr 1997;65: Thornton Snider J, et al. Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among Medicare patients with COPD. Chest Deutz N, et al. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin Nutr 2016;35: Zhang H, et al. Impact of nutrition support on clinical outcome and cost-effectiveness analysis in patients at nutritional risk: A prospective cohort study with propensity score matching. Nutrition 2017;37: Elia M, et al. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings. Clin Nutr 2016;35: Elia M, et al. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting. Clin Nutr 2016;35: Philipson TJ, et al. Impact of oral nutritional supplementation on hospital outcomes. Am J Manag Care 2013;19: Cereda E, et al. Cost-effectiveness of a disease-specific oral nutritional support for pressure ulcer healing. Clin Nutr 2017;36: Zhong Y, et al. The Cost-Effectiveness of Oral Nutrition Supplementation for Malnourished Older Hospital Patients. Appl Health Econ Health Policy 2017;15: