Quality Outcomes and Financial Benefits of Nutrition Intervention. Tracy R. Smith, PhD, RD, LD Senior Clinical Manager, Abbott Nutrition

Transcription

1 Quality Outcomes and Financial Benefits of Nutrition Intervention Tracy R. Smith, PhD, RD, LD Senior Clinical Manager, Abbott Nutrition January 28, 2016

2 SHIFTING MARKET DYNAMICS PROVIDE AN OPPORTUNITY TO ELEVATE THE ROLE OF NUTRITION Aging Population CMS Payments Life Expectancy Disease Incidence Transitional Care Quality of Care Evolving Demographics Evolving Health Policy Quality of Life Healthcare Consumption Cost of Care Role of Nutrition in Improving Patient Outcomes January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 2

3 MALNUTRITION IS AN INDEPENDENT PREDICTOR OF POOR CLINICAL OUTCOMES January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 3

4 BED REST, AGE AND HOSPITALIZATION INCREASE LOSS OF MUSCLE 0 Healthy Young 28 Days Inactivity 1 Healthy Elders Elderly Inpatients 10 Days Inactivity 2 3 Days Hospitalization lb loss of muscle 2.2 lb loss of muscle 2.2 lb loss of muscle 1 Paddon-Jones D et al. J Clin Endocrinol Metab. 2004;89: Kortebein P et al. JAMA. 2007;297: Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, Ohio. January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 4

5 MALNUTRITION: SCOPE OF THE PROBLEM Prevalent across all healthcare settings Healthcare Setting Prevalence Hospital 30-50% 1-4 Long-Term Care 21%-51% 5 Outpatient & Homecare 13-30% 5 Risk is increased in: 6 Older adults Critically ill patients Patients with comorbid chronic diseases, e.g., cancer, COPD, chronic kidney disease 1 Coats KG et al. J Am Diet Assoc.1993;93: Giner M et al. Nutrition.1996;12: Thomas DR et al. Am J Clin Nutr.2002;75: Somanchi M et al. JPEN. 2011;35: Guigoz Y. J Nutr Health Aging. 2006;10: Jensen GL, et al. JPEN J Parenter Enteral Nutr. 2010;34: January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 5

6 RISK OF NEVER EVENTS WITH PRE-EXISTING MALNUTRITION/WEIGHT LOSS 1 Odds Ratio Surgical site infection 2.5 Pressure Ulcer 3.8 Catheter-associated UTI 5.1 Mediastinitis after CABG Fry DE, et al. Arch Surg. 2010;145: January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 6

7 POST-HOSPITAL SYNDROME 1 Associated Causes: Poor Nutrition Pain and Discomfort Decline in Mental Functioning Malnutrition during hospitalization may cause poor outcomes, yet often receives little attention Sleep Deprivation 1 Krumholz HM. N Engl J Med 2013; 368: January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 7

8 NATIONAL SURGICAL QUALITY IMPROVEMENT PROJECT PROTOCOL 1 National Surgical Quality Improvement Project protocol to identify risk factors associated with 30-day readmission. Preoperative, intraoperative, and postoperative outcomes were collected 1442 inpatient general surgery procedures at a single academic center between 2009 and Four Most Common Readmission Reasons Operations With Highest Readmission Rates Gastrointestinal complications (28%) Pancreatectomy (18%) Surgical infection (22%) Colectomy/colostomy (13%) Malnutrition (10%) Small bowel resection (12%) Wound complications (8%) Gastrectomy (11%) 1 Kassin M et al, J Am Coll Surg Sep;215(3): January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 8

9 IN A RECENT STUDY, PATIENTS AT NUTRITIONAL RISK WERE MORE LIKELY TO EXPERIENCE EMERGENT CARE VISITS AND REHOSPITALIZATIONS 1 Objective To identify the association between baseline nutritional status and subsequent health service utilization and mortality Population N = 198 older adults receiving Medicare home health services for 1 year Key Findings 12% were malnourished and 51% were at risk Those who were malnourished or at risk at initial assessment were more likely to experience: Subsequent Hospitalization (P=.040) Number of Hospital Admissions (P=.045) ER Visit (P=.047) Mortality (6 months, P=.001; 1 year, P=.031) 1 Yang Y et al. J Am Med Dir Assoc 2011; 12: January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 9

10 ORAL NUTRITION SUPPLEMENTATION (ONS) HAS SHOWN SIGNIFICANT CLINICAL BENEFITS Reduction in Pressure Ulcer Incidence 1 Reduction in Serious Complications (e.g., infections) 2 Reduction in Hospital Readmission 2 25% % CI ( ) 19% P< % P< Stratton RJ et al. Ageing Res Rev. 2005;4(3): Cawood et al. Ageing Res Rev. 2012;11(2): January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 10

11 ORAL NUTRITION SUPPLEMENTS REDUCE HOSPITAL ADMISSIONS 1 Elderly community 2 Benign GI disease 3 * Elderly hospital discharges 4 Elderly hospital discharges 5 Hip fracture hospital discharges 6 Elderly hospital discharges 7 * Routine care ONS - Recent meta-analysis of 6 studies OR = 0.56 * P< % admitted to hospital 1 Stratton RC and Elia M. Proc Nutr Soc. Annual Meeting of the Nutrition Society and BAPEN 2010; Eddington J et al. Clin Nutr. 2004;23: Normal K et al. Clin Nutr. 2008;27: Gariballa S et al. Am J Med. 2006;119: Chapman IM et al. Am J Clin Nutr. 2009;89: Miller MD et al. Clin Rehabil. 2006;20: Price R et al. Gerontology. 2005;51: January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 11

12 ORAL NUTRITION SUPPLEMENTATION PROVIDED DURING HOSPITALIZATION WAS ASSOCIATED WITH: 1 21% decrease in length of stay (2.2 days) 21.6% decrease in episode costs ($4734) 6.7% decrease* in probability of 30-day readmissions Monetary figures are based on 2010 US dollars and inflation adjusted. *Readmission defined as return to study hospital for any diagnosis. Data measured delayed readmission and does not include patients not readmitted due to recovery or death. 1 In a retrospective health economic study, Philipson T et al. Am J Manag Care. 2013;19(2): January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 12

13 AN INVESTMENT IN ORAL NUTRITIONAL SUPPLEMENTATION THERAPY CAN HELP GENERATE POSITIVE RETURN 1 Annual Admissions 20,000 Additional Annual Patients Fed 1% Total Additional Annual Patients Fed 200 Cost Reduction/Episode $ 4,734 Cost of ONS $ Net Cost Reduction/Episode $ 4,646 Total Net Savings $ 929,148 1 In a retrospective health economic study, Philipson T et al. Am J Manag Care. 2013;19(2): January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 13

14 ONS IMPROVED THE FOLLOWING OUTCOMES IN MEDICARE PATIENTS AGES 65 AND OLDER: 1 8.4% decrease in probability of 30-day readmission day (16%) decrease in hospital length of stay 1 $3079 (15.8%) decrease in episode cost 1 1 In a retrospective health economic study, Lakdawalla D et al., Forum for Health Economics and Policy,2014 DOI /fhep January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 14

15 ONS IMPROVED OUTCOMES AND REDUCED HOSPITAL COSTS IN THREE TARGETED MEDICARE POPULATIONS 1 Acute Myocardial Infarction (AMI) Congestive Heart Failure (CHF) Pneumonia (PNA) -5.1% ($1,538) -5.2% -12% * -10.9% * (1.2 days) -10.1% * -7.8% * ($1,266) -8.5% * (0.8 days) -10.6% * ($1,516) -14.2% (1.3 days) 30-day Readmission Probability Length of Stay Episode Cost * indicates significance at the 1% level indicates significance at the 5% level 1 In a retrospective health economic study, Lakdawalla D et al., Forum for Health Economics and Policy, 2014 DOI /fhep January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 15

16 THE IMPACT OF ORAL NUTRITION SUPPLEMENTATION AMONG HOSPITALIZED PATIENTS WITH COPD WAS STUDIED IN A LARGE SAMPLE 1 Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Probability Length of Stay Episode Cost % * % * A one to one matched sample was created from a ($1,570) 10,322 ONS episodes and 368,097 non-ons episodes data population % (1.88 days) *Out of 10,322 ONS episodes and 368,097 non-ons episodes, a one-to-one match sample was created (N=14,326). 1 In a retrospective health economic study, Thornton Snider J et al., Chest Oct 30. doi: /chest January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 16

17 ONS DECREASED THE PROBABILITY OF 30-DAY READMISSIONS IN SPECIFIC 65+ MEDICARE POPULATIONS 1,2 Change in 30-Day Readmission Probability with ONS COPD 1 Acute Myocardial Infarction (AMI) 2 Congestive Heart Failure (CHF) 2 Pneumonia (PNA) 2 All Diagnoses (Ages 65+) 2-5.2% -13.1%* -12.0%* -10.1%* -8.4%* * Indicates significance at the 1% level 1. In a retrospective health economic study, Thornton Snider J et al., Chest Oct 30. doi: /chest In a retrospective health economic study, Lakdawalla D et al. Forum for Health Economics and Policy,2014 DOI /fhep January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 17

18 ADVOCATE HEALTH CARE SYSTEM Largest ACO in the US (Modern Healthcare) and a Top 5 large health system based on quality by Truven Analytics Largest health system in Illinois based in Chicago, Illinois. 250 sites of care, with 11 acute-care hospitals 6 Advocate hospitals have earned Magnet Recognition 5 Advocate hospitals were named among the nation s Top 100 Hospitals Largest physician network of specialists and subspecialists in Illinois Advocate s goal is to be a leader in population health management Proprietary and confidential do not distribute January 28,

19 RESEARCH QUESTION & PRIMARY ENDPOINT Purpose of Project: Advocate aligned with the evidence on ONS intervention and readmissions and wanted to use ONS as a tool to reduce 30-day readmissions Study Hypothesis: Administration of a rapid, automatic ONS intervention from screening to discharge will decrease 30-day readmission rate by 20% or more and yield superior cost-effectiveness compared to their existing ONS protocol in patients at risk for malnutrition Primary Endpoint: Incidence of non-elective readmission 30-days post discharge Patient Population: 18+, any primary diagnosis, risk for malnutrition (MST 2) Proprietary and confidential do not distribute January 28,

20 RESEARCH/QIP DESIGN Baseline/Standard of Care Prior to the QIP: 20% readmission rate for malnourished patients who received ONS Nutrition screening tool was not validated 5 questions any positive triggered an RD consult Notification to RD by manual system Intervention with ONS was not automatically sent to patients at risk for malnutrition Delivery of ONS to patient > 72 hours or not at all Nutrition discharge education was not routine Post-discharge reminders about nutrition were not in place Process Change Occurred in 4 Hospitals: Two hospitals were designated as QIP Two hospitals were designated as QIP+ Proprietary and confidential do not distribute January 28,

21 QIP PROCESS CHANGE QIP: Two hospitals utilized the Malnutrition Screening Tool (MST) in Cerner Targeted ONS intervention for all patients with MST hours to receive ONS Ensure Complete, Ensure Clear, Glucerna, or Nepro Nutrition discharge education was not routine Post-discharge calls were made, but did not include reminders about nutrition and continuing ONS Proprietary and confidential do not distribute January 28,

22 QIP+ PROCESS CHANGE QIP+: Two hospitals utilized the Malnutrition Screening Tool (MST) in Cerner Automatic ONS for all patients at risk for malnutrition (MST 2) Less than 24 hours to receive ONS Ensure Complete, Ensure Clear, Glucerna, or Nepro Received instruction/coupons at discharge to continue ONS Received 4 follow-up phone calls post discharge confirming ONS consumption 1st call by Patient Experience Nurses or automated 2nd, 3rd, and 4th calls were automated Proprietary and confidential do not distribute January 28,

23 RESULTS FOR QIP SITES Readmission Rate: 20% Readmission Rate: 16.4% Pre-QIP QIP Screening Intervention Education Post discharge Non-validated screening tool No early intervention No formalized nutrition discharge education No post-discharge reminders about nutrition Validated (MST) screening tool integrated into EMR Targeted ONS intervention in hours No formalized nutrition discharge education No post-discharge reminders about nutrition 18% Reduction vs. Baseline p<0.01 Proprietary and confidential do not distribute January 28,

24 RESULTS FOR QIP+ SITES Readmission Rate: 20% Readmission Rate: Pre-QIP Pre-QIP 15.6% QIP+ Screening Intervention Education Post discharge Non-validated screening tool Non-validated screening tool No early intervention No early intervention No formalized No formalized nutrition nutrition discharge education discharge education No post-discharge reminders No post-discharge reminders about nutrition about nutrition Validated (MST) screening tool integrated into EMR Automatic ONS intervention in 24 hours Formalized nutrition discharge education with coupons Follow-up calls encouraging ONS adherence 22% Reduction vs. Baseline p<0.01 Proprietary and confidential do not distribute January 28,

25 RESULTS FOR QIP AND QIP+ SITES Screening Readmission Rate: 20% Readmission Rate: 16.4% Readmission Rate: 15.6% Pre-QIP Non-validated screening tool QIP Validated (MST) screening tool integrated into EMR QIP+ Validated (MST) screening tool integrated into EMR Intervention No early intervention Automatic ONS intervention in hours Automatic ONS intervention in 24 hours Education No formalized nutrition discharge education No formalized nutrition discharge education Formalized nutrition discharge education with coupons Post discharge No post-discharge reminders about nutrition No post-discharge reminders Follow-up calls encouraging ONS adherence 18% Reduction vs. Baseline p< % Reduction vs. Baseline p<0.01 Proprietary and confidential do not distribute January 28,

26 HEALTH CARE SYSTEM ONS QIP: COST SAVINGS ILLUSTRATION QIP+ SITES (500 patients enrolled) 500 pts x 20% = 100 pts Expected Readmissions 500 pts x 15.6% = 78 pts Observed Readmissions 100 Expected - 78 Observed = 22 Prevented Readmissions x $18,500 Average Readmission Cost* = $407,000 QIP SITES (769 patients enrolled) 769 pts x 20% = 154 pts Expected Readmissions 769 pts x 16.4% = 126 pts Observed Readmissions 154 Expected 126 Observed = 28 Prevented Readmissions x $18,500 Average Readmission Cost = $518,000 Total 6-Month Savings = $925,000 Annual Savings Projection = $1,850,000** Proprietary and confidential do not distribute * Philipson, American Journal of Managed Care, Vol 19 No 2, p 121. ** Based ONLY only on application of current, limited QIP protocol. January 28,

27 3 STEPS FOR ADDRESSING MALNUTRITION Screen and recognize all patients at risk of malnutrition Rapidly implement nutrition interventions and continue monitoring your patients Include nutrition in every discharge plan with education on why nutrition is important to recovery January 28, 2016 Quality Outcomes and Financial Benefits of Nutrition Intervention 27

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