Transcript Document

Avoiding
Inappropriate
Prescribing of Oral
Nutritional
Supplements in
Primary Care
Kim Malcolmson
[email protected]
Tel: 01256 313232
Preamble - Figure dropping
 Malnutrition affects 5-10% of your Practice population
 UK associated health costs > £13 billion annually
 NICE identifies better nutritional care as the THIRD
largest potential source of cost savings to the NHS
 Nutritional Supplements are clinically beneficial in
treating malnutrition
Therefore, if appropriate,
oral nutritional supplements
are very cost-effective
National Institute for Health and Clinical Excellence (NICE). (2006) Guideline32
What are Oral Nutritional Supplements (ONS) - 1
BNF:
Milkshake type
Enteral feeds
Fruit Juice type
Nutritional Supplement
Specialised Formulas
Crème and desserts
Feed supplements
Made up with milk
Feed additives
No protein
Foods for special diets
Nutritional supplements for metabolic diseases
Clinically beneficial in treating malnutrition
National Institute for Health and Clinical Excellence (NICE). (2006) Guideline32
nutritional complete
juice-type
dessert
made up with milk/water
1Kcal/ml or less
Ensure + Commence
Ensure + juice
Ensure+ creme
Enshake
Ensure
No Protein
Enteral Feed
Osmolite
Ensure Twocal
Osmolite 1.5 kcal
Ensure+ fibre
Osmolite Plus
Ensure+ Milkshake
Osmolite HP
Ensure+ savoury
Jevity
Ensure+ yoghurt
Procal
Jevity 1.5 kcal
ProSure
Procal shot
Jevity Plus
Suplena
Quickcal
Jevity Plus HP
Vitasavoury cup
Jevity Promote
Vitasoury sachet
Vitaflo / Abbott
Twocal
Vitapro
Fortisip Bottle
Fortijuice
Fortisip compact
Fortisip fruit dessert
Fortimel Regular
Forticreme complete
Fortisip Compact Fibre
Vitajoule
Perative
Calogen
Nutrison
Polycal
Nutrison 1000 Complete MultiFibre
Protifar
Nutrison 1200 Complete Multi Fibre
Fortisip Extra
Nutrison Concentrated
Fortisip multifibre
Nutrison Energy
Fortisip Range
Nutrison Energy Multi Fibre
Fortisip Savoury Multi Fibre
Nutrison Low Sodium
Fortisip Yoghurt
Nutrison MCT
Nutilis Complete stage 1
Nutrison Multi Fibre
Renilon 7.5
Nutrison Peptisorb
Respifor
Nutricia - SHS
Scandishake
Fresubin 2Kcal
Provide Xtra
Fresubin 2Kcal Fibre
Fresubin Crème
Calshake
Fresubin original
Maxijul
Nutrison Protein Plus
Liquigen
Nutrison Protein Plus MultiFibre
Duobar
Nutrison Soya
Duocal
Nutrison Soya Multi Fibre
Energivit
Elemental 028 Extra
Fresubin 5Kcal shot
Fresubin Original
Fresubin YOcreme
Fresubin Original Fibre
Fresubin Energy drink
Fresubin HP Energy
Fresubin Energy Fibre
Fresubin 2250 Complete
Fresubin Protein Energy
Fresubin Energy
Fresubin Thickened
Fresubin Energy Fibre
Supportan drink
Fresubin Soya Fibre
Survimed OPD drink
Fresubin 1000 Complete
Fresubin 1200 Complete
Fresubin 1800 Complete
Fresubin 1500 Complete
Survimed
Reconvan
Fresenius Kabi
Supportan
Resource 2 fibre
Resource fruit
Clinutren Dessert
Oral Impact
Caloreen
Isosource Fibre
Resource Energy
Resource dessert
energy
Isosource Standard
Resource Protein
Resource dessert
fruit
Isosource Energy Fibre
Resource SeniorActiv
Isosource Energy
Novasource GI control
Novasource GI Forte
Peptamen
Nestle
Peptamen HN
Foodlink Complete
MCT Oil
Foodlink Complete fibre
Casilan
Vegenat med balanced prot
Vegenat med high prot
Others
Complan shake
What are Oral Nutritional Supplements (ONS) - 2
Hampshire-wide:
12% saving potential
when supplement
<1.5Kcal/ml removed
(£245K)
Per Full Cream
100ml Milk (FCM)
Fortified
FCM
1kcal
per ml
1.5 kcal
per ml
2kcal per
ml
Kcal
66
110
100
150
200
Prot
(g)
3.3
7.5
4
5.6
10
Cost
(£)
0.08
0.17
0.88
0.92
0.96
ONS Spend in Hampshire

Hampshire PCT: £2 Million spent this year (ePACT data)
Furthermore:

One GP Practice, Basingstoke (20,000 registered):
 Spent £14,760 on ONS (april-sep2011) eq. to £29,500/year for <60 patients
 35% of prescriptions deemed inappropriate after dietetic review
 ?10K savings, or 0.3WTE /11hrs a week band 6 dietitian

Aldershot practice (14,000 registered):
 63% of patients on ONS deemed inappropriately so
 57% of current prescription inappropriate
 Potential savings £9,950 / year
(56% of annual ONS spend of 17,466/y)
4 steps to avoid inappropriate
prescription
1. Screening /Assessment is Key:

Weight

BMI

Weight loss

Cause
2. First Line should be dietary advice
3. ≤ 300Kcal per day  little therapeutic benefit
4. Monitoring of prescriptions
ONS<1.5Kcal/mls and ONS with
only fat and/or sugar should only
be prescribed with clear rationale
4 Steps to avoid inappropriate prescribing - Step 1
1. Screening for malnutrition (MUST – validated tool)

BMI < 18.5

> 10% Unintentional weight loss (last 3-6months)

BMI < 20 AND > 5% unintentional weight loss (last 3-6 months)
Or Malnutrition Risk

Little or no intake for > 5 days

Poor absorptive capacity/high nutrient losses
MUST: Malnutrition Universal Screening Tool, freely available on:
http://www.bapen.org.uk/musttoolkit.html
Quiz time
What is the ideal BMI range
18.5-22.5
%weight loss=
weight loss/initial weightx100
18.5-29
20-25
22.5-29
What is the percentage weight
loss of a normally 70kg man
who lost 6kg
How many kg in 1 stone
7.5
5.2
8.6
6.3
9.8
7.1
10.2
8.4
4 Steps to avoid inappropriate prescribing - Step 2
2. First Line: dietary advice
 Give high calorie/high protein advice + written
information
Diet sheet available on Pages4PrimaryCare: http://www.hampshire.nhs.uk/primarycare/gps/documents/cat_view/43-gps/173-prescribing/587-nutrition
 Suggest over the counter products such as Complan,
Build-up, Nutrament and Nurishment
 Referal to appropriate support teams if needed by GP
(social services, SALT, OT etc.)
Quiz Time: what is the common fact that links these
1 Slice Toast with
1 Tbsp butter
1 Cup whole milk
Calories: 312
2 oz Cheese
4 crackers
Calories: 295
1 Cereal Bar
1 Cup 100%
Fruit Juice
Calories: 300
They all
have
300Kcal
3 Steps to avoid inappropriate prescribing - Step 3
3. Consider ONS twice a day / 600Kcal if:

Food First approach is not feasible OR if Food first approach
tried for 1 month with no progress

Patient meets ACBS criteria
Short bowel syndrome, Intractable malabsorption, Pre-operative preparation of
patients who are malnourished, Proven inflammatory Bowel Disease, Following
a gastrectomy, dysphagia, Disease related malnutrition, Continuous
ambulatory peritoneal dialysis (CAPD) or Haemodialysis

The following are Agreed / Specified:
GOALS, DOSE, TIMING, DURATION
4. Monitoring
• GOALS: Measurable goals
• Once goals are set its easier to measure progress
• DOSE: Prescribe at least bd or 600kcals/day
• To reach therapeutic dose
• TIMING: Not a meal replacement
• Advise to take between meals, sheet on P4PC
• DURATION: Avoid prescribing on repeat
• Monitor prescriptions are they having a positive effect do they need to
be weaned down? If not do they need to be adjusted?
Prescribing supplements
 ONS although similar are all slightly different
 ONS play different roles for some people, the same ONS
may be used for different reasons, if patient queries occur
over products refer to GP or Dietitian advice
 Advise to take between meals and not as meal replacement
 Few patients will clinically require more than bd doseslarge doses likely to reduce food
 Check BNF to ensure products meet the needs of the
patient i.e. allergies, religious restriction, diabetes
What to remember
 Screening /Assessment is Key:
 Weight
 BMI
 Weight loss
 First Line should be dietary advice
 300Kcal or less per day is of little benefit
 Reviewing and monitoring of prescriptions is important
 ONS<1.5Kcal/mls and ONS with only fat and/or sugar
should only be prescribed with clear rationale
So...
The best way to achieve this is...
 Communication with GP’s – Is a review needed?
 Give out info when dispensing?
 Ability to weight patients – Liaise with GPs
 More advice available for pharmacy to access
How can we help you or you help us to achieve
Avoiding Inappropriate Prescribing of Oral
Nutritional Supplements in Primary Care?
North Hampshire Care Home ONS Audit
Report
Kimberley Malcolmson & Aude Cholet
Prescribing support dietitians
Data collected
 28 Nursing and Residential homes in
North Hants area (Calleva) with 15
% of pts on ONS
beds or more
 2-3 hours per home (dependant on
how many pts on ONS)
 1100 Total occupied beds
 100 Patients on supplements (9% of
total)
Pts on
ONS
Total
pts
Audit Standards
1.
2.
3.
4.
5.
6.
7.
8.
9.
All residents on ONS should have a MUST score
All residents on ONS should meet at least one ACBS criteria
If ACBS criteria is disease related malnutrition, this should be
established by a MUST score of 1 or more
All residents on ONS should have a clear nutrition care plan
documented
All residents on ONS should be receiving fortified diet and/or
extra snacks and/or nourishing drinks
All residents on ONS should be offered ONS as a supplement,
not as a meal replacement unless strong rationale
demonstrated
Residents on ONS should be offered ONS bd, or in excess of
400Kcal/d
All residents on ONS should have clear goals that ONS are
hoped to achieve
ONS therapy goals should be monitored on at least a monthly
basis
Results
 Individual Care Home report written and sent to
medicine management team lead for GP practice(s)
covering Care Home
 Recommendations made for supplements at that time
based on nutritional and clinical assessment
 3 Recommendations for prescriptions were for them to:
 Continue, or
 Stop, or
 Change (to meet therapeutic dose or avoid non
recommended product)
Results
Results
80
% of Homes
70
60
50
40
30
20
10
0
Use MUST
Accurate MUST
Systematic Food
Fortification
Regular Malnutrition
training
MUST = Malnutrition Universal Screening Tool
Results
 1 home recommended spend increased, 27 decreased
 44% of prescriptions advised to be stopped (44 Patients)
Total Daily cost Total daily cost Potential
Potential
of ONS before of ONS after
Saving per day saving per
audit
audit
year
£240.43
£125.35
£115.08
(47.9%)
£42,004
Conclusion
Potential saving = 42 K a year
i.e. 45 hours/week of Band 6
Dietitian/year
 Need for ongoing training and support for
 Screening (MUST)
 Food fortification
 Nutrition Care planning
Improvement in patient nutritional care possible
 Training so far
 63 people trained (4 sessions)
 ongoing process
Cost of Malnutrition
 Cost of malnutrition in the UK
£13 billion annually
 NICE have identified malnutrition as the
3rd largest potential saving for the NHS
 Those that are malnourished are more likely to:
 Visit GPs
 Spend longer in hospitals
 More likely to be admitted to hospital
Appropriate use of ONS has been shown
to reduce these costs to the NHS
Studies have shown improved nutritional care can
reduce emergency admissions, infection risk,
improve wound care and reduce their associated
costs
 BAPEN report provision of ONS to malnourished
patients reduces complications such as
 Infections and wound breakdown by 70%
 Mortality by 40%
 Better nutritional care for individuals at risk can result in
substantial cost savings to the NHS
BAPEN, Malnutrition Matters Meeting Quality Standards in
Nutritional Care 2010
ePact Data – % of Non preferred ONS
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
North
6.00%
Fareham and
Gosport
North East
4.00%
South East Hants
West Commisioning
Group
2.00%
0.00%
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
Apr-11
North East cost of non
preferred ONS
£8,210
last Dec-11
3 months
Jun-11
Aug-11 Oct-11
Feb-12 Apr-12
=£32,840/year