Download appropriate prescribing of oral nutritional supplements

Malnutrition in the
UK: appropriate
prescribing of
oral nutritional
supplements
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RXANI120220
Date of preparation June 2012
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Eliminating avoidable
malnutrition: the role of
commissioners and primary care
Ailsa Brotherton, Senior Research Fellow, School of Health, University of Central Lancashire;
Anne Holdoway, Specialist Dietitian in Gastroenterology and Nutrition Support, Bath;
and Mike Stroud, Consultant Gastroenterologist, University Hospitals Southampton and Senior
Lecturer in Medicine & Nutrition, NIHR Biomedical Research Centre for Nutrition, Southampton
Introduction
Calls to action
M
Clinical commissioning groups (CCGs) who focus their attention
urgently to improving nutritional care in the community will
undoubtedly save lives while simultaneously saving money. This
article is a call to action to all CCGs, GPs, and medicines managers.
The benefits of improving nutritional care and providing adequate
hydration in primary care are immense, especially for those with
long-term conditions and problems such as stroke, pressure ulcers, or
falls. The evidence shows that if nutritional needs are ignored, health
outcomes are worse, and CCGs that fail to invest in nutritional care
will undoubtedly face significant additional costs associated with
the treatment of malnourished individuals in their local populations.
The current establishment of CCGs therefore affords a unique
opportunity to deliver excellent nutritional care in the community at
a local level.
alnutrition is both a cause and a consequence of disease
and leads to worse health and clinical outcomes in all social
and NHS care settings.1 The British Association for Parenteral &
Enteral Nutrition (BAPEN) estimates that malnutrition affects
over 3 million people in the UK at any one time and costs the
health economy £13 billion per annum, 2 yet many GP surgeries
are not screening their patients for malnutrition and are failing to
provide good nutritional care.
Available guidance
NICE guidance on Nutrition support in adults sets out clear
recommendations for nutritional screening in hospitals
and the community and the development of personalised
nutritional care pathways for patients at risk. 3 The importance of
screening for malnutrition and treating all those at risk is widely
recognised.4–6
Importance of identifying malnourishment
Malnutrition is a general term for the medical condition resulting
from consumption of an improper or inadequate diet and refers
most commonly to undernutrition although it can also include
overnutrition. It is therefore not often viewed by either GPs or
their patients as a ‘medical condition’, and is rarely diagnosed in
the same way as other diseases and conditions. Indeed there are
currently no accepted diagnostic tools or criteria for the diagnosis
of malnutrition. Patients are unlikely to visit their GP as a result of
concerns about malnourishment alone and are unlikely to initiate a
conversation about malnutrition itself. It is therefore essential that
all GPs are actively looking for malnutrition in vulnerable patients,
including any visible signs of weight loss such as loose-fitting clothing
and/or jewellery. It is also vital to check the patient’s recent history to
identify any decrease in food intake, reduced appetite, or dysphagia
over the previous 3–6 months and any underlying disease or
psychosocial/physical disabilities likely to cause weight loss. 8
The NICE clinical guideline advises nutritional support for
patients who are malnourished, defined as those who have:3
›› body mass index (BMI) <18.5 kg/m 2
›› lost >10% of their weight unintentionally over the previous
3–6 months
›› BMI <20 kg/m 2 and unintentional weight loss >5% over the
previous 3–6 months.
People at risk of malnutrition and who require nutritional support
are defined by NICE as having:3
›› eaten little or nothing for >5 days and/or are likely to eat little
or nothing for ≥5 days
›› poor absorptive capacity and/or high nutrient losses and/or
increased nutritional needs from causes such as catabolism.
A recent report from the Care Quality Commission (CQC)
on Essential standards of quality and safety includes advice and
recommendations on meeting nutritional needs for patients in
care, which includes provision of nutritious food and hydration
in sufficient quantities for their needs.7 Although not uniformly
implemented, quality improvements in nutritional care in acute
hospitals have been accomplished at pace and scale as a direct
result of the establishment of nutrition steering committees and
nutrition support teams, yet nutritional care in the community
remains at best very fragmented.
It is important to note that patients of any age can present with
malnutrition, but some are more vulnerable than others. Recent data
highlighted that of 7541 patients who were screened on admission to
hospital, 25% were found to be at risk of malnutrition. Of the patients
included in the survey, 73% were admitted directly from their own
homes, 23% of whom were at risk, which suggests that malnutrition
largely originates in the community.9 Strategies to prevent, identify,
and treat malnutrition in community settings are therefore urgently
required.
2
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
The same report also highlights that malnutrition is common in all
age groups and diagnostic categories, but is more common in:9
›› women (28% vs 22%), who were older than men
›› subjects aged 65 years and over than under 65 years (28% vs 21%)
›› certain diagnostic categories compared with others—e.g.
gastrointestinal disease (38%) and respiratory disease (31%)
versus musculoskeletal conditions (18%) and cardiovascular
disease (16%).
The clinical and cost benefits of ONS as a short-term treatment in
disease-related malnutrition have been demonstrated repeatedly; the
challenge is to identify these individuals and prescribe appropriately.
Potential short-term cost savings from reducing prescribing of
ONS in the community have been identified in some areas, and
where prescribing has been inappropriate this is the correct course
of action. However, the process has also led to many initiatives
to reduce the usage of ONS, which can result in inappropriate
protocols1 and delayed appropriate prescription, which may then
result in increases in: hospital admissions; length of hospital stay;
readmission rates; and an increased number of falls and pressure
ulcers. Although a ‘food first’ approach should undoubtedly be
used to prevent or treat malnutrition when there is no appetite loss
from, for example, intercurrent illness or injury, Cochrane metaanalyses show little or no benefit from dietetic interventions when
malnutrition accompanies acute illness, whereas ONS have been
shown to be very effective in such circumstances.11 Furthermore,
the cost of enteral and parenteral nutrition, tube feeding, and ONS
used in the UK is only about 2% of the overall costs of malnutrition,12
and it is therefore logical to prescribe ONS promptly for vulnerable
individuals with a poor appetite in order to minimise further
deterioration in nutritional status. Prescription of ONS should be
part of an integrated care pathway, with appropriate monitoring and
effective management of repeat prescribing to prevent inappropriate
continuation or wastage.
Malnutrition was also found to be significantly higher in those
patients with cancer than in those without (34% vs 23%), and
of 523 residents recently admitted and screened in care homes,
41% were ‘malnourished’, while 19% of 543 patients screened
were ‘malnourished’ on admission to Mental Health Units.9 All
GP surgeries should have a local policy to screen all patients on
registration at the surgery and where there is clinical concern, as
recommended by NICE. 3
Role of the GP and community healthcare
Once patients have been screened using a validated screening tool
(e.g. the ‘Malnutrition Universal Screening Tool’ [‘MUST’]10), those
identified as ‘at risk’ require a detailed assessment and personalised
care plan. The ‘MUST’ tool provides management guidelines, and
management of the patient should be tailored to the level of risk.10
A patient’s nutritional care plan should:8
Appropriate prescribing of oral nutritional supplements
›› set aims and objectives of treatment
›› treat any underlying conditions
›› include treatment of the malnutrition with food and/or oral
Appropriate prescribing of ONS is not difficult to achieve and
new community management guidelines are in development
and will shortly be available to assist with this (see
www.malnutritionpathway.co.uk). The pathway will provide
a practical guide to support GPs and healthcare professionals in
the community in identifying and managing individuals at risk of
disease-related malnutrition, including the appropriate use of ONS.
The guidance has been produced and agreed by a multiprofessional
consensus panel with expertise and an interest in malnutrition, is
based on clinical evidence, clinical experience, and accepted best
practice, and aims to put an end to inappropriate prescribing.
nutritional supplements (ONS) where appropriate. Patients who
are unable to meet their nutritional requirements orally may
require artificial nutritional support, e.g. enteral or parenteral
nutrition. None of these methods are exclusive and combinations
of any or all may be needed. If subjects are overweight or obese,
follow local guidelines for weight management
›› monitor and review nutritional intervention and care plan
›› reassess subjects identified at nutritional risk as they move
through care settings.
When considering oral nutritional interventions, advice should be
provided for patients to assist them to make appropriate food choices,
ensuring appetising food of good nutritional value during and
between meals. The full range of nutrients (including macronutrients
and micronutrients) are required daily, together with sufficient fluid,
as managing malnutrition is not only about managing kilocalorie
intake, it is also important to ensure that patients and their carers
understand that the usual ‘healthy eating’ principles do not apply and
that it is crucial to ensure an adequate intake of energy, protein, and
micronutrients to improve health outcomes. Education on nutrition
for GPs needs to be improved to enable appropriate nutritional care
planning in the community. 3
If it is not possible to meet your patient’s nutritional requirements
from food, ONS should be prescribed; typically an additional daily
intake of 250–600 kcal can be of value in treating malnutrition.8
Ideally, dietary advice and counselling should also be given when
recommending ONS and it is important to collaborate with local
dietitians, who will be well placed to work with you to develop local
protocols. This is particularly important because of the variation
in community dietetic services across the country. There is a wide
variety of ONS styles, including: milkshake, juice, yogurt, and
savoury. Formats available include: liquids, powder, desserts,
pre-thickened, and other types with, for example, added fibre,
high protein, and varying energy densities. Usage is dependent on
nutritional needs, patient preference, and desired consistency.
Failure of current systems
Improving care: listening to your patients
Currently, use of ONS in the community is varied, resulting in
many patients with a clinical need for supplements not receiving
them, or not receiving them for long enough, while others who no
longer need them are still receiving them, sometimes for prolonged
periods. This inappropriate prescribing has led to many medicines
managers reviewing current practice and there is a need for new
protocols that will ensure ONS are prescribed where indicated, based
on the available evidence (such as Grade A evidence from NICE3).
In their recent report, Malnutrition in the community and
hospital setting, the Patients Association has made a number of
recommendations on improving nutritional care. These include
advice for GPs and commissioners to:13
›› ensure information on malnutrition is tailored to local services
and covers the whole ‘malnutrition journey’ from diagnosis to
3
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Key actions
››
››
››
››
››
››
››
››
Assess the nutritional needs of your local population
Identify the potential cost savings for your health economy using the NICE cost-reporting tool
Set up a community nutrition steering committee
Design a nutritional care pathway that spans your local health economy so that patients’ nutritional care is seamless
Ensure all GP surgeries adopt and implement a local policy for nutrition screening and care planning
Collaborate with your local dietetic department to ensure appropriate patient information is available
Develop criteria for referral to the dietitian and secondary care for specialist nutritional care
Develop a local scheme for commissioning for quality and innovation (CQUIN) to measure the quality improvements in nutritional care.
nutritional treatments that can be prescribed by the GP and also
following up and monitoring in the community
›› ring-fence funding for community-based dietetic services and
treatment options if clinically required.
The case study that follows this article is not unusual. It typifies
the routine lack of attention to nutrition screening to identify
malnutrition risk and delays in referral to professionals with expertise
in nutrition. It outlines how management could have been improved
and such severe disease-related malnutrition avoided or minimised
through appropriate and timely oral nutritional support strategies.
The same report recommends improved education for GPs and
commissioners as to the cost benefits of treating malnutrition.13
The Patients Association’s leaflet, Malnutrition—how to stop the
signs and what to expect from treatment (available at www.patientsassociation.com) should be provided by GP surgeries and healthcare
professionals to patients and carers who may be vulnerable or at risk
of malnutrition.13 All patients who are identified as being at risk of
malnutrition should be monitored on a regular basis to ensure that
their care plan continues to meet their needs. Clinical commissioning
groups must work with their local dietetic departments and secondary
care services to agree protocols for referral to specialist services.
Malnutrition does matter in primary care and evidence highlights the
need for the development of nutritional quality outcomes. Yet it has,
to date, been largely neglected in primary care, for multiple reasons
including the omission of ‘nutrition’ from the curriculum for GP
training, which has led to a lack of awareness of the problem among
GPs, a lack of collaboration between the RCGP and leading nutrition
organisations, which is now being addressed, a lack of nutrition
steering committees in SHAs and PCTs, and the initial primary
research focus for malnutrition being acute hospitals. However,
research findings and recent articles have highlighted the dangers of
malnutrition and the importance of shifting the focus to prevention,
early detection, and early treatment; all of which can only be achieved
in primary care.15,16
Focus on finance: cost-effective prescribing
Malnourished individuals visit their GPs more often, are admitted
to hospital more frequently, stay on the wards for longer, succumb to
infections, and can even end up being admitted to long-term care or
dying unnecessarily.1 Most GPs and medicines managers, however,
do not appreciate the significant costs associated with malnutrition
beyond the limited view of their supplement prescriptions budget,
and so the real costs and problems continue to be unrecognised and
untreated in their local populations. Even conservative estimates of
the savings related to implementing the NICE Clinical Guideline
on Nutrition support in adults in the community amount to around
£28,000 for the average PCT through reductions in GP attendances,
outpatient appointments, hospital admissions, length of hospital stay,
and complications such as infection, pressure ulcers, and delayed
wound healing.14
Declaration of interest
The authors have no interests to declare. The honoraria the authors
would have received for writing this article have been donated, at
their request, to the charity supporting Patients on Intravenous and
Nasogastric Nutrition Therapy (PINNT).
References
1. British Association of Parenteral and Enteral Nutrition. Malnutrition matters:
meeting quality standards in nutritional care. Redditch: BAPEN, 2010.
Available at: bapen.org.uk/pdfs/toolkit-for-commissioners.pdf
2. Elia M, Russell C (eds). Combating malnutrition; Recommendations for Action.
Output of a meeting of the Advisory Group on Malnutrition 12 June 2008.
Redditch: BAPEN, 2009.
3. National Institute for Health and Clinical Excellence. Nutrition support in
adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
Clinical Guideline 32. London: NICE, 2006. Available at:
nice.org.uk/CG32
4. Royal College of Nursing. Nutrition Now: Enhancing nutritional care. London:
RCN, 2009. Available at: rcn.org.uk/nutritionnow
5. Department of Health. Improving nutritional care. London: DH, 2007.
Available at: dh.gov.uk/publications
6. Royal College of Physicians. Nutrition and Patients: A doctor’s responsibility.
Reprint of a working party of the Royal College of Physicians. London: RCP,
2002.
7. Care Quality Commission. Essential standards of quality and safety. London:
CQC, 2010. Available at: cqc.org.uk/standards
8. Todorovic V, Russell C, Elia M for the Malnutrition Action Group (MAG).
The ‘MUST’ explanatory booklet: A guide to the ‘Malnutrition Universal
Screening Tool’ (‘MUST’) for adults. Revised version. Redditch: BAPEN, 2011.
Available at: bapen.org.uk/pdfs/must/must_explan.pdf
9. Russell C, Elia M on behalf of BAPEN. Nutrition Screening Survey in the UK
and Republic of Ireland in 2011. Redditch: BAPEN, 2012. Available at: bapen.
org.uk/pdfs/nsw/nsw-2011-report.pdf
10.Malnutrition Advisory Group of BAPEN. The Malnutrition Universal
Screening Tool ‘MUST’ tool. Revised version 2010. Available at: www.bapen.
org.uk/must_itself.html
Financial savings in acute care are also considerable and anyone with
responsibility for commissioning acute services should undertake
the calculations of the estimated savings using the NICE Costing
Report.14
Conclusion
Although screening for nutritional risk, using a validated nutritional
screening tool (e.g. ‘MUST’), is recommended by the CQC7 and
NICE, 3 in some cases hospitals, care homes, and primary care are still
failing to screen patients as they should. This impedes the initiation
of appropriate care. Treatment and monitoring of malnutrition is
currently very fragmented in primary care and systems need to be
developed that will ensure that malnourishment is identified in
patients who are visiting their GP and that they receive appropriate
nutritional care. Toolkits like that available from the BAPEN website
(bapen.org.uk), can assist with assessing the nutritional needs of
local populations and with commissioning appropriate services.
4
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Case study
2009: Mrs A, 78 years old, presented to her GP with fatigue and was diagnosed with microcytic anaemia, with ferritin undetectable. Her GP
noted an unintentional weight loss of 14 kg, but that her diet was not unusual and was not a cause of low haemoglobin. Body mass index and
percentage weight loss were not recorded. She was referred to a gastroenterologist and underwent gastroscopy and ileocolonoscopy. Findings
were normal other than the existence of a previously diagnosed hiatus hernia. The patient was happy to continue on iron supplements and for
no other tests to be pursued, and as her weight was stable, it was considered of no concern.
April 2011: Mrs A complained of recurrent abdominal pain. Further unintentional weight loss had occurred, but the amount was not
recorded. She was referred for magnetic resonance enterography, which showed narrowing of the distal small bowel. Mrs A was happy to selfmanage pain through her diet. No record was made of her weight or BMI, and despite unintentional weight loss and dietary restrictions, no
referral to the dietitian was made.
January 2012: Mrs A returned to her GP with recurrent intestinal obstruction, and was only able to manage a liquid diet. She was referred
for surgical opinion and underwent emergency laparoscopy. Due to her ‘poor nutritional state’ and likely diagnosis of Crohn’s disease, the
surgeon chose to perform a defunctioning ileostomy and planned a second-stage operation when ‘nutrition improved’. Nutrition screening at
admission to hospital and during her stay using ‘MUST’ was recorded as 2: high risk of malnutrition. Oral nutritional supplements were given
in hospital, but not continued at discharge. She was not referred to a dietitian despite a local protocol advising this. Dietary advice to manage
stoma output including food avoidances was provided on discharge by the nursing staff and surgeon, and OTC nutritional supplements were
recommended.
February 2012: 1 week post-discharge, Mrs A was visited at home by the stoma nurse due to problems with stoma leakage and stoma
formation. She was then referred to the dietitian due to concerns regarding post-operative recovery, poor nutritional status, low BMI
(17 kg/m 2) and previous significant unintentional weight loss. When seen by the registered dietitian (2 weeks post-discharge) Mrs A’s diet
history revealed suboptimal energy/dietary intake since 2007 as a result of self-imposed dietary changes to manage abdominal symptoms.
Mrs A had commenced OTC nutritional drinks as advised on discharge from hospital, and reported reasonable appetite, although easily
satiated on small portions, but was feeling ‘weak’, lacking energy, and unable to perform activities of daily living.
Dietitian’s advice
Advice was tailored according to food preferences/choices to maximise intake of macronutrients (energy and protein), and micronutrients,
without adversely affecting stoma output. Advised on increased frequency of food/snacks/nourishing drinks. Due to social circumstances,
early satiation, low BMI, weight loss, and poor nutritional status, advised on use of prescribable ONS to increase intake of all essential
nutrients. Samples were provided and merits of the various types discussed. Patient-centred nutritional goals discussed and agreed
including higher energy levels, increased dependence, improved well being, and immunity and better nutritional status to undergo second
GI operation. Further supply of preferred ONS arranged via GP on Form FP10, prescribable under the ‘ACBS’ indications ‘disease-related
malnutrition’ and ‘inflammatory bowel disease’. At review 2 weeks later, Mrs A was enjoying and tolerating two packs of low fibre ONS per
day, with nutrients from ONS additive to diet providing protein and micronutrient requirements with no suppression of appetite. She was
eating three small meals and two snacks. Positive energy balance, protein, and micronutrient requirements being met, this resulted in weight
gain of 2 kg in 2 weeks, with activities of daily living and grip strength improved. The patient was to continue following dietary advice and
ONS intake until review in a further 2 weeks.
Failed opportunities
›› Despite altered dietary intake, history of unintentional weight loss, and subsequent low BMI, no formal nutritional screen was
undertaken until the most recent hospital admission
›› Dietary advice and/or referral to a registered dietitian was not provided in primary or secondary care during a 4-year period despite
altered dietary intake and weight loss
›› When screening was undertaken during hospital stay, the screen failed to trigger dietetic referral despite a protocol being in place.
Learning points
Screening using a validated tool to include weight, BMI, and percentage unintentional weight loss, would have identified the declining
nutritional status and a high risk of malnutrition (‘MUST’ score of 2) on several occasions
›› A more timely and appropriate nutritional care plan and earlier use of dietetic skills would have improved nutritional status, wound
healing, well-being, and potentially permitted all surgery to be undertaken at the time of the first operation, thus avoiding the need for a
second operation with subsequent cost and risk and would have reduced the need for nursing care in the community post-operatively
›› ONS in the post-operative period was additive to dietary intake, in conjunction with dietary advice this resulted in improved nutritional
status and did not suppress voluntary intake of food.
‘MUST’=’Malnutrition Universal Screening Tool’; OTC=over the counter; BMI=body mass index; ONS=oral nutritional supplements; ACBS=Advisory Committee on Borderline Substances
14.National Institute for Health and Clinical Excellence. Nutrition support in
adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
Costing Report. Clinical Guideline 32. London: NICE, 2006. Available at:
nice.org.uk/CG32/CostingReport/pdf/English
15.Rana S, Bary J, Menzies-Gow N et al.Short term benefits of post-operative
oral dietary supplements in surgical patients. Clin Nutr 1992 11: (6);
337–344.
16.Brotherton A, Simmonds N, Bowling T, Stroud M. Malnutrition is dangerous:
The importance of effective nutritional screening and nutritional care. Clin
Risk 2011, 17 (4): 137–142.
11.Baldwin C, Weekes C. Dietary advice with or without oral nutritional
supplements for disease-related malnutrition in adults (review). Cochrane
Database of Systematic Reviews 2011; 9. Published online DOI:
10.1002/14651858.CD002008.pub4, 2011. Available at: mrw.interscience.
wiley.com/cochrane/clsysrev/articles/CD002008/frame.html
12.Elia M, Stratton R, Russell C et al. The cost of disease-related malnutrition in
the UK and economic considerations for the use of oral nutritional supplements
(ONS) in adults. Executive summary. Redditch: BAPEN, 2005.
13.The Patients Association. Malnutrition in the community and hospital setting.
2011. Available at: tinyurl.com/d89um7y. Accessed 18 March 2012.
5
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Optimising use of oral
nutritional supplements
Andrew Riley, Strategic Lead for Medicines Management at the Staffordshire
Cluster of PCTs
Introduction
››
››
››
››
››
››
The focus of this article is to examine whether there is an opportunity
to review approaches to prescribing oral nutritional supplements
(ONS) in primary care. What is clear is that overall healthcare costs
(including prescribing costs) of managing patients with previously
undiagnosed malnutrition is higher than for patients who are not
malnourished1 and yet the prescribing spend on ONS varies hugely.
pre-operative preparation of malnourished patients
dysphagia
proven inflammatory bowel disease
following total gastrectomy
short-bowel syndrome
bowel fistula.
Whether non-disease-related malnutrition is a justified use
of ONS is frequently discussed, but any ONS product that is
prescribed should be subject to review, like any other drug, and the
prescriber should continue to prescribe only if the predetermined
treatment outcome has been achieved in that individual patient.
There are a growing number of quality, innovation, productivity, and
prevention (QIPP) initiatives in primary care, which are seeking to
rationalise observed variation in prescribing and improve the clinical
effectiveness of commonly prescribed drugs and treatments.
Prescribing recommendations
The full NICE Clinical Guideline (CG) 32 from the National
Collaborating Centre for Acute Care on Nutrition support for adults
discusses improving the overall outcomes for individuals and
achieving better healthcare resource utility for the population as a
whole.2
NICE CG32 defined criteria for recognising patients at risk of
malnutrition3 and healthcare professionals should be alert to these.
There is no one group best placed to determine who would most
benefit from prescription of ONS, but GPs are the gatekeepers of
treatment on prescription and routine assessment of nutritional
status using the ‘Malnutrition Universal Screening Tool’ (‘MUST’)8
will ensure that patients at risk of malnutrition are being treated
rationally. Goal setting in the early management of patients will
optimise prescribing of ONS and improve treatment outcome.
Background
All patients who are prescribed ONS should be considered at high
risk of malnutrition, and in already malnourished elderly subjects it
may be too late to expect to improve function or quality of life or to
reduce healthcare costs simply by providing nutritional supplements
after hospitalisation. Prevention is key, and all elderly patients
should be nutritionally assessed as part of their routine care, and
appropriate intervention initiated early. 3 Latest estimates from the
British Association for Parenteral and Enteral Nutrition (BAPEN)
estimate the risk of malnutrition in adults of 80 years of age or over
at 33%.4 Additionally many older adults take multiple medications
daily, which interact with food and impact absorption, metabolism,
and excretion of nutrients. 5
Patients who exhibit any of the signs of malnourishment as defined
by NICE2 need to be actively managed and a cause for the weight
loss investigated. Patients need to be regularly assessed while on
treatment, and prescription of ONS should be considered. 2 The
prescription should be regularly reviewed according to the patients
progress, and care should be taken using food fortification outside
of a balanced dietary plan as this may supplement energy and/or
protein without adequate micronutrients and minerals, which would
be included in a dietitian plan.
In the general population, it is estimated that one in seven subjects
aged 65 years and over has a medium or high risk of malnutrition,
but the prevalence is higher in subjects living in care homes than in
those who are living in their own homes. Malnutrition predisposes
to disease, delays recovery from illness, and adversely affects body
function, well-being, and clinical outcome. 6
The NICE Costing Guide for CG32 supports the argument that
overall healthcare costs as a result of earlier identification and
appropriate management of malnutrition will be reduced in the
medium term.9 This could be achieved through service redesign
so that dietetic expertise is more easily accessed and nutritional
status is routinely recorded; this in turn will ensure that earlier
intervention occurs and patients are put on an improving trajectory
as a result of a care plan that positions ONS appropriately.
Prescribing indications
Defined treatment outcomes
The Advisory Committee on Borderline Substances (ACBS) advises
that, in certain circumstances, ONS can be regarded as ‘drugs’ and
prescribed on FP10 for medicinal purposes. The standard ACBS
indication list includes:7
›› disease-related malnutrition
›› intractable malabsorption
Rationalising prescribing of ONS should aim to move as many
patients to a ‘balanced diet’ as soon as the early treatment goals of
prescribed ONS have been achieved and the risk of malnutrition has
been reduced.
6
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Where nutritional goals have been met, ONS should be
discontinued. Patients should be closely monitored and ONS
reinstated if the patient becomes malnourished once more. Carers
should be encouraged to let GPs know when the patients ability to
eat normally has returned and the weight loss has been recovered.
This allows the ONS to be stopped, but with the reassurance
that it can always be reinstated if needed. Where patients are not
responding to treatment, referral for specialist dietetic advice should
be considered.
using the NICE Costing Template showed that the average clinical
commissioning group (CCG), which did not have a dedicated
nutritional support nurse, could expect to incur additional costs of
£122,000 per year, estimated savings of £150,000 per year, leading
to an annual estimated net saving of £28,000.10
The cost of improving the general standard of education and
training for all healthcare professionals and care workers to support
routine assessment and screening of patients needs to be considered
carefully by CCGs; this should be done alongside the wider
healthcare costs incurred as a result of patients achieving a slower
recovery and the associated medical intervention and treatment
costs.
Use of ONS in care homes
Demand for ONS by care home managers should be limited to
those indications as set out by the ACBS for which prescribed ONS
is allowed. However one of the key recommendations in the NICE
Costing Report that accompanies CG32 is that all patients being
admitted to care homes should be screened for malnutrition:9
The role of nutrition in recovery and the impact of QIPP
Adequate nutrition plays an important role in preventing the
occurrence of certain conditions (such as pressure ulcers)11 and
this is part of the QIPP Safe Care workstream.12 Data from the
West Midlands shows that there are approximately £45 million in
QIPP savings (from ‘across the board efficiency savings’ not just,
but including, suboptimal ONS prescribing) across this region
that are not being accessed because they will only be reached by
a coordinated approach between provider and commissioning
organisations. However, because the savings are not shared equitably
and the provider sees no direct financial benefit, these QIPP savings
have proved hard to reach by commissioners.
‘The assessment of care home residents that could be undertaken by
community dietitians, or referred to hospital dietitians, is also included.
This is assumed to be 20% of the population of care homes who are
malnourished or at risk. Unlike the initial screening, the assessment and
treatment of this group of patients is a cost to the NHS.’
The aim of QIPP should be to balance all the attributes and ensure
that the quality of prescribing outcomes is improved overall,
enabling access to prompt treatment with ONS for medicinal
purposes for disease-related malnutrition. This will improve the
productivity of prescribed ONS, allowing QIPP savings to be
redirected to newly screened patients who have been diagnosed with
malnutrition (or who are at high risk of developing this condition).
This is an example of how commissioners need to think differently
and consider a ‘gain sharing’ with providers, so they can use some
of the shared savings to improve the clinical infrastructure. By
opening up access to education and training they can support routine
assessment and ongoing management of malnourished patients by
community health and social care staff. NHS Midlands and East is
proposing a coordinated strategic approach to target such hard-toreach prescribing savings in a prescribing QIPP programme called
PrescQIPP (clingov.eoe.nhs.uk/prescqipp/).
Collaboration with dietitians can play a significant role in optimising
patient recovery by implementing phased dietary plans, which
appropriately position prescribed ONS alongside a balanced diet
and avoid the use of ONS for low-risk patients who can eat normally.
Care home managers should help to rationalise demand for ONS by
treating it like any other drug and administering it to the patient(s)
for whom it has been prescribed and providing concordance
feedback to dietitians.
Conclusion
Medicines optimisation is a new process, which focuses on a patient’s
ability to use prescribed treatments optimally; redefining ONS as
a prescribed drug treatment offers an opportunity for its use to be
reconsidered.
Nurse prescribing
Community Partnership Trusts have nurse prescribers and dietitians
who are competent to manage ONS prescribing on behalf of GPs,
to enable management of escalating prescribing costs. Savings that
accrue from a more proactive approach, including withdrawal of ONS
when appropriate, can be used to increase the capacity of funding to
treat more patients from the same budget.
A review conducted in 2009 revealed a lack of evidence to support
interventions designed to improve nutritional care, in particular with
reference to their effects on nutritional and clinical outcomes and
costs. The authors concluded that, ‘Screening alone may be insufficient
to achieve beneficial effects and thus more research is required to determine
the most cost-effective interventions in each part of the nutritional care
pathway, in a variety of healthcare settings and across all age ranges, to
impact upon nutritional and clinical outcomes’.13 Best practice examples
are improving the understanding of the therapeutic uses of ONS and
how it can prevent morbidity and the associated spiralling costs.
The NICE Costing Report recommends that:9
›› all healthcare professionals who are directly involved in patient
care should receive education and training, relevant to their post,
on the importance of providing adequate nutrition
›› screening for malnutrition and the risk of developing it should be
carried out by healthcare professionals with appropriate skills and
training.
The objective of the NICE guidance is to improve detection and
treatment of malnourishment. Malnourished patients access health
services more often, and when admitted to hospital have more
complications, longer inpatient stays, and higher mortality rates. It
is logical to assume that if a patient’s nutritional status is improved
then savings will arise; however, the level of savings is very difficult to
predict.
Therefore service redesign plans need to factor-in the additional
costs of improving access to dietitians, recruiting specialist
nutritional nurse expertise, and expanding access to education
and training for all healthcare professionals directly involved in
caring for patients at risk of malnutrition. A sample calculation
7
APPROPRIATE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS
Key points
›› ONS can be prescribed as ‘drugs’ in line with the classification laid down by the ACBS
›› Patients need to be regularly assessed while on treatment—the prescription should be reviewed according to the patient’s progress
›› The NICE Costing Guide for Clinical Guideline 32 supports the argument that overall healthcare costs as a result of earlier identification
and appropriate management of malnutrition will be reduced in the medium term
›› The goal should be to seek more efficient use of resources thus allowing QIPP savings to be redirected to newly screened patients with
malnutrition (or who are at high risk of malnutrition)
›› Service redesign plans need to factor-in the additional costs of improving access to dietitians, recruiting specialist nutritional nurse
expertise, and expanding access to education and training for all healthcare professionals directly involved in caring for patients at risk of
malnutrition
›› Costs of training and education need to be considered alongside the wider healthcare costs incurred as a result of patients achieving a
slower recovery and the associated medical intervention and treatment costs
›› A multidisciplinary team, including nurse prescribers and dietitians, enables a more proactive approach to prescribing ONS and early
prescribing to avoid malnutrition in those at high risk. It also enables routine review of ONS, especially institutional use, which can be
outside of ACBS guidelines and may result in wastage and poor outcomes
›› QIPP is a balanced approach to improving Quality while allowing Innovation in service delivery, Prevention of disease, and improved
Productivity in the use of NHS resources. Medicines optimisation aims to improve the quality of treatment outcomes associated with
the use of prescribed medicines, and ONS should be considered alongside other medicines. Their use needs to be better focused for good
treatment outcomes to be achieved as a direct ‘cause and effect’ of their use for medicinal purposes.
ONS=oral nutritional supplements; ACBS=Advisory Committee on Borderline Substances; QIPP=quality, innovation, productivity, and prevention
It should also be noted that savings will not be immediate; they will
require full implementation of the assessment, screening, treatment,
and training across primary and secondary care to deliver maximum
benefit.
5. Visvanathan R, Chapman I. Undernutrition and anorexia in the older person.
Gastroenterol Clin N Am 2009; 38: 393–409.
6. Elia M. The ‘MUST’ report: Nutritional screening of adults: a multidisciplinary
responsibility. Executive summary. Redditch: BAPEN, 2003. Available at:
bapen.org.uk/pdfs/must/must_exec_sum.pdf
7. NHS Business Services Authority. Electronic Drug Tariff. Section XV. Available
at: www.ppa.org.uk/edt/April_2012/mindex.htm
8. Malnutrition Advisory Group of BAPEN. The Malnutrition Universal
Screening Tool ‘MUST’ tool. Revised version 2010. Available at: www.bapen.
org.uk/must_itself.html
9. National Institute for Health and Clinical Excellence. Nutrition support in
adults: oral nutrition support, enteral tube feeding and parenteral nutrition.
Costing Report. Clinical Guideline 32. London: NICE, 2006. Available at:
nice.org.uk/CG32/CostingReport/pdf/English
10.National Institute for Health and Clinical Excellence. Nutrition support in
adults: oral supplements, enteral and parenteral feeding. Costing template.
Clinical Guideline 32. London: NICE, 2006. Available at: guidance.nice.org.
uk/CG32/CostingTemplate/xls/English
11.National Institute for Health and Clinical Excellence. Pressure ulcers: The
managemenet of pressure ulcers in primary and secondary care. Clinical Guideline
29. London: NICE, 2005. Available at: guidance.nice.org.uk/CG29/
NICEGuidance/pdf/English
12.Department of Health. QIPP Workstreams. Available at: dh.gov.uk/en/
Healthcare/Qualityandproductivity/QIPPworkstreams/DH_115447
13.Weekes C, Spiro A, Baldwin C et al. A review of the evidence for the impact
of improving nutritional care on nutritional and clinical outcomes and cost.
J Hum Nutr Diet 2009; 22 (4): 324–335.
Declaration of interest
The author has no conflicting interests and wishes to donate his
honorarium for writing this article to the Alzheimer’s Society.
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