Health (Nutrition)

Economics

&

Disease Related

Malnutrition

Karen Freijer (nutritionist/dietician)

Health Economics Manager

PhD (student) Maastricht University

H

ECONOMICS

A

L

T

H

- How can I improve my ability to

treat/manage my patients?

- How confident am I in the evidence?

- Can we afford to do it?

- Can we afford not to do it?

- Impact on key performance indicators

- Length of Stay / Infections / Care of

Elderly / chronic diseases / Enhanced

Recovery

- What will the impact be for me?

- How can we help my budget holder to say

yes?

Healthcare professional

Content

• Malnutrition (undernutrition)

• Medical nutrition

• Health Economics

• Health Economics & medical nutrition

- NL

- Other European countries

• Health economics & Nutrition economics

• Conclusions & Questions

http://www.medicalnutritionindustry.com

Malnutrition

Mortality & muscle mass (protein depot)

Fasting in healthy people

Fasting in illness

Relationship muscle mass & mortality1

less-no adaptation catabolism

increase rest metabolism

increase need protein & energy – breakdown muscle mass

adaptation metabolism

reduction rest metabolism

energy through breakdown fat mass

1. Sauerwein HP et al. Ned Tijdschr Geneeskd 1999: 143; 886-889. [Dutch].

healthy: death after approx. 70 days

ill: death after approx. 28 days

Loss of muscle mass

> 40% = death

The ‘hidden’ problem of DRM

Disease related malnutrition

has far-reaching consequences

Impaired ability

to fight infection

Apathy, depression,

reduced QOL

Impaired wound

healing

Increased morbidity

and mortalityMore GP visits and

hospital admissions

Reduced ability to work,

shop, cook, self-care

Reduced muscle

strength, fatigue,

mobility

Stratton RJ, Green CJ, Elia M. Disease-related Malnutrition: An Evidence based

Approach to Treatment, 1st Ed., Oxford: UK CABI Publishing; 2003.

Clinical & economic consequences

1. Ljungqvist O, de Man F. Nutr Hosp 2009; 24:368-70.

In Europe:

33 million people1

In Europe:

€170 billion per year1

Those elderly at risk:

About 1 in 3 in hospitals

1 in 3 in care homes

1 in 3 living independently

Prevalence of DRM

Almost 1 in 5 children admitted to

hospital at risk

Malnutrition affects people of all ages

References on elderly :Russell C & Elia M. Redditch, BAPEN. 2008. Russell C & Elia M. Redditch, BAPEN. 2009;

Russell C & Elia M. Redditch, BAPEN 2011.Russell C & Elia M. Redditch, BAPEN. 2012. Imoberdorf R et al.

Clin Nutr 2010; 29(1):38-41. Kaiser MJ et al. J Am Geriatr Soc 2010; 58(9):1734-1738. Vanderweek et al.

J Adv Nurs 2011; 67(4):736-746. Suominen MH et al. Eur J Clin Nutr 2009; 63(2):292-296. Lelovics Z et al.

Arch Gerontol Geriatr 2009; 49(1):190-196. Parsons EL et al. Proc Nutr Soc 2010; 69:E197.

Reference on children: Joosten KF et al. Arch Dis Child 2010; 95(2):141-145.

Medical Nutrition

Management of malnutritionwww.fightmalnutrition.eu

• Early identification is key to effective management of

malnutrition

• Screening using validated tools should be routine practice

• A range of strategies can be used to manage malnutrition,

e.g. dietary advice and /or medical nutrition

*Based on the ESPEN definition.

Lochs H et al. Clin Nutr 2006; 25(2):180-186. 2.

Department of Health Services Research

• Chemical entities

• In general 1 compound

tested in clinical trials

(phase I-IV: safety,

efficacy)

• European registration

(EMEA)

• For patients use; part of

total medical treatment

(medical supervision)

• Usually reimbursed

• Nutrients

• In general combination

of nutrients tested in

clinical trials (safety,

tolerance, efficacy)

• National registration/

notification

• For patients use; part of

total medical treatment

(medical supervision)

• Frequently reimbursed

• Normal food

• In general NOT tested

in clinical trials

•No registration

• For (healthy)

consumer use

•Not reimbursed

Food/nutrition Medical Nutrition Pharma products

Differences

Activity

Quality of life

Independence measures

Medicalnutrition

Evidence

Economic

benefits?

Nutritional

benefits

Functional

benefits

Clinical

benefits

Complications

Length of stay

(re)admission

Stratton RJ et al. Wallingford: CABI Publishing; 2003.

MNI report ONS 2012 –http://www.medicalnutritionindustry.com

Cawood et al. syst review 2012;Stratton RJ et al. syst review 2013

Health Economics

Scarcity

Choices

Health economics

Value

A set of techniques

that attempt to

allocate limited

health care

resources among

unlimited wants

and needs to

achieve the

maximum health

benefit

Definition Health Economics

WHOSE PERSPECTIVE?

the maximum health gain per euro (value for money)

Value for money

Basic concepts

Cost of illness

Decisionmaking

Budget Impact

Economic evaluation

Cost-benefit

Cost-effectiveness

Cost-utility

(Cost-minimization)

Cost of illness

What happens to the patient and how often?

Health care journey of patient with DRM

Cost of DRM in Netherlands

• Ad

Costs DRM higher than costs of

obesity

DRM

resource use

hospitalisation

Prevalence

DRM (hospital,

residential

&nursing

home, home

care)

Costs by

diseases(ICD-9-CM)

Freijer K. et al. Clinical Nutrition 2013 ;32: 36-141

Men Women Total

Age >18 and <60 > 60 >18 and <60 > 60 All ages

Hospital setting 188 424 184 437 1,233

Nursing- and

residential home

setting

9 107 6 331 453

Home care

setting

6 43 9 126 185

Total 203 574 200 894 1,871

Table: Total additional costs of disease related malnutrition according to gender, age

and healthcare sector * 1,000,000 (Euro 2011)

Freijer K. et al. Clinical Nutrition 2013 ;32: 36-141

Cost of DRM in Netherlands

Cost effectiveness

A: No medical nutrition

B: medical nutrition

Effectiveness+

Willingness

to pay

-

Costs

+

-

Cost effectiveness plane

Perspectives and silos

Government

Health Insurers

Health care institutions:

Hospital

Nursing home

Home care

WHOSE PERSPECTIVE?

Rutten-van Molken M. Van kosten tot effecten: een handleiding voor

evaluatiestudies in de gezondheidszorg. second edition, Elsevier gezondheidszorg:

Maarssen; 2010 [Dutch]

Type of costs - resource use

Safety EffectivenessCost

Effectiveness

Different stakeholders need different

evidence

Reimbursement

Authorities

Registration

Authorities

Medical

Community

Payers

HE & DRM & Medical

Nutrition

Cost effectiveness oral medical

nutrition

• AdPrevalence

DRM

(abdominal

surgery

patients)

Freijer K. et al EJCN 2010; 64: 1229-1234

Abdominal surgery patients

No ONS

ONS

7-10 days 7-10 days

Cost effectiveness oral medical

nutrition

• Ad

Difference

use ONS –

no use

ONSresource use

ONS &

hospitalisation

Prevalence

DRM (abdominal

surgery

patients)

Freijer K. et al EJCN 2010; 64: 1229-1234

Base case:

- DRM 30%

- LOS 8 vs 10,4 days

- ONS 2 bottles/day

(€2.19/bottle)

- ONS duration 17 days

Cost effectiveness oral medical

nutrition

• Ad

Difference

use ONS –

no use

ONSresource use

ONS &

hospitalisation

Prevalence

DRM (abdominal

surgery

patients)

Freijer K. et al EJCN 2010; 64: 1229-1234

Cost effectiveness oral medical

nutrition

• Ad

Difference

use ONS –

no use

ONSresource use

ONS &

hospitalisation

Prevalence

DRM (abdominal

surgery

patients)

Total

prevalence

patient

group

(160.283/year)The additional costs of ONS

are more than balanced by a

reduction of hospitalization

costs

Freijer K. et al EJCN 2010; 64: 1229-1234

* €1000

€ 57.335 €70.321

Revenues

Budget Impact ONS community

Freijer K. et al Front. Pharmacol. 2012.

.......

Effect use

ONS – no

use ONS on

DRM

ONS & DRM

((re)hospitali-

sation

Prevalence

& costs of

DRM (community

dwelling

elderly)

Costs of DRM

(2 bottles/day

3 months)

25% less

(re)hospitalisation

Reduction costs DRMTotal

prevalence

patient

group

Budget Impact ONS community

Freijer K. et al Front. Pharmacol. 2012.

.......

Effect use

ONS – no

use ONS on

DRM

ONS & DRM

((re)hospitali-

sation

Prevalence

& costs of

DRM (community

dwelling

elderly)

Total

prevalence

patient

group

The additional costs of ONS

are more than balanced by a

reduction of hospitalization

costs

Publication Patients Results Conclusion

Freijer K, et al.

Eur J Clin Nutr

2010

Virtual cohort of patients

with DRM undergoing

abdominal surgery (≥18

years)

Per patient: €252 cost saving

(7,6% savings)

Per annum: €40,4 million cost saving

Cost-saving

Freijer K, et al.

Front Pharmacol

2012

Virtual cohort of community

(residential and home care)

dwelling elderly (>65 years)

with DRM

The use of ONS reduces costs from

€275,643 million to €262,657 million, i.e.

cost saving of €12,986 million (4,7%

savings)

Cost-saving

Neelemaat F, et

al. Clin Nutr

2012

Elderly patients (≥60 years)

with DRM admitted to

hospital and followed for 3

months after discharge

ICER for functional limitations: -€618.Cost-

effectiveness acceptability curves: €6,500

investment is necessary to reach 95%

chance of improvement of functional

limitations (threshold of €20,000).

Cost-effective

re improving

functional

limitations

Rypkema G, et

al. J Nutr Health

Aging 2003

Patients (>60 years) with

DRM admitted to geriatric

wards in two hospitals

ICER total costs (net costs): - €392/kg

weight gained (€56/kg weight gained) with

Max Willingness to pay of €530/kg gained

(€38-105/kg gained) (95% CI).

Cost-effective

re weight gain

Wyers CE, et al.

Osteoporos Int

2012

Elderly (≥ 55 years) hip

fracture patients admitted

for surgical treatment and

followed for 3 months after

surgery;

ICER for total societal costs was €241/kg

weight increase (high probability of being

cost-effective)

Cost-effective

re weight gain

Economic evaluations medical nutrition

NL1

1. Freijer et al JAMDA 2014; 15: 17-29

Economic evaluations medical

nutrition NL1

Additional costs DRM* 1,000,000 (Euro 2011)

Setting Additional

costs

Hospital 1,2

Residential &

home care

(>65 years)

276

Cost-savings by using medical

nutrition

1. Freijer et al JAMDA 2014; 15: 17-29

Publication Patients Results

Freijer K, et al. Eur

J Clin Nutr 2010

Virtual cohort of

patients with DRM

undergoing

abdominal surgery

(≥18 years)

7,6% cost savings

Freijer K, et al.

Front Pharmacol

2012

Virtual cohort of

community

(residential and

home care)

dwelling elderly

(>65 years) with

DRM

4,7% savings

€92

€13

Overview HE in Europe

Economic consequences of malnutrition

1. Elia M & Russell C. Redditch, BAPEN. 2009; 2. House of Commons Health Committee. 2004; 3. Cepton. Munich. 2007.

4. Freyer K et al. Clin Nutr 2013; 5. Rice N & Normand C. Pub Health Nur. 2011.

Country Costs of

malnutrition

Note

UK1 €15 billion Public expenditure on malnutrition in

2007

Germany3 €9 billion Additional costs due to malnutrition

across all care sectors in 2003

The

Netherlands4

€1.9 billion Additional costs due to malnutrition in

2011

Republic of

Ireland5

€1.4 billion Public expenditure on malnutrition in

2007

Financial benefits medical nutrition

Milte RK et al. European Journal of Clinical Nutrition (2013) 67, 1243–1250

Freijer K et al. JAMDA (2014) 15, 17-29

Database analysis of around 20% of all US hospital admissions between

2000 and 2010

......700,000 hospital episodes of adult patients using ONS

......matched with 44 million non-ONS inpatient episodes .

Using Propensity Scoring they produced otherwise comparable groups -

only differing on their ONS use. Comparing the two they found ONS

patients did better….

Cost of ONS = $88

Length of Stay - reduction of 21% (2.3 days)

Readmission in 30 days – reduction of 6.7%

Cost Savings per inpatient stay - $4734

Invest $1

Return $50

T.J. Philipson, Am J Manag Care. 2013;19(2):121-128)

Financial benefits of oral medical

nutrition in hospital

Health economics

&

Nutrition economics

Economic evaluations - guidelines

Country specific

• Study design

• Study population

• Choice of comparator

• Perspective

• Data collection procedure

(alongside clinical trial or

modeling)

• Discounting (time-frame)

General

• Hard clinical outcomes which

can be valued, e.g.

LOS, Complications, (re-) admissions to

health institutions, QoL

• More real world evidence

Guidelines for pharmacoeconomic

evaluations

www.ispor.org

Various checklists:

• Drummond et al.o Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for

the Economic Evaluation of Health Care Programmes. 3rd edn. (Oxford University

Press: Oxford, UK, 2005.

o Drummond M, Manca A, Sculpher M. Increasing the generalizability of economic

evaluations: recommendations for the design, analysis, and reporting of studies. Int J

Technol Assess Health Care 2005;21:165–71.

• QHES Ofman JJ, Sullivan SD, Neumann PJ, et al. Examining the value and quality of health economic

analyses: implications of utilizing the QHES. J Manage Care Pharm 2003; 9: 53-61.

- ........

Quality HE studies medical nutrition

(Medical) Nutrition/food Medicines/drugs

Energy (KH, Fat), Construction (Protein),

vit, min

Nutrients focus on multiple

fysiological systems,

safety has been proven

(Medical) Nutrition

Novel synergistic combinations of

nutrients

Pharma

(New) Chemical Entity

(one compound)

Focus on single intervention, adverse

events

Nutrition economics within HTA

Freijer K. Nutrition Economics: DRM & Economic value of medical nutrition-Thesis 2014

Specific characteristics of medical nutrition do have implications for the interpretation

of the evidence available for a valid and reliable health economic evaluation. The

consensus reached, as well as suggestions to further elaborate the appropriate

methodology for resolving the identified issues in study design, in conduct and in

interpretation allowing a better evaluation of the overall benefits of medical nutrition,

are reported here.

Nutrition economics - International expert meeting

Health economics for medical nutrition in disease related malnutrition –

what are the challenges?

Karen Freijer1*, Irene Lenoir-Wijnkoop2, Christine A. Russell3, Marc A. Koopmanschap4, Hinke M. Kruizenga5, Stefan K. Lhachimi6, Kristina Norman7, Mark J.C. Nuijten8, Jos M.G.A. Schols9

Freijer K. Nutrition Economics: DRM & Economic value of medical nutrition-Thesis 2014: Manuscript submitted for publication

Link to ISPOR

• End 2013 - Special Interest Group “Nutrition Economics”

founded within ISPOR

• Already 25 persons from several universities and medical

nutrition industries have shown their interest of becoming a

member

• Goals SIG: Multidisciplinary group

to investigate methodological issues &

concepts

to develop & provide scientific guidance

in field of Nutrition Economics incl.

epidemiology

SIG “Nutrition Economics”

Conclusions

Medical Nutrition economics

• Costs of Medical Nutrition are a small proportion of healthcare

budgets

– 1-3% in Europe

• Biggest cost is due to the consequences of undernutrition

– Hospital (re-)admissions and LOS

– Complications (e.g. infections)

– Healthcare professionals

– Medical treatments

Biggest Cost is the Consequence of

Untreated Condition, Not Its Management

Enteral Medical Nutrition - a part of the cost

containment solution

Reduced mortality

Reduced complications

Better recovery

Shorter ICU stay

Shorter hospital stay

Fewer hospital (re)admissions

Integrating enteral medical nutrition can deliver…

Maximum health

… Optimal (minimize) costs of care

- How can I improve my ability to

treat/manage my patients?

- How confident am I in the evidence?

- Can we afford to do it?

- Can we afford not to do it?

- Impact on key performance indicators

- Length of Stay / Infections / Care of

Elderly / chronic diseases / Enhanced

Recovery

- What will the impact be for me?

- How can we help my budget holder to say

yes?

Healthcare professional

PhD thesis outline

Economic burden

(Chapter 2)

Cost-effectiveness of

medical nutrition in

management

(Chapter 3, 4 & 5)

Issues in health

economics for medical

nutrition

(Chapter 6)

DRM

PhD thesis Contents• Chapter 1: General introduction

• Chapter 2:

The total additional costs of managing adult patients with DRM were estimated to

be €1.9 billion in 2011 which equals 2.1% of the total Dutch national health

expenditure and 4.9% of the total costs of the health care sectors analyzed in this

study.

PhD thesis Contents

• Chapter 3:

The use of ONS reduces the costs with a €252 (7.6%) cost saving per patient. The

hospitalization costs reduce from €3,318 to €3,044 per patient, which is a 8.3% cost

saving and corresponds with 0.72 days reduction in length of stay. The use of ONS

would lead to an annual cost saving of a minimum of €40.4 million per year.

PhD thesis Contents

• Chapter 4:

Using ONS for the treatment of DRM in community dwelling elderly, leads to a total

annual cost savings of € 13 million (18.9%savings), when all eligible patients are

treated.

The additional costs of ONS (€57million) are more than balanced by a reduction of

other health care costs, e.g. re-hospitalization(€70million).

PhD thesis Contents

• Chapter 5:

Managing several patient populations suffering from or at risk of DRM in different

health care settings with enteral medical nutrition, seems to be an efficient

intervention from a health economic perspective, in most cases even leading to cost

savings.

PhD thesis Contents

• Chapter 6:

Specific characteristics of medical nutrition do have implications for the interpretation

of the evidence available for a valid and reliable health economic evaluation. The

consensus reached, as well as suggestions to further elaborate the appropriate

methodology for resolving the identified issues in study design, in conduct and in

interpretation allowing a better evaluation of the overall benefits of medical nutrition,

are reported here.

Nutrition economics - International expert meeting

Health economics for medical nutrition in disease related malnutrition –

what are the challenges?

Karen Freijer1*, Irene Lenoir-Wijnkoop2, Christine A. Russell3, Marc A. Koopmanschap4, Hinke M. Kruizenga5, Stefan K. Lhachimi6, Kristina Norman7, Mark J.C. Nuijten8, Jos M.G.A. Schols9

PhD thesis Contents

• Chapter 7: General discussion

Fig 1 Nutrition economics within health economics

PhD thesis Key Messages

Nutrition is a fundamental human need and has a vital role in the

effective management of many health conditions

Disease Related Malnutrition caries a heavy burden on individuals and society;

Costs of DRM account for roughly 2% of total Dutch Health Care costs, most of

which is bourne iby hospitals and in the management of the elderly

The costs of ONS in the management of DRM in community dwelling elderly

were more than balanced by a reduction in the use of health care resources,

decreasing the costs of DRM

The use of enteral medical nutrition in the management of DRM can be efficient

from a health economic perspective, leading in most cases to costs savings

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6 Medical Nutrition deserves different rules for Health Technology

Assessment

The use of ONS in the management of DRM in hospitals is cost effective and

even cost saving