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
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