Lisa-Jayne El-Sour explains how a Warwickshire initiative highlighted the importance of assessing nutritional status and reviewing prescribed treatments for malnutrition
Malnutrition can be defined as: ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, and composition) and function and clinical outcome.’1 It should be noted that for the purposes of this article, the term malnutrition is used to refer to undernutrition. Although there is currently a significant focus on the obesity epidemic, malnutrition is still commonplace in the UK. It is estimated that over 3 million adults are malnourished, costing the NHS £13 billion each year.2 It is therefore essential that malnutrition is identified and treated effectively.
There is evidence that prescribed oral nutritional supplements (ONS) are of benefit to malnourished patients;3 however, there is also concern that the use of these products is increasing and that they are not always prescribed appropriately.4 This results in unnecessary expense for the NHS and, potentially, impacts on patient safety.
Prescribing of ONS in Warwickshire
In 2011, the population of Warwickshire was estimated to be 546,600, having increased by 2.5% since 2008; however, during this intervening period the cost of ONS prescriptions rose by a total of 26% (see Figure 1). It is projected that the local population will rise to 658,900 by 2035, with the largest increase occurring in people aged over 65 years.5 Older people are at higher risk of malnutrition,6 suggesting that the cost of treating this condition in Warwickshire could increase exponentially.
In 2010, a full-time Medicines Management Dietitian was employed, with the aim of addressing malnutrition in the community and ensuring appropriate use of ONS. This article describes the work that has been undertaken so far and the impact that this has had on ONS prescribing.
|Figure 1: Expenditure on oral nutritional supplements prior to and following employment of a Medicines Management Dietitian|
Identification of malnutrition
Early identification is key to the effective management of malnutrition. By monitoring patients at risk, appropriate actions can be taken early, thus reducing the risk of developing the adverse consequences associated with malnutrition and decreasing the need for ONS. NICE Clinical Guideline 32 on nutrition support recommends that screening should be carried out in care homes and in general practice surgeries and that this should include assessment of body mass index (BMI) and weight loss.3
Audits undertaken in GP practices across Warwickshire by the Medicines Management Dietitian revealed that screening for malnutrition prior to initiation of ONS was often not performed (see Figure 2). Of the 420 audited prescriptions:
- 48% were started following an assessment of weight
- 30% were started following an assessment of BMI
- weight loss was recorded for 34% of prescriptions
- the use of a nutrition screening tool score was recorded in only 5% of cases.
Assessment of nutritional status not only identifies malnutrition, but also sets a baseline figure to assist with monitoring patient progress and to determine whether the ONS prescription is effective. To ensure consistent and accurate assessment, the Malnutrition Universal Screening Tool (MUST; www.bapen.org.uk)7 is now being used across Warwickshire, in both primary and secondary care. The Warwickshire Dietetic Department provides MUST training to healthcare professionals and care-home staff across the county. Patients at risk of malnutrition, such as older people and people with long-term conditions, should be at a higher priority for screening.
|Figure 2: The percentage of prescription records that included evidence of assessment prior to initiating an ONS prescription|
Treatment of malnutrition
A nutrition pathway to ensure consistent and effective treatment of malnutrition, and which encompasses both primary and secondary care, has been developed for Warwickshire. The pathway details the procedure for identifying malnutrition and the appropriate dietary treatment, depending on risk category, A ‘food-first’ approach is encouraged before considering ONS. A local set of guidelines was produced for primary care that fits within this nutrition pathway. The Guidelines for the use of prescribable oral nutritional supplements detail the appropriate treatment of malnutrition, which may or may not include the use of ONS (see Figure 3).
Dietary advice is a crucial element of managing malnutrition; however audits carried out by the Medicines Management Dietitian showed that this was only given at the same time as 36% of ONS prescriptions. A set of patient information leaflets was therefore written for use alongside the guidelines to ensure that patients receive appropriate dietary advice to aid improved nutritional status. These resources have been made available to all community teams, including GP practices.
A second set of guidelines was created to improve nutrition within care homes: Guidelines for the management of malnutrition in care homes provides recommendations on nutritional screening and dietary interventions appropriate to an individual’s risk of malnutrition. The dietary interventions focus on the provision of ordinary foods, such as snacks containing more than 200 calories per portion and nutritious drinks, and fortifying meals with high-calorie ingredients. The guidelines are provided to care homes with a training package to ensure they are effectively implemented. As of October 2012, 48 of the 194 nursing and residential homes in Warwickshire have received the guidelines and appropriate training.
Prescriptions of ONS
Patients found to be at risk of malnutrition and who have not responded to dietary treatment may be considered for ONS. To ensure that the prescription of ONS is appropriate, the local guidelines recommend consideration of:
- treatment goals
- prescribing indication
- taste preferences
- when to review the patient.
Agreement of treatment goals is important, not only for the prescriber who will be able to discontinue the prescription when the target is met, but also for the patient, who will understand that the prescription is (in most cases) a short-term treatment option. It is also important to consider whether the prescription meets one of the prescribing indications for ONS set by the Advisory Committee on Borderline Substances (ACBS). These are:8
- short-bowel syndrome
- intractable malabsorption
- pre-operative preparation of undernourished patients
- proven inflammatory bowel disease
- following total gastrectomy
- bowel fistula
- disease-related malnutrition.
Most patients in the community who are prescribed ONS fall into the category of disease-related malnutrition, but, as shown by the audits undertaken in Warwickshire, ONS may be inappropriately prescribed in some cases, for reasons such as fatigue, vitamin supplementation, and low body weight (not related to disease).
The local guidelines recommend prescribing a sample quantity of ONS before initiating a regular prescription to improve compliance. Milkshake-style ONS containing 1.5 kcal/ml are the most commonly prescribed as these are often preferred over the juice-style and savoury supplements and are more cost effective than 1 kcal/ml ONS. The daily dosage for ONS should be decided according to the individual, taking into consideration their risk of malnutrition, co-morbidities, appetite, treatment goals, and ability to make dietary changes.
Patients who are prescribed ONS should be monitored to:
- ensure compliance
- determine the effectiveness of the prescription
- allow the prescription to be discontinued once the treatment goal has been met (or if the prescription is no longer appropriate).
Local audits have shown that only one-third of ONS prescriptions are reviewed through regular reassessment of weight (see Figure 4,).
When reviewing ONS prescriptions during patient consultations, the Medicines Management Dietitian found many cases of poor compliance and inappropriate use, such as patients continuing to use the products despite being overweight and having a hearty appetite, or using them so infrequently that they had little impact on nutritional intake. In fact, of the 255 prescriptions that have so far been reviewed by the Medicines Management Dietitian and the practice GPs, 39% have been discontinued, highlighting the importance of reviewing ONS prescriptions.
|Figure 3: ONS prescribing pathways for initial appointment and review|
ONS=oral nutritional supplement; ACBS=Advisory Committee on Borderline Substances
Impact on ONS prescribing
Since the employment of a Medicines Management Dietitian in 2010, a definite change in expenditure on ONS has been shown (see Figure 1). Prior to 2010, expenditure increased annually by approximately 16%. During the 2010/11 financial year, expenditure increased by only 5%. The following year, expenditure decreased by 8%, a reduction in spend of almost £96,000.
The costs associated with this project include the employment of a full-time Medicines Management Dietitian and travel expenses. The cost of developing resources, such as patient information leaflets, were met by the Warwickshire Dietetic Department and the Medicines Management Team.
It is expected that ONS expenditure in Warwickshire will rise in line with increasing product cost and population. However, this increase can be mitigated through appropriate prescribing. It is also expected that savings will be made through the minimisation of risks associated with malnutrition, such as reduced consumption of health resources and hospital admissions.4 As yet, due to the infancy of the project and difficulty accessing appropriate patient statistics, it has not been possible to prove the impact that this initiative has had in this respect, but this will be addressed by the Medicines Management Dietitian as the work progresses.
|Figure 4: The percentage of ONS prescription records that have been reviewed using weight and body mass index|
ONS=oral nutritional supplement; BMI=body mass index
The biggest challenge for this project, is the size of the county: Warwickshire has 76 GP practices and nearly 200 care homes, resulting in significant time spent training, auditing, and travelling. Changing the management of malnutrition and embedding this into practice will require the adoption of several approaches. This cannot be achieved single-handedly by a Medicines Management Dietitian, but rather as a team approach by the whole Dietetic Department. Communication and access to information still have to be addressed: staff awareness of malnutrition and appropriate prescribing of ONS needs to be raised, and resources, including the guidelines and patient information leaflets, have to be made accessible to all community teams. It is expected that financial savings will reduce with time, meaning that the project will need to prove its value in other ways, such as by improved patient safety and outcomes. This is an immediate challenge for the Medicines Management Dietitian to resolve.
Addressing the use of ONS is a massive task that requires a focus on both prevention and treatment of malnutrition. This project has developed over the past 2 years and will continue to evolve to ensure that these aims are met. The current focus of the Warwickshire Dietetic Department is the provision of ONS following discharge from hospital and the development of resources appropriate for particular patient groups known to be at risk of malnutrition (e.g. individuals with dementia and people with a history of alcohol and substance abuse). Awareness of malnutrition needs to be raised further by informing the public of the risks and consequences, encouraging self monitoring, and working with care groups to ensure people at risk of malnutrition are identified early. Patient information leaflets and training will need to be provided to achieve these goals.
In addition to addressing the use of ONS, the Medicines Management Dietitian is working with the Warwickshire Dietetic Department and the Medicines Management Team to ensure appropriate prescribing of other nutritional products, including gluten-free foods and infant formula.
- Oral nutritional supplements represent a significant impact on local prescribing budgets and are often prescribed inappropriately as a result of lack of dietetic assessment
- Investment in specific dietetic input to establish local care pathways that ensure effective assessment and dietetic advice is likely to be recouped by reduced costs from prescriptions of ONS
- Commissioners should be made aware that ONS are often provided at full cost in the community, but at low cost to hospitals to encourage brand prescribing and this possibility should be investigated
- With specific dietetic advice, food can often be recommended over ONS to the benefit of both patients and prescribing budgets
- Targeting residential care homes in terms of education and support can have a significant impact and is a suitable intervention to prioritise.
- Stratton R, Green C, Elia M. Disease-related malnutrition, an evidence based approach to treatment. Oxon: CABI Publishing, 2003.
- Elia M, Russell C. Combating malnutrition: Recommendations for action. Worcester: British Association of Parenteral and Enteral Nutrition, 2009. Available at: www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf
- National Institute for Health and Care Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. London: NICE, 2006. Available at: www.nice.org.uk/guidance/cg32
- Todorovic V. Evidence-based strategies for the use of oral nutritional supplements. Br J Comm Nurs 2005; 10 (4): 158–164.
- Warwickshire Observatory website. Population estimates. www.warwickshireobservatory.org/observatory/observatorywcc.nsf/refdocs/EBSH-72CHDY (accessed 12 October 2012).
- 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
- BAPEN website. Introducing MUST. www.bapen.org.uk/screening-for-malnutrition/must/introducing-must (accessed 22 October 2012).
- NHS Business Services Authority website. Electronic drug tariff. Section XV. Available at: www.ppa.org.uk/edt/November_2012/mindex.htm (accessed 1 November 2012).