Cost-effectiveness of oral nutritional supplements in older malnourished care home residents1
Article: Elia M et al. Clinical Nutrition 2017;1-8
Disease-related malnutrition is a common and costly problem and is associated with poor clinical outcomes. In care homes, disease-related malnutrition predisposes residents to infections, pressure ulcers and a greater number of days in bed, with detrimental effects on quality of life. Malnutrition is a particular problem in care homes as the prevalence of malnutrition generally increases with age. With this in mind it is surprising that there is limited information within the care home setting about the effect of nutritional interventions, such as oral nutritional supplements (ONS) or dietary advice, on outcomes such as quality of life. Furthermore, cost effectiveness of nutritional interventions through quality of life (QoL) analyses have rarely been reported.
This pragmatic randomised trial compared the cost-effectiveness of ONS to dietary advice alone for maintaining quality of life in care home residents in England.
Method (adapted from Parsons E et al., 2017)2
An incremental cost-effectiveness analysis was undertaken prospectively in 104 malnourished, care home residents (medium + high risk), identified using the Malnutrition Universal Screening Tool ('MUST'), (mean age 88.5 ± 7.9y) who were randomised to receive either dietary advice by a dietitian (n=51) or ONS (N=53) for 12 weeks. Dietary intake was measured using 24 h dietary recall, and QoL was assessed using EuroQol (EQ-5D), a scale which patients complete stating their ability to carry out activities which may enhance quality of life as well as including time trade off (TTO) and visual analogue scale (VAS) for self-perceived health.
This pragmatic randomised trial looked at ready-made ONS compared with dietary advice, specifically concentrating on resources use, cost, and quality adjusted life years (QALYs) and involved one of the oldest groups of individuals ever subjected to a cost-utility analysis.In the ready-made ONS group of participants, the mean cost per QALY was found to be £9875, which is substantially lower than the thresholds that NICE deem to be cost effective (£20,000-£30,000). It was also demonstrated that the amount of considered years in perfect health were significantly higher in the group receiving ready-made ONS.
- Malnourished, elderly care home residents had more QALYs when they received ready-made ONS compared to when they received dietary advice alone
- Ready-made ONS are cost effective relative to dietary advice alone in this population and setting
This cost-utility analysis adds to the limited available information on cost per QALY in care homes. In summary, this study suggests that the use of ready-made ONS in care home residents can be cost effective relative to dietary advice (improved QoL and gains in QALY’s at a cost that is within the generally acceptable range for ‘willingness to pay’).These results can be used to highlight to payers the cost effectiveness of ready-made ONS so that they can then make informed decisions in managing and funding effective treatments.
Glossary of terms:
QALY’s- Generic measure of disease burden, including both the quality and quantity of life lived. One QALY equates to one year in perfect health
EuroQol – Questionnaire to measure generic health status
Time trade off– tool used to determine quality of life by requesting patients state if they would rather live less years in a better state of health
Visual analogue scale – psychometric response scale used in questionnaires to capture attitudes which cannot be directly measured