Abstract

Background
Malnutrition is associated with both personal (poor quality of life, increased morbidity and mortality) and financial costs, with recent estimates of the cost of malnutrition exceeding £19 billion (NHS England, 2015). Oral nutritional supplements (ONS) are nutritionally dense products regularly prescribed to treat malnutrition (NICE 2012). A pilot audit within Sunderland CCG demonstrated that ONS were not being prescribed within NICE guidelines despite costs for ONS increasing annually. This in an evaluation of a dietetic service commissioned by Sunderland CCG to promote optimisation of the use of ONS for patient care.

Methods
A dietitian-led service was commissioned to review ONS patients in GP practices. 398 patients (57% female; mean age 70) on ONS from 15 practices who were not already under the care of a dietitian had their suitability for ONS reviewed in line with NICE (2012) guidelines. As a result of these reviews, patients were either invited to clinic for a more thorough assessment with the dietitian or their ONS was stopped. Patients who were seen in clinic (n=89) received dietary and ONS advice and where necessary followed up in further clinics until stable. Spend on ONS was assessed using NHS prescription services data, using total actual cost of ONS prescribing per practice. Other key outcome measures collected included Body Mass Index (BMI) and patient satisfaction (Friends and Family test). Differences between before and after mean BMI scores for patients with complete data sets (n=40) were analysed using a paired samples t-test; the level of significance was 0.05.

Results
Financial data is shown in Figure 1 for GP Practices where dietetic reviews have started (n=14) and where there hasn’t yet been any dietetic reviews (n=37). There was no significant difference in BMI from baseline (M = 20.7, SD = 3.9) to follow-up (M = 20.8, SD = 3.9), t (39) = 2.023 (p = 0.8; 95% Confidence Interval (CI) -0.10 to 0.29). Twelve patients returned satisfaction questionnaires. Of those responses, all were likely (3/12) or extremely likely (9/12) to recommend the service to friends or family.

Discussion and conclusion
Recent guidelines demonstrate the importance of commissioning services to ensure high quality malnutrition treatment (NHS England, 2015). Although the service evaluation design of this study does not enable us to prove causality, it does provide evidence that reducing inappropriate ONS prescribing is associated with cost savings, while having no demonstrable adverse effect on patients’ BMI. Overall patients appear satisfied with the service provided.