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 aimed to establish if ONS was being used appropriately in general practices, in line with NICE Guidelines. This enabled identification of patients who required review of their ONS prescriptions.

Methods
A dietitian-led service was commissioned to review ONS patients in 15 GP practices. Searches were run at participating practices to identify patients who required a review of their ONS prescriptions. Those who were not already under the care of the existing dietetic service were identified. General practice records were reviewed for information required to support management of malnutrition in adults, including the reason for ONS prescribing. Where records suggested potentially high clinical risk, further assessment was undertaken in clinic by the dietitian.

Results
Of the 624 patients being prescribed ONS 64% were not under the care of existing dietetic services. Of these, all patients did not have clearly documented indications for ONS or nutritional care plans with clear treatment goals (as recommended by NICE (2012) malnutrition guidelines. Figure 1 shows how patients were screened and reviewed. 89 patients (to date) have been seen in clinic and 86 have had a BMI calculated (alternative measurements where needed). Of these, 54 had a BMI in the healthy weight range, 20 were underweight, 9 overweight and 3 obese.
Overall, 268 patients had their ONS prescription completely stopped, 23 reduced or switched to a more cost effective product, 2 were increased/switched to more expensive (safer) products and 4 had no change made. All patients seen in clinic had an up-to-date BMI (or alternative measurement) documented along with a nutritional care plan and treatment aim.

Discussion
It appears that there may be large numbers of patients in primary care who do not have sufficient information documented within their medical records to enable review of ONS in line with national guidance. It is unclear whether those patients who were not underweight who had ONS prescribed were due to correction of previous malnutrition and that ONS had simply continued without review, or whether ONS had been inappropriately initiated without dietetic input.

Conclusion
Training may be needed in primary care to better support general practice in the management of patients with malnutrition and/or appropriate with prescribing of ONS and/or awareness of dietetic services.