FCDs Reduce Spending on Prescribing - An Audit of ONS Prescribing in one PCN

An Audit of the Prescribing of Oral Nutrition Supplements 

Joe Alvarez - First contact Dietitian and Supplementary Prescriber at Shoreditch Park and City PCN (London)

Background 

As defined by the British Association for Parenteral and Enteral Nutrition (BAPEN), malnutrition is ‘ 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 functional and clinical outcomes’. Malnutrition and dehydration have significant adverse effects on health, disease and wellbeing in community, residential care and hospital settings. Malnutrition and dehydration also have a substantial impact on the NHS with increased demands on primary care services, out of hours’ services and increased rates of transfer across pathways of care. As estimated by Preqsuipp yearly cost savings of between £172 and £229 million could be made to health and social care through full implementation of appropriate pathways of nutritional care, ​(Prescquipp, 2017)​. 

Malnutrition is a common clinical and public health problem in England and individuals of all ages can have malnutrition. It is found across healthcare setting and all disease categories. The Malnutrition Universal Screening Tool (MUST) for adults is a tool to identify is someone is at risk of malnutrition ​(British Association for Parenteral and Enteral Nutrition (BAPEN), 2011)​. Using this tool, it is also estimated that 5% of the adult population of England have malnutrition. In addition, it estimated to affect about 10% of adults vising their GP and 30% of adults on admission to hospital. With an aging population the problem is expected to increase further since the prevalence of malnutrition increases with age ​(Marinos Elia on behalf of the Malnutrition Action Group of BAPEN and the  National Institute for Health Research Southampton Biomedical Research Centre, 2015)​. 

MUST Score ​(British Association for Parenteral and Enteral Nutrition (BAPEN), 2011)​. 

• A BMI of less than 18.5kg/m2 

• Unintentional weight loss greater than 10% within the last 3 to 6 months  

• BMI of less than 20kg/m2 and unintentional weight loss greater than 10% within the last 3 to 6 months  

People with malnutrition have higher healthcare requirements than well-nourished people. Research has shown that malnutrition increases visits to the GP as well as prescription costs. There is also plenty of evidence showing that it increases hospital admissions and length of hospital stay, as well as hospital readmission following discharge from hospital. The risk of becoming dependent on others and becoming a permanent resident in care homes, especially those with nursing care is also increased ​(Marinos Elia  on behalf of the Malnutrition Action Group of BAPEN and the  National Institute for Health Research Southampton Biomedical Research  Centre, 2015)​. 

Oral Nutritional Supplements  

Oral Nutritional Supplements (ONS) are sterile liquids, semi-solids or powders which provide macro and macronutrients. They are designed to fill the deficit between an individual’s nutritional requirements and their current nutritional intake, in those who cannot meet their requirements through diet alone. There are a huge range of products available in the U.K. from powdered shakes, to ready to drink bottles, in addition to dessert style pots, savoury soup style drinks and more recently, plant-based smoothie style supplements. There are also various nutrients profiles available depending on the use, for example high protein, high calorie, fat based, milk based, or juice based. As per NICE guidelines CG32 for nutrition support for adults ONS should be consider using ONS for those who are malnourished or at risk of malnutrition.  

Methodology  

Dietitians working in primary care have been shown to improve frailty and nutritional status of patients at risk of malnutrition. Their input improves outcomes including weight, BMI and hand grip strength. They have also been shown to save money by ensuring that oral nutrition supplements (ONS) are appropriately prescribed, and this saving can help fund their time ​(Hickson, Child and Collinson, 2023)​. It is for this reason that aslong woth my dietitian colleague, I carry out a quarterly audit of the prescribing of ONS across the practices. A search was run to identify any patient aged 18 and above with a prescription of any oral nutrition supplement on their EMIS record in the past 6 months. A patient list was created. I completed a desktop review of all the patient’s prescriptions, initially sorting them into categories of green, amber or red as per the local prescribing ONS formulary. The name of the surgeries have been anonymised for the purposes of this article. 

Green - first line 

Amber - second line  

Red - not on the formulary  

Again, a desktop review of each patient was performed. Using the record system to assess when the patient started the prescription, what dose and when was the last review. In cases where patients who were currently under a dietitian either in the PCN or in secondary care, where a review had not been completed in the past 6 months, the dietitian or team was contacted to ensure that a review was planned. If a review was planned or had been completed in the last 6 months this was documented on the patient’s notes.  Those who had not been reviewed in the past 6 months who were not under the care of a dietitian, were called and a review was carried out, once consent had been gained to do so. 

A full nutritional assessment was completed, considering medical history and any recent changes in health, social history and any recent changes in medications in addition to checking any allergies or intolerances. The social history is very important as so many factors can affect how an individual takes ONS. For example, does the patient have a fridge at home to store milk to make a powdered style ONS? Does the patient have space in their home to store large packages of bottles of ONS? Is the patient able to stand to mix the powder with the milk? Compliance to ONS was also checked in a non-judgemental manner using an open questioning style. If there was no recent weight, the patient was invited to have their weight checked at the surgery. Based on this, I made a recommendation to to either continue, change, or stop the prescription. The local formulary was used to guide the prescription choice, in addition to patent preference, and clinical judgement to which product meets the patient’s needs. Where possible patients on red or amber products were changed to green. A change was also recommended if the patient was not compliant with the ONS, usually due to taste fatigue or in some cases inability to make up a powdered shake. If appropriate, the prescription was recommended to be stopped. To recommend stopping a prescription meant that the patients’ weight has been stable for at least 3 months, and they were assessed to be meeting their nutritional requirements with their diet alone. 

Results 

In this current January 2024 audit, surgery A had the highest number of prescriptions overall. They also had the highest number of ‘red’ prescriptions that were off formulary (30%), and lowest number of first line (green) prescriptions (65%). Surgery B had the lowest number of prescriptions and the highest number of ‘green’ prescriptions (73%) but also the highest number of ‘amber ‘prescriptions as a percentage of total prescriptions (15%). Both the surgery B+C s had the same number of red prescriptions (12%). 

Across the practices around 1/3 of patients were already under the care of a dietitian (29%) In many 21% of cases their prescriptions were continued as normal, A small number it was changed (6%) and between 17% of cases their prescription was stopped. 19% of patients were no longer prescribed ONS and between 8% of patients were not able to be contacted. This data could not be compared to last year as this dull data set had not been collected in last year’s audit.  

Table 1. Shows the outcome of an audit of ONS prescribing in 3 practices at Shoreditch Park & City PCN in January 2024 

Comparison between June 2023 and January 2024 Audit 

Overall Prescribing Across the Surgeries 

Compared to the June 2023 audit, there was a 9% total reduction in ONS Prescribing across the surgeries. The biggest reduction was seen in ‘green’ products (7%) followed by amber (5%) and then red (0.6%). 

Surgery A 

Surgery A had a 14% reduction in prescribing. The biggest reduction was seen in amber products at 50% decrease, followed by green products at 16%. There was a slight increase of 9% in red product prescribing (from 20 to 22 patients).  

Surgery B 

Surgery B saw the highest decrease in prescribing at 18%, with a reduction of 27% in prescribing of green products. There was however an increase in prescribing of amber products, by 1 patient. Prescribing of red products was the same with 3 patients prescribed these, although due to the overall reduction in prescription the percentage number increased from 9% to 12% of prescriptions 

Surgery C 

Surgery C had a 13% increase in overall ONS prescribing. However, this practice had the largest decrease in prescribing of red products (50% decrease). They also had decrease in amber prescribing (20% decrease), (from 19% to 12% of total prescription for red and from 16% to 11% for amber). There was a 25% increase in prescribing of ‘green’’ products.  

Table 2. Number of prescription if ONS at Shoreditch Park and City PCN in June 2023 and January 2024  

Reflection and Learning  

The results of the audit showed a 9% reduction in prescribing of ONS from June 2023 to January 2024. There was also a reduction in the number of ‘off formulary’ products that were prescribed overall. The audit ensure that patients were prescribed the most appropriate product and were only prescribed ONS if it was required to treat or reduce the risk of malnutrition. The findings demonstrated the benefit of carrying out an audit of prescribing in primary care, and the benefits of having a dietitian in the practice to focus on this. As previously discussed, this ensures patients are on appropriate prescriptions, and that they are reviewed, monitored, and stopped when no longer required. This is all part of responsible prescribing. In addition, we know that polypharmacy is detrimental to patients' long-term health and therefore reviewing prescriptions and deprescribing are key part of healthcare. Furthermore, there will be economic benefits to this, as previously mentioned. To show this, Forefront Rx data* demonstrates a 4% decrease in spending at over the 3 practices since last quarter. This was compared to all other PCNs in the neigbourhood which all have increased spending since the last quarter. 

Another significant finding from this audit was that only 29% of patients were under the care of a dietitian, despite being prescribed ONS, and the local formulary strongly encouraging staff to refer to a dietitian when a patient is at risk of malnutrition. Therefore, one action from this audit will be to arrange to attend the staff meeting at each practice, to remind them of the guidelines and to explain the referral process to ensure staff are aware.  

Additionally, for future audits it would be beneficial to investigate who started the prescription and how long the patient had been prescribed the ONS for. This will give me further information to analyse and understand the prescribing practices across the PCN. This will enable me to more specifically target certain practices and or prescribers to improve prescribing practice and ensure that the formulary is adhered to as much as possible. This will mean a more efficient and cost effect prescribing for the practices and will improve patient care to ensure that patients are prescribed the most effective and appropriate ONS prescriptions. 

*Forefront Rx is a system to find out prescribing trends of nutritional supplements across the UK. Data is freely available for anyone to view at: https://www.forefrontrx.com/ 

References 

​​British Association for Parenteral and Enteral Nutrition (BAPEN) (2011) Malnutrition Universal Screening Tool . Available at: https://www.bapen.org.uk/pdfs/must/must_full.pdf (Accessed: 25 April 2024). 

​ ​Health & Care Professions Council (2023) Standards of Proficiency: Dietitians. Available at: https://www.hcpc-uk.org/globalassets/resources/standards/standards-of-proficiency---dietitians.pdf (Accessed: 11 April 2024). ​ 

​Health and Care Professions Council (2021) Prescribing, Health and Care Professions Council. (2012, March 25). Prescribing. Https://Www.Hcpc-Uk.Org/Standards/Meeting-Our-Standards/Scope-of-Practice/Medicines-and-Prescribing-Rights/Prescribing/. ​ 

​Hickson, M., Child, J. and Collinson, A. (2023) ‘A case study of the impact of a dietitian in the multi‐disciplinary team within primary care: a service evaluation’, Journal of Human Nutrition and Dietetics, 36(5), pp. 1760–1770. Available at: https://doi.org/10.1111/jhn.13217 ​ 

​Marinos Elia  on behalf of the Malnutrition Action Group of BAPEN and the  National Institute for Health Research Southampton Biomedical Research  Centre (2015) The cost of malnutrition in England and  potential cost savings from nutritional  interventions (full report). Available at: https://www.bapen.org.uk/pdfs/economic-report-full.pdf (Accessed: 25 April 2024). ​ 

​National Institute for Health and Care Excellence (2006) Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical guideline [CG32]. Available at: https://www.nice.org.uk/guidance/cg32/chapter/Recommendations#oral-nutrition-support-in-hospital-and-the-community (Accessed: 25 April 2024). 

​​Prescquipp (2017) Guidelines for the appropriate prescribing of oral  nutritional supplements (ONS) for adults in primary care. Available at: https://www.prescqipp.info/umbraco/surface/authorisedmediasurface/index?url=%2fmedia%2f1512%2fb145-ons-guidelines-30.pdf (Accessed: 25 April 2024). 

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