A local dietetic led project had previously developed and disseminated a structured approach to treatment of malnutrition in Primary Care based on the NICE guidelines(1) using MUST. The main guidelines to prescribers were: ONS are for patients with MUST score of 2 or more, prescribe acutely, two bottles of first line ONS for one month, refer to dietitian and arrange monitoring. The aim of this project was to collect data concerning ONS prescribing in selected surgeries, calculate the costs incurred and then compare them to the costs that would be expected if these guidelines for prescribing were being followed.
Searches carried out in four surgeries identified any patients prescribed ONS in the last six months and any adult patients with a BMI ⩽18.5. The results of the first were subtracted from the second in order to highlight who would be eligible for ONS according to the local guidelines but who were not receiving any. The total number of ONS prescriptions for the previous year and the associated costs were obtained from NHS Business Services Authority. Individual patient records were then examined, looking for evidence that nutritional screening and assessment had taken place, co-morbidities known to be associated with malnutrition had been recorded and that monitoring of the effectiveness of ONS use was in place.
The number of patients on ONS was 112. Average spend was £147 per patient, ranging from £68 to £358. All surgeries were spending 63–71% of their total ONS costs on repeat prescriptions. The estimated cost of prescribing and referring according to the guidelines would be £184 per patient. This is based on the cost of first line ONS for which the PCT have negotiated a contract price.
The number of patients identified with BMI ⩽18.5 but not on ONS was 122. If guidelines had been followed for these patients an additional £22,448 might have been spent. However, 94 patients who were on ONS had a BMI at or above the normal range. MUST screening of these patients may justify the need for prescribable ONS but there is little evidence from their medical notes to support their use. The total spend on ONS for the PCT area over the last year was £449,553.
Little evidence was found in the medical records indicating that prescribing decisions were rationalised and based on screening outcomes or recognition of co-morbidities. Serial measurements of weight and BMI were inconsistent. It was evident than monitoring could be greatly improved, especially if register information was also used as a prompt for review of nutritional status.
In conclusion, it was difficult to identify a rational approach to ONS prescribing decisions or find evidence of follow up and monitoring of their usefulness. Consolidating the introduction of local guidelines and encouraging the use of data that is already being routinely collected has the potential to develop more appropriate use but not necessarily at a reduced overall cost.
