The incidences, causes and consequences of disease-related malnutrition (DRM) in the community have been well documented(Reference Green1–Reference Milne, Avenell and Potter3). Prescription of oral nutritional supplements (ONS) has been indicated as an initial part of dietary intervention for DRM and has been positively reported to improve nutritional status(Reference Stratton4). However, a previous primary care audit has identified increased ONS prescription initiation amongst acute-based dietitians and general practitioners (GP), in which the majority were discontinued during dietetic review due to inappropriateness. There currently still exists an increase in the prescription and spending on ONS within the Wirral Primary Care setting.
The aims of the present audit were to identify current trends and compare with previous trends in ONS prescription patterns in the Wirral Primary Care setting and to assess appropriateness of prescription initiation and continuation.
In total 129 adult patients currently receiving ONS were referred from ten GP practices across the Wirral that were identified as presenting the greatest spending increases on ONS prescriptions. Patients were screened and appropriate consultation arranged. Full nutritional assessment was performed by a registered dietitian. Individualised nutritional care plans were formulated, including provision of food-first and food fortification dietary advice where appropriate. ONS were continued, discontinued or altered as appropriate and need for further review was also assessed.
Of the 129 patients referred for primary care dietetic support ONS were predominantly initiated by acute-based dietitians (Fig. 1). Furthermore, 47% of patients initiated on ONS in secondary care or by GP were receiving no dietetic support at the time of referral to the Wirral Primary Care Dietetic Service.
Fig. 1. Origin of ONS initiation in patients (n 129) referred to the Wirral Primary Care Nutrition and Dietetic Service (% total).
Fig. 2. Outcome of ONS prescription review by Wirral Primary Care Nutrition and Dietetic Services (% total outcome based on review of seventy patients).
The outcome of review for seventy patients is summarised in Fig. 2. Discontinuation of inappropriate ONS prescription predominately occurred with prescription initiated by unknown origin and acute-based medical staff. Continuation of appropriate ONS prescription predominately occurred with prescription initiated by primary care dietitians and GP.
The current audit indicates and supports previous audit findings that ONS prescriptions commenced in secondary care are more likely to require discontinuation or dose reduction in primary care. Compared with previous audits, GP have reduced the numbers of initiated prescriptions but still show a substantial discontinuation rate on dietetic review. ONS prescribing and review guidelines are required to improve the transfer of patients on ONS from secondary care to primary care, while primary care dietetic review and assessment of ONS appropriateness should precede GP prescription initiation.
