Nutrition-Focused Care for Community-Living Adults: Healthcare Utilization and Economic Benefits.

OBJECTIVES: We assessed the impact of a recently reported nutritional quality improvement program (QIP) on healthcare resource utilization and costs for older, community-living adults in Bogotá, Colombia. METHODS: The study included 618 community-dwelling, older adults (> 60 years) who were at risk or malnourished and receiving outpatient clinical care. The intervention was a QIP that emphasized nutritional screening, dietary education, lifestyle counseling, 60-day consumption of oral nutritional supplements, and 90-day follow-up. For economic modeling, we performed 90-day budget impact and cost-effectiveness analyses from a Colombian third-party payer perspective. The base-case analysis quantified mean healthcare resource use in the QIP study population. Analysis was based on mean input values (deterministic) and distributions of input parameters (probabilistic). As the deterministic analysis provided a simple point estimate, the cost-effectiveness analysis focused on the probabilistic results informed by 1000 iterations of a Monte-Carlo simulation. RESULTS: Results showed that the total use of healthcare resources over 90 days was significantly reduced by > 40% (hospitalizations were reduced by approximately 80%, emergency department visits by > 60%, and outpatient clinical visits by nearly 40%; P < .001). Based on economic modeling, total cost savings of $129 740 or per-patient cost savings of $210 over 90 days could be attributed to the use of nutritional QIP strategies. Total cost savings equated to nearly twice the initial investment for QIP intervention; that is, the per-dollar return on investment was $1.82. CONCLUSIONS: For older adults living in the community in Colombia, the use of our nutritional QIP improved health outcomes while lowering costs of healthcare and was thus cost-effective.

A nutritionally focused program for community-living older adults resulted in improved health and well-being.

OBJECTIVES: Among older adults, malnutrition is common and is associated with increased risk for impaired health and functionality, conditions further associated with poorer quality of life. In this study of community-living older adults, our objective was to quantify outcome changes following identification and treatment of malnutrition or its risk. DESIGN: Our intervention was a nutritional quality improvement program (QIP). The nutritional QIP included: (i) education of participants about the importance of complete and balanced macro- and micronutrient intake plus physical exercise, (ii) nutritional intervention with dietary counseling; and (iii) provision of oral nutritional supplements (ONS) for daily intake over 60 days. Follow-up measurements took place 30 days after ONS treatment ended, i.e., 90 days after start of intervention. SETTING AND PARTICIPANTS: We recruited 618 transitional-care, chronically ill, older adults (>60 years) with malnutrition/risk (per Mini Nutrition Assessment-Short Form, MNA-SF) from the outpatient clinic of Hospital Universitario San Ignacio, in Bogotá, Colombia. METHODS: For pre-post comparisons, we examined cognition (Mini-Mental State Exam, MMSE), physical abilities (Barthel Activities of Daily Living, ADL; Short Physical Performance Battery, SPPB), affective disorder status (Global Depression Scale, GDS), and quality of life (QoL; EuroQoL-5D-3L, EQ-5D-3L; EuroQoL-Visual Analog Scale, EQ-VAS). RESULTS: Participants were mean age 74.1 ± 8.7 y, female majority (69.4%), and had an average of 2.6 comorbidities with cardiovascular and respiratory diseases predominant (28.5%). QIP-based nutritional intervention led to significant improvements in cognitive (MMSE) and physical functions (ADL and SPPB), affective disorder status (GDS), and health-related quality of life (EQ-VAS); all differences (P < 0.001). Self-reported QoL (EQ-5D-3L) also improved. CONCLUSIONS AND IMPLICATIONS: Over 90 days, the nutritional QIP led to improvements in all measured outcomes, thus highlighting the importance of addressing malnutrition or its risk among community-living older adults. From a patient's perspective, maintaining mental and physical function are important and further linked with quality of life. BRIEF SUMMARY: For older, community-living adults, nutrition care can improve health and well-being outcomes. Care includes screening for malnutrition risk, dietary and exercise counseling, and daily nutritional supplements when needed. GOV IDENTIFIER: NCT04042987.

Use of a nutrition-focused quality improvement program for community-living older adults at malnutrition risk is associated with better nutritional outcomes.

BACKGROUND & AIMS: Among older adults, malnutrition or its risk is common and is associated with increased morbidity and mortality plus increased need for healthcare utilization. We aimed to identify and treat malnutrition risk among older adults who received care at an outpatient clinic after a recent hospitalization and/or for management of a chronic disease. METHODS: From the outpatient clinic of Hospital Universitario San Ignacio, Bogotá, Colombia, we recruited older adults (>60 years) with malnutrition or its risk according to the Mini Nutritional Assessment-Short Form (MNA-SF). Patients were excluded if they had dementia or were not expected to live 90 days or more. Intervention was a nutrition-focused quality improvement program (QIP) including: i) education of patients and caregivers about the health importance of complete and balanced macro- and micronutrient intake plus physical exercise; and ii) nutritional intervention with dietary counseling and provision of oral nutritional supplements (ONS) for daily intake. To assess the effect of our intervention, we collected nutritional outcome data pre- and post-participation of patients in the nutrition-focused QIP. For pre-post comparisons, we used MNA-SF scores and calf circumference (a proxy for leg muscle mass) measures along with nutrition-related anthropometric determinations of body weight and body mass index (BMI). The ONS treatment phase was 60 days, with follow-up measurements up to 30 days after ONS treatment ended (90 days after intervention start). RESULTS: Of 677 enrolled patients, 618 completed the QIP, while 565 had complete anthropometric data. Patients had a mean age of 74.1 ± 8.7 years, an average of 2.6 comorbidities, included a high proportion of females (69.4%), with medium socioeconomic status (76%). After QIP intervention, 324 (52.4%) patients had improvement in nutritional outcomes; improvement was significant in all four measures (P-values < 0.001). Higher ONS adherence was associated with the highest improvement in nutritional status. CONCLUSIONS: For community-living older adults receiving outpatient care, comprehensive nutritional care offered via a nutrition-focused QIP was associated with significant improvements in indicators of nutritional status (MNA-SF scores and calf circumference) and maintenance or improvements in nutrition-related anthropometric measures (body weight and BMI). GOV IDENTIFIER: NCT04042987.

Hospital nutrition care informs potential cost-savings for healthcare: A budget impact analysis.

BACKGROUND AND AIM: In Mexico, about half of hospitalized patients are malnourished or at risk of malnutrition upon hospital admission, while many others experience deterioration of their nutritional status while in the hospital. Such patients often experience poor health outcomes and have increased hospital costs. The aim of our budget-impact analysis was to estimate potential savings associated with the implementation of a Mexican hospital-based program of nutrition care for patients at malnutrition risk or malnourished. METHODS: The budget-impact model was based on data published previously. Our model compared patients assigned to receive individualized early nutrition therapy (initiated within 24-48 h of hospital admission) with those who received standard delayed nutrition therapy (not initiated early). Outcomes included length of stay, infectious complications, and 30-day readmissions. We modeled a 30-day time-horizon, estimated event probabilities on the basis of published data, and projected costs in 2020 US dollars. RESULTS: Average total healthcare costs over 30-days were $3527 for patients with early nutrition therapy vs $6032 for patients with standard nutrition therapy-a savings of $2505 per early nutrition-treated patient (41.5% lower). Cost differences between the groups were $2336 vs $3065 for hospital-associated costs (23.8% lower), $262 vs $780 for 30-day readmissions (66.4% lower) and $1348 for malnutrition-associated infections. Applying these potential savings from individualized early nutrition care to a one-year estimate of 3.22 million Mexican hospital patients with malnutrition or its risk, the total overall savings for public health expenditures was equivalent to $8.1 billion per year or 32.1% of total healthcare expenditures. CONCLUSIONS: The results demonstrated the potential for hospital-based nutrition care programs to reduce costs of patient hospitalizations. These notable findings provide a rationale for Mexican healthcare institutions to implement programs of comprehensive nutrition-focused care for inpatients with malnutrition or its risk. To this end, we advise implementation of professional programs for education and training in order to increase awareness of patients' nutritional needs and to better prepare clinical personnel to identify, treat, and monitor patients at-risk/malnourished.

Targeting malnutrition: Nutrition programs yield cost savings for hospitalized patients.

BACKGROUND & AIMS: Between 30 and 50% of Colombian patients are malnourished or at-risk of malnutrition on hospital admission. Malnutrition is associated with poor outcomes and increased costs. We used cost modeling to estimate savings that could be derived from implementation of a nutrition therapy program for patients at malnutrition risk. METHODS: The budget impact analysis was performed using previously-published outcomes data. Outcomes included length of stay, 30-day readmissions, and infectious/non-infectious complications. We developed a Markov model that compared patients who were assigned to receive early nutrition therapy (started within 24-48 h of hospital admission) with those assigned to receive standard nutrition therapy (not started early). Our model used a 60-day time-horizon and estimated event probabilities based on published data. RESULTS: Average total costs over 60 days were $3770 US dollars for patients with delayed nutrition therapy vs $2419 for patients with early nutrition therapy-a savings of $1351 (35.8% decrease) per nutrition-treated patient. Cost differences between the groups were: $2703 vs $1600 for hospital-associated costs; $883 vs $665 for readmissions; and $176 vs $94 for complications. Taken broadly, the potential costs savings from a nutrition care program for an estimated 638,318 hospitalized Colombian patients at malnutrition risk is $862.6 million per year. CONCLUSIONS: Our budget impact analysis demonstrated the potential for hospital-based nutrition care programs to improve health outcomes and reduce healthcare costs for hospitalized patients in Colombia. These findings provide a rationale for implementing comprehensive nutrition care in Colombian hospitals.

[Comparative analysis of insulin glargine vs. insulin detemir: A cost-minimization study applicable to Colombia]. / Análisis comparativo de insulina glargina frente a la insulina detemir: un modelo de minimización de costos aplicable en Colombia.

INTRODUCTION: More than 90% of subjects diagnosed with diabetes mellitus present with type 2, which is recognized for peripheral insulin resistance. OBJECTIVE: To determine the costs of achieving glycemic target with the use of basal insulin analogs, insulin glargine (IG) once a day vs. insulin detemir (ID) once or twice a day, with a cost minimization model built from a third-party payer perspective in Colombia. MATERIALS AND METHODS: A systematic review of comparative clinical trials between IG and ID in patients with insulin-resistant type 2 diabetes was performed to determine data of use, effectiveness and frequency of and adverse events. The goal of glycemic control (effectiveness measure) was defined as HbA1c=7%. The costs of insulin were extracted from the Integrated System of Medication Prices 2012 (Ministerio de Salud y Protección Social de Colombia) and the IMS Consulting Group mobile average cost for the past year as of December, 2012. Sensitivity analyses were performed via Montecarlo simulations for dose and medication costs (insulin). RESULTS: Five publications met inclusion criteria. The range of the difference between insulin doses was 3.2 IU to 33 IU. The percentage of patients requiring two ID doses was 12.6-100%. There were no significant differences in hypoglycemic events. For both retail and institutional channels, there was a higher differential cost between IG vs. ID favoring IG in 4 and 5 studies, respectively. For the retail channel only one study showed the opposite results. CONCLUSIONS: As only medication costs are considered, differences in insulin units between IG and ID result in a differential cost in favor of IG that makes it a cost/effective alternative.

Análisis comparativo de insulina glargina frente a la insulina detemir: un modelo de minimización de costos aplicable en Colombia / Comparative analysis of insulin glargine vs. insulin detemir: A cost-minimization study applicable to Colombia

Introducción. Más del 90 % de los individuos diagnosticados con diabetes mellitus presentan el tipo 2, cuya resistencia periférica a la acción de la insulina es conocida. Objetivo. Desarrollar un modelo de minimización de costos del tratamiento con insulina glargina una vez al día o con insulina detemir, una o dos veces al día, en pacientes con diabetes mellitus de tipo 2 que requieren insulina, desde la perspectiva del tercer pagador en Colombia. Materiales y métodos. Se hizo una búsqueda sistemática de estudios clínicos comparativos de la administración de insulina glargina e insulina detemir en pacientes con diabetes mellitus de tipo 2 que requieren insulina, con el fin de extraer los datos sobre su uso y efectividad, y sobre la frecuencia de eventos secundarios. La meta establecida de control glucémico fue de HbA1c=7 %. Los costos de la insulina se tomaron del Sistema Integrado de Precios de Medicamentos, 2012, del Ministerio de Salud y Protección Social, y los precios por tableta se basaron en el promedio móvil de doce meses en diciembre de 2012 según el IMS Consulting Group. Los análisis de sensibilidad se hicieron con simulaciones de Montecarlo para las dosis y los costos de la insulina. Resultados. Cinco publicaciones cumplieron con los criterios de inclusión. El rango de la diferencia entre dosis de insulina fue de 3,2 a 33 UI. El porcentaje de pacientes que requirieron dos dosis de insulina detemir estuvo entre 12,6 y 100 %. No hubo diferencias significativas en los eventos hipoglucémicos. Tanto para el canal de compra al por menor como para el de compras institucionales, la diferencia de costos entre la insulin glargina y la detemir favoreció a la primera en cuatro y cinco estudios, respectivamente. Solo un estudio mostró lo contrario en lo concerniente a la venta al por menor. Conclusiones. La diferencia en cuanto a la dosis promedio entre la insulina ganglir y la detemir, genera costos anuales que favorecen el uso de la insulina ganglir, lo que la convierte en una alternativa costo-efectiva frente a la determir.

Introduction: More than 90% of subjects diagnosed with diabetes mellitus present with type 2, which is recognized for peripheral insulin resistance. Objective: To determine the costs of achieving glycemic target with the use of basal insulin analogs, insulin glargine (IG) once a day vs. insulin detemir (ID) once or twice a day, with a cost minimization model built from a third-party payer perspective in Colombia. Materials and methods: A systematic review of comparative clinical trials between IG and ID in patients with insulin-resistant type 2 diabetes was performed to determine data of use, effectiveness and frequency of and adverse events. The goal of glycemic control (effectiveness measure) was defined as HbA1c=7%. The costs of insulin were extracted from the Integrated System of Medication Prices 2012 (Ministerio de Salud y Protección Social de Colombia) and the IMS Consulting Group mobile average cost for the past year as of December, 2012. Sensitivity analyses were performed via Montecarlo simulations for dose and medication costs (insulin). Results: Five publications met inclusion criteria. The range of the difference between insulin doses was 3.2 IU to 33 IU. The percentage of patients requiring two ID doses was 12.6-100%. There were no significant differences in hypoglycemic events. For both retail and institutional channels, there was a higher differential cost between IG vs. ID favoring IG in 4 and 5 studies, respectively. For the retail channel only one study showed the opposite results. Conclusions: As only medication costs are considered, differences in insulin units between IG and ID result in a differential cost in favor of IG that makes it a cost/effective alternative.

Evaluación de costo/efectividad de tres combinaciones fijas de acetaminofén y opiáceos para el manejo del dolor agudo en Colombia / Cost/effectiveness evaluation of three fixed combinations of acetaminophen and opioids in the management of acute pain in Colombia

Objective: To compare the cost-effectiveness of three different formulations indicated for moderate and severe acute pain, commercialized in Colombia [acetaminophen 500 mg + codeine 30 mg (AC), acetaminophen 500 mg + hydrocodone 5 mg (AH) and acetaminophen 325 mg+ tramadol 37.5 mg (AT)]. Materials and methods:Cost-effectiveness analysis using the NNT as the health outcome indicator. The costs were evaluated in two specific settings: Institutional Channel (IC), representing the cost for the Colombian Ministry of Health (SISMED 2011); Retail Channel (RC), representing consumer prices, obtained from the IMS annual average for 2011, plus an adjustment to include the average profit margin for pharmacies (10%). The incremental cost effectiveness ratios (ICER) were calculated for the three formulations and the two settings (IC and RC). The intervention values are expressed in Colombian pesos (COP). Results: The prices/NNT for each formulation were $1816 COP/2.2 for AC, $4772 COP/2.3 for AH and $5342/2.6 for AT. Using these data and taking AC as the comparator, the ICER for the other formulations shows the following results: in the RC, $5065 COP for AT and $19,600 COP for AH; in the IC setting, $8790 COP for AT and $29,460 COP for AH. The probabilistic sensitivity analysis demonstrated that the majority of simulation results fell between the 1st and 4th quadrants of the cost-effectiveness matrix, using AC as a reference. Conclusion: The analysis, from the payer and patient perspectives, demonstrates that the AC formulation has a lower cost and is more effective inreducingpain within the first 4-6 h after administration, compared with the AH and AT formulations in their specific indications.

Objetivo: Comparar diferencias en costo-efectividad de 3 formulaciones comercializadas en Colombia (acetaminofén 500 mg + codeína 30 mg [AC], acetaminofén 500 mg + hidrocodona5 mg [AH] y acetaminofén 325 mg + tramadol 37,5 mg [AT]) indicadas para el tratamiento del dolor agudo moderado-severo. Materiales y métodos: Análisis de costo-efectividad, usando el NNT como medida de desenlace. Los costos fueron evaluados en 2 canales específicos: canal institucional (CI), representado por los costos relacionados con el medicamento consignados en SISMED 2011,y canal al por menor (CM), que representa los precios al consumidor tomados de IMS promedio anual 2011 más margen de farmacia (10%). Se calcularon las razones de costo-efectividad incremental (RCEI) para las 3 formulaciones en cada canal (CI y CM). Los valores de las intervenciones fueron expresados en pesos colombianos. Resultados: Los precios/NNT para cada formulación fueron $1.816 COP/2,2 para AC, $4.772COP/2,3 para AH y $5.342/2,6 para AT. Con base en estos datos y tomando AC como el comparador, las RCEI para las otras formulaciones fueron: en el CM, $5.065 COP para la formulación AT y $19.600 COP para la formulación AH; en el CI, $8.790 COP para la formulación AT y$29.460 COP para la formulación AH. El análisis de sensibilidad probabilístico evidencia que las observaciones simuladas se ubican entre el primer y el cuarto cuadrante del plano de costo-efectividad, tomando como referente AC. Conclusión: El análisis, desde la perspectiva del tercer pagador y el paciente, permite concluir que la formulación AC tiene un menor costo y mayor efectividad para reducir el dolor en las primeras 4-6 h, comparada con AH y AT es sus indicadores específicos.

Cost-effectiveness Analysis of Viscosupplementation versus Conventional Supportive Therapy for Knee Osteoarthritis in Colombia.

BACKGROUND: Treatment goals for knee osteoarthritis (OA) include preservation of mobility, control of pain, and delaying total knee replacement (TKR). OBJECTIVE: To estimate the cost-effectiveness of viscosupplementation (hylan G-F 20) alone compared with conventional supportive therapy (CST) in the treatment of knee OA in Colombia. METHODS: Microsimulation in patients with knee OA, modeling of clinical outcomes (disease progression, symptom improvement, TKR), and estimation of associated costs were performed (drugs, diagnostic tests, procedures, and hospitalizations). The probabilities for disease progression and clinical events were correlated with patients' characteristics. Clinical outcome information was obtained from the literature. The costs were drawn from institutional databases from health maintenance organizations and the Colombian standard tariffs handbook (ISS 2001. Agreement No. 256 of 2001. Tariffs for the health promoter Social Security EPS-ISS. Social Insurance Board of Directors. December 19, 2001). Sensitivity analyses were performed for costs and transition probabilities. RESULTS: Monte-Carlo simulation for 1000 patients with knee OA showed that viscosupplementation with hylan G-F 20 delayed the occurrence of TKR by 3 years compared with CST. Western Ontario and McMaster Universities Arthritis Index scores indicate improvement in symptoms and function with hylan G-F 20. The incremental cost-effectiveness ratio for viscosupplementation is dominant, with reduction of US $576 in treatment cost in favor of hylan G-F 20, with more cost-effectiveness per quality-adjusted life-year during the first 10 years of treatment compared with CST. CONCLUSIONS: The results of mathematical simulation indicate that in comparison to conventional support therapies, viscosupplementation with hylan G-F 20 improved disease symptoms, joint function, and quality of life, reduced direct treatment costs, delayed TKR by 3 years, and was cost-effective in Colombia.