Management of overprescribing of oral nutritional supplements in a community hospital

Malnutrition costs the UK an astounding £23.5bn annually^​1​, an increase from £19.5bn reported by the British Association for Parenteral and Enteral Nutrition (BAPEN) in 2015, with half of this amount spent on its treatment in older people aged over 65 years^​2​. Dehydration and malnutrition can have serious negative impacts on health, disease and wellbeing, yet they are frequently ignored and mistreated^​3​.   

It was observed by the head of medicines management that patients discharged from acute trusts to Caterham Dene Community Hospital First Community Health and Care (CDH) were often initiated oral nutritional supplements (ONS) without subsequent follow-up plans in the discharge letter received and that there was no process in place for reviewing patients on ONS. Instead, the medicines management team — which comprises the head of medicines management, ward pharmacist and pharmacy assistant — initiate a pathway to refer all patients to a dietician for review and monitoring.

A review was conducted to enhance the quality, cost-effectiveness and clinical applicability of oral nutritional supplement use and to ensure prescribing is in line with National Institute for Health and Care Excellence (NICE) and BAPEN national guidelines and recommendations^​2,4​.

The objectives were to ensure that:

• Before oral nutritional supplements are prescribed, all patients should be referred to a dietitian;
• ONS prescribing should adhere to the local NHS board ONS formulary to guarantee proper, clinical and economical oral nutritional supplement prescribing;
• The first-line preferred primary care formulary product is used with a clear nutritional monitoring strategy in place when ONS are necessary after hospital discharge;
• Patients who are prescribed ONS have regular reviews during their course of care to determine whether the product is still appropriate and whether the patient still has a clinical need for ONS. 

All patients admitted to CDH with oral nutritional supplements between May 2023 and May 2024 were reviewed by the pharmacist. The pharmacist checked if they were seen by the dietician prior to ONS initiation at the acute hospital and ensured all patients were switched over to supplements recommended in the local NHS board formulary.

All patients identified by the pharmacist who were not known to the dietician were referred by the medicines management team for a review. The dietician conducted comprehensive assessments, including gathering information on weight history, BMI (both prior to ONS initiation and current), past medical history, current medical status and a detailed diet history spanning three to five days. Based on assessment by the dietician, recommendations were made regarding whether to continue, stop or adjust the supplements to achieve the desired outcome. Patients who were prescribed ONS were reviewed weekly during their course of care to determine whether the patient still had a clinical need for ONS.

A total of 372 patients were admitted, 69 (18.6%) of whom were taking ONS. All patients were admitted on Fresubin (Fresenius Kabi) were switched to Altraplen (Nualtra), as per the Surrey Heartland Integrated Care System (ICS) local formulary by the ward pharmacist. A total of 52 patients (75.4%) admitted on ONS were stopped after the first review by the dietician because they were found to be inappropriate and the patient had not been reviewed prior to prescribing.

In 8 patients (11.6%), ONS was continued but stopped on discharge and 9 patients (13%) were discharged on ONS, with dietician follow-up arranged with community dietetic team. A total of 69 patients were switched to ONS recommended in the local formulary on admission to the ward. According to ward data obtained, the total saving for based on patient total stay of three weeks was £13,628.16. One bottle twice daily of oral nutritional supplements was £6.24 each, based on two weeks supply of ONS on discharge, with a total saving for all 60 patients who did not receive ONS at the point of discharge of £10,483.20. 

Prescription data for East Surrey Integrated Care Partnership in Surrey Heartland ICS demonstrated a decrease in average spend per 1,000 ASTRO-PU [an age, sex, and temporary resident originated prescribing unit] between July 2023 and March 2024 from £25,226 to £20,209.

Implementing a process where all patients admitted with oral nutritional supplements are reviewed upon admission by a dietitian can reduce overprescribing and substantial cost savings. This approach should be supported by ongoing dietetic assessments and reviews for patients at risk of malnutrition or requiring enteral feeding, in collaboration with the multidisciplinary team. Further, this aligns with guidance recommendations^​2​.

By sharing this experience and results with other community hospitals locally, but also more widely, the author hopes to encourage others to actively review the use of ONS. However, they note that this locally based research would require adaptation for national implementation.

Temitope Odetunde, head of medicines management and non-medical prescribing lead, Caterham Dene Hospital First Community Health and Care