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© 2016 Abbott Laboratories

Quality Outcomes and Financial Benefits of Nutrition Intervention

Tracy R. Smith, PhD, RD, LDSenior Clinical ManagerAbbott Nutritiont.r.smith@abbott.com

EVOLVING DEMOGRAPHICS AND HEALTH POLICY ENABLE NUTRITION TO HAVE A POSITIVE ECONOMIC IMPACT

2

Role of Nutrition in Economic Impact and Quality of Patient Care

Aging Population

Disease Incidence

Healthcare Consumption

Quality of Life

Life Expectancy

EvolvingDemographics

CMS Payments

Quality of Care

Costs of Care

Transitional Care

EvolvingHealth Policy

MALNUTRITION IS PREVALENT ACROSS HEALTHCARE SETTINGS

3

Healthcare Setting Prevalence

Hospital 30-50%1-4

Long-Term Care 21%-51%5

Outpatient & Homecare 13-30%5

Risk is increased in:6

• Older adults

• Critically ill patients

• Patients with comorbid chronic diseases, e.g., cancer, COPD, chronic kidney disease

1 Coats KG et al. J Am Diet Assoc.1993;93:27-33. 2 Giner M et al. Nutrition.1996;12:23-29. 3 Thomas DR et al. Am J Clin Nutr.2002;75:308-313. 4 Somanchi M et al. JPEN. 2011;35:209-216. 5 Guigoz Y. J Nutr Health Aging. 2006;10:466-487. 6 Jensen GL, et al. JPEN J Parenter Enteral Nutr. 2010;34:156-159.

BED REST, AGE AND HOSPITALIZATION INCREASE LOSS OF MUSCLE

4

Elderly Inpatients

3 Days Hospitalization3

Healthy Elders

10 Days Inactivity2

Healthy Young

28 Days Inactivity1

≈ 1 lbloss of muscle

≈ 2.2 lbloss of muscle

≈ 2.2 lbloss of muscle

1 Paddon-Jones D et al. J Clin Endocrinol Metab. 2004;89:4351-4358. 2 Kortebein P et al. JAMA. 2007;297:1772-1774.

3 Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, Ohio.

-2.5

-2.0

-1.5

-1.0

.5

0

NUTRITIONAL STATUS IS PROGRESSIVELY COMPROMISED OVER THE CONTINUUM OF CARE

5

1. Sriram K, Sulo S, VanDerBosch G, et al. J Parenter Enteral Nutr. 2016;1-8. http://journals.sagepub.com/doi/abs/10.1177/0148607116681468.2. Gariballa S, Elessa A. Clinical Nutrition. 2013; http://dx.doi.org/10.1016/j.clnu.2013.01.010. 3. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. J Hosp Med. 2011;6:54–60.

30% to 50% of patients are

malnourished uponadmission1

Weight loss and loss of

muscle increase risk of readmissions2,3

Many patients with normal nutrition

status experience a decline during

hospitalization1

Upon Admission to the Hospital

During Hospital Stay

Post-discharge

UNRECOGNIZED MALNUTRITION CAN LEAD TO COSTLY CONSEQUENCES

6

Increased LOS1

Increased cost of care1

Increasedmorbidity/mortality1

Higher complication rates1

Increased risk of pressure ulcers2

1. Philipson TS, Thorton Snider J, Lakdawalla DN, et al. Am J Manag Care. 2013;19(2):121-128.2. Shahin ES et al. Nutrition. 2010;26(9):886-889.

Increased readmission rates1

PRE-EXISTING MALNUTRITION/WEIGHT LOSS INCREASES RISK OF NEVER EVENTS1

7

Surgical site infection

Pressure Ulcer

Catheter-associated UTI

Mediastinitis after CABG

Odds Ratio

0 1 2 3 4 5 6

2.5

3.8

5.1

5.3

1 Fry DE, et al. Arch Surg. 2010;145:148-151.

NUTRITION CONTRIBUTES TO POST-HOSPITAL SYNDROME1

8

Malnutrition during

hospitalization may cause poor

outcomes, yet often receives

little attention

Associated Causes:

Poor Nutrition

Pain and Discomfort

Decline in Mental Functioning

Sleep Deprivation

1 Krumholz HM. N Engl J Med 2013; 368: 100-102.

MALNUTRITION IS A COMMON REASON FOR READMISSION1

9

National Surgical Quality Improvement Project protocol to identify risk factors associated with 30-day readmission.

Preoperative, intraoperative, and postoperative outcomes were collected 1442 inpatient general surgery procedures at a single academic center between 2009 and 2011.

Four Most Common Readmission Reasons

Operations With Highest Readmission Rates

Gastrointestinal complications (28%) Pancreatectomy (18%)

Surgical infection (22%) Colectomy/colostomy (13%)

Malnutrition (10%) Small bowel resection (12%)

Wound complications (8%) Gastrectomy (11%)

1 Kassin M et al, J Am Coll Surg. 2012 Sep;215(3):322-30.

PATIENTS “AT NUTRITIONAL RISK” ARE MORE LIKELY TO EXPERIENCE EMERGENT CARE VISITS AND REHOSPITALIZATIONS1

10

To identify the association between baseline nutritional status and subsequent health service utilization and mortality

N = 198 older adults receiving Medicare home health services for 1 year

12% were malnourished and 51% were at risk

Those who were malnourished or at risk at initial assessment were more likely to experience:

• Subsequent Hospitalization (P=.040)

• Number of Hospital Admissions (P=.045)

• ER Visit (P=.047)

• Mortality (6 months, P=.001; 1 year, P=.031)

Objective

Population

Key

Findings

1 Yang Y et al. J Am Med Dir Assoc 2011; 12: 287-294.

ORAL NUTRITION SUPPLEMENTATION (ONS) HAS SHOWN SIGNIFICANT CLINICAL BENEFITS

11

25%0.75 95% CI

(0.62-0.89)

19%P<0.001

30%P<0.004

Reduction in Pressure Ulcer

Incidence1

Reduction in Serious Complications

(e.g., infections)2

Reduction inHospital

Readmission2

1 Stratton RJ et al. Ageing Res Rev. 2005;4(3):422-450. 2 Cawood et al. Ageing Res Rev. 2012;11(2):278-296.

A LARGE HEALTH ECONOMIC STUDY OF ONS DURING HOSPITALIZATION DOCUMENTED ECONOMIC BENEFITS1

Study Design

• 11-year retrospective analysis

Premier Research Database

• Includes detailed information on adult (18+) U.S. hospital episodes from 2000 to 2010

– 460 hospitals in the United States

– 44 million adult inpatient episodes

– ONS use identified in 724,027 of 43,968,567 adult inpatient episodes

– Rate of ONS use=1.6%

12

1. Philipson et al. Am J Manag Care. 2013; 19(2):121-128.

LARGE HEALTH ECONOMICS STUDY SHOWED ONS DURING HOSPITALIZATION IMPROVED OUTCOMES1

13

21% decrease in LOS

(2.3 days)

6.7% decrease*

in probability of 30-day readmissions

21.6% decrease†

in episode costs ($4734)

*Readmission defined as return to study hospital for any diagnosis. Data measured delayed readmission and do not include patients not readmitted due to recovery or death.

†Monetary figures are based on 2010 US dollars and inflation-adjusted.

1. Philipson TJ et al. Am J Manag Care. 2013;19(2):121-128.

REDUCED

ONS IMPROVED OUTCOMES AND REDUCED HOSPITAL COSTS IN FOUR TARGETED MEDICARE POPULATIONS1,2

14

-12%*-10.9%*

(1.2 days)

-5.1%†

($1,538)

-10.1%*

-7.8%*

($1,266)

-5.2%

-8.5%*

(0.8 days)-10.6%*

($1,516)

30-day Readmission Probability LOS Episode Cost

Acute Myocardial Infarction (AMI)1

Congestive Heart Failure (CHF)1

Pneumonia (PNA)1

-14.2%(1.3 days)

*Indicates significance at the 1% level. †Indicates significance at the 5% level.‡ One to one matched sample was created from a 10,322 ONS episodes and 368,097 non-ONS episodes data population (N=14,326).

1. Lakdawalla D et al., Forum for Health Economics and Policy. 2014 DOI 10.1515/fhep-2014-0011.

2. Thornton Snider J et al. Chest. 2014 Oct 30. doi: 10.1378/chest.14-1368.

Data from 2 retrospective health economic studies1,2

Chronic Obstructive Pulmonary Disease (COPD)2

-21.50%(1.88 days)

-12.50%($1,570)

-13.1%*

ADVOCATE HEALTH CARE QUALITY IMPROVEMENT STUDY OVERVIEW1

15

Study DesignMulti-site, 2-group, pre-post QIP study Conducted from October 13, 2014 to April 2, 2015

Patient Population(N=1269*; 45.2% at risk for malnutrition)

• Older adults; mean age of 66.6 ± 17.2 years

• Most were white/caucasian (70.4%)• Admitted for a primary medical diagnosis (77.3%)

Study Scheme

Two hospitals implemented a QIP-basic program—QIP-b

Two hospitals implemented a QIP-enhanced program—QIP-e

1. Sriram K, Sulo S, VanDerBosch G, et al. J Parenter Enteral Nutr. 2016;1-8. http://journals.sagepub.com/doi/abs/10.1177/0148607116681468

*2808 patients were screened with 1269 patients enrolled.

THE RESEARCH QUESTION AND ENDPOINTS

• Study Hypothesis: Nutrition-focused QIP will decrease 30-day readmission rate by 20% compared with existing ONS protocol in patients at risk/malnourished

• Sample Size:

– Baseline comparator patients (n=4611)—January 1, 2013-December 31, 2013

– Enrolled in QIP (N=1269; QIP-b n=769; QIP-e n=500)—October 13, 2014-April 2, 2015

– Validation comparator patients (n=1319)—October 13, 2013-April 2, 2014

• Primary Endpoint: Non-elective readmission 30-days post-discharge

• Secondary Endpoint: Length of hospital stay

• Patient Population: Aged 18+ years, any primary diagnosis, risk for malnutrition (Malnutrition Screening Tool [MST] score ≥2)

16

DIFFERENCES BETWEEN QIP-E AND QIP-B

17

Differences between QIP-e and QIP-b

ProgramsQIP-e QIP-b

MST is a part of EMR

RN completes MST

ONS selection via automatic drop-down menu by RN -

ONS ordered by MD, RN, or RD

RD consultation

Time to RD consultation: <24 hours -

Time to ONS delivery (in hours) 1 – 24 h 24 – 48 h

Discharge planning instructions

Discharge materials including coupons and literature -

Standard post-discharge phone calls (24-72 hours) *

Nutrition-focused post-discharge phone calls (N = 4) * -

MST=Malnutrition Screening ToolEMR=Electronic Medical Record*Nutrition-focused questions were incorporated in the standard post-discharge phone calls.

QIP-E PROGRAMS REDUCEDREADMISSIONS, LOS, AND COSTS2

18

*Data from QIP-e intervention, percentage expressed as relative risk reduction (RRR) compared to pre-QIP. †Data from validation comparison cohort: 6-month hospital savings for the 4 QIP hospitals was $4,896,758 (when QIP program cost is subtracted).‡Products available in each hospital's formulary were used.

1. Sriram K, Sulo S, VanDerBosch G, et al. J Parenter Enteral Nutr. 2016;1-8. http://journals.sagepub.com/doi/abs/10.1177/01486071166814682. Sulo et al. Budget Impact of a Comprehensive Nutrition-Focused Quality Improvement Program for Malnourished Hospitalized Patientsforthcoming July 2017 ADHB.

www.linktocomedecember6.com. Accessed November 22, 2016.

Length of Hospital Stay1

-26%*

All-cause 30-day Readmissions1

-29%*

Costs2

6-Month Savings:

$4,896,758

REDUCED

QIP-e, including ONS therapy, reduced all cause 30-day readmission rates by 29% vs pre-QIP

QIP-e, including ONS therapy, reduced length of hospital stay by 26% (1.9 [±3.6] days) vs pre-QIP

A Healthcare Quality Outcomes Study that included interventions with Abbott Nutrition formulary for the QIP hospitals during a 6-month period reduced healthcare costs from avoided readmissions and reduced LOS†‡

ALL SUBPOPULATIONS BENEFITED FROM THE NUTRITION FOCUSED QIP1-4

19

1. Sriram K, Sulo S, VanDerBosch G, et al. J Parenter Enteral Nutr. 2016;1-8. http://journals.sagepub.com/doi/abs/10.1177/0148607116681468.2. Gariballa S, Elessa A. Clinical Nutrition. 2013; http://dx.doi.org/10.1016/j.clnu.2013.01.010. 3. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. J Hosp Med. 2011; 6:54–60.

Age <65

MST > 2

Across all MST Scores

Age 65+ Medical Patients

Surgical Patients

CV Oncology GI

MST = 2

NUTRITION INTERVENTION IMPROVES OUTCOMES FOR ALL MALNOURISHED PATIENTS1-6

20

Length of Hospital Stay*1,3-6

All-cause 30-day Readmissions*1,3-6

Costs2†‡

REDUCED

*Data from QIP-e intervention, percentage expressed as RRR compared to pre-QIP. Products available in each hospital's formulary were used. † Data from baseline comparison cohort: 6-Month Hospital Savings for the 4 QIP hospitals was $5,452,309 (when QIP program cost is subtracted).‡ Products available in each hospital's formulary were used.

1. Sriram K, et al. J Parenter Enteral Nutr. 2016 Dec 6 [Epub ahead of print]. 2. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT02262429. Accessed November 22, 2016. 3. Sulo S, et al. Poster presented at: ESPEN Congress; Copenhagen, Denmark; September 19, 2016. 4. Sulo S, et al. Poster presented at: SMDM Meeting; Vancouver, Canada; October 26, 2016. 5. Sriram K, et al. Poster presented at: ASPEN Meeting; Austin, TX, January 17, 2016. 6. Sulo S, et al. Abstract submitted to: SHM Society of Hospital Medicine. May 1-4, 2017, Las Vegas, NV. Awaiting Acceptance Confirmation.

3 STEPS FOR ADDRESSING MALNUTRITION

21

Screen and recognizeall patients at risk of malnutrition

Rapidly implement nutrition interventionsand continue monitoring your patients

November 8, 2017 22

Reducing Readmissions –LTC Perspective

FAST FACTS IN LTC1

November 8, 2017 23

1. AHCA ‘Skilled Nursing Care Centers’; 2015. https://www.ahcancal.org/Pages/Default.aspx. Accessed 10/16/17.

LTC ECONOMIC IMPACT IN THE US1

November 8, 2017 24

1. AHCA ‘Skilled Nursing Care Centers’; 2015. https://www.ahcancal.org/Pages/Default.aspx. Accessed 10/16/17.

REDUCING READMISSIONS – THE VIEW FROM LTC1

• Pressures to reduce readmissions due to relationships with AC entities or ACOs

• Benefits to the Residents, Staff and Nursing Home

• Nursing Home - Financial and marketing benefits

• Nursing homes save time and money because work associated with hospitalizations and readmissions are eliminated

• Nursing homes will meet the national Partnership for Patients efforts and Quality Assurance Performance Improvement (QAPI) requirements by reducing transfers to the hospital

• Nursing homes will prepare for payment reform and partnering with hospitals, home health agencies and others in accountable care organizations and other similar initiatives

November 8, 2017 25

1. https://www.nhqualitycampaign.org/goalDetail.aspx?g=hosp. Accessed 6/15/171.

IMPROVING MEDICARE POST-ACUTE CARE TRANSFORMATION (IMPACT) ACT AND FIVE STAR RATINGS

IMPACT ACT 1

• October 2014 became law

• October 2018 implementation

• Incorporates a standardized assessment, including PAC providers, SNF, LTC

• Quality Metrics – including pressure ulcers, major falls and functional status

FIVE STAR RATINGS2

• Helps families and caregivers compare and evaluate nursing homes

• 24 quality areas, including % of patients with pressure injury, new pressure injury and worsened pressure injury (as reported on the MDS 3.0)

November 8, 2017 26

1. https://www.ahcancal.org/advocacy/issue_briefs/Issue%20Briefs/IMPACT-IB.pdf. Accessed 10/16/172. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs.html. Accessed 10/16/17

HISTORY OF QUALITY IMPROVEMENT (QAPI)1

• 2006 Advancing Excellence Campaign (grant)– initiated

• Goal-’make nursing homes a better place to stay and visit’

• 2007 Advancing Excellence in America’s Nursing Homes Campaign launch

• 2016 NH Quality Campaign evolved – Advancing Excellence in America’s Nursing Homes

• CMS and its contractors continue with mission

• Nine Goals / Areas of Focus for improvement

• Organizational (4), Clinical (5)

November 8, 2017 27

1. https://www.nhqualitycampaign.org/history.aspx. Accessed 10/16/17.

Where does nutrition fit?

NATIONAL NURSING HOME QI CAMPAIGN GOALS1

November 8, 2017 28

1. https://www.nhqualitycampaign.org/goals.aspx. Accessed 10/16/17.

NUTRITION

MALNOURISHED PATIENTS HAD UP TO 3X HIGHER RATE OF INFECTIONS1

November 8, 2017 Quality Outcomes and Financial Benefits of Nutrition Intervention 29

1 Schneider SM et al. Br J Nutr;.2004; 92:105-11.

16.0%

WellNourished

Moderately Malnourished

Severely Malnourished

14.0%

12.0%

10.0%

8.0%

6.0%

2.0%

0.0%

4.4%

7.6%

14.6%

P=0.009

4.0%

No

soco

mia

l In

fect

ion

%

RELATIONSHIP BETWEEN MUSCLE, MALNUTRITION, AND FALLS

• Increased injury risk is associated with

– Age-related bone loss

– Muscle strength

– Muscle tissue stores

• Muscle weakness is the most common risk factor for falls in older persons1

• Malnutrition increases muscle loss2

• Nutrients that influence muscle function are lower in older people admitted to the hospital after a fall3,4

• Malnutrition is significantly associated with reduced mobility5

November 8, 2017 Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

1 Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on

Falls Prevention. J Am Geriatr Soc. May 2001;49(5):664-672. 2 Hebuterne X, Bermon S, Schneider SM. Current Opinion in Clinical Nutrition & Metabolic Care. 2001; 4:

295-300. 3 Vellas B, Baumgartner R, Wayne A, et al. Nutrition.1992; 8:105-8. 4 Vellas B, Conceicao J, Lafont C, et al. Lancet. 1990; 336:1447. 5 Vivanti et al. J Nutr Health

Aging, 2011:15: 388.

NUTRITIONAL THERAPY: WHY ARE ONS IMPORTANT TO PATIENT’S RECOVERY

Oral Nutritional Supplements in addition to routine medical care have been shown to reduce complications such as infections by 56%1

Some Evidence-Based Guidelines:

• Use nutritional support in patients with severe nutritional risk for 10-14 days prior to surgery, even if surgery needs to be delayed (ESPEN Strength of Evidence A)2

• The RD should recommend ONS for older adults who are undernourished or at risk of undernutrition (i.e., those who have infection) (JAND)3

November 8, 2017 Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

ORAL NUTRITIONAL SUPPLEMENTATION (ONS) LED TO FEWER FALLS AMONG FRAIL ELDERLY IN THE COMMUNITY1

November 8, 2017 Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

DEMOGRAPHICS

Frail elderlyliving at home in the community

12 WEEKS OF TREATMENT

Group 1 (treatment)ONS twice a day

RESULTS

Number of falls

was lower in

treatment group

(0% vs. 21%; P=0.05)

1. Gray-Donald K, Payette H, Boutier V. J Nutr. 1995;125:2965-2971.

N=50

Group 2 (control)Routine care

November 8, 2017 Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

NUTRITION INTERVENTION LED TO FEWER FALLS AMONG MALNOURISHED OLDER ADULTS1

DEMOGRAPHICS

Malnourished older adultsnewly admitted to an acute care hospital

3 MONTHS OF TREATMENT

Group 1 (treatment)Energy- and protein-enriched diet, oral nutritional supplementation (ONS; calcium/vitamin D supplement), telephone counseling

Group 2 (control)Routine care

RESULTS

Fewer patients in the

ONS group fell

compared with those

receiving usual care

10 subjects (10%) vs 24 subjects (23%) in the control group (HR, 0.41; 95% CI, 0.19-0.86)

1. Neelemaat F, Lips P, Bosmans JE, Thijs A, Seidell JC, van Bokhorst-de van der Schueren MA. J Am Geriatr Soc. 2012;60(4):691-699.

N=210

CI, confidence interval; HR, hazard ratio

WHO DEVELOPS PRESSURE INJURY IN THE HOSPITAL1

November 8, 2017

1 Fry D et al. Arch Surg. 2010;145:148-151.

30 1 2 4 5 6

CABG Surgery 3.3

Diabetic Complications 5.3

Chronic Renal Failure 4.7

Malnutrition/Weight Loss 3.8

Odds Ratio

Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

NPUAP NUTRITION GUIDELINES 20141

• “Offer high protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure injury risk because of acute and chronic disease, or following a surgical intervention.”

– Strength of Evidence A

• Rating is based upon the strength of the studies that were reviewed, in this case, randomized controlled trials.

November 8, 2017

1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide., page 21 Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

Improving Economic and Quality Outcomes Through the Nutrition Care Process March 2017 150746(1)

November 8, 2017 36

Discussion

RESOURCES

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapiresources.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/QAPIAtaGlance.pdf

https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/fsqrs.html

November 8, 2017 37

1. Medicare Payment Advisory Commission. Refining the hospital readmissions reduction program. In: Report to the Congress: Medicare and the Health Care Delivery System. June 2013. http://www.medpac.gov/documents/reports/jun13_ch04.pdf. Accessed August 31, 2015. 2. Medicare Payment Advisory Commission. Report to the Congress: Promoting Greater Efficiency in Medicare. June 2007. http://www.caretransitions.org/documents/MedPAC%20report.pdf. Accessed August 31, 2015. 3. Healthcare Information and Management Systems Society. Solving Preventable Readmissions: Challenges, Strategies and the Need for a Clinical Analytics Solutions. http://njhimss.org/images/documents/whitepapers/Solving-Preventable-Readmissions-White_Paper.pdf. Accessed August 31, 2015.