Previous studies have shown that malnutrition, which is associated with increased medical complications in older patients, can be attenuated by providing oral nutritional supplements (ONS). This study evaluates the cost-effectiveness of an ONS in malnourished older hospitalized patients using data from a randomized controlled trial.
A multicenter, prospective study (NOURISH) was conducted in the United States between May 2012 and October 2014. Malnourished older adults hospitalized for congestive heart failure (CHF), acute myocardial infarction (AMI), pneumonia, or chronic obstructive pulmonary disease (COPD) were randomized to two groups, receiving either a specialized ONS containing high protein and β-hydroxy β-methylbutyrate HMB (HP-HMB; n = 313) or placebo supplements (n = 309). The trial collected data on survival, readmission, resource utilization, and quality of life at baseline (hospital discharge), 30, 60, and 90 days post-discharge. We used both a 90-day (post-discharge) and lifetime horizon to calculate incremental cost-effectiveness ratios (ICERs). The analysis used published findings to estimate patient life expectancy beyond 90 days post-discharge. ICERs were calculated as either cost per quality-adjusted life year (QALY) gained (90-day horizon) or cost per life-year saved (LYS) (lifetime horizon).
On average, 90-day costs for treatment group patients totaled $22,506 per person, compared to $22,133 per person for the placebo group. Through the 90-day follow-up period, treatment group patients gained 0.011 more QALYs than control group subjects, reflecting the treatment group’s significantly greater probability of survival through 90 days follow-up, as reported by the clinical trial. The 90-day follow-up period ICER was $33,818/QALY. In the lifetime analysis, estimated life expectancy for treatment group patients exceeded placebo group life expectancy by 0.71 years. Hence, the lifetime ICER was $524/LYS.
HP-HMB improved health at a cost of no more than $34,000/QALY within the first 90 days post discharge (below the commonly cited benchmark of $50,000/QALY). If the cohort were followed for their entire lifetime, the intervention would cost $524 per life year saved. Conservatively assuming that over each life year, a patient gains 0.6 QALYs (i.e., assuming quality of life is severely compromised) yields a cost-per-QALY ratio of $873 per QALY gained. This result compares favorably to a number of accepted health care interventions, including treatment of atrial fibrillation in 70 year-olds with Warfarin ($2,573/QALY), dialysis for critically ill 60-year-old men with kidney injury ($5,590/QALY), Aspirin for the prevention of CHD in 65-year-old women with moderate risk ($16,122/QALY) and influenza vaccinations for the U.S. population over 50 ($8053/QALY). The results of our study on use of HP-HMB suggest an opportunity to improve health and survival at a low marginal cost.