ReviewA systematic review and meta-analysis of the impact of oral nutritional supplements on hospital readmissions
Introduction
There is increasing interest in the influence of interventions used in clinical practice on health care use, and especially the effects on costly hospital admission and readmission rates. The adverse effects of disease-related malnutrition on health care use are well substantiated, and these include increased hospital admissions as well as increased GP visits and longer hospital stays (Elia, 2006, Elia and Stratton, 2005, Stratton et al., 2003). Consequently the financial public expenditure on malnutrition is considerable, most recently estimated to be ∼£13 billion (€16.24 billion; 02.10.12) annually (population ∼60 million, 2007 data) for the UK (Elia and Stratton, 2009). However, these estimates are based on observational studies without specific interventions. The effect of nutritional interventions on resource use, specifically hospital readmissions, is unclear and requires exploration. One of the commonly used treatments for malnutrition is oral nutritional supplements. These supplements are typically ready-made liquids and contain energy, protein and a range of vitamins, minerals and trace elements. There is already a synthesis of the evidence from systematic reviews and meta-analyses (Koretz et al., 2007, Milne et al., 2006, National, 2006, Stratton et al., 2005, Stratton and Elia, 2007, Stratton et al., 2003) (including that of the National Institute for Health and Clinical Excellence, NICE) of the effects of all types of oral nutritional supplements on nutritional intake and status (e.g. body weight) and some functional (e.g. muscle strength) and clinical outcomes (e.g. complications such as infections and pressure ulcers) in various patient groups. However, a critical review and synthesis of the impact of the use of liquid multi-nutrient ONS on hospital (re)admissions is lacking. A preliminary communication of the effects of ONS on hospital readmissions (Stratton et al., 2011) and two subsequent systematic reviews of nutritional support (dietary approaches and/or ONS (4 RCT) (Beck et al., 2012); ONS high in protein (>20% energy from protein) (2 RCT) (Cawood et al., 2012)), which included hospital (re)admissions as an outcome measure, were not designed to comprehensively address the effects of all types of liquid multi-nutrient ONS on this outcome across all patient groups in the community setting.
Therefore, this systematic review aimed to critically review and synthesise the literature to assess the impact of oral nutritional supplements used in the community setting across all patient groups on hospital admissions and readmissions (indicated as (re)admissions).
Section snippets
Eligibility criteria
Studies were deemed eligible for inclusion in the review if they conformed to the pre-determined inclusion and exclusion criteria (Table 1). Clinical studies were restricted to randomised controlled trials (RCT) published in English, and there was no exclusion on the basis of study size or duration of follow up. Participants were adults (mean age ≥18 years) of any nutritional status (within the spectrum of malnourished to well nourished, and irrespective of whether the population involved only
Results
A total of 18,125 potentially relevant publications were identified from electronic database searches (Embase = 5767, Medline = 5858, Cochrane = 6500), of which 660 duplicates were excluded. On the basis of title and abstract, 17,271 studies were excluded at first pass (Fig. 1). On re-application of the review inclusion criteria to the 197 full-text papers, and to 3 additional studies identified via hand searching, a further 188 were excluded at second pass. Therefore, 9 publications meeting the
Discussion
This is the first systematic review and meta-analysis to comprehensively examine the impact of ONS on hospital (re)admissions. The findings that use of ONS can lead to a subsequent reduction in (re)admissions to hospital appear to be robust in that they are observed in various subgroups of patients (according to reported nutritional status (malnourished or a mixture of malnourished and well nourished), age category (<65 years or ≥65 years), setting (community or hospital initiated), type of
Disclosure statement
R.S. is also an employee of Nutricia Ltd.
Acknowledgements
Personal communication from S. Gariballa and K. Norman. Abacus International for assistance with systematic searches.
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