550000 research-article2014
PENXXX10.1177/0148607114550000Journal of Parenteral and Enteral NutritionSnider et al
Original Communication
Economic Burden of Community-Based Disease-Associated Malnutrition in the United States
Journal of Parenteral and Enteral Nutrition Volume 38 Supplement 2 November 2014 77S–85S © 2014 Abbott Nutrition DOI: 10.1177/0148607114550000 jpen.sagepub.com hosted at online.sagepub.com
Julia Thornton Snider, PhD1; Mark T. Linthicum, MPP1; Yanyu Wu, PhD1; Chris LaVallee, MS1; Darius N. Lakdawalla, PhD2; Refaat Hegazi, MD, PhD3; and Laura Matarese, PhD, RDN, LDN, CNSC, FADA, FASPEN4
Abstract Background: The burden imposed by disease-associated malnutrition (DAM) on patients and the healthcare system in food-abundant industrialized countries is often underappreciated. This study measured the economic burden of community-based DAM in the United States. Methods: The burden of DAM was quantified in terms of direct medical costs, quality-adjusted life years lost, and mortality across 8 diseases (breast cancer, chronic obstructive pulmonary disease [COPD], colorectal cancer [CRC], coronary heart disease [CHD], dementia, depression, musculoskeletal disorders, and stroke). To estimate the total economic burden, the morbidity and mortality burden was monetized using a standard value of a life year and combined with direct medical costs of treating DAM. Disease-specific prevalence and malnutrition estimates were taken from the National Health Interview Survey and the National Health and Nutrition Examination Survey. Deaths by disease were taken from the Center for Disease Control and Prevention. Estimates of costs and morbidity were taken from the literature. Results: The annual burden of DAM across the 8 diseases was $156.7 billion, or $508 per U.S. resident. Nearly 80% of this burden was derived from morbidity associated with DAM; around 16% derived from mortality and the remainder from direct medical costs of treating DAM. The total burden was highest in COPD and depression, while the burden per malnourished individual was highest in CRC and CHD. Conclusion: DAM exacts a large burden on American society. Therefore, improved diagnosis and management of community-based DAM to alleviate this burden are needed. (JPEN J Parenter Enteral Nutr. 2014;38(suppl 2):77S-85S)
Keywords disease-associated malnutrition; community-based; malnutrition; quality of life; quality-adjusted life year; burden of disease
Clinical Relevancy Statement In an era of abundant food and rising obesity rates, diseaseassociated malnutrition (DAM) is often overlooked in industrialized countries such as the United States. Yet DAM is highly prevalent, and the burden it imposes on society is considerable. Many studies have examined the prevalence and consequences of DAM in particular diseases and populations, but few countrywide estimates of the burden of DAM exist. We sought to quantify the community-based burden of DAM in the United States, in terms of morbidity, mortality, and healthcare costs. We found that DAM takes over 670,000 quality-adjusted life years (QALYs) each year. When this loss of life and health is combined with the direct medical costs of DAM, it amounts to an annual burden of $157 billion, or $508 per U.S. resident. Given that cost-effective solutions for treating and preventing DAM exist, we recommend that clinicians, payers, patients, and policy makers work together to identify and treat DAM in those afflicted and prevent it in those at risk.
impairment.1 Disease-associated malnutrition affects about 10% of chronically ill patients in the community2 and between From 1Precision Health Economics, Los Angeles, California; 2the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California; 3Abbott Nutrition, Columbus, Ohio; and 4East Carolina University, Greenville, North Carolina. Financial disclosure: Financial support for the publication of the supplement in which this article appears was provided by Abbott Nutrition. Conflicts of interest: This contribution was prepared at the request of and within the scope of the authors’ employment with Abbott Nutrition (for R.H.) and Precision Health Economics (for J.T.S., M.T.L., Y.W., C.L., and D.N.L.), which was contracted by Abbott to conduct the research, and as such copyright is owned by Abbott Nutrition. D.N.L. holds the position of partner at Precision Health Economics. L.M. receives grant support from Abbott Nutrition. A technical appendix for this article is available online at http://pen. sagepub.com/supplemental. Received for publication June 3, 2014; accepted for publication July 22, 2014.
Introduction Disease-associated malnutrition (DAM) occurs when the severity or persistence of an inflammatory response in an individual results in the loss of lean body mass and/or functional
Corresponding Author: Julia Thornton Snider, PhD, Precision Health Economics, 11100 Santa Monica Blvd, Suite 500, Los Angeles, CA 90026, USA. Email: [email protected]
Downloaded from pen.sagepub.com at Univ of Connecticut / Health Center / Library on June 26, 2015
78S
Journal of Parenteral and Enteral Nutrition 38(Suppl 2)
30% and 50% of patients admitted to hospitals.3,4 It has been linked to poor outcomes in the hospital setting, including increased length of stay,4-8 higher episode cost,5,7,9 increased complication rates,10,11 and increased mortality rates.12,13 In the community setting, malnutrition increases morbidity of disease, increases disability associated with disease, and decreases quality of life.14 In addition to affecting the mortality, health outcomes, and quality of life of individuals living with disease, DAM is an important concern for society in general, and policy makers and healthcare providers in particular. The morbidity, mortality, and direct medical costs associated with DAM impose a substantial social burden. Furthermore, unlike many primary diseases, such as stroke,15 coronary heart disease,16 and breast and colorectal cancer,17 DAM can be prevented and treated with a variety of low-cost interventions, such as malnutrition screening and appropriate nutrition intervention.4,6,18-20 There is a growing body of literature on DAM that emphasizes its importance, but these studies generally focus on describing the prevalence of DAM and documenting its effects on individual-level outcomes. For example, in a nationally representative study of hospitalized patients, a malnutrition diagnosis was associated with higher medical costs, an increased length of stay, and increased rates of complications.7 Malnutrition associated with diseases, such as stroke,21 pneumonia,22 and cancer,23 has frequently been shown to contribute to adverse outcomes. Among geriatric patients, decreased functionality, depressive symptoms, and increased morbidity were all related to malnutrition.24 To date, however, few studies have measured the societal impacts of DAM. One exception is the study conducted by Inotai and coauthors,25 who developed an economic model to measure the societal burden of DAM in Europe. By constructing a model based on inputs from the published literature, Inotai et al found that DAM imposes a total health and financial burden of $432.17 billion per year through increased morbidity, mortality, and direct medical costs. No estimate currently exists, however, of the societal benefits to be gained by addressing community-based DAM in the United States. In this study, nationally representative data were used to first estimate the prevalence of selected disease states and of the degree of malnutrition within those diseases in order to then model the morbidity, mortality, and direct medical costs associated with community-based DAM in the United States. Finally, the potential economic benefit of reducing the prevalence of community-based DAM was estimated.
in the United States, a model was developed to measure the prevalence of DAM and its consequences in terms of morbidity, mortality, and healthcare costs. The model to be structure is presented in Figure 1. To facilitate comparisons between the United States and Europe, we constructed the model to be similar to that by Inotai et al25 on the burden of DAM in Europe. For each disease of interest, the model uses data on the prevalence of DAM as well as estimates from the literature on the burden it imposes on afflicted individuals. These inputs are then used to calculate the morbidity, mortality, and direct medical cost impact of DAM for each disease and overall. Intuitively, the model calculates the cost of malnutrition within each disease in 3 steps: (1) compute the number of malnourished patients within a disease, (2) multiply this by the cost per person of malnutrition to produce the total cost within that disease, and (3) aggregate costs across all the diseases in the model to produce a total cost.
Methods
The model quantifies 3 effects of malnutrition: morbidity, mortality, and direct medical costs. Because estimates of the impact of malnutrition on these 3 variables were generally not available by disease, a uniform effect of malnutrition was assigned across all 8 diseases.25 Based on previously published studies, it was assumed that malnutrition reduces utility (or quality of
Conceptual Framework The total social cost of community-based DAM was estimated using a burden of disease (also known as cost-of-illness) approach.26 To quantify the burden of community-based DAM
Disease Definition and Prevalence Following Somanchi et al,4 malnutrition was defined as low body weight (
PENXXX10.1177/0148607114550000Journal of Parenteral and Enteral NutritionSnider et al
Original Communication
Economic Burden of Community-Based Disease-Associated Malnutrition in the United States
Journal of Parenteral and Enteral Nutrition Volume 38 Supplement 2 November 2014 77S–85S © 2014 Abbott Nutrition DOI: 10.1177/0148607114550000 jpen.sagepub.com hosted at online.sagepub.com
Julia Thornton Snider, PhD1; Mark T. Linthicum, MPP1; Yanyu Wu, PhD1; Chris LaVallee, MS1; Darius N. Lakdawalla, PhD2; Refaat Hegazi, MD, PhD3; and Laura Matarese, PhD, RDN, LDN, CNSC, FADA, FASPEN4
Abstract Background: The burden imposed by disease-associated malnutrition (DAM) on patients and the healthcare system in food-abundant industrialized countries is often underappreciated. This study measured the economic burden of community-based DAM in the United States. Methods: The burden of DAM was quantified in terms of direct medical costs, quality-adjusted life years lost, and mortality across 8 diseases (breast cancer, chronic obstructive pulmonary disease [COPD], colorectal cancer [CRC], coronary heart disease [CHD], dementia, depression, musculoskeletal disorders, and stroke). To estimate the total economic burden, the morbidity and mortality burden was monetized using a standard value of a life year and combined with direct medical costs of treating DAM. Disease-specific prevalence and malnutrition estimates were taken from the National Health Interview Survey and the National Health and Nutrition Examination Survey. Deaths by disease were taken from the Center for Disease Control and Prevention. Estimates of costs and morbidity were taken from the literature. Results: The annual burden of DAM across the 8 diseases was $156.7 billion, or $508 per U.S. resident. Nearly 80% of this burden was derived from morbidity associated with DAM; around 16% derived from mortality and the remainder from direct medical costs of treating DAM. The total burden was highest in COPD and depression, while the burden per malnourished individual was highest in CRC and CHD. Conclusion: DAM exacts a large burden on American society. Therefore, improved diagnosis and management of community-based DAM to alleviate this burden are needed. (JPEN J Parenter Enteral Nutr. 2014;38(suppl 2):77S-85S)
Keywords disease-associated malnutrition; community-based; malnutrition; quality of life; quality-adjusted life year; burden of disease
Clinical Relevancy Statement In an era of abundant food and rising obesity rates, diseaseassociated malnutrition (DAM) is often overlooked in industrialized countries such as the United States. Yet DAM is highly prevalent, and the burden it imposes on society is considerable. Many studies have examined the prevalence and consequences of DAM in particular diseases and populations, but few countrywide estimates of the burden of DAM exist. We sought to quantify the community-based burden of DAM in the United States, in terms of morbidity, mortality, and healthcare costs. We found that DAM takes over 670,000 quality-adjusted life years (QALYs) each year. When this loss of life and health is combined with the direct medical costs of DAM, it amounts to an annual burden of $157 billion, or $508 per U.S. resident. Given that cost-effective solutions for treating and preventing DAM exist, we recommend that clinicians, payers, patients, and policy makers work together to identify and treat DAM in those afflicted and prevent it in those at risk.
impairment.1 Disease-associated malnutrition affects about 10% of chronically ill patients in the community2 and between From 1Precision Health Economics, Los Angeles, California; 2the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California; 3Abbott Nutrition, Columbus, Ohio; and 4East Carolina University, Greenville, North Carolina. Financial disclosure: Financial support for the publication of the supplement in which this article appears was provided by Abbott Nutrition. Conflicts of interest: This contribution was prepared at the request of and within the scope of the authors’ employment with Abbott Nutrition (for R.H.) and Precision Health Economics (for J.T.S., M.T.L., Y.W., C.L., and D.N.L.), which was contracted by Abbott to conduct the research, and as such copyright is owned by Abbott Nutrition. D.N.L. holds the position of partner at Precision Health Economics. L.M. receives grant support from Abbott Nutrition. A technical appendix for this article is available online at http://pen. sagepub.com/supplemental. Received for publication June 3, 2014; accepted for publication July 22, 2014.
Introduction Disease-associated malnutrition (DAM) occurs when the severity or persistence of an inflammatory response in an individual results in the loss of lean body mass and/or functional
Corresponding Author: Julia Thornton Snider, PhD, Precision Health Economics, 11100 Santa Monica Blvd, Suite 500, Los Angeles, CA 90026, USA. Email: [email protected]
Downloaded from pen.sagepub.com at Univ of Connecticut / Health Center / Library on June 26, 2015
78S
Journal of Parenteral and Enteral Nutrition 38(Suppl 2)
30% and 50% of patients admitted to hospitals.3,4 It has been linked to poor outcomes in the hospital setting, including increased length of stay,4-8 higher episode cost,5,7,9 increased complication rates,10,11 and increased mortality rates.12,13 In the community setting, malnutrition increases morbidity of disease, increases disability associated with disease, and decreases quality of life.14 In addition to affecting the mortality, health outcomes, and quality of life of individuals living with disease, DAM is an important concern for society in general, and policy makers and healthcare providers in particular. The morbidity, mortality, and direct medical costs associated with DAM impose a substantial social burden. Furthermore, unlike many primary diseases, such as stroke,15 coronary heart disease,16 and breast and colorectal cancer,17 DAM can be prevented and treated with a variety of low-cost interventions, such as malnutrition screening and appropriate nutrition intervention.4,6,18-20 There is a growing body of literature on DAM that emphasizes its importance, but these studies generally focus on describing the prevalence of DAM and documenting its effects on individual-level outcomes. For example, in a nationally representative study of hospitalized patients, a malnutrition diagnosis was associated with higher medical costs, an increased length of stay, and increased rates of complications.7 Malnutrition associated with diseases, such as stroke,21 pneumonia,22 and cancer,23 has frequently been shown to contribute to adverse outcomes. Among geriatric patients, decreased functionality, depressive symptoms, and increased morbidity were all related to malnutrition.24 To date, however, few studies have measured the societal impacts of DAM. One exception is the study conducted by Inotai and coauthors,25 who developed an economic model to measure the societal burden of DAM in Europe. By constructing a model based on inputs from the published literature, Inotai et al found that DAM imposes a total health and financial burden of $432.17 billion per year through increased morbidity, mortality, and direct medical costs. No estimate currently exists, however, of the societal benefits to be gained by addressing community-based DAM in the United States. In this study, nationally representative data were used to first estimate the prevalence of selected disease states and of the degree of malnutrition within those diseases in order to then model the morbidity, mortality, and direct medical costs associated with community-based DAM in the United States. Finally, the potential economic benefit of reducing the prevalence of community-based DAM was estimated.
in the United States, a model was developed to measure the prevalence of DAM and its consequences in terms of morbidity, mortality, and healthcare costs. The model to be structure is presented in Figure 1. To facilitate comparisons between the United States and Europe, we constructed the model to be similar to that by Inotai et al25 on the burden of DAM in Europe. For each disease of interest, the model uses data on the prevalence of DAM as well as estimates from the literature on the burden it imposes on afflicted individuals. These inputs are then used to calculate the morbidity, mortality, and direct medical cost impact of DAM for each disease and overall. Intuitively, the model calculates the cost of malnutrition within each disease in 3 steps: (1) compute the number of malnourished patients within a disease, (2) multiply this by the cost per person of malnutrition to produce the total cost within that disease, and (3) aggregate costs across all the diseases in the model to produce a total cost.
Methods
The model quantifies 3 effects of malnutrition: morbidity, mortality, and direct medical costs. Because estimates of the impact of malnutrition on these 3 variables were generally not available by disease, a uniform effect of malnutrition was assigned across all 8 diseases.25 Based on previously published studies, it was assumed that malnutrition reduces utility (or quality of
Conceptual Framework The total social cost of community-based DAM was estimated using a burden of disease (also known as cost-of-illness) approach.26 To quantify the burden of community-based DAM
Disease Definition and Prevalence Following Somanchi et al,4 malnutrition was defined as low body weight (
