1.4.3.2 FINANCIAL COSTS

Malnutrition increases healthcare costs

The financial burden of malnutrition is, increasingly, being defined and recognised. Historically much of the data on the costs of malnutrition has arisen from the UK from work undertaken by the British Association of Enteral and Parenteral Nutrition (BAPEN), with the first report on the costs of malnutrition being published in 2005.³⁵⁰ The reports from BAPEN have been used by other workers to help estimate the cost of DRM in their own countries or for Europe as a whole.^351-353

Increases in health and social care budgets together with improvements in defining and recording costs have led to an updated version of the report which aims to provide more accurate assessment of the costs of malnutrition.³⁵⁴ The latest report is specific to England rather than the UK as a whole. This is because, as the four devolved nations of the UK (England, Scotland, Wales, and Northern Ireland) have been developing their own distinct healthcare systems using specific budgets allocated to their countries, it has become increasingly difficult to use a common framework to establish the cost of malnutrition in the UK as a whole.

Increasingly, data on the costs of malnutrition is available in other countries. Some of this data has been generated by prospective studies that measure the direct costs of hospital admissions for a malnourished vs. a well-nourished patient. Other estimates are made based on economic models that look at disease prevalence, malnutrition prevalence within disease states and financial data on the cost of treating the disease. However, what is clear from all of these reports and studies is that the financial burden of DRM is significant both at an individual level and at a population level.

The costs of DRM have increased and the cost of treating a malnourished patient is 2-3 times greater than for a non-malnourished patient.

• The public health and social care expenditure associated with malnutrition in adults and children in England in 2011–12, identified using the ‘Malnutrition Universal Screening Tool’ (‘MUST’), was estimated to be £19.6 billion, or about 15% of the total expenditure on health and social care.³⁵⁴
• Previous BAPEN reports have suggested that malnutrition accounted for >10% of the total costs in the UK.^350,355 However, according to the latest report the estimated cost of disease-related malnutrition appears to have increased considerably over time:
  • >£7.3 billion in the UK in 2003;
  • >£13 billion in the UK in 2007;
  • £19.6 billion in England in 2011–12;
  • £23.5 billion in UK in 2015.

This is thought to be due to a striking increase in the budget for health and social care between 2003 and 2012 and the fact that the previous costs were based on minimum estimates. The latest BAPEN report involves a more complete analysis of all the major services and associated costs providing a better estimate of the costs of disease related malnutrition.³⁵⁴

Total expenditure of £19.6 billion is made up of £15.2 billion expenditure on healthcare costs and £4.4 billion relating to social are costs (Figure 1.31).

Figure 1.31

The cost of disease-related malnutrition in England 2011-2012. (adapted from Elia M, 2015)³⁵⁴

• The distribution of expenditure in the malnourished population is broadly similar to that of the general population, although a greater proportion is distributed towards secondary care and to older subjects (≥65 years) in the malnourished population (Figure 1.32)
  ).

Figure 1.32

The distribution of total public health and social care expenditure in England (£127.5 billion) and in the subgroup of individuals with malnutrition (£19.6 billion) according to type of care (upper chart) and age category (lower chart) base case analysis. (adapted from Elia M, 2015)³⁵⁴

1ry = primary care; 2ry = secondary care.

• The extra (incremental) cost of treating malnutrition was calculated as being 2–3 times greater than for a non-malnourished subject (Figure 1.33).

Figure 1.33

Public expenditure on health and social care per subject in the general population, per subject without malnutrition and per subject with malnutrition (medium + high risk according to ‘MUST’). (adapted from Elia M, 2015). ³⁵⁴

The top of the bars represent the values calculated assuming that 5% of the population is malnourished or at risk of malnutrition. The tip of the upper arrow heads above the bar for the malnourished represents the value calculated assuming that 4% of the population is malnourished and the tip of the lower arrowhead assuming that 6% of the population is malnourished. No arrowheads are shown for the non-malnourished because the base case value was affected by only about ± 1%

• In comparison, estimates of the direct NHS costs of treating overweight and obesity, and related morbidity in England have ranged from £479.3 million in 1998 to £6.5 billion in 2022,^354,356,357 significantly lower than the costs associated with DRM.

Increasingly, more data is now available on the financial burden of malnutrition in many other countries. Estimates for Europe alone suggest that the cost of DRM is €170 billion³⁵² or €120 billion³⁵³ in the EU. This estimate is based on health economic evidence from the UK showing that the costs for managing patients at risk of malnutrition exceed €15 billion.³⁵⁵ The recent update by BAPEN puts the figure at £19.6 billion for England alone so it is highly likely that the figures above are now a very conservative estimate of the true cost of malnutrition in Europe.

• In a Spanish study hospitalization costs were calculated, based on a patients’ nutritional status throughout their hospital journey. The highest costs were seen in subjects that were both malnourished on admission and at discharge and hospitalisation costs increased generally for any patient that was malnourished on discharge.³³⁵ (Figure 1.34)
• In Italy, DRM is highly prevalent and imposes a significant financial burden on the healthcare system, exceeding €10 billion annually, with even the most conservative estimate exceeding €2.5 billion. Meta-analysis showed DRM prevalence of ~50% in hospitalised adults and ~30% in paediatric patients, with even higher rates in long-term care facilities. ³⁵⁸
• A systematic review assessed the healthcare costs associated with poststroke oropharyngeal dysphagia (OD) and its complications, including malnutrition, dehydration, pneumonia, and mortality. Among 10 included studies conducted across 8 countries (Spain, Germany, France, Italy, Sweden, the United Kingdom, Canada, and the United States), OD was found to increase hospital costs, with studies reporting additional expenses ranging from $3,950 to $15,300 per hospitalization. Patients requiring tube feeding had an increased cost of $6,589, while those with OD incurred additional costs of $4,510 in the first year after stroke. Pneumonia was associated with increased hospitalization costs between $1,456 and $27,633. ³⁵⁹
• In Colombia, the economic burden of malnutrition in hospitalised patients was highlighted by a study showing that, without early nutrition therapy, costs could reach $3,770 for patients with delayed nutrition therapy to $2419 for patients with early nutrition therapy. This represents a significant financial strain on the healthcare system, with potential annual excess costs exceeding $862.6 million. ³⁶⁰
• In Asia, hospital malnutrition imposes an economic burden of $30.1 billion annually, primarily due to increased length of stay (LOS) and higher medication costs. Increased LOS accounts for $23.2 billion (77.2%) in general wards and $3.5 billion (11.5%) in ICUs, while medication costs for infectious complications add $3.4 billion (11.3%). ¹¹²

Figure 1.34

Hospitalisation cost comparisons of subjects according to their nutritional status on admission and/or discharge (adapted from Gastalver-Martin et al. 2015)³³⁵

• More recently estimates have been made to quantify the cost of malnutrition in the community with a study based on an economic model in the US estimating the annual cost at $156.7 billion or $508 per US resident,³⁶¹ whilst a Spanish study estimated that the cost of treating a malnourished patient was over 3.5 times higher than a well-nourished patient ³⁶² in a community setting.

As the volume of evidence on the costs of DRM has increased over recent years, relevant studies have been summarised in Table 1.18 according to the following categories:

• across healthcare settings
• hospital
• community
• children

Data are also now available for the costs of DRM in children

Up until recently, data on the cost implication of malnutrition in children has been lacking. However, a recent report from BAPEN provides financial estimates of the burden of malnutrition in the paediatric population in England: ³⁵⁴

• It is estimated that around 6% of the total public expenditure on malnutrition in health and social care is spent on children in England. This equates to around £1.2 billion ³⁵⁴
• This estimate of the cost of malnutrition in children has been made based on the assumption that malnutrition affects 15% of children admitted to a typical hospital in England and that it prolongs length of hospital stay by 1.3 times, as for adults ³⁵⁴
  • malnutrition accounted for 18.7% of costs, when calculated using the same procedures as for adults;
  • in relation to outpatients it was assumed that 7.5% of attendances and costs were due to malnutrition
  • it was assumed that malnutrition accounted for only 3% of the costs of the children’s social services, including those for looked-after children.

In addition to these estimates, a study using US data from 2010 of hospitalised children showed that:³⁵⁴

• Hospitalisation costs were US$ 55,255 for children with a malnutrition diagnosis vs. US$17,309 without ³⁰⁹
• Hospitalised children with a diagnosis of malnutrition were also less likely to have a routine discharge and almost 3.5 times more likely to require post-discharge home care, suggesting higher costs in the community too.

A cost-of-illness analysis in The Netherlands estimated the annual additional costs of DRM in hospitalised paediatric patients. The total additional medical costs were €51 million for acute malnutrition, €46 million for chronic malnutrition, and €80 million for overall malnourished children, accounting for 5.6% of total Dutch hospital costs for paediatric patients. ³⁶³

Country	Author (year) Patient group	Healthcare setting	Study design	Method used to calculate costs	Cost of DRM per patient	Total cost of DRM per annum
Across health care settings
China	Linthicum et al. (2015)225 Covers all ages and genders with a range of diseases with a range of diagnoses >20 years	Unclear	Economic model	Economic model based on population surveys, current literature and census information quantifies the health burden of DRM (does not include direct medical costs)	NR	US$66 billion ($25.2 billion associated with ≥60 years)
Croatia	Benkovic V et al. (2014)228 Adults	Across healthcare settings	Economic model based on national data	Adapted WHO model that direct costs estimated from disease prevalence and undernutrition incidence based on national disease treatment costs	€1640.48 per person	€97.35 million for the range of diagnoses specified
Germany	Cepton Report227 (unclear) Adults	Across healthcare settings	Economic model	Only direct costs considered	NR	€9 billion (additional costs due to malnutrition in 2003)
Ireland	Rice and Normand (2012)217 Adults (age NR)	Across healthcare settings	Economic model based on national data	Costs based on DRM prevalence and official costs of healthcare utilisation using an adapted BAPEN model	Additional cost of €5357 per patient	€1.4 billion (in 2007)
The Netherlands	Kok (2014)228 Adults 20 years	Hospital, nursing home and residential care	Economic model based on national data	Costs based on DRM prevalence and healthcare costs (as part of a societal cost-benefit analysis)	NR	€1.8 billion (in 2011) made up of: Hospital: €1.1 billion; Residential care and nursing homes: €523 million; Cost of the value of life: €244 million
The Netherlands	Freijer et al. (2013)229 Adults >18 years with a range of disease categories	Across healthcare settings	A cost of illness study using only direct healthcare costs	Formula developed based on disease category costs, prevalence of malnutrition in disease category and increased costs of managing malnourished patients	€135 per head of population of 14 million (per capita in 2011)	€1.9 billion in 2011 made up of: Hospital: €1.2 billion; Nursing and residential homes: €453 million; Home care setting: €185 million
Hospital
Australia	Rowell and Jackson (2011)230 Hospital patients >14 years (n = 256,865)	Hospital	Retrospective analysis	Costs were calculated using patient level costing data. Economic model used to estimate the cost of untreated malnutrition	Malnutrition increased costs by AU$1745	AU$10.7 million in 2003-2004
Australia	Banks et al. (2010)231 Hospital patients ≥18 years (n=241,415 hospital discharges)	Hospital	Economic model	Costs based on hospital discharge data, incidence of pressure ulcers (PU), effect of malnutrition on the development of PU, effect of PU on LOS, cost of patient bed day.	NR	Cost of PU attributable to malnutrition in 2002/2003: AU$12,968,669 (SD$4,924,148)
Belgium	Ethgen et al. (2005)232 Malnourished (n = 927) vs. well-nourished (matched controls n = 26067) (age NR).	Hospital	Observational analysis	Compared overall hospital costs of malnourished vs. well-nourished	Mean cost difference per patient’s hospital stay between malnourished and well-nourished €1,152 (95% CI €870; €1433)	NR
Canada	Curtis et al. (2016) Adult patients ≥18 years admitted to surgical or medical wards (n = 958)	Hospital	Multi-center Prospective cohort study	LOS calculated for each participant by tracking admissions and transfers. Standardised data on per diem expenses and direct expenses for functional units purchased from the Canadian Institute for Health Information	Total additional cost of malnutrition at hospital admission roughly estimated to be: Severely malnourished: 38% higher total costs than well-nourished (p = 0.002) and 55% higher medical costs (p=0.003). Moderately malnourished: 31% higher total costs than well-nourished (p = 0.003), 29% higher medical costs (p=0.004) and 34% higher surgical costs (p = 0.022)	Approx. $1.56 to $2.1 billion per year
France	Melchior et al. (2012)204 Hospital patients undergoing Colorectal cancer surgery	Hospital	Post-hoc analysis of prospective study	Individual costs were calculated by mean LOS × hospitalisation costs valued according to the French National Cost Construction Study (2008)	Cost of hospitalisation increased by €3360 per patient for malnourished vs. non-malnourished	€10,159,436 per annum
Germany	Thomas et al. (2016)207 Hospital Surgical patients mean age 57.3 years	Hospital	Prospective observational study	Cost compensation calculated using the German Diagnosis-Related Group (G-DRG) system	Re-imbursement of €1979.67 per patient at risk for malnutrition and total re-imbursement for all malnourished patients €79,186.73	NR
Portugal	Guerra et al. (2016)233 Hospital Adults aged 18-91 years	Hospital	Prospective observational study	Hospitalisation cost was calculated for each inpatient based on the amounts defined by the discharge DRG codes	Cost of a nutritionally-at-risk or undernourished patient is between €416 (95% CI = €156-675) and €617 (95% CI = €293-855) higher than the average of the respective DRG	NR
Singapore	Lim et al. (2012)51 Hospital Adults aged 51.9 years ± 15.4 (n = 818)	Hospital	Prospective study (matched case-control)	Hospital costs calculated according to DRG codes	Mean difference between the actual hospital cost and the average cost of hospitalisation for malnourished patients (SGA B+C) was greater than for well-nourished patients S$1392±6150 vs S$488±3494 (p = 0.014)	NR
Spain	Gastalver-Martín C et al. (2015)209 Adults	Hospital	Prospective observational study	Individual costs calculated per patient on discharge (see Figure 1.33)	Hospitalisation costs increased for patients that were malnourished 1747.95 (p = 0.015). Hospitalisation costs: 4158.90€ +4148.51 malnourished vs. cost of non-malnourished 2864.21€	NR
Spain	Álvarez Hernández et al. (2015)208 Adults with dysphagia (mean age 69.15 years)	Hospital	Observational study	Costs based on average cost/day of admission provided by the Ministry of Health and Consumer Affairs (2009)	Increased costs for malnourished subjects €8004 ± 5854 vs. €6967 ± 5630, p = 0.11 Note result ns.	NR
Spain	Leon-Sanz et al. (2015)199 Adults mean age 73.7 years (malnourished) 60.48 years (controls)	Hospital	Case-control study	Costs calculated from direct costs of treatment and services and extrapolated to estimate national costs	Hospitalisation costs higher in malnourished €8590 ± €6127 vs. not malnourished €7085 ± €5625, (p = 0.015)	€1.143 billion per annum
Spain	Marco et al. (2011)52 Adults (mean age malnourished 72.37 years (sd 17.89) vs. not malnourished 70.82 years (7.21)) (n =>1.5 million)	Hospital	Retrospective analysis	Malnourished patients identified from the Minimum Basic Data Set from Spanish hospitals, costing data also obtained from this	Cost per patient mean (sd): malnourished €5228.46 (€4593.04) vs. non-malnourished €3537.8 (€2858.07), p<0.001	NR
Switzerland	Khalatbari-Soltani and Marques-Vidal (2016)53 Adult patients (≥18 years)	Hospital	Retrospective study of electronic administrative data	Actual costs for each patient extracted from the hospital billing system	Hospital costs higher in at risk patients vs. not at risk patients (excess 5642.25±1479.80 CHF in 2013 and 5529.52±847.02 CHF in 2014)	NR
UK	Gomes et al. 2016212 Stroke patients (mean age 74.7 years)	Hospital	Prospective observational study	Costs based on hospital payment system in place in England (2012-2013)	Hospitalization costs increased with malnutrition risk category, from a median of less than £5000 (low risk) to more than £8000 (high risk) (p<0.001)	NR
US	Weiss et al. (2016)72 All non-maternal and non-neonatal hospital inpatient stays (n=27.6 million)	Hospital	Descriptive summary report of Health care Cost and Utilisation Project (HCUP)	Administrative health care data from the National (Nationwide) Inpatient Sample (NIS)	NR	In 2013, hospital stays involving malnutrition accounted for nearly $42 billion or 12.1% of aggregate non-maternal, non-neonatal hospital costs
Community
Germany	Baumeister et al. (2011)234 Adults (55-74 years)	Community	Economic study using population based cohort	Costs calculated by self-reported health-care resource use and standard costs based on official statistics	Predicted annual cost at 10 year follow-up €1383.16 (mean GNRI) vs. €2040.43 (low GNRI)	NR
Spain	Rodríguez-Mañas et al. (2014)224 Older adults (age NR)	Community (including those living in institutions)	Systematic review	Costs calculated from malnutrition prevalence, GP visits and hospitalizations. Unit costs were derived from health care cost databases available in Spain (Euros, 2014)	Annual cost of malnourished patient (™5,000.66) was 3.5 times higher than that of a well-nourished (€1,433.78).	NR
The Netherlands	Meijers et al. (2012)235 Nursing home residents (110 nursing homes, 9855 patients)	Nursing homes	Economic study based on data obtained by a survey of 30 dietitians	Costs calculated based on individual treatment and resources, malnutrition prevalence and extrapolated to entire nursing home population	Additional costs €8000/patient/year for at risk patient €10000/patient/year for malnourished patient	Additional costs of malnutrition in nursing homes €279 million/year
UK	Collins et al. (2011)238 COPD patients (age NR)	Community	Prospective study	Costs calculated according to Department of Health NHS reference costs 2007	Highest costs associated with being underweight (BMI < 20 kg/m²) (Actual costs NR)	NR
UK	Guest et al. (2011)80 Adults ≥18 years (mean age 63 years)	Community	Economic study based on The Health Improvement Network database (THIN)	Costs calculated using a computer based model using the THIN dataset and costs based on 2007-08 prices	Cost per patient over 6 month period was £1753 (95% CI: £1628; £1878) per malnourished patient and £750 (95% CI: £684; £816) per non-malnourished patient	£3.7 billion for the first 6 months after diagnosis of malnutrition (based on incidence of malnutrition in community of 6%)
USA	Snider et al. (2014)223 Covers all ages and genders	Community	Economic model based on population surveys, current literature and census information	Cost of community-based DRM was estimated using a burden of disease approach	$508 per U.S. resident	$156.7 billion ($51.3 billion associated with >65 years)
Children
USA	Abdelhadi et al. (2016)200 Children (≤17 years)	Hospital	Retrospective analysis using patient-level data on hospital inpatient stays	Costs based on the 2010 Healthcare Cost and Utilization Project	Hospitalisation costs were US$55,255 for children with a malnutrition diagnosis vs. US$17,309 without	NR
Thailand	Kittisakmontri and Sukhosa (2016)237 Children >5 years (mean age 26.8 ± 1.8 months) (n = 105)	Hospital	Prospective cohort study	Direct costs were calculated individually	The cost (median (range)) of: Bed, 3500 Baht (400.0-12,400) vs. 2275 Baht (400.0-36,400) p = 0.01), enteral formula 86 Baht (0-3300) vs. 312 Baht (0-16332); p<0.01 medical apparatus 2371.5 Baht (460-345,936) vs. 8074 Baht (240-125,667); p=0.01 and nursing care, 5920 Baht (582-119,520) vs. 11,235 Baht (1300 – 37,970); p=0.02 were significantly higher in the group of children classified as having stunting and wasting compared to those who were well nourished. Note difference in overall costs was ns	NR