Home enteral nutrition reduces complications, length of stay, and health care costs: results from a multicenter study1–3 Stanislaw Klek, Adam Hermanowicz, Grzegorz Dziwiszek, Konrad Matysiak, Kinga Szczepanek, Piotr Szybinski, and Aleksander Galas
INTRODUCTION
Clinical nutrition (nutritional therapy) enables an adequate provision of nutrients. This method of medical intervention uses either the route of gastrointestinal tract (enteral nutrition; EN) or intravenous access (parenteral nutrition). EN is undoubtedly the method of choice for artificial feeding because of its physiologic
transport route, lower cost, and safety (1). It may be performed with oral diets, but more preferably via enteral tubes (nasogastric or nasojejunal catheters, gastrostomy, or jejunostomy), which additionally ensure the correct provision. It can be performed at hospitals, long-term health care facilities, palliative care centers, or home. Long-term nutrition has been used for many years in North America, South America, all of Western and Central Europe, Some Asian countries, and Australia and has always been recognized as a life-saving procedure. Guidelines of the European Society for Clinical Nutrition and Metabolism precisely describe the vindications and methods for home artificial nutrition (2). With the ongoing economic crisis, however, some authors criticized and questioned the benefits of these interventions because they were perceived as procedures that contributed significantly to annual costs paid by health care systems. The prevalence of home enteral nutrition (HEN) in the United States is 4 to 10 times that in other Western European countries, and after it was doubled in the early nineties finally they were estimated to cost between 9000 and 25,000 USD per patient in 2000, whereas in some European countries the amount varied between 9048 and 10,140 USD a year (3–14). The escalating costs of home care because of the widespread use of HEN has raised concerns about the cost-efficiency of the procedures of the National Health Systems (6–8, 15). For that reason, some insurance companies and even governments decided to either not initiate reimbursement or to decrease it. Some Eastern European countries, such as Russia, Lithuania, Ukraine, Belarus, Latvia, and Estonia, decided to not reimburse for HEN.
1 From Stanley Dudrick’s Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG). 2 There were no sources of support for this article. 3 Address correspondence and reprint requests to S Klek, Stanley Dudrick’s Memorial Hospital, General Surgery Unit, 32-050 Skawina, 15 Tyniecka Street, Poland. E-mail: [email protected]. Received December 29, 2013. Accepted for publication May 19, 2014. First published online June 25, 2014; doi: 10.3945/ajcn.113.082842.
Am J Clin Nutr 2014;100:609–15. Printed in USA. Ó 2014 American Society for Nutrition
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Abstract Background: Home enteral nutrition (HEN) has always been recognized as a life-saving procedure, but with the ongoing economic crisis influencing health care, its cost-effectiveness has been questioned recently. Objective: The unique reimbursement situation in Poland enabled the otherwise ethically unacceptable, hence unavailable, comparison of the period of no-feeding and long-term feeding and the subsequent analyses of the clinical value of the latter and its cost-effectiveness. Design: The observational multicenter study in the group of 456 HEN patients [142 children: 55 girls and 87 boys, mean (6SD) age 8.7 6 5.9 y; 314 adults: 151 women and 163 men, mean age 59.3 6 19.8 y] was performed between January 2007 and July 2013. Two 12-mo periods were compared. During the first period, patients were tube fed a homemade diet and were not monitored; during the other period, patients received HEN. HEN included tube feeding and complex monitoring by a nutrition support team. The number of complications, hospital admissions, length of hospital stay, biochemical and anthropometric variables, and costs of hospitalization were compared. Results: Implementation of HEN enabled weight gain and stabilized liver function in both age groups, but it hardly influenced the other tests. HEN implementation reduced the incidence of infectious complications (37.4% compared with 14.9%; P , 0.001, McNemar test), the number of hospital admissions [1.98 6 2.42 (mean 6 SD) before and 1.26 6 2.18 after EN; P , 0.001, Wilcoxon’s signed-rank test], and length of hospital stay (39.7 6 71.9 compared with 11.9 6 28.5 d; P , 0.001, Wilcoxon’s signed-rank test). The mean annual costs ($) of hospitalization were reduced from 6500.20 6 10,402.69 to 2072.58 6 5497.00. Conclusions: The study showed that HEN improves clinical outcomes and decreases health care costs. It was impossible, however, to determine precisely which factor mattered more: the artificial diet itself or the introduction of complex care. This trial was registered at clinicaltrials.gov as NCT02122120. Am J Clin Nutr 2014;100:609–15.
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Regrettably, the price of artificial enteral diets and monitoring by nutrition support teams constitutes significantly to the total cost of this procedure, which makes some authorities believe that the use of blenderized food by patients or caregivers, which is significantly less expensive, is more beneficial. The paucity of data substantiating the benefits of HEN seems to support the latter thesis. Moreover, it is not feasible and is unethical nowadays to carry out a clinical trial recruiting patients deprived of HEN. In Poland, however, it was possible to perform an analytic study investigating the cost-effectiveness of HEN because of the sudden onset of reimbursement for HEN, which took place in 2007. Before January 2007, most Polish patients were forced to prepare blenderized homemade diets for tube feeding using household products because commercial formulas were too expensive. The unique reimbursement situation provided an exceptional opportunity to evaluate the clinical outcomes and the cost-effectiveness of HEN.
This multicenter observational study was performed in 4 Polish medical centers (Skawina, Bialystok, Ostroleka, and Poznan) between 1 January 2007 and 1 January 2013. In total, 456 patients (142 children: 55 girls and 87 boys, mean 6 SD age of 8.7 6 5.9 y; 314 adults: 151 women and 163 men, mean age of 59.3 6 19.8 y) were recruited from the sample of 3620 eligible patients. The Local Ethical Committee of Skawina Hospital approved the protocol. The inclusion criteria were as follows: indications for home tube feeding, complete present and past medical history, tube feeding for $12 mo before HEN and $12 mo afterward. Exclusion criteria included doubtful indications for HEN, no access or an incomplete medical record, or a treatment period shorter than 12 mo either before or after enrollment. As mentioned above, the initial sample comprised 3620 patients; 3164 were excluded, however, from the analysis because they did not meet the inclusion criteria (incomplete medical record or treatment period shorter than 12 mo either before or after enrollment). In each case patient (if possible), the family member or caregiver was trained in home tube feeding. Trainings were carried out repeatedly at home and included diet administration, wound care, equipment handling, and monitoring for complications. In all patients, only blenderized food was administered via tube before the enrollment to HEN. Home tube feeding, carried out on a routine basis by family or caregivers, was supervised by nurses and physicians during regular home visits. Family members and/or caregivers kept records on daily intake. The selection of artificial diet was based on the type of primary disease (eg, a higher amount of energy required in patients with cystic fibrosis, a lower amount required in patients with neurologic problems), comorbidities (eg, specialized formula diets in diabetes mellitus), fluid restrictions (eg, hypercaloric formula in children with cystic fibrosis with overnight feeding), and type of enteral access (eg, oligopeptic diets in jejunostomy patients). The assessment of this initial 12-mo period was performed on a retrospective basis (analysis of medical records, recording of medical history). During that period, patients were fed only with a homemade blenderized kitchen diet.
TABLE 1 Primary (underlying) diagnosis Type of disease Neurovascular Cerebral palsy Abdominal cancer Inherited disease Digestive tract diseases Head and neck cancer Head/spinal injury Dementia SLA1 Sclerosis multiplex Neurodegenerative Alzheimer disease Parkinson disease Cystic fibrosis Huntington disease Crohn disease Muscular dystrophy Miscellaneous Psychological Epilepsy Overall 1
SLA, amyotrophic lateral sclerosis.
Patients n (%) 137 (30.0) 74 (16.2) 19 (12.2) 51 (11.2) 26 (5.7) 23 (5.0) 22 (4.8) 18 (3.9) 17 (3.7) 17 (3.7) 13 (2.9) 11 (2.4) 7 (1.5) 6 (1.3) 4 (0.9) 4 (0.9) 3 (0.7) 2 (0.4) 1 (0.2) 1 (0.2) 456 (100)
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SUBJECTS AND METHODS
The second 12-mo period was assessed prospectively; during this period, patients received only artificial EN delivered by a home nutrition company. Patients and their caregivers were visited at home by one or more of the team members, and they were instructed regarding tube-feeding regimens and care of the access site. Nutritional status was assessed at the first home visit by clinical examination, Nutritional Risk Screening 2002 and Subjective Global Assessment, laboratory, and anthropometric (triceps skinfold thickness, midarm circumference) tests. Regular follow-up home visits were performed every 2 to 3 mo. They included nutritional reassessment, enteral access site evaluation, and laboratory tests (erythrocytes, leukocytes, hemoglobin, hematocrit, platelets, acid-base balance, serum sodium, potassium, calcium, magnesium, phosphate concentration, glucose, albumin, serum and urea amylase and lipase, blood urea, creatinine, cholesterol and triglycerides, bilirubin, aspartate aminotransferase, alanine aminotransferase, g-glutamyl transpeptidase, alkaline phosphatase, international normalized ratio, and C-reactive protein). All patients and legal caregivers were informed about the advantages of commercial diets and the prospects of our home care before enrollment. An informed consent form was signed in each case. The latter allowed HEN and the access to medical history. To evaluate the efficacy of EN, the number of hospital admissions, length of hospital stay and intensive care unit stay, and costs of hospitalization were compared between both study periods. Costs of hospital treatment were evaluated based on the diagnosis-related group system adopted in 2007 by the Polish National Health Service and by calculating the payments for the hospitals based primarily on the diagnosis of discharged patients. To provide descriptive statistics for the investigated groups, means, SDs, and ranges were provided for continuous variables
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VALUE OF HOME ENTERAL NUTRITION TABLE 2 Type of enteral diet Type of diet
Patients n (%) 310 (67.9) 42 (9.2) 41 (8.99) 21 (4.6) 20 (4.3) 5 (1.09) 14 (3.07) 3 (0.65)
Standard diet Energy-rich Fiber-rich Oligopeptide Diabetes formula Protein-rich Infant formula Other
RESULTS
All 456 patients were eligible for the detailed analysis. Dysphagia of neurovascular etiology was the most common
TABLE 3 Anthropometric and laboratory data in children before and after HEN introduction1 Homemade diet Body mass (kg) Mean 6 SD Range Hemoglobin (g/dL) Mean 6 SD Range AST (U/L) Mean 6 SD Range ALT (U/L) Mean 6 SD Range GGTP (U/L) Mean 6 SD Range Blood urea nitrogen (mmol/L) Mean 6 SD Range Creatinine (mmol/L) Mean 6 SD Range Albumin (g/L) Mean 6 SD Range
After HEN
P value W
P 18.0 6 11.7 (135) 3.3–78.0
24.0 6 13.7 (135) 5.6–80.0
11.9 6 2.2 (139) 6.4–16.0
12.3 6 2.5 (139) 6.2–16.8
, 0.001
PW = 0.006
Change
Proportional change (%)
6.0 6 5.4 (135)2 29.0 to 27.0
43.2 6 40.0 (135) 231.0 to 214.8
0.39 6 1.76 (139)2 25.5 to 6.0
3.9 6 15.9 (139) 238.1 to 63.6
23.6 6 13.2 (137)2 259.0 to 47.0
23.2 6 43.3 (137) 277.4 to 244.4
0.04 6 18.5 (137)2 241 to 99
17.8 6 84.6 (137) 292.6 to 385.7
0.12 6 47.0 (125)2 2177 to 299
17.4 6 105.4 (125) 281.3 to 715.4
0.19 6 1.92 (140)2 26.9 to 5.3
16.6 6 55.9 (140) 265.2 to 264.3
21.67 6 15.32 (140)2 277.4 to 32.6
21.2 6 29.0 (140) 282.4 to 106.1
PW = 0.001 32.1 6 18.6 (137) 9–142
28.5 6 17.0 (137) 7–112
21.3 6 15.4 (137) 2–82
21.3 6 22.4 (137) 1–172
PW = 0.177
PW = 0.240 49.4 6 62.0 (125) 7–417
49.5 6 75.5 (125) 6–636
4.2 6 3.0 (140) 0.8–27.0
4.4 6 2.9 (140) 1.1–24.0
PW = 0.103
PW = 0.263 48.6 6 24.0 (140) 7.0–167.2
46.9 6 24.0 (140) 6.0–125.8
39.9 6 4.8 (138) 25.7–51.0
38.6 6 5.3 (138) 20.6–54.0
Pt = 0.005 21.3 6 5.4 (138) 213.4 to 14.7
22.5 6 14.3 (138) 239.4 to 50.3
n in parentheses. ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGTP, g-glutamyl transpeptidase; HEN, home enteral nutrition; t, Student’s t test for dependent samples; W, Wilcoxon’s signed-rank test. 2 Shapiro-Wilk test ,0.05. 1
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and percentages for categorical variables. Because there were paired measurements, the normality of the distributions for differences were tested before the variables were compared by using the Shapiro-Wilk test; the paired t test for normally distributed differences and Wilcoxon’s signed-rank test for nonnormally distributed variables were used. For categorical variables the change in the proportion of patients presenting a condition of interest was tested by the McNemar test. Results with a P value , 5% were considered to be statistically significant. IBM SPSS Statistics version 21 software was used for the calculations.
diagnosis (n = 137; 30% of patients); the second and third most common diagnoses were cerebral palsy (n = 74; 17% of patients) and inherited disease (n = 51; 11% of patients). Detailed characteristics are presented in Table 1. The mean time of feeding reached 25 mo. EN was performed via percutaneous endoscopic gastrostomy (n = 344 patients; 75.43%), surgical gastrostomy (n = 39; 8.54%), low-profile gastrostomy (n = 3; 0.65%), jejunostomy (n = 12; 2.63%), and nasogastric tube (n = 58; 12.71%). Diets were administered as boluses (150–300 mL), microboluses (50– 100 mL/dose), or continuous infusion (20 mL/h at the beginning up to 150 mL/h during normal treatment) to meet the caloric goal, which was estimated at 30–35 kcal/kg. The bolus method of delivery was much more popular than continuous infusion (76.09% compared with 23.91%, respectively). The standard diet was the most popular (67.9%), whereas energy-rich and fiber-rich diets were less frequent (9.2% and 8.99%, respectively). The different types of diets are shown in Table 2. They were manufactured by Nutricia Ltd Poland, Fresenius Kabi Germany, Nestle´ France, and B Braun Germany. The delivery route, type of diet, and administration method did not differ between groups. The relation of the caregiver to a patient was as follows: spouse (n = 125; 27.3%), parent (n = 176; 38.4%), sibling (n = 9; 1.9%), child (n = 75; 16.4%), other relative (n = 21; 4.5%), and caregiver unrelated to patient (46, 10.0%). The remaining 8 (1.6%) patients took care of themselves. Female caregivers were much more frequent than male caregivers: 381 (83.55%) compared with 75 (16.45%). Caregivers were mainly moderately educated: basic education (grammar school, 8 years: n = 46; 10.08%),
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TABLE 4 Anthropometric and laboratory data in adults before and after HEN introduction1 Before HEN
P value W
P 52.9 6 14.9 (291) 18.0–100.0
57.8 6 14.1 (291) 19.0–100.0
11.4 6 2.6 (290) 4.9–17.7
11.5 6 2.8 (290) 3.6–17.4
, 0.001
PW = 0.308
PW = 0.593 24.3 6 16.0 (292) 7–142
23.8 6 18.0 (292) 8–180
24.6 6 24.8 (293) 5–178
21.5 6 19.4 (293) 3–190
PW = 0.129
PW = 0.019 40.8 6 42.1 (255) 5–329
42.3 6 69.3 (255) 6–887
5.6 6 2.8 (291) 0.8–24.3
6.1 6 2.6 (291) 1.2–23.1
67.6 6 30.4 (293) 10.6–167.6
68.5 6 36.5 (293) 5.0–378.4
34.0 6 6.1 (292) 13.0–49.0
34.3 6 5.7 (292) 15.5–53.0
Change
Proportional change (%)
4.9 6 8.6 (291)2 226.0 to 45.0
11.9 6 18.9 (291) 234.2 to 112.5
0.09 6 2.04 (290)2 29.9 to 8.4
2.3 6 21.3 (290) 271.9 to 172.2
20.47 6 21.6 (292)2 298.0 to 149.0
14.2 6 75.3 (292) 285.4 to 647.8
23.1 6 28.6 (293)2 2157 to 162
19.7 6 100.5 (293) 290.2 to 805.9
1.5 6 67.8 (255)2 2213 to 818.4
24.0 6 130.8 (255) 293.2 to 1197.3
0.47 6 2.63 (291)2 29.2 to 9.4
22.8 6 72.1 (291) 262.5 to 780.0
0.87 6 29.34 (293)2 263.0 to 325.6
6.8 6 52.4 (293) 272.2 to 616.7
0.31 6 6.6 (292)2 220.9 to 27.7
3.6 6 24.2 (292) 253.7 to 213.1
PW = 0.002
PW = 0. 491
PW = 0.420
n in parentheses. ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGTP, g-glutamyl transpeptidase; HEN, home enteral nutrition; W, Wilcoxon’s signed-rank test. 2 Shapiro-Wilk test P , 0.05. 1
medium education (n = 312; 68.42%), and high education (n = 98; 21.5%). Most participants were Roman Catholics (n = 355; 77.85%), one participant was a Jehovah’s Witness (n = 1; 0.21%), and the remaining participants (n = 100; 21.92%) were of unknown status. Living conditions were as follows: bad (n = 1; 0.21%), average (n = 125; 27.41%), good (n = 258; 56.57%), and very good (n = 72; 15.78%). None of these characteristics differed significantly between the investigated groups. Implementation of the artificial enteral diet in children enabled weight gain, increased the hemoglobin concentration, and stabilized liver function; in adults, it also increased body weight and helped the liver and kidneys to recover. However, this diet did not influence hemoglobin and other variables (Tables 3 and 4). The introduction of EN reduced the incidence of infectious complications, including the 2 most common: pneumonia and urinary tract infections—these results are presented in Table 5. Differences between the homemade and EN diet periods were noticeable if all study participants were considered (37.4% compared with 14.9%) together and when children were considered separately from adults. No differences were seen in regard to noninfectious complications (Table 6). EN significantly reduced the number of hospital admissions and the length of hospital stay, both in children and in adults (Tables 7 and 8). The need for hospitalization was significantly reduced when considering all participants (1.98 on homemade diet and 1.26 on EN; P , 0.001) and also in both age groups (Table 7). The use of EN over 1 y led to the reduction of an average length of hospitalization by 27 d per patient (length of hospital stay before EN introduction was 39.7 and was 11.9 d afterward; P , 0.001). These changes significantly reduced
mean (6 SD) annual costs ($) of hospitalization from 6500.20 6 10402.69 to 2072.58 6 5497.00, as presented in Table 9. A subanalysis was performed to evaluate the differences between cancer and noncancer patients after the implementation of HEN. The only difference was found in the hospitalization ratio attributable to infection; the remaining variables were comparable between groups as presented in Table 10.
DISCUSSION
The cost-effectiveness of nutritional procedures has always been an important issue. The benefits of short-term nutrition were TABLE 5 Infectious complications in the patients1
Infectious complications, all All groups (n = 457) Children (n = 142) Adults (n = 314) Pneumonia All groups (n = 457) Children (n = 142) Adults (n = 314) Urinary tract infection All groups (n = 457) Children (n = 142) Adults (n = 314) 1
Before HEN
After HEN
n (%)
n (%)
P value
171 (37.4) 68 (47.9) 103 (32.8)
68 (14.9) 26 (18.3) 42 (13.4)
PMcN , 0.001 PMcN , 0.001 PMcN , 0.001
145 (31.7) 64 (45.1) 81 (25.8)
51 (11.2) 22 (15.5) 29 (9.2)
PMcN , 0.001 PMcN , 0.001 PMcN , 0.001
65 (14.2) 11 (7.7) 54 (17.2)
26 (5.7) 7 (4.9) 19 (6.1)
PMcN , 0.001 PMcN = 0.424 PMcN , 0.001
HEN, home enteral nutrition; McN, McNemar test.
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Body mass (kg) Mean 6 SD Range Hemoglobin (g/dL) Mean 6 SD Range AST (U/L) Mean 6 SD Range ALT (U/L) Mean 6 SD Range GGTP (U/L) Mean 6 SD Range Blood urea nitrogen (mmol/L) Mean 6 SD Range Creatinine (mmol/L) Mean 6 SD Range Albumin (g/L) Mean 6 SD Range
After HEN
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VALUE OF HOME ENTERAL NUTRITION TABLE 6 Noninfectious complications in the patients1
GI access problems All groups (n = 187) Children (n = 66) Adults (n = 121) Feeding intolerance All groups (n = 187) Children (n = 66) Adults (n = 121) Respiratory failure All groups (n = 187) Children (n = 66) Adults (n = 121) 1
TABLE 8 Length of hospital stay before and after the introduction of HEN1
Before
After
P value
n (%)
n (%)
47 (25.1) 19 (28.8) 28 (23.1)
45 (24.1) 17 (25.8) 28 (23.1)
PMcN = 0.902 PMcN = 0.845 PMcN = 1.000
5 (2.7) 4 (6.1) 1 (0.8)
13 (7.0) 8 (12.1) 5 (4.1)
PMcN = 0.096 PMcN = 0.388 PMcN = 0.219
10 (5.3) 7 (10.6) 3 (2.5)
13 (7.0) 5 (7.6) 8 (6.6)
PMcN = 0.648 PMcN = 0.774 PMcN = 0.125
Before HEN
P value
d d Children and adults (n = 451) Length of hospital stay 39.7 6 71.92 11.9 6 28.5 PW , 0.001 Median (Q1–Q3) 19 (7–49) 0 (0–12) Range 0–1044 0–363 Children (n = 141) Length of hospital stay 46.4 6 64.9 17.0 6 41.6 PW , 0.001 Median (Q1–Q3) 19 (6.5–69.5) 1 (0–14) Range 0–409 0–363 Adults (n = 312) Length of hospital stay 36.7 6 74.8 9.6 6 19.4 PW , 0.001 Median (Q1–Q3) 19 (7–40.3) 0 (0–10.3) Range 0–1044 0–130 1
GI, gastrointestinal; McN, McNemar test.
2
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank test. Mean 6 SD (all such values).
a multidisciplinary team, which resulted in improved patient outcomes. They concluded that available evidence did not allow estimating the effectiveness of a particular intervention or team composition. Some other studies suggested that HEN may even be associated with poorer survival rates or impaired quality of life of patients and their caregivers (24–30). Although current practice recommendations for EN formulated by the American Society for Parenteral and Enteral Nutrition state that selection of the enteral formulation must rely on several variables, such as nutritional and physical assessment, metabolic abnormalities, gastrointestinal function, overall medical condition, and expected outcomes, the superiority of specialized over standard enteral formulas remains insufficiently substantiated, and there are no firm data supporting clinical benefits of commercial diets over blenderized food (8, 23, 31). It looks as if it has been generally believed that commercial enteral formulas are superior to homemade enteral diets, even in light of the lack of hard evidence (2, 9, 10, 32, 33). For these reasons, the unique Polish reimbursement scenario provided a unique insight into the topic. In Poland, the Polish National Health Service started to reimburse home enteral tube TABLE 9 Costs of hospital stay before and after the introduction of HEN1
TABLE 7 Number of hospital admissions’ ratio before and after the introduction of HEN1
Children and adults (n = 453) No. of hospital admissions Median (Q1–Q3) Range Children (n = 141) No. of hospital admissions Median (Q1–Q3) Range Adults (n = 312) No. of hospital admissions Median (Q1–Q3) Range
Before HEN
After HEN
1.98 6 2.422 1 (1–2) 0–31
1.26 6 2.18 0 (0–2) 0–20
2.30 6 2.43 1 (1–3) 0–14
1.62 6 2.33 1 (0–2) 0–10
P
1.84 6 2.40 1 (1–2) 0–31
1.11 6 2.10 0 (0–1) 0–20
PW , 0.001
PW , 0.001
W
= 0.013
1
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank
2
Mean 6 SD (all such values).
Cost All groups (n = 455) Cost of hospitalization Median (Q1–Q3) Range Children (n = 141) Cost of hospitalization Median (Q1–Q3) Range Adults (n = 314) Cost of hospitalization Median (Q1–Q3) Range 1
test.
2
Before HEN
After HEN
$
$
6500 6 10,4032
2073 6 5497
2850 (938–7313) 0–72,343
0 (0–1938) 0–39,000
8405 6 12,738
3082 6 8226
PW , 0.001
PW , 0.001
2969 (940–11,969) 163 (0–2231) 0–231,500 0–73,125 5513 6 9043
1619 6 3592
2846 (906–5958) 0–64,688
0 (0–1594) 0–25,782
PW , 0.001
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank test. Mean 6 SD (all such values).
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analyzed in detail. It was proven that artificial nutrition, both enteral and parenteral, resulted in shortening the length of hospital stay, reduction of complication, and health care cost (16). The cost-effectiveness of long-term intervention has not, however, been well documented so far. Although that topic was recently addressed by some authors, officials from insurance companies, and even governments—mostly attributable to economic crisis—assumptions were inconclusive. Most authors raised concerns about the cost-efficiency of the procedure for the National Health System (6–8, 15). Moreover, some authors, as Koretz, questioned the value of EN in general, pointing out that EN has been accepted and implemented despite the lack of convincing scientific support of efficacy (17). On the other hand, there is some proof that long-term tube feeding at home is more cost-effective than prolonged therapy in hospitals or nursing homes at the level of 75%, with savings of $3100 to $4200 per patient (8, 18–23). This testimonial proves, however, only the economic efficacy of out-of-hospital treatment and not the nutrition. Majka et al (15) analyzed 15 clinical trials on HEN and found positive effects of such therapy, but they focused on a positive association of care coordination by
After HEN
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KLEK ET AL TABLE 10 Differences in improvement between cancer and noncancer patients after the implementation of HEN1 Noncancer patients (n = 419) Reduction in hospitalizations due to infection [n (%)] Reduction in hospitalizations due to pulmonary infections [n (%)] Reduction in hospitalizations due to urinary tract infections [n (%)] Decrease in the number of hospitalizations Mean 6 SD Range Decrease in the length of hospitalizations (d) Mean 6 SD Range 1 2
Cancer patients (n = 35)
P value F
65 (15.5) 42 (10.0)
1 (2.9) 1 (2.9)
P = 0.044 PF = 0.233
10 (2.4)
0 (0.0)
PF = 1.000 PMW = 0.275
0.7 6 3.1 210 to 30
0.4 6 4.4 219 to 9
28.5 6 77.42 2267 to 970
20.1 6 31.52 266 to 96
2
2
PMW = 0.438
F, Fisher test; HEN, home enteral nutrition; MW, Mann-Whitney U test. Shapiro-Wilk test P , 0.05.
Our study showed that the artificial EN helped to reduce the rate of infectious complications and length of hospital stay and improved anthropometric body variables. It also resulted in lower health care costs. Those findings are consistent with some results of the aforementioned meta-analysis published by Majka et al (15) and with our previous study, which showed the importance of dedicated nutrition support teams (34). Initially, the current study tried to prove the importance of diet itself, because the other variables concerning caregivers were regarded unimportant from the statistical point of view at the beginning. The wide-ranging and detailed analysis showed, however, that the improvement was not solely the results of the change in the diet, because there were several reasons for the significant decrease in hospital admissions, intensive care unit stay, and the length of hospitalization. Three of them seem to be the most important. First, commercial diets are nutritionally complete, in contrast with blenderized meals (which are more likely to be incomplete), and they facilitate the proper provision, subsequently avoiding putting patients at risk of long-term incorrect nutrient delivery. Second, they also save time for the caregivers. The last factor, unfortunately inseparable from the latter, was the introduction of professional complex care. All those elements improved the outcome. That finding confirms the observation of Majka et al (15), who emphasized the role of nutrition support team as the key element of the home care To our knowledge, this was the first large-scale report to substantiate clinically and economically the benefits of long-term EN. Other studies, such as randomized controlled trials, needed for evidence-based medicine evaluation would never be justified ethically. In conclusion, it must be said that the implementation of HEN for long-term patients, even in times of economic crisis, can improve the outcome and decrease the health care expenses eventually. Major changes, including the introduction of a Nutrition Support Team and the administration of an artificial tube diet, must be applied together to achieve that goal.
The authors’ responsibilities were as follows—SK: coordinator and supervisor of the study, responsible for the conception, and contributed to the design, data analysis, interpretation, and writing of the manuscript; AG: contributed to the writing of the manuscript, data analysis, statistical analysis, and data interpretation; AH, KM, PS, and KS: carried out the study, responsible for the data collection, and contributed to the writing of the manuscript. SK acts as a lecturer for Nutricia, Fresenius Kabi, B Braun, Baxter, and Nestle´. None of the remaining authors declared a conflict of interest.
REFERENCES 1. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P; DGEM (German Society for Nutritional Medicine), Jauch KW, Kemen M, Hiesmayr JM, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006;25:224-44. 2. Staun M, Pironi L, Bozzetti F, Baxter J, Forbes A, Joly F, Jeppesen P, Moreno J, He´buterne X, Pertkiewicz M, et al. ESPEN guidelines on parenteral nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr 2009;28:467–79. 3. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009;15: CD007209. 4. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365–70. 5. Rabeneck L, Wray NP, Petersen NJ. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med 1996;11:287–93. 6. Parver AK, Mutinsky SE. Enteral nutrition reimbursement—the rationale for the policy: the US perspective. Nestle´ Nutr Workshop Ser Clin Perform Programme 2009;12:53–70. 7. Pahne N. Enteral nutrition reimbursement–the rationale for the policy: the German perspective. Nestle´ Nutr Workshop Ser Clin Perform Programme 2009;12:71–8. 8. DiBaise JK, Scolapio JS. Home parenteral and enteral nutrition. Gastroenterol Clin North Am 2007;36:123–44. 9. Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology 1995;108:1282–301. 10. Hebuterne X, Bozzetti F, Moreno Villares JM, Pertkiewicz M, Shaffer J, Staun M, Thul P, Van Gossum A. Home enteral nutrition in adults: a European multicentre survey. Clin Nutr 2003;22:261–6. 11. Delegge MH. Home enteral nutrition. Demographics and utilization in the United States. Nestle´ Nutr Workshop Ser Clin Perform Programme 2005;10:45–54. 12. Moreno JM, Shaffer J, Staun M, Hebuterne X, Bozzetti F, Pertkiewicz M, Thul P, Van Gossum A. Survey on legislation and funding of home artificial nutrition in different European countries. Clin Nutr 2001;20: 117–23. 13. Howard L, Ament M, Fleming CR, Shike M, Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States. Gastroenterology 1995;109:355–65.
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feeding in January 2007. Before that time, patients had to prepare tube diets themselves using regular food and blenders, because they could not afford artificial admixtures. Therefore, it was possible to observe differences in the clinical course when patients received both types of tube feeding.
VALUE OF HOME ENTERAL NUTRITION
25. Schneider SM, Pouget I, Staccini P, Rampal P, Hebuterne X. Quality of life in long-term home enteral nutrition patients. Clin Nutr 2000; 19:23–8. 26. Bannerman E, Pendlebury J, Phillips F, Ghosh S. A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy. Eur J Gastroenterol Hepatol 2000;12:1101–9. 27. Paccagnella A, Mauri A, Berto R, Falchero S, Baruffi C, Marcon ML, Faronato PP, Dal Ben G, Foscolo G. Biopsychosocial approach to home enteral nutrition: measure of subjective satisfaction and quality of life. Minerva Med 2007;98:5–17. 28. Heyman MB, Harmatz P, Acree M, Wilson L, Moskowitz JT, Ferrando S, Folkman S. Economic and psychologic costs for maternal caregivers of gastrostomy-dependent children. J Pediatr 2004;145:511–6. 29. Loeser C, von Herz U, Kuchler T, Rzehak P, Muller MJ. Quality of life and nutritional state in patients on home enteral tube feeding. Nutrition 2003;19:605–11. 30. Silver HJ, Wellman NS, Galindo-Ciocon D, Johnson P. Family caregivers of older adults on home enteral nutrition have multiple unmet task-related training needs and low overall preparedness for caregiving. J Am Diet Assoc 2004;104:43–50. 31. Brotherton A, Lyons C. The impact of HETF for adults with neurological conditions. Br J Community Nurs 2006;11:511–8. 32. Chen Y, Peterson SJ. Enteral nutrition formulas: which formula is right for your adult patient? Nutr Clin Pract 2009;24:344–55. 33. Campbell SM. An anthology of advances in enteral tube feeding formulations. Nutr Clin Pract 2006;21:411–5. 34. Klek S, Szybinski P, Sierzega M, Szczepanek K, Sumlet M, Kupiec M, Koczur-Szozda E, Steinhoff-Nowak M, Figula K, Kowalczyk T, Kulig J. Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding. JPEN J Parenter Enteral Nutr 2011;35:380–5.
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14. Elia M, Stratton RJ, Holden C, Meadows N, Micklewright A, Russell C, Scott D, Thomas A, Shaffer J, Wheatley C, et al. Committee of the British Artificial Nutrition Survey (BANS). Home artificial nutritional support: the value of the British Artificial Nutrition Survey. Clin Nutr 2001;20:61–6. 15. Majka AJ, Wang Z, Schmitz KR, Niesen CR, Larsen RA, Kinsey GC, Murad AL, Prokop LJ, Murad MH. Care coordination to enhance management of long-term enteral tube feeding: a systematic review and metaanalysis. JPEN J Parenter Enteral Nutr 2014;38:40–52. 16. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:235–9. 17. Koretz RL. Enteral nutrition: a hard look at some soft evidence. Nutr Clin Pract 2009;24:316–24. 18. DeLegge MH. Consensus statements regarding optimal management of home enteral nutrition (HEN) access. JPEN J Parenter Enteral Nutr 2006;30:S39–40. 19. A.S.P.E.N. Board of Directors. Standards for home nutrition support. Nutr Clin Pract 1999;14:151–62. 20. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, et al. A.S.P.E.N. Board of Directors. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr 2009;33:122–67. 21. Elia M, Stratton RJ. A cost-utility analysis in patients receiving enteral tube feeding at home and in nursing homes. Clin Nutr 2008;27:416–23. 22. Fuhrman MP. Home care for the elderly. Nutr Clin Pract 2009;24:196–205. 23. Fuhrman MP, Galvin TA, Ireton-Jones CS, Thorpe J. Practice paper of the American Dietetic Association: home care—opportunities for food and nutrition professionals. J Am Diet Assoc 2009;109:1092–100. 24. Howard L, Malone M. Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition. Am J Clin Nutr 1997;66:1364–70.
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INTRODUCTION
Clinical nutrition (nutritional therapy) enables an adequate provision of nutrients. This method of medical intervention uses either the route of gastrointestinal tract (enteral nutrition; EN) or intravenous access (parenteral nutrition). EN is undoubtedly the method of choice for artificial feeding because of its physiologic
transport route, lower cost, and safety (1). It may be performed with oral diets, but more preferably via enteral tubes (nasogastric or nasojejunal catheters, gastrostomy, or jejunostomy), which additionally ensure the correct provision. It can be performed at hospitals, long-term health care facilities, palliative care centers, or home. Long-term nutrition has been used for many years in North America, South America, all of Western and Central Europe, Some Asian countries, and Australia and has always been recognized as a life-saving procedure. Guidelines of the European Society for Clinical Nutrition and Metabolism precisely describe the vindications and methods for home artificial nutrition (2). With the ongoing economic crisis, however, some authors criticized and questioned the benefits of these interventions because they were perceived as procedures that contributed significantly to annual costs paid by health care systems. The prevalence of home enteral nutrition (HEN) in the United States is 4 to 10 times that in other Western European countries, and after it was doubled in the early nineties finally they were estimated to cost between 9000 and 25,000 USD per patient in 2000, whereas in some European countries the amount varied between 9048 and 10,140 USD a year (3–14). The escalating costs of home care because of the widespread use of HEN has raised concerns about the cost-efficiency of the procedures of the National Health Systems (6–8, 15). For that reason, some insurance companies and even governments decided to either not initiate reimbursement or to decrease it. Some Eastern European countries, such as Russia, Lithuania, Ukraine, Belarus, Latvia, and Estonia, decided to not reimburse for HEN.
1 From Stanley Dudrick’s Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG). 2 There were no sources of support for this article. 3 Address correspondence and reprint requests to S Klek, Stanley Dudrick’s Memorial Hospital, General Surgery Unit, 32-050 Skawina, 15 Tyniecka Street, Poland. E-mail: [email protected]. Received December 29, 2013. Accepted for publication May 19, 2014. First published online June 25, 2014; doi: 10.3945/ajcn.113.082842.
Am J Clin Nutr 2014;100:609–15. Printed in USA. Ó 2014 American Society for Nutrition
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Abstract Background: Home enteral nutrition (HEN) has always been recognized as a life-saving procedure, but with the ongoing economic crisis influencing health care, its cost-effectiveness has been questioned recently. Objective: The unique reimbursement situation in Poland enabled the otherwise ethically unacceptable, hence unavailable, comparison of the period of no-feeding and long-term feeding and the subsequent analyses of the clinical value of the latter and its cost-effectiveness. Design: The observational multicenter study in the group of 456 HEN patients [142 children: 55 girls and 87 boys, mean (6SD) age 8.7 6 5.9 y; 314 adults: 151 women and 163 men, mean age 59.3 6 19.8 y] was performed between January 2007 and July 2013. Two 12-mo periods were compared. During the first period, patients were tube fed a homemade diet and were not monitored; during the other period, patients received HEN. HEN included tube feeding and complex monitoring by a nutrition support team. The number of complications, hospital admissions, length of hospital stay, biochemical and anthropometric variables, and costs of hospitalization were compared. Results: Implementation of HEN enabled weight gain and stabilized liver function in both age groups, but it hardly influenced the other tests. HEN implementation reduced the incidence of infectious complications (37.4% compared with 14.9%; P , 0.001, McNemar test), the number of hospital admissions [1.98 6 2.42 (mean 6 SD) before and 1.26 6 2.18 after EN; P , 0.001, Wilcoxon’s signed-rank test], and length of hospital stay (39.7 6 71.9 compared with 11.9 6 28.5 d; P , 0.001, Wilcoxon’s signed-rank test). The mean annual costs ($) of hospitalization were reduced from 6500.20 6 10,402.69 to 2072.58 6 5497.00. Conclusions: The study showed that HEN improves clinical outcomes and decreases health care costs. It was impossible, however, to determine precisely which factor mattered more: the artificial diet itself or the introduction of complex care. This trial was registered at clinicaltrials.gov as NCT02122120. Am J Clin Nutr 2014;100:609–15.
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Regrettably, the price of artificial enteral diets and monitoring by nutrition support teams constitutes significantly to the total cost of this procedure, which makes some authorities believe that the use of blenderized food by patients or caregivers, which is significantly less expensive, is more beneficial. The paucity of data substantiating the benefits of HEN seems to support the latter thesis. Moreover, it is not feasible and is unethical nowadays to carry out a clinical trial recruiting patients deprived of HEN. In Poland, however, it was possible to perform an analytic study investigating the cost-effectiveness of HEN because of the sudden onset of reimbursement for HEN, which took place in 2007. Before January 2007, most Polish patients were forced to prepare blenderized homemade diets for tube feeding using household products because commercial formulas were too expensive. The unique reimbursement situation provided an exceptional opportunity to evaluate the clinical outcomes and the cost-effectiveness of HEN.
This multicenter observational study was performed in 4 Polish medical centers (Skawina, Bialystok, Ostroleka, and Poznan) between 1 January 2007 and 1 January 2013. In total, 456 patients (142 children: 55 girls and 87 boys, mean 6 SD age of 8.7 6 5.9 y; 314 adults: 151 women and 163 men, mean age of 59.3 6 19.8 y) were recruited from the sample of 3620 eligible patients. The Local Ethical Committee of Skawina Hospital approved the protocol. The inclusion criteria were as follows: indications for home tube feeding, complete present and past medical history, tube feeding for $12 mo before HEN and $12 mo afterward. Exclusion criteria included doubtful indications for HEN, no access or an incomplete medical record, or a treatment period shorter than 12 mo either before or after enrollment. As mentioned above, the initial sample comprised 3620 patients; 3164 were excluded, however, from the analysis because they did not meet the inclusion criteria (incomplete medical record or treatment period shorter than 12 mo either before or after enrollment). In each case patient (if possible), the family member or caregiver was trained in home tube feeding. Trainings were carried out repeatedly at home and included diet administration, wound care, equipment handling, and monitoring for complications. In all patients, only blenderized food was administered via tube before the enrollment to HEN. Home tube feeding, carried out on a routine basis by family or caregivers, was supervised by nurses and physicians during regular home visits. Family members and/or caregivers kept records on daily intake. The selection of artificial diet was based on the type of primary disease (eg, a higher amount of energy required in patients with cystic fibrosis, a lower amount required in patients with neurologic problems), comorbidities (eg, specialized formula diets in diabetes mellitus), fluid restrictions (eg, hypercaloric formula in children with cystic fibrosis with overnight feeding), and type of enteral access (eg, oligopeptic diets in jejunostomy patients). The assessment of this initial 12-mo period was performed on a retrospective basis (analysis of medical records, recording of medical history). During that period, patients were fed only with a homemade blenderized kitchen diet.
TABLE 1 Primary (underlying) diagnosis Type of disease Neurovascular Cerebral palsy Abdominal cancer Inherited disease Digestive tract diseases Head and neck cancer Head/spinal injury Dementia SLA1 Sclerosis multiplex Neurodegenerative Alzheimer disease Parkinson disease Cystic fibrosis Huntington disease Crohn disease Muscular dystrophy Miscellaneous Psychological Epilepsy Overall 1
SLA, amyotrophic lateral sclerosis.
Patients n (%) 137 (30.0) 74 (16.2) 19 (12.2) 51 (11.2) 26 (5.7) 23 (5.0) 22 (4.8) 18 (3.9) 17 (3.7) 17 (3.7) 13 (2.9) 11 (2.4) 7 (1.5) 6 (1.3) 4 (0.9) 4 (0.9) 3 (0.7) 2 (0.4) 1 (0.2) 1 (0.2) 456 (100)
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SUBJECTS AND METHODS
The second 12-mo period was assessed prospectively; during this period, patients received only artificial EN delivered by a home nutrition company. Patients and their caregivers were visited at home by one or more of the team members, and they were instructed regarding tube-feeding regimens and care of the access site. Nutritional status was assessed at the first home visit by clinical examination, Nutritional Risk Screening 2002 and Subjective Global Assessment, laboratory, and anthropometric (triceps skinfold thickness, midarm circumference) tests. Regular follow-up home visits were performed every 2 to 3 mo. They included nutritional reassessment, enteral access site evaluation, and laboratory tests (erythrocytes, leukocytes, hemoglobin, hematocrit, platelets, acid-base balance, serum sodium, potassium, calcium, magnesium, phosphate concentration, glucose, albumin, serum and urea amylase and lipase, blood urea, creatinine, cholesterol and triglycerides, bilirubin, aspartate aminotransferase, alanine aminotransferase, g-glutamyl transpeptidase, alkaline phosphatase, international normalized ratio, and C-reactive protein). All patients and legal caregivers were informed about the advantages of commercial diets and the prospects of our home care before enrollment. An informed consent form was signed in each case. The latter allowed HEN and the access to medical history. To evaluate the efficacy of EN, the number of hospital admissions, length of hospital stay and intensive care unit stay, and costs of hospitalization were compared between both study periods. Costs of hospital treatment were evaluated based on the diagnosis-related group system adopted in 2007 by the Polish National Health Service and by calculating the payments for the hospitals based primarily on the diagnosis of discharged patients. To provide descriptive statistics for the investigated groups, means, SDs, and ranges were provided for continuous variables
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VALUE OF HOME ENTERAL NUTRITION TABLE 2 Type of enteral diet Type of diet
Patients n (%) 310 (67.9) 42 (9.2) 41 (8.99) 21 (4.6) 20 (4.3) 5 (1.09) 14 (3.07) 3 (0.65)
Standard diet Energy-rich Fiber-rich Oligopeptide Diabetes formula Protein-rich Infant formula Other
RESULTS
All 456 patients were eligible for the detailed analysis. Dysphagia of neurovascular etiology was the most common
TABLE 3 Anthropometric and laboratory data in children before and after HEN introduction1 Homemade diet Body mass (kg) Mean 6 SD Range Hemoglobin (g/dL) Mean 6 SD Range AST (U/L) Mean 6 SD Range ALT (U/L) Mean 6 SD Range GGTP (U/L) Mean 6 SD Range Blood urea nitrogen (mmol/L) Mean 6 SD Range Creatinine (mmol/L) Mean 6 SD Range Albumin (g/L) Mean 6 SD Range
After HEN
P value W
P 18.0 6 11.7 (135) 3.3–78.0
24.0 6 13.7 (135) 5.6–80.0
11.9 6 2.2 (139) 6.4–16.0
12.3 6 2.5 (139) 6.2–16.8
, 0.001
PW = 0.006
Change
Proportional change (%)
6.0 6 5.4 (135)2 29.0 to 27.0
43.2 6 40.0 (135) 231.0 to 214.8
0.39 6 1.76 (139)2 25.5 to 6.0
3.9 6 15.9 (139) 238.1 to 63.6
23.6 6 13.2 (137)2 259.0 to 47.0
23.2 6 43.3 (137) 277.4 to 244.4
0.04 6 18.5 (137)2 241 to 99
17.8 6 84.6 (137) 292.6 to 385.7
0.12 6 47.0 (125)2 2177 to 299
17.4 6 105.4 (125) 281.3 to 715.4
0.19 6 1.92 (140)2 26.9 to 5.3
16.6 6 55.9 (140) 265.2 to 264.3
21.67 6 15.32 (140)2 277.4 to 32.6
21.2 6 29.0 (140) 282.4 to 106.1
PW = 0.001 32.1 6 18.6 (137) 9–142
28.5 6 17.0 (137) 7–112
21.3 6 15.4 (137) 2–82
21.3 6 22.4 (137) 1–172
PW = 0.177
PW = 0.240 49.4 6 62.0 (125) 7–417
49.5 6 75.5 (125) 6–636
4.2 6 3.0 (140) 0.8–27.0
4.4 6 2.9 (140) 1.1–24.0
PW = 0.103
PW = 0.263 48.6 6 24.0 (140) 7.0–167.2
46.9 6 24.0 (140) 6.0–125.8
39.9 6 4.8 (138) 25.7–51.0
38.6 6 5.3 (138) 20.6–54.0
Pt = 0.005 21.3 6 5.4 (138) 213.4 to 14.7
22.5 6 14.3 (138) 239.4 to 50.3
n in parentheses. ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGTP, g-glutamyl transpeptidase; HEN, home enteral nutrition; t, Student’s t test for dependent samples; W, Wilcoxon’s signed-rank test. 2 Shapiro-Wilk test ,0.05. 1
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and percentages for categorical variables. Because there were paired measurements, the normality of the distributions for differences were tested before the variables were compared by using the Shapiro-Wilk test; the paired t test for normally distributed differences and Wilcoxon’s signed-rank test for nonnormally distributed variables were used. For categorical variables the change in the proportion of patients presenting a condition of interest was tested by the McNemar test. Results with a P value , 5% were considered to be statistically significant. IBM SPSS Statistics version 21 software was used for the calculations.
diagnosis (n = 137; 30% of patients); the second and third most common diagnoses were cerebral palsy (n = 74; 17% of patients) and inherited disease (n = 51; 11% of patients). Detailed characteristics are presented in Table 1. The mean time of feeding reached 25 mo. EN was performed via percutaneous endoscopic gastrostomy (n = 344 patients; 75.43%), surgical gastrostomy (n = 39; 8.54%), low-profile gastrostomy (n = 3; 0.65%), jejunostomy (n = 12; 2.63%), and nasogastric tube (n = 58; 12.71%). Diets were administered as boluses (150–300 mL), microboluses (50– 100 mL/dose), or continuous infusion (20 mL/h at the beginning up to 150 mL/h during normal treatment) to meet the caloric goal, which was estimated at 30–35 kcal/kg. The bolus method of delivery was much more popular than continuous infusion (76.09% compared with 23.91%, respectively). The standard diet was the most popular (67.9%), whereas energy-rich and fiber-rich diets were less frequent (9.2% and 8.99%, respectively). The different types of diets are shown in Table 2. They were manufactured by Nutricia Ltd Poland, Fresenius Kabi Germany, Nestle´ France, and B Braun Germany. The delivery route, type of diet, and administration method did not differ between groups. The relation of the caregiver to a patient was as follows: spouse (n = 125; 27.3%), parent (n = 176; 38.4%), sibling (n = 9; 1.9%), child (n = 75; 16.4%), other relative (n = 21; 4.5%), and caregiver unrelated to patient (46, 10.0%). The remaining 8 (1.6%) patients took care of themselves. Female caregivers were much more frequent than male caregivers: 381 (83.55%) compared with 75 (16.45%). Caregivers were mainly moderately educated: basic education (grammar school, 8 years: n = 46; 10.08%),
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TABLE 4 Anthropometric and laboratory data in adults before and after HEN introduction1 Before HEN
P value W
P 52.9 6 14.9 (291) 18.0–100.0
57.8 6 14.1 (291) 19.0–100.0
11.4 6 2.6 (290) 4.9–17.7
11.5 6 2.8 (290) 3.6–17.4
, 0.001
PW = 0.308
PW = 0.593 24.3 6 16.0 (292) 7–142
23.8 6 18.0 (292) 8–180
24.6 6 24.8 (293) 5–178
21.5 6 19.4 (293) 3–190
PW = 0.129
PW = 0.019 40.8 6 42.1 (255) 5–329
42.3 6 69.3 (255) 6–887
5.6 6 2.8 (291) 0.8–24.3
6.1 6 2.6 (291) 1.2–23.1
67.6 6 30.4 (293) 10.6–167.6
68.5 6 36.5 (293) 5.0–378.4
34.0 6 6.1 (292) 13.0–49.0
34.3 6 5.7 (292) 15.5–53.0
Change
Proportional change (%)
4.9 6 8.6 (291)2 226.0 to 45.0
11.9 6 18.9 (291) 234.2 to 112.5
0.09 6 2.04 (290)2 29.9 to 8.4
2.3 6 21.3 (290) 271.9 to 172.2
20.47 6 21.6 (292)2 298.0 to 149.0
14.2 6 75.3 (292) 285.4 to 647.8
23.1 6 28.6 (293)2 2157 to 162
19.7 6 100.5 (293) 290.2 to 805.9
1.5 6 67.8 (255)2 2213 to 818.4
24.0 6 130.8 (255) 293.2 to 1197.3
0.47 6 2.63 (291)2 29.2 to 9.4
22.8 6 72.1 (291) 262.5 to 780.0
0.87 6 29.34 (293)2 263.0 to 325.6
6.8 6 52.4 (293) 272.2 to 616.7
0.31 6 6.6 (292)2 220.9 to 27.7
3.6 6 24.2 (292) 253.7 to 213.1
PW = 0.002
PW = 0. 491
PW = 0.420
n in parentheses. ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGTP, g-glutamyl transpeptidase; HEN, home enteral nutrition; W, Wilcoxon’s signed-rank test. 2 Shapiro-Wilk test P , 0.05. 1
medium education (n = 312; 68.42%), and high education (n = 98; 21.5%). Most participants were Roman Catholics (n = 355; 77.85%), one participant was a Jehovah’s Witness (n = 1; 0.21%), and the remaining participants (n = 100; 21.92%) were of unknown status. Living conditions were as follows: bad (n = 1; 0.21%), average (n = 125; 27.41%), good (n = 258; 56.57%), and very good (n = 72; 15.78%). None of these characteristics differed significantly between the investigated groups. Implementation of the artificial enteral diet in children enabled weight gain, increased the hemoglobin concentration, and stabilized liver function; in adults, it also increased body weight and helped the liver and kidneys to recover. However, this diet did not influence hemoglobin and other variables (Tables 3 and 4). The introduction of EN reduced the incidence of infectious complications, including the 2 most common: pneumonia and urinary tract infections—these results are presented in Table 5. Differences between the homemade and EN diet periods were noticeable if all study participants were considered (37.4% compared with 14.9%) together and when children were considered separately from adults. No differences were seen in regard to noninfectious complications (Table 6). EN significantly reduced the number of hospital admissions and the length of hospital stay, both in children and in adults (Tables 7 and 8). The need for hospitalization was significantly reduced when considering all participants (1.98 on homemade diet and 1.26 on EN; P , 0.001) and also in both age groups (Table 7). The use of EN over 1 y led to the reduction of an average length of hospitalization by 27 d per patient (length of hospital stay before EN introduction was 39.7 and was 11.9 d afterward; P , 0.001). These changes significantly reduced
mean (6 SD) annual costs ($) of hospitalization from 6500.20 6 10402.69 to 2072.58 6 5497.00, as presented in Table 9. A subanalysis was performed to evaluate the differences between cancer and noncancer patients after the implementation of HEN. The only difference was found in the hospitalization ratio attributable to infection; the remaining variables were comparable between groups as presented in Table 10.
DISCUSSION
The cost-effectiveness of nutritional procedures has always been an important issue. The benefits of short-term nutrition were TABLE 5 Infectious complications in the patients1
Infectious complications, all All groups (n = 457) Children (n = 142) Adults (n = 314) Pneumonia All groups (n = 457) Children (n = 142) Adults (n = 314) Urinary tract infection All groups (n = 457) Children (n = 142) Adults (n = 314) 1
Before HEN
After HEN
n (%)
n (%)
P value
171 (37.4) 68 (47.9) 103 (32.8)
68 (14.9) 26 (18.3) 42 (13.4)
PMcN , 0.001 PMcN , 0.001 PMcN , 0.001
145 (31.7) 64 (45.1) 81 (25.8)
51 (11.2) 22 (15.5) 29 (9.2)
PMcN , 0.001 PMcN , 0.001 PMcN , 0.001
65 (14.2) 11 (7.7) 54 (17.2)
26 (5.7) 7 (4.9) 19 (6.1)
PMcN , 0.001 PMcN = 0.424 PMcN , 0.001
HEN, home enteral nutrition; McN, McNemar test.
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Body mass (kg) Mean 6 SD Range Hemoglobin (g/dL) Mean 6 SD Range AST (U/L) Mean 6 SD Range ALT (U/L) Mean 6 SD Range GGTP (U/L) Mean 6 SD Range Blood urea nitrogen (mmol/L) Mean 6 SD Range Creatinine (mmol/L) Mean 6 SD Range Albumin (g/L) Mean 6 SD Range
After HEN
613
VALUE OF HOME ENTERAL NUTRITION TABLE 6 Noninfectious complications in the patients1
GI access problems All groups (n = 187) Children (n = 66) Adults (n = 121) Feeding intolerance All groups (n = 187) Children (n = 66) Adults (n = 121) Respiratory failure All groups (n = 187) Children (n = 66) Adults (n = 121) 1
TABLE 8 Length of hospital stay before and after the introduction of HEN1
Before
After
P value
n (%)
n (%)
47 (25.1) 19 (28.8) 28 (23.1)
45 (24.1) 17 (25.8) 28 (23.1)
PMcN = 0.902 PMcN = 0.845 PMcN = 1.000
5 (2.7) 4 (6.1) 1 (0.8)
13 (7.0) 8 (12.1) 5 (4.1)
PMcN = 0.096 PMcN = 0.388 PMcN = 0.219
10 (5.3) 7 (10.6) 3 (2.5)
13 (7.0) 5 (7.6) 8 (6.6)
PMcN = 0.648 PMcN = 0.774 PMcN = 0.125
Before HEN
P value
d d Children and adults (n = 451) Length of hospital stay 39.7 6 71.92 11.9 6 28.5 PW , 0.001 Median (Q1–Q3) 19 (7–49) 0 (0–12) Range 0–1044 0–363 Children (n = 141) Length of hospital stay 46.4 6 64.9 17.0 6 41.6 PW , 0.001 Median (Q1–Q3) 19 (6.5–69.5) 1 (0–14) Range 0–409 0–363 Adults (n = 312) Length of hospital stay 36.7 6 74.8 9.6 6 19.4 PW , 0.001 Median (Q1–Q3) 19 (7–40.3) 0 (0–10.3) Range 0–1044 0–130 1
GI, gastrointestinal; McN, McNemar test.
2
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank test. Mean 6 SD (all such values).
a multidisciplinary team, which resulted in improved patient outcomes. They concluded that available evidence did not allow estimating the effectiveness of a particular intervention or team composition. Some other studies suggested that HEN may even be associated with poorer survival rates or impaired quality of life of patients and their caregivers (24–30). Although current practice recommendations for EN formulated by the American Society for Parenteral and Enteral Nutrition state that selection of the enteral formulation must rely on several variables, such as nutritional and physical assessment, metabolic abnormalities, gastrointestinal function, overall medical condition, and expected outcomes, the superiority of specialized over standard enteral formulas remains insufficiently substantiated, and there are no firm data supporting clinical benefits of commercial diets over blenderized food (8, 23, 31). It looks as if it has been generally believed that commercial enteral formulas are superior to homemade enteral diets, even in light of the lack of hard evidence (2, 9, 10, 32, 33). For these reasons, the unique Polish reimbursement scenario provided a unique insight into the topic. In Poland, the Polish National Health Service started to reimburse home enteral tube TABLE 9 Costs of hospital stay before and after the introduction of HEN1
TABLE 7 Number of hospital admissions’ ratio before and after the introduction of HEN1
Children and adults (n = 453) No. of hospital admissions Median (Q1–Q3) Range Children (n = 141) No. of hospital admissions Median (Q1–Q3) Range Adults (n = 312) No. of hospital admissions Median (Q1–Q3) Range
Before HEN
After HEN
1.98 6 2.422 1 (1–2) 0–31
1.26 6 2.18 0 (0–2) 0–20
2.30 6 2.43 1 (1–3) 0–14
1.62 6 2.33 1 (0–2) 0–10
P
1.84 6 2.40 1 (1–2) 0–31
1.11 6 2.10 0 (0–1) 0–20
PW , 0.001
PW , 0.001
W
= 0.013
1
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank
2
Mean 6 SD (all such values).
Cost All groups (n = 455) Cost of hospitalization Median (Q1–Q3) Range Children (n = 141) Cost of hospitalization Median (Q1–Q3) Range Adults (n = 314) Cost of hospitalization Median (Q1–Q3) Range 1
test.
2
Before HEN
After HEN
$
$
6500 6 10,4032
2073 6 5497
2850 (938–7313) 0–72,343
0 (0–1938) 0–39,000
8405 6 12,738
3082 6 8226
PW , 0.001
PW , 0.001
2969 (940–11,969) 163 (0–2231) 0–231,500 0–73,125 5513 6 9043
1619 6 3592
2846 (906–5958) 0–64,688
0 (0–1594) 0–25,782
PW , 0.001
HEN, home enteral nutrition; Q, quartile; W, Wilcoxon’s signed-rank test. Mean 6 SD (all such values).
Downloaded from ajcn.nutrition.org at KAINAN UNIVERSITY on January 6, 2015
analyzed in detail. It was proven that artificial nutrition, both enteral and parenteral, resulted in shortening the length of hospital stay, reduction of complication, and health care cost (16). The cost-effectiveness of long-term intervention has not, however, been well documented so far. Although that topic was recently addressed by some authors, officials from insurance companies, and even governments—mostly attributable to economic crisis—assumptions were inconclusive. Most authors raised concerns about the cost-efficiency of the procedure for the National Health System (6–8, 15). Moreover, some authors, as Koretz, questioned the value of EN in general, pointing out that EN has been accepted and implemented despite the lack of convincing scientific support of efficacy (17). On the other hand, there is some proof that long-term tube feeding at home is more cost-effective than prolonged therapy in hospitals or nursing homes at the level of 75%, with savings of $3100 to $4200 per patient (8, 18–23). This testimonial proves, however, only the economic efficacy of out-of-hospital treatment and not the nutrition. Majka et al (15) analyzed 15 clinical trials on HEN and found positive effects of such therapy, but they focused on a positive association of care coordination by
After HEN
614
KLEK ET AL TABLE 10 Differences in improvement between cancer and noncancer patients after the implementation of HEN1 Noncancer patients (n = 419) Reduction in hospitalizations due to infection [n (%)] Reduction in hospitalizations due to pulmonary infections [n (%)] Reduction in hospitalizations due to urinary tract infections [n (%)] Decrease in the number of hospitalizations Mean 6 SD Range Decrease in the length of hospitalizations (d) Mean 6 SD Range 1 2
Cancer patients (n = 35)
P value F
65 (15.5) 42 (10.0)
1 (2.9) 1 (2.9)
P = 0.044 PF = 0.233
10 (2.4)
0 (0.0)
PF = 1.000 PMW = 0.275
0.7 6 3.1 210 to 30
0.4 6 4.4 219 to 9
28.5 6 77.42 2267 to 970
20.1 6 31.52 266 to 96
2
2
PMW = 0.438
F, Fisher test; HEN, home enteral nutrition; MW, Mann-Whitney U test. Shapiro-Wilk test P , 0.05.
Our study showed that the artificial EN helped to reduce the rate of infectious complications and length of hospital stay and improved anthropometric body variables. It also resulted in lower health care costs. Those findings are consistent with some results of the aforementioned meta-analysis published by Majka et al (15) and with our previous study, which showed the importance of dedicated nutrition support teams (34). Initially, the current study tried to prove the importance of diet itself, because the other variables concerning caregivers were regarded unimportant from the statistical point of view at the beginning. The wide-ranging and detailed analysis showed, however, that the improvement was not solely the results of the change in the diet, because there were several reasons for the significant decrease in hospital admissions, intensive care unit stay, and the length of hospitalization. Three of them seem to be the most important. First, commercial diets are nutritionally complete, in contrast with blenderized meals (which are more likely to be incomplete), and they facilitate the proper provision, subsequently avoiding putting patients at risk of long-term incorrect nutrient delivery. Second, they also save time for the caregivers. The last factor, unfortunately inseparable from the latter, was the introduction of professional complex care. All those elements improved the outcome. That finding confirms the observation of Majka et al (15), who emphasized the role of nutrition support team as the key element of the home care To our knowledge, this was the first large-scale report to substantiate clinically and economically the benefits of long-term EN. Other studies, such as randomized controlled trials, needed for evidence-based medicine evaluation would never be justified ethically. In conclusion, it must be said that the implementation of HEN for long-term patients, even in times of economic crisis, can improve the outcome and decrease the health care expenses eventually. Major changes, including the introduction of a Nutrition Support Team and the administration of an artificial tube diet, must be applied together to achieve that goal.
The authors’ responsibilities were as follows—SK: coordinator and supervisor of the study, responsible for the conception, and contributed to the design, data analysis, interpretation, and writing of the manuscript; AG: contributed to the writing of the manuscript, data analysis, statistical analysis, and data interpretation; AH, KM, PS, and KS: carried out the study, responsible for the data collection, and contributed to the writing of the manuscript. SK acts as a lecturer for Nutricia, Fresenius Kabi, B Braun, Baxter, and Nestle´. None of the remaining authors declared a conflict of interest.
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