Cost-effectiveness of nutritional intervention on healing of pressure ulcers

Factors affecting severity of pressure ulcers: Impact of number of medications

Polypharmacy, which refers to the situation of a patient taking more medications than is clinically necessary, has become a major problem in recent years. Although the effects of medications on pressure ulcers have been reported, there are no reports on the impact of the total number of medications on pressure ulcers. The purpose of this study was to investigate the effect of number of medications on the severity of pressure ulcers. Participants included 94 patients who were admitted to Chiba University Hospital with pressure ulcers between April 2013 and March 2021. Univariate analysis identified ulcer depth, weight loss and anticoagulant use to be factors that contributed to the severity of pressure ulcers. Multiple regression analysis was performed for six variables, namely, the number of medications, ulcer depth, weight loss and anticoagulant use, as well as diabetes status and total serum protein level, which have been reported to be associated with pressure ulcers in previous studies. The following independent risk factors were identified: weight loss (β 0.207, 95% confidence interval [CI] 0.700-3.193; p = 0.003), anticoagulant use (β 0.161, 95% CI 0.271-3.088; p = 0.020) and ulcer depth (β 0.719, 95% CI 7.172-10.329; p < 0.001). The number of medications was not a significant factor. This study revealed that the number of medications a patient is taking does not affect the severity of pressure ulcers. The findings should provide useful information for the management of pressure ulcers.

[Nutritional status and use of health resources following the implementation of a PEG tube nutrition program for neurological patients in home hospitalization]

Objective: the objective of this study was to demonstrate that implementation of enteral nutrition by gastrostomy tube by the Home Hospitalization Unit (HHU) in patients suffering from neurological diseases, significantly improves their nutritional status, both in terms of anthropometric and analytical parameters. Methods: data on admissions, days of hospital stay, emergency room visits and nutritional parameters were collected during the 6 months before and 6 months after placement of a percutaneous endoscopic gastrostomy (PEG) tube in 100 patients from the UHD at General University Hospital in Elda (Alicante). Results: a total of 100 neurological patients were included in the study; 58 % of them were women and with a mean age (standard deviation, SD) of 78.3 (13.3) years, with 60 % of the patients being > 80 years. The monitoring and home treatment of these patients by the HHU of General University Hospital in Elda led to improvement in quality of life and nutritional parameters (weight, body mass index, proteins, albumin, prealbumin, creatinine, and hemoglobin), as well as a decrease in the number of complications derived from the nutritional management of patients at their home, and a significant reduction in number of admissions (90.27 %) and days of hospital stay (94.05 %), as well as of visits to emergency services (79.47 %), with a consequent reduction in healthcare costs. Conclusions: the implementation of a home-based monitoring program for patients with PEG by a HHU improves their nutritional status and reduces healthcare costs.

The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations

GENERAL PURPOSE

To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendations.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Distinguish nutrition and malnutrition, especially as they relate to the development and healing of pressure injuries.2. Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations.3. Identify interventions for improving nutrition status and promoting pressure injury healing.

ABSTRACT

Macro- and micronutrients are required by each organ system in specific amounts to promote the growth, development, maintenance, and repair of body tissues. Specifically, nutrition plays an important role in the prevention and treatment of pressure injuries. The purpose of this manuscript is to review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Nutrition for pressure injury management is discussed in the context of the recommendations.

[Assessing the implementation of a nutritional screening protocol in patients admitted to the Medicine Department of a local hospital]

Introduction

Background: the techniques for screening and nutritional intervention in hospitalized patients are a cost-effective measure. In clinical practice the problem lies in their administration. Objective: to evaluate the implementation of a nutritional screening tool in patients admitted to our Medicine Ward (M). Material and methods: a single-center, prospective, observational study in patients admitted to M. Exclusion criteria: end-stage cancer patients, inpatient stay less than 72 h, and hospital readmission of previously included patients. One out of every 2 hospital admissions was selected. We assessed the following: whether nurses performed the screening test, the Short Nutritional Assessment Questionnaire (SNAQ); the score obtained; consultations with dieticians (ICD); prescribed nutritional support; and coding of malnutrition in the discharge report. Dieticians repeated the SNAQ for one in every 3 patients. Results: during the study period 726 patients were admitted, 377 were selected, and 315 were included. The nursing staff administered the SNAQ to 93.6% of patients and malnutrition was present in 19%. Dieticians detected malnutrition in 37.8%. In 41.9% of patients with severe malnutrition an ICD was performed, whereas in 40% of them no nutritional intervention was implemented. The diagnosis of malnutrition was recorded in the discharge report of 42.1% of our cases. Conclusion: Compliance with screening test administration was good, but there is disagreement with the assessment made by dieticians. For most malnourished patients nutritional support fals to be prescribed, no ICDs are performed, and a malnutrition diagnosis is not included in the discharge report.

Risk factors affecting pressure ulcer healing: Impact of prescription medications

Treatment of pressure ulcers requires removing the cause as well as eliminating factors that interfere with healing. There are no reports on the effect of medications prescribed for underlying diseases on pressure ulcers. Accordingly, the aim of this study was to investigate whether medications prescribed to patients with pressure ulcers could be a factor that influences pressure ulcer healing. We retrospectively reviewed the records of patients with pressure ulcer who were admitted to Chiba University Hospital between June 2009 and June 2015. A total of 110 patients were included in this study. In univariate analysis, there were significant differences in corticosteroid use and total caloric intake. Logistic regression analysis was performed for four factors, including corticosteroid use and total caloric intake, which were significant at P < .05, plus the two factors malignancy and body mass index, which were previously reported as factors that may affect pressure ulcer healing. The results showed that corticosteroid use [odds ratio (OR) 0.205, 95% confidence interval (CI): 0.046 to 0.911, P = .037] and total caloric intake [OR 1.002, 95% CI: 1.000 to 1.003, P = .006] were significant risk factors influencing pressure ulcer healing. This study revealed that use of corticosteroids and total caloric intake could be risk factors affecting pressure ulcer healing. These findings provide useful information for the management of pressure ulcer.

Economic Evaluation of Nutrition Support in the Prevention and Treatment of Pressure Ulcers in Acute and Chronic Care Settings: A Systematic Review

BACKGROUND

Recent developments in nutrition intervention indicated clinical effectiveness for pressure ulcer (PU) prevention and treatment, but it is important to assess whether they are cost-effective. The aims of this systematic review are to determine the cost-effectiveness and clinical outcomes of nutrition support in PU prevention and treatment.

METHODS

A systematic search of randomized controlled trials, observational studies, and statistical models that investigated cost-effectiveness and economic outcomes for prevention and/or treatment of PUs were performed using standard literature and electronic databases.

RESULTS

Fourteen studies met the inclusion criteria, which included 3 randomized controlled trials with their companion economic evaluations, 4 model-based, 2 cohort, 1 pre and post, and 1 prospective controlled trial. Risk of bias assessment for all of the uncontrolled or observational trials revealed high or serious risk of bias. Interventions that incorporated specialized nursing care appeared to be more effective in prevention and treatment of PUs, compared with single intervention studies. There is a trend of improved PU healing when additional energy/protein are provided. PU prevention ($250-$9,800) was less expensive than treatment ($2,500-$16,000). Nutrition intervention for PU prevention was cost-effective in 87.0%-99.99% of the simulation models.

CONCLUSIONS

There is potential cost-saving and/or cost-effectiveness of nutrition support in the long term, as predicted by the model-based PU prevention studies in the review. Prevention of PU also appears to be more cost-effective than treatment. A multidisciplinary approach to managing PU is more likely to be cost-effective.

Home Enteral Nutrition: Towards a Standard of Care

The purpose of this overview is to make the case for the establishment and publication of standards for home enteral nutrition (HEN) therapy in adult patients who require a long-term alternative to oral feeding. Overviews can provide a broad and often comprehensive summation of a topic area and, as such, have value for those coming to a subject for the first time. It will provide a broad summation, background and rationale, review specific considerations unique to HEN (tubes, products and supplies) and we describe a recent audit of seven HEN programs which highlights tube and process related challenges. Based on the overview of the literature and our experience with the audit we propose a way forward for best home enteral nutrition care.

A systematic review of the cost and economic outcomes of home enteral nutrition

OBJECTIVES

Studies are lacking in the health economic implications of home enteral nutrition (HEN) in home-residing and long-term care/institutionalized patients. The aims of this review were to determine the total costs, the cost-effectiveness and other economic outcomes for HEN.

DESIGN

A systematic search of randomized trials and observational studies available from January 2000 to April 2016 was performed using standard literature and electronic databases. Inclusion criteria were adults receiving HEN with economic outcomes in the long-term care or home settings. There was no restriction to the control groups used in the studies.

RESULTS

A total of 10 studies met the inclusion criteria. The majority of the studies were not specifically designed for economic evaluation. Cost per QALY was lower in residents residing in home compared to long-term care facilities, and HEN appeared to be cost-effective for those with pressure ulcers. Higher costs were incurred for patients with dementia on HEN. Lower hospitalization costs and infection rates were reported for patients who switched to commercial feeds from blenderized food. The availability of nutritional support teams may decrease overall costs but these studies were of poor study quality.

CONCLUSIONS

The lack of good quality economic evaluation studies affected the ability to conclude the overall cost-effectiveness of HEN. There is a trend for cost-saving and improved clinical outcomes in some populations. HEN is unlikely beneficial for patients with dementia. The availability of a nutrition support team may lead to cost savings and improved clinical outcomes for HEN.

Pressure ulcer is associated with malnutrition as assessed by Nutritional Risk Screening (NRS 2002) in a mixed hospital population

Background and aim: Pressure ulcers (PUs) and malnutrition represent a significant health problem for hospital inpatients. Satisfactory nutritional status is crucial for proper wound healing. Risk of malnutrition can be identified using standardized screening tools, such as the Nutritional Risk Screening (NRS) 2002.

Objective: The objective of this study was to examine whether nutritional status based on the NRS 2002 is associated with PU in hospital inpatients.

Design: The data for this cross-sectional analysis were based on 10 screening days between September 2012 and May 2014. All adult inpatients admitted to a medical or surgical ward on the screening days were evaluated for eligibility. Nursing students and ward nurses conducted the NRS 2002 initial screening and skin examinations for PU classification (Stages I–IV). A registered clinical dietician conducted all NRS 2002 final screenings.

Results: The sample consisted of 651 patients, with mean age 62.9 years. Skin examinations indicated an 8% PU prevalence. Factors associated with PUs included age ≥ 70 years, low body mass index (BMI) and hospitalization in the medical department. Based on the initial screening, 48% were at ‘Low risk’ for malnutrition and 52% were at ‘Possible risk’. After final screening, 34% of the sample was identified as ‘At risk’ for malnutrition. Patients identified at ‘Possible risk’ by the initial screening or ‘At risk’ by the final screening were more likely than patients at ‘Low risk’ to have a PU (OR = 2.58 and 2.55, respectively). Each of the three initial screening items was significantly associated PU, with ‘Is BMI<20?’ and ‘Ate less past week?’ having the strongest associations.

Conclusion: Nutritional risk using the NRS 2002 is associated with the presence of PU in a mixed hospital population. The final screening had a slightly stronger association with PU compared to the initial screening.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology

BACKGROUND & AIMS

Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services.

METHODS

To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients?

RESULTS

For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups.

CONCLUSIONS

This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.