Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis

BACKGROUND

Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas.

METHODS

Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay.

RESULTS

3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001).

CONCLUSIONS

Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study

BACKGROUND & AIMS

Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization.

METHODS

A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions.

RESULTS

Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001).

CONCLUSIONS

Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.

Healthcare Resource Utilization and Cost Comparisons of High-Protein Enteral Nutrition Formulas Used in Critically Ill Patients

Background: High-protein enteral nutrition is advised for patients who are critically ill. Options include immunonutrition formulas of various compositions and standard high-protein formulas (StdHP). Additional research is needed on the health economic value of immunonutrition in a broad cohort of severely ill hospitalized patients. Objective: The study goal was to compare healthcare resource utilization (HCRU) and cost between immunonutrition and StdHP using real-world evidence from a large US administrative database. Methods: A retrospective cohort study was designed using the PINC AI™ Healthcare Database from 2015 to 2019. IMPACT® Peptide 1.5 (IP) was compared with Pivot® 1.5 (PC), and StdHP formulas. Inclusion criteria comprised patients age 18+ with at least 1 day's stay in the intensive care unit (ICU) and at least 3 out of 5 consecutive days of enteral nutrition. Pairwise comparisons of demographics, clinical characteristics, HCRU, and costs were conducted between groups. Multivariable regression was used to assess total hospital cost per day associated with enteral nutrition cohort. Results: A total of 5752 patients were identified across 27 hospitals. Overall, a median 7 days of enteral nutrition was received over a 16-day hospital and 10-day ICU stay. Median total and daily hospital costs were lower for IP vs PC ($71 196 vs $80 696, P<.001) and ($4208 vs $4373, P=.019), with each higher than StdHP. However, after controlling for covariates such as mortality risk, surgery, and discharge disposition, average total hospital cost per day associated with IP use was 24% lower than PC, and 12% lower than StdHP (P<.001). Readmissions within 30 days were less frequent for patients receiving IP compared with PC (P<.02) and StdHP (P<.001). Discussion: Choice of high-protein enteral nutrition for patients in the ICU has implications for HCRU and daily hospital costs. Considering these correlations is important when comparing formula ingredients and per unit costs. Among the enteral nutrition products studied, IP emerged as the most cost-saving option, with lower adjusted hospital cost per day than PC or StdHP. Conclusions: Using a select immunonutrition formula for critically ill patients may provide overall cost savings for the healthcare system.

Importance of public-private partnerships for nutrition support research: An ASPEN Position Paper

Parenteral and enteral nutrition support are key components of care for various medical and physiological conditions in infants, children, and adults. Nutrition support practices have advanced over time, driven by the goals of safe and sufficient delivery of needed nutrients and improved patient outcomes. These advances have been, and continue to be, dependent on research and development studies. Such studies address aspects of enteral and parenteral nutrition support: formulations, delivery devices, health outcomes, cost-effectiveness, and related metabolism. The studies are supported by public funding from the government and by private funding from foundations and from the nutrition support industry. To build public trust in nutrition support research findings, it is important to underscore ethical research conduct and reporting of results for all studies, including those with industry sponsors. In 2019, American Society for Parenteral and Enteral Nutrition's (ASPEN's) Board of Directors established a task force to ensure integrity in nutrition support research that is done as collaborative partnerships between the public (government and individuals) and private groups (foundations, academia, and industry). In this ASPEN Position Paper, the Task Force presents principles of ethical research to guide administrators, researchers, and funders. The Task Force identifies ways to curtail bias and to minimize actual or perceived conflict of interests, as related to funding sources and research conduct. Notably, this paper includes a Position Statement to describe the Task Force's guidance on Public-Private Partnerships for research and funding. This paper has been approved by the ASPEN Board of Directors.

A Meal Replacement Program for the Treatment of Obesity: A Cost-Effectiveness Analysis from the Swiss Payer's Perspective

BACKGROUND

Obesity is a disease associated with high direct medical costs and high indirect costs resulting from productivity loss. The high prevalence of obesity generates the need for payers to identify cost-effective weight loss approaches. Among various weight management techniques, the OPTI (Optifast®) program is a clinically recognised total meal replacement diet that can lead to significant weight loss and reduction in complications. This study's objective is to assess OPTI program's cost-effectiveness in Switzerland in comparison to "no intervention" and pharmacotherapy.

METHODS

An event-driven decision-analytic model was used to estimate the payer's cost savings through the reimbursement of OPTI program over a 1-year period as well as a lifetime in Switzerland. The analysis was performed on a broad population of people with obesity with a body mass index (BMI) higher than 30 kg/m2 following the OPTI program vs two comparators (liraglutide and "no intervention"). The model incorporated a higher risk of complications due to an increased BMI and their related healthcare costs. Data sources included published literature, clinical trials, official Swiss price/tariff lists and national population statistics. The primary perspective was that of a Swiss payer. Scenario analyses - for example, for patients with existing complications (such as myocardial infarction, stroke, type 2 diabetes mellitus) or severe obesity - were conducted to test the robustness of the results.

RESULTS

The OPTI program results in cost savings of CHF 20,886 (€ 18,724) and CHF 15,382 (€ 13,790) per person compared with "no intervention" and liraglutide 3 mg, respectively. In addition, OPTI program led to 1.133 and 0.734 quality-adjusted life years (QALYs) gained respectively against its comparators. Scenario analyses showed similar outcomes with cost savings and QALYs gained.

CONCLUSION

OPTI program is a dominant strategy compared to "no intervention" and liraglutide 3 mg as it leads to both cost savings and QALY gain. Therefore, reimbursing the OPTI program for patients with obesity would be cost-effective for Swiss payers.

Real-World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide-Based Diets in the United States

Objective

Peptide ‐based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real‐world GI tolerance, healthcare utilization, and resource use costs of 100% whey‐protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics.

Method

Using medical claims data from the United States, we analyzed GI intolerance events occurring in adults receiving 100% whey‐protein PB ETF (Peptamen^® adult formulas) for one year before and after initiation of ETF. Resource use costs were subsequently estimated using a multivariate general linearized model and adjusted for age, gender, and Charlson Comorbidity Index score.

Results

The proportion of adults experiencing no GI intolerance events increased from 41% (418/1022) to 59% (601/1022) in the one‐year period after initiation of 100% whey PB ETF (P < .001). The proportion of patients with at least one hospital inpatient visit also decreased from 100% (1022/1022) to 72% (737/1022) over the same period, and the mean number of inpatient visits per patient decreased from 15.6 to 13.0. Cost modeling revealed that outpatient visits accounted for 42% ($1174/$2820) of total estimated healthcare resource costs in the first 30 days after 100% whey PB ETF initiation, with only 9% ($255/$2820) due to emergency room visits.

Conclusion

These 100% whey‐protein PB ETF formulas are a valuable nutrition treatment option for patients with or at risk of malnutrition who show intolerance to standard ETF formulas and may reduce hospital inpatient visits and associated costs.

A health economic model to assess the cost-effectiveness of OPTIFAST for the treatment of obesity in the United States

OBJECTIVES

Obesity is associated with high direct medical costs and indirect costs resulting from productivity loss. The high prevalence of obesity generates a justified need to identify cost-effective weight loss approaches from a payer's perspective. Within the variety of weight management techniques, OPTIFAST is a clinically recognized and scientifically proven total meal replacement Low Calorie Diet that provides meaningful results in terms of weight loss and reduction in comorbidities. The objective of this study is assess potential cost-savings of the OPTIFAST program in the US, as compared to "no intervention" and pharmacotherapy.

METHODS

An event-driven decision analytic model was used to estimate payer's cost-savings from reimbursement of the 1-year OPTIFAST program over 3 years in the US. The analysis was performed for the broad population of obese persons (BMI >30 kg/m²) undergoing the OPTIFAST program vs liraglutide 3 mg, naltrexone/bupropion and vs "no intervention". The model included the risk of complications related to increased BMI. Data sources included published literature, clinical trials, official US price/tariff lists, and national population statistics. The primary perspective was that of a US payer; costs were provided in 2016 US dollars.

RESULTS

OPTIFAST leads over a period of 3 years to cost-savings of USD 9,285 per class I and II obese patient (BMI 30-39.9 kg/m²) as compared to liraglutide and USD 685 as compared to naltrexone/bupropion. In the same time perspective, the OPTIFAST program leads to a reduction of cost of obesity complications of USD 1,951 as compared to "no intervention", with the incremental cost-effectiveness ratio of USD 6,475 per QALY. Scenario analyses also show substantial cost-savings in patients with class III obesity (BMI ≥ 40.0 kg/m²) and patients with obesity (BMI = 30-39.9 kg/m²) and type 2 diabetes vs all three previous comparators and bariatric surgery.

CONCLUSIONS

Reimbursing OPTIFAST leads to meaningful cost-savings for US payers as compared with "no intervention" and liraglutide and naltrexone/bupropion in obese patients. Similar results can be expected in matching healthcare settings of other countries. Moreover, OPTIFAST has additional clinical and economic advantages through very low complication and adverse events rates.