Trend Observations in Home Parenteral Nutrition. Prevalence, Hospitalizations and Costs: Results from a Nationwide Analysis of Health Care Provider Data

BACKGROUND

The population of patients on home parenteral nutrition (HPN) worldwide is growing. Since only a few counties provide data from national registries long-term observations are valuable to address this specific area of nutrition support. This study is a nationwide analysis determining the trends in the epidemiology of HPN (prevalence, age distribution, death rates), indications for HPN, causes for hospitalizations, and cost analysis of HPN reimbursement in Poland between 2010-2020.

METHODS

A retrospective analysis of data obtained from the national health fund (NHF) of Poland on adult patients on HPN.

RESULTS

The prevalence of adult patients on HPN in Poland in 2020 was 53.26 per million citizens with a 2.99-fold increase and a growing trend observed from 2010. Significant decrease in the percentage of patients between 18-34, 45-54 and an increase in patients between 65-74 and patients over 75 years old was observed. Trend analysis showed an increase in new patients between 65-74 and a decrease between 35-54. Malnutrition (34.28%), postprocedural disorders of the GI tract (19.61%), intestinal malabsorption/other intestinal diseases (20.41%) and GI obstruction due to cancer (17.36% as primary and 23.16% as secondary diagnosis) were mostly reported as the primary indications for HPN. Cancer patients were mostly gastric, ovarian and colon cancer (34.74%, 17.83% and 12.3%). HPN and total health cost reimbursement increase was 2.6 and 2.57-fold respectively. Costs of HPN and total health care costs in 2020 per patient were € 10,015 and € 16,038, respectively. Overall death risk rate during the first year of nutrition was 0.59 with a significant increase in the observation period p-trend < 0.004. A significant increase in the death rate was observed in patients above 75 years old (estimate 1.629, p-trend < 0.030). Cancer, infection, malnutrition and GI symptoms were the most common indications for hospitalizations of HPN patients. The rate of patients with a maximal length of HPN of 5 months in 2010 was 54.9% and was growing up to 78.1% in 2020.

CONCLUSIONS

The prevalence of HPN in Poland is growing. Trends of age distribution show increasing numbers of patients with more advanced age and shorter survival. Costs of HPN are comparable with other European data.

Repair of central venous access devices in intestinal failure patients is safe and cost-effective: A retrospective single centre cohort study

INTRODUCTION

Patients with chronic intestinal failure (IF) require home parenteral nutrition (HPN). Central venous access is needed for prolonged use of PN, usually via a long term central venous access device (CVAD). Post insertion there may be mechanical complications with a CVAD such as catheter rupture or tear. Repair of damaged CVADs is possible to avoid risks associated with catheter replacement in patients with IF. However, catheter related blood stream infections (CRBSI) are a concern when CVAD's are accessed or manipulated.

AIMS

To investigate the success of repair of CVADs in patients with IF on HPN, related to repair longevity and incidence of CRBSI following repair.

METHOD

Nutrition team records of CVAD repairs carried out in patients with IF were reviewed retrospectively for the period April 2015 to March 2019.

RESULTS

Nutrition Clinical Nurse Specialists carried out 38 repairs in 27 patients. Male n = 5, female n = 22; mean age 55 years. Catheter longevity before first repair (n = 27): median 851 days, IQR 137-1484 days. 30/38 (78.9%) of repairs were successful lasting ≥30days. Hospital admission was avoided in 76% of cases. 4 patients in the failed repair group underwent catheter re-insertion where 4 had a further, subsequently successful, repair, an overall success rate of 89.4% (34/38). 30-day CRBSI rate was 0.09/1000 catheter days in repaired catheters. In comparing costs, there is a potential cost saving of 2766GBP for repair compared to replacement of damaged CVADs.

CONCLUSION

Repair of tunnelled CVADs in patients with IF is successful and safe with no increased risk of CRBSI. Significant cost savings may be made.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

BACKGROUND

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective.

METHODS

In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests.

RESULTS

Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002).

CONCLUSIONS

A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

Economic Analysis of HomevsHospital-Based Parenteral Nutrition in Ontario, Canada

BACKGROUND

Advances in technology and infrastructure have facilitated transfer of complex services from acute care hospitals to the home. This increases the burden on community resources but may provide net savings to the health care system. We undertook a retrospective cohort study of patients transferred from hospital to home while receiving home parenteral nutrition (PN) to assess their costs of care.

METHODS

A detailed review of medical records was undertaken for all patients managed by the Hamilton Health Sciences Home PN Program between 1996 and 2001 whose PN was initiated in hospital. Mean per diem direct medical costs were estimated from the perspective of the provincial Ministry of Health for 3 periods: the last 2 weeks before discharge and the first month after discharge. Costs were compared among time intervals and among patients subgroups defined by age and underlying disease.

RESULTS

Twenty-nine eligible subjects were identified. Common indications for PN included malignancy (n = 12), inflammatory bowel disease (n = 6), and intestinal ischemia (n = 4). Mean per diem costs in the last week of hospitalization were higher than those in the first month after discharge (dollars 567 vs dollars 405, p < .0001). Acute care resources accounted for <10% of the overall costs on home PN. The estimated monthly savings per patient maintained on home PN were dollars 4860 (95% confidence interval dollars 2700-dollars 7000). Savings were even greater among patients with underlying malignancy and advanced age.

CONCLUSIONS

Home PN is cost saving when compared with hospital-based PN. Neither age nor underlying malignancy should pose a barrier to receipt of home PN.

Complex home care: Part 2- family annual income, insurance premium, and out-of-pocket expenses

Annual costs paid by families for intravenous infusion of home parenteral nutrition (HPN) health insurance premiums, deductibles, co-payments for health services, and the wide range of out-of-pocket home health care expenses are significant. The costs of managing complex chronic care at home cannot be completely understood until all out-of-pocket costs have been defined, described, and tabulated. Non-reimbursed and out-of-pocket costs paid by families over years for complex chronic care negatively impact the financial stability of families. National health care reform must take into account the long-term financial burdens of families caring for those with complex home care. Any changes that may increase the out-of-pocket costs or health insurance costs to these families can also have a negative long-term impact on society when greater numbers of patients declare bankruptcy or qualify for medical disability.

Current status of pediatric home enteral nutrition in Spain: the importance of the NEPAD register

Home enteral nutrition (HEN) is a type of enteral nutrition (EN) which is becoming progressively more widespread in pediatrics due to the benefits it affords to patients, their families and to reducing hospital costs. However, the true extent of its use is unknown in Spain as the data-base set up for this purpose is still underused (Registro de Nutrición Enteral Pediátrica Ambulatoria y Domiciliaria -NEPAD-). More thorough registration of patients in the NEPAD online register will provide information about the characteristics of HEN in Spain: prevalence, diagnosis, the population sector being administered HEN, complications and developments. Likewise, forecast and planning of the necessary resources could be made while those in use could be analysed.

[An economic consideration of the lower respiratory tract infection treatment in children with severe neurodegradative diseases under the hospice care]

Congenital and acquired neurodegradative diseases are always the reason for prolonged stay in hospital, at the beginning of the establishment of diagnosis and treatment and afterwards for stabilizing all functional adaptation to an existence with the severe disability. Also infections of the lower respiratory tract accompanying the later course of the disease are usually directed to hospital treatment. The aim of the study was to delineate the role of hospice care of patients staying at home, in economical approach to the medical care of severly and incurably ill children. The study group consisted of 29 children with neurodegradative diseases, aged 6 months to 18 years, admitted to the home care of Priest Józef Tischner Cracovian Children' Hospice. The costs of yearly treatment (based on 2008 data) of the infections of the lower airways in the studied group, performed at home under the hospice care and in hospital, were compared. The actual expenses of home treatment were counted. Considering the hospital therapy costs, the simulation was performed following median expenses of a 10-day-treatment of a 20 kg-in-weight child with uncomplicated lower respiratory tract infection in pediatric department with the use of the first line therapy antibiotic. Three parameters were taken to calculations: the medical care costs, the expenses of laboratory tests and X-ray pictures and the costs of antibiotics. In studied children 61 cases of lower respiratory tract infections were diagnosed in 2008 (the median incidence was 2,1 per year; ranged 0-7), of which 48 cases were treated at home. The median time of antibiotics administration in home treatment was 13 days. In 31% of infections more than one antibiotic was used. In 19% of cases in home therapy parenteral medicine was necessary. The median summarized cost of treat- ment at home was calculated as 2657 zl. The need for hospital care in our group concerned 13 incidences. The median estimated cost of treatment of the lower airways infection in hospital for one child equaled 4942 zl. The expenses of home treatment of the lower airways infections under the hospice care were twice lower than the costs of the therapy in hospital. Apart from the obvious psychological and social benefits, also economic aspect contributes to the promotion of the hospice care of staying-at-home patient in the improvement of medical care for children with severe neurodegradative diseases.

Home parenteral and enteral nutrition

Home parenteral and enteral nutrition (HPEN) has evolved to become a very successful, lifesaving treatment in the management of patients with intestinal and oral failure, respectively. Nevertheless, the provision of HPEN remains intrusive, expensive, and continues to be associated with significant morbidity. The management of HPEN by a nutrition support team that optimally includes an experienced clinician, nurse specialist, dietitian, and pharmacist reduces HPEN-related morbidity and may reduce costs associated with its use. Because clinical expertise in the management of patients receiving HPEN is not widely available, the referral of these patients to experienced centers for periodic assessment should be encouraged.

Home parenteral nutrition: survival, cost, and quality of life

This article summarizes what is known about which factors influence survival of patients on home parenteral nutrition, the costs related to this therapy, and the quality of life for patients living on home parenteral nutrition. The article refers to both North American and European experiences with this complex therapy.

Quality of life and changes in health insurance in long-term home care

Changes in health insurance and concomitant changes in quality of life in patients receiving long-term home parenteral nutrition care were explored. A decrease in quality of life and increase in depression were significantly associated with a change of insurance providers. Knowing the importance of health insurance as a family economic resource, nurses working in these settings may be alert for potential socio-emotional problems when health insurance providers change or coverage is less. Policymakers also have an opportunity to ease the financial burden of long-term disease management by expanding coverage for prescription drugs in Medicare benefits.

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

The technology-dependent child

Improvements in the provision of oxygen, mechanical ventilation, tracheostomy care, enteral and parenteral nutrition, and dialysis have expanded the population of technology-dependent children. This article attempts to review pertinent points regarding these services, including common complications. Primary care and subspecialty physicians must smooth the transition of these children to the home environment, but a comprehensive team approach is necessary for the recognition of medical complications and provision of appropriate family teaching and psychosocial supports.

Survey on legislation and funding of home artificial nutrition in different European countries

RATIONALE

Home Artificial Nutrition (HAN) has been an expanding area over the last 30 years. HAN programs have been often developed prior to the regulation by the National Health Systems (NHS) leading to different policies within European countries. The aim of this study was to compare legislation regarding HAN in Europe.

METHOD

The Group elaborated two structured questionnaires (one for Home Enteral Nutrition--HEN--and one for Home Parenteral Nutrition--HPN) which were presented to all the members of the HAN-Working group and to the 21 ESPEN Council members.

RESULTS

Twelve questionnaires were returned, covering for more than 375 million inhabitants. HEN: regulated in seven countries, Italy and France being the first to implement reimbursement policy in 1988. Except in France, Croatia and the Czech Rep almost any physician can prescribe HEN. NHS totally or partially fund HEN, although in Austria and Israel expenses are paid for the patients. Provision of enteral diets and equipment varies widely within countries. As in HPN, most of the countries have written guidelines for health care workers and for patients. HPN: legislated in six countries, Denmark being the first in 1975. HPN programs are restricted to a few hospitals and patients are followed by Nutrition Support Teams (NST). The budget for HPN is 100% supported by NHS. Hospital pharmacy, private pharmacists and Home Care companies are involved in a different degree in providing and distributing solutions and disposables.

CONCLUSIONS

HPN regulation preceded HEN regulation by 10-20 years. Due to this longer experience and high level of care, HPN patients are usually followed by NST. Despite different policies, funding is relatively uniform, NHS supporting most of the expenses for HAN. ESPEN could play a key role developing common standards for HAN all over Europe.

Economic aspects of paediatric home parenteral nutrition

Children account for 15-20% of home parenteral nutrition programmes. Underlying irreversible intestinal diseases lead to potential indications for intestinal transplantation. Therefore, new controversial issues are timing for referring children for transplantation, and comparison between home parenteral nutrition and transplantation in terms of costs and quality of life.

[Recent spread of home parenteral nutrition in Japan--the view of an HPN managing company]

Terumo Corporation has developed a nation wide home healthcare management system "Home-Joint," which helps hospitals to safely discharge patients early. Recently, this system mainly has been adopted with HPN (home parenteral nutrition) patients. This report evaluates 472 HPN patients who underwent the "Home-Joint" program in 1998, and also presents some issues from the standpoint of a HPN managing company. I. Profiles of HPN patients Number: 472 (female 43%, male 57%) Age: 1-104 (47% patients over 70) DIAGNOSIS: cancer 54%, others 25%, unknown 21% Infusion devices: ambulatory pump 85%, stationary pump 15%, gravity none. Therapeutic periods: average 65.6 days (1-437) for 300 patients who completed the program. II. HPN trends from 1997 to 1998 1. Increase in patients directly supported by hospitals. 2. Wider patient variation: increase in patients under 70 years old, in non-cancer patients and in longer periods (longer than 2 months). III. Issues 1. Development of hospital-clinic-pharmacy local relationship. 2. Development of devices for easier infusion control. 3. Evaluation of HPN outcome for patients' QOL and for cost-effectiveness. HPN is becoming a popular home healthcare therapy in Japan, and it requires higher level of performance by medical staff and managing companies.

Home parenteral nutrition in children: the Polish experience

BACKGROUND

Home parenteral nutrition has become routine for management of intestinal failure in patients. In Poland the main obstacle to widespread use of home parenteral nutrition is the lack of interest of commercial companies in delivering feedings and ancillaries to patients.

METHODS

Twenty-five home parenteral nutrition patients aged from 4 months to more than 13 years were reviewed. The mother or both parents were trained in home parenteral nutrition techniques for 4 to 6 weeks and compounded the nutrients themselves at home.

RESULTS

The mean duration of home parenteral nutrition was 10,117 patient days. Hospital stays of patients receiving parenteral feedings were significantly shorter than the duration of administration of home parenteral nutrition (p < 0.001). Eleven children are continuing the home parenteral nutrition program. Eighty-three catheters were used in these patients. The rate of catheter occlusion decreased within the observation period, and in 1997 not one case of occlusion was observed. In 1997 only three catheters were removed during 7.8 patient years, and the overall incidence of catheter-related complications was 0.38 per patient year. The overall occurrence of septicemia was one case in 516 days and of catheter infection was one in 459 days. In 1997 a catheter was infected on average of once every 1419 days. There was significant improvement in the z score for weight during therapy. The average monthly cost of nutrients and ancillary items was approximately $1200 (4200 Polish zlotys [PLN]). These costs are 1.6 to 3 times lower than those recorded in other studies.

CONCLUSION

Home parenteral nutrition in children with nutrients mixed by caregivers in the home setting is a safe and appropriate method of treatment that can be used in countries where home parenteral nutrition solutions are not manufactured or where commercial home parenteral nutrition is not economically feasible.

Home enteral and parenteral nutrition in children

The prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world, in children as in adults. Home artificial nutrition, especially parenteral nutrition, is an expensive technology but is life-saving for many patients. The only possible alternative to home treatment is keeping patients in hospital, and cost-benefit studies have demonstrated that home nutrition is about 70% more cost-effective than hospital-based therapy. Although home nutrition is usually considered by children and families to lead to an improvement in their quality of life, the complications of these techniques, including psychological consequences, have to be carefully assessed and prevented.

The economics of home parenteral nutrition

During the past 30 y long-term parenteral nutrition has evolved from a novel technique to a well-established intervention for gastrointestinal failure. The development of home care has been driven by technological advances and patient/family choice as well as financial constraints, reflecting a shift in resources from hospital to community. Annual costs for adult home parenteral nutrition have recently been estimated to range from US $150,000-250,000 in the USA, and are around 55,000 Pounds in the UK, perhaps only 25-50% of in-hospital costs. In the absence of any alternative treatment for children with gastrointestinal failure, parenteral nutrition is life saving, and when performed at home offers the prospect of maintaining a good quality of life. Cost-utility appraisals of home parenteral nutrition in adults incorporating quality of life assessment have shown the cost of one quality adjusted life year to be around 69,000 Pounds in the UK (1995), and Can $14,600 in Canada (1984), making home parenteral nutrition relatively cost-effective compared with other ways of spending money to improve health. Because there are no published economic appraisals of pediatric home parenteral nutrition, this paper is based on a review of the literature relating to adult patients.

Cost and outcome analysis of home parenteral and enteral nutrition

BACKGROUND

Previous estimates of the cost of home parenteral and enteral nutrition (HPEN) have excluded hospitalization costs or were conducted abroad and have limited applicability in the United States. Few studies have used validated measures to determine the effect of home nutrition support on quality of life.

METHOD

A cost and clinical outcome analysis was performed by retrospective review of charts of patients receiving HPEN from 1991 to 1996. Questionnaires to determine the influence of therapy on lifestyle (n = 41) and a general health status questionnaire, the short form 36-item survey (n = 39), were mailed to patients.

RESULTS

The annual cost per patient for parenteral solutions was $55,193 +/- 30,596 (mean +/- SD) based on Medicare charges and for enteral tube feedings was $9605 +/- 9327. The annual cost of hospitalization ranged from zero to $140,220 in the parenteral nutrition group and from zero to $39,204 in the enteral nutrition group. The annual number of hospitalizations per patient for patients receiving parenteral nutrition ranged from 0.52 to 1.10, compared with 0 to 0.50 in the enteral nutrition population. The health status of HPEN patients was significantly lower (p < .05) in five of the eight short-form 36 health domains compared with the general population. The areas of lifestyle most frequently affected were travel, sleep, exercise and leisure.

CONCLUSIONS

The majority of the cost of therapy was associated with the direct provision of nutrition, although in some patients the hospitalization expenditure exceeded this cost. Home nutrition support had a significant negative impact on a patient's quality of life and lifestyle.

Home artificial nutritional support in gastrointestinal disease

Recent studies in the area of home artificial nutrition have shown that the prevalence of home enteral and parenteral nutrition programmes is rising rapidly all over the world. Other features of the past few years are the shift from non-malignant towards malignant indications and the increasing number of geriatric patients.

Home parenteral nutrition: a systematic review

OBJECTIVES

The objective of this Review was to locate, appraise and summarise evidence from scientific studies on home parenteral nutrition (HPN) in order to answer specific research questions on the effectiveness of this technology. The following questions were asked. What patients have received HPN? What has been the experience of patients on HPN programmes? How have HPN programmes been organised, and what techniques and equipment have been used, and to what effect? What comparative information is available on effectiveness? What evidence exists for the cost-effectiveness of HPN? What questions about the provision of HPN could be answered with additional research, and what studies would be most suitable?

DATA SOURCES

A comprehensive list of studies was provided by an extensive search of electronic databases (including MEDLINE, Embase, Science Citation Index, Uncover, Cinahl, Caredata, Food Science and Technology Abstracts, NTIS, Pascal, Psychlit, and Economic Literature Index), relevant journals (including Journal of Parenteral and Enteral Nutrition, Clinical Nutrition, American Journal of Clinical Nutrition, Nutrition, Clinical Gastroenterology, Nutrition Reviews, Annals of Nutrition and Metabolism, Nutrition and Cancer, Nutrition and Health, and Journal of Paediatric Nutrition and Metabolism), and scanning of reference lists, as well as other search strategies outlined in the protocol.

STUDY SELECTION

Studies relevant to the questions were selected. The inclusion criteria were fairly broad because of the quality of the studies located.

DATA EXTRACTION

Data extraction forms were used to collect data from studies included in the review. The data was checked by a second researcher to reduce error.

DATA SYNTHESIS

Quantitative analysis was difficult owing to the type of studies located. The data is discussed in a qualitative manner. Where complication rates have been given, we have attempted to combine the results in a quantitative manner.

RESULTS

The age and sex of patients on HPN varies according to the underlying disease but, on the whole, patients are young (see Tables 4a and 4b). There are trends showing an increased use of the technology at the extremes of the age range. There are marked differences between countries on the underlying diseases for which HPN is indicated. For example, many more patients with an underlying malignancy are treated in Italy and the USA than in the UK (40-67% versus 8%). Morbidity rates for the majority of patients are acceptable (see Table 8), the complications tend to be related to the central venous catheter. It is fairly clear that a minority of patients are susceptible to recurrent problems and that many patients have very few complications. The mortality rate for HPN patients (see Table 10) was good for those patients with benign underlying disease (for example, 5% of Crohn's HPN patients die per year), and there are very few reports of patients dying from complications of the technology. The survival of those with malignant disease and AIDS is poor, almost all having died from the underlying disease at one year; despite this, most programme growth worldwide is due to an increase in the numbers of patients with these diagnoses (see Table 5). Quality of life is reasonable for patients with benign disease (see Table 9); no studies were found that examined the quality of life of HPN patients with malignant disease. Economic analysis shows that the cost of HPN treatment is cheaper than the alternative of in-patient care (see Table 18). There is a paucity of comparative studies examining different aspects of the technology, and this accounted for the majority of gaps in the evidence.

CONCLUSIONS

The use of HPN for benign intestinal failure is supported by evidence from the scientific studies located. There are, however, large gaps in the evidence, particularly relating to the use of HPN in malignant disease and AIDS. A programme of research is suggested at the end of this review.

Community parenteral therapy project: a pilot study

The pilot study reported in this paper was devised to develop and compare service delivery models that would achieve the provision of high quality parenteral therapy care to patients in the Gold Coast District Health Service community. All data were collected on 113 patients for a 12-month period, January to December 1996. The study compared the provision of outreach nursing services and contracted nursing services on measures of satisfaction and cost. The study showed that patient and carers indicated a preference for community care, medical officers advocated the benefits of administering parenteral therapies in the community, general practitioners were interested in managing future community parenteral therapies, and contracted (nurse) service providers endorsed the development of a parenteral therapy resource centre. The findings also revealed considerable potential cost savings in community-based care.

Guidelines for the care of the patient on home nutrition support. An appendix

A significant portion of the health care provided in this country has been shifted to the home care environment. As a result, patients are discharged from the hospital earlier, with increased needs for highly skilled care. Much of the daily, hands-on care patients require, is provided by family members or care givers and supported by periodic visits from health care professionals. Home nutrition support is one of the many "technical" therapies that is routinely administered at home. To ensure the success of home nutrition support one must identify appropriate candidates, develop a nutritional plan of care agreeable to the patient/care giver, design a prescription appropriate for the home setting, and properly train the patient/care giver.

Opiate and sedative dependence predicts a poor outcome for patients receiving home parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is used to treat intestinal failure. A minority of HPN patients are dependent on opiates and benzodiazepines to control pain and anxiety. The aim of this study was to determine what effects such drug dependence had on patient outcomes.

METHODS

Ten dependent patients were prospectively compared with 10 well-matched, nondependent HPN patients for the same 12-month period. Episodes of line sepsis and other complications were documented and the cost of treatment estimated. Health status was measured using the SF36 and EuroQol instruments.

RESULTS

The dependent group had significantly more episodes of central line sepsis (p = .0007) as well as other complications (p = .0002). This led to significantly longer periods of inpatient care (p = .0004) and therefore higher costs of treatment. Health status was lower in the dependent group; they reported more pain (p = .04) and less energy (p = .04).

CONCLUSIONS

The complication rate and increased cost of treatment for opiate- and sedative-dependent patients receiving HPN significantly detract from the overall outcome of this therapy.

Home artificial nutrition in advanced cancer

Attitudes to home artificial nutrition (HAN) in cancer vary greatly from country to country. A 6-year prospective survey of the practice of HAN in advanced cancer patients applied by a hospital-at-home programme in an Italian health district was performed to estimate the utilization rate, to evaluate efficacy in preventing death from cachexia, maintaining patients at home without burdens and distress and improving patients' performance status, and to obtain information about costs. Patients were eligible for HAN when all the following were present: hypophagia; life expectancy 6 weeks or more, suitable patient and family circumstances; and verbal informed consent. From July 1990 to June 1996, 587 patients were evaluated; 164 were selected for HAN (135 enteral and 29 parenteral) and were followed until 31 December 1996. The incidence of HAN per million inhabitants was 18.4 in the first year of activity and 33.2-36.9 in subsequent years, being 4-10 times greater than rates reported by the Italian HAN registers. On 31 December 1996, 158 patients had died because of the disease and 6 were on treatment. Mean survival was 17.2 weeks for those on enteral nutrition and 12.2 weeks for those on parenteral nutrition. Prediction of survival was 72% accurate. 95 patients had undergone 155 readmissions to hospital, where they spent 15-23% of their survival time. Burdens due to HAN were well accepted by 124 patients, an annoyance or scarcely tolerable in the remainder. The frequency of major complications of parenteral nutrition was 0.67 per year for catheter sepsis and 0.16 per year for deep vein thrombosis. Karnofsky performance score increased in only 13 patients and body weight increased in 43. The fixed direct costs per patient-day (in European Currency Units) were 14.2 for the nutrition team, 18.2 for enteral nutrition and 61 for parenteral nutrition. The results indicate that definite entry criteria and local surveys are required for the correct use of HAN in advanced cancer patients, that HAN can be applied without causing additional burdens and distress, and that its costs are not higher than hospital costs.

Economics of home parenteral nutrition

The past 30 years have seen long term parenteral nutrition evolve from a novel technique to an accepted intervention for gastrointestinal failure. The development of home parenteral nutrition (HPN) has parallelled a shift in resources from hospital to community care and has been driven by technological advances, the growth of commercial home care companies and patient choice. Costs for HPN per patient year have been estimated to range from $US 150,000 to $US 250,000 in the US, and are around 55,000 pounds in the UK, perhaps only 25 to 50% of in-hospital costs. In the absence of any alternative treatment for many patients with gastrointestinal disease, parenteral nutrition is life saving and offers the prospect of maintaining a good quality of life. The cost of 1 quality-adjusted life-year for HPN has been estimated as 69,000 pounds in the UK (1995 values), and $Can 14,600 in Canada (1984 values), making HPN relatively cost effective compared with other ways of spending money to improve health. HPN is also given to patients in whom life expectancy is unlikely to be influenced, such as those with cancer or AIDS. Although there is considerable heterogeneity between countries in the proportion of HPN patients with a particular disease, malignancy is now the single most common indication. HPN can be expected to improve quality of life over a short period of terminal care, and whilst a strong case can be made for use of HPN in some of these patients, its use has not been subjected to detailed medical or economic appraisal.

Cost-utility analysis of home parenteral nutrition

An economic evaluation of home parenteral nutrition (HPN) for intestinal failure is presented. The cost-utility of HPN and factors affecting the cost-utility ratio were examined to determine whether current practice is the most efficient way of treating intestinal failure. Quality-adjusted life-years (QALYs) gained were measured using a validated health status questionnaire. The cost of treating a patient with intestinal failure was calculated, and marginal cost per QALY gained ratios were obtained. The cost per QALY for an average patient was approximately 68,975 pounds, but the value for patients over 55 years of age of about 126,865 pounds compared with approximately 58,233 pounds for those under 44 years. Treating a patient in hospital rather than at home increased the estimated cost per QALY to approximately 190,000 pounds. The current practice of home care is about 65 per cent more cost-effective than hospital care.

[Study of medical economy in home parenteral nutrition]

The authors studied the relation between home parenteral nutrition (HPN) and medical economy. The items of study are 1) cost benefit of HPN compared with TPN, 2) hospital intention to promote HPN, 3) economical demerits for outpatients receiving HPN.

RESULTS

1) HPN had the advantage of cost benefit compared with TPN in reimbursement; however, hospitals did not have such an intention. 2) It is necessary for advanced home care to improve reimbursement in the health insurance system; and in the existing situation, hospitals do not profit from HPN. 3) Home care companies are unprofitable because of nursing visits and reimbursement issues which do not ease legal restrictions. 4) HPN in the present situation depends on the ability of patients to pay and the ability of care givers to provide care.

Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States

BACKGROUND & AIMS

Home nutrition support, especially when delivered parenterally, is very costly. The aim of this study is to examine current usage of home parenteral and enteral nutrition (HPEN) in the United States and the quality of therapy outcome.

METHODS

Medicare HPEN use from 1989 to 1992 was analyzed to assess use, growth, and costs. National Registry information collected on 9288 patients treated with HPEN from 1985 to 1992 was used to assess disease distribution and therapy outcome.

RESULTS

In the United States, there were approximately 40,000 parenteral and 152,000 enteral home patients in 1992. The usage of HPEN doubled between 1989 and 1992, and a large proportion was in patients with short survival. The prevalence of HPEN in the United States was 4-10 times higher than in other Western countries. Outcome data showed both therapies were relatively safe. The primary disease strongly influenced survival and rehabilitation, and age, per se, was not a reason to deny HPEN.

CONCLUSIONS

Predicted quality survival at home for several months, rather than a specific diagnosis, seems to be the soundest justification for HPEN. Its role in terminal conditions and patients without primary gastrointestinal diseases needs further evaluations.

Quality of life of patients receiving home parenteral or enteral nutrition support

Limited data are available on the impact of enterally or parenterally supplied home nutritional support on quality of life. Data from national registries have been useful in identifying the outcome of different patient groups in terms of their functional capacity and rehabilitation status. Results in patients with inflammatory bowel disease are used as the 'gold standard' for this type of therapy. The annual cost of home parenteral nutrition can range from $US100 000 to $US150 000 per patient, depending on the frequency of feeding. Only one cost-utility analysis has been reported in the literature, based on a Canadian home parenteral nutrition programme which suggested that the estimated quality-adjusted survival of patients receiving this treatment is 4 times greater than if they had not been treated. There are many controversial areas associated with the use of home parenteral and enteral nutrition, including the treatment of patients with terminal malignant disease or severe dementia, and those infected with human immunodeficiency virus. To date, the clinical benefit of providing this type of nutritional support for these patient groups has not been clearly demonstrated. Prospective randomised controlled trials are necessary to evaluate the costs and benefits of this expensive high technology treatment.

Home parenteral nutrition in advanced cancer

The use of home parenteral nutrition (HPN) in advanced cancer evokes ethical problems related to risk/benefit, patient autonomy, justice, medical futility, and cost. Case series have been beneficial for some patients, particularly when survival is expected to be longer than 2 months. A team approach to involving the patient and family in evaluating risk and benefits is preferred. Social workers serve a key role in enabling the patient and family to make end-of-life decisions by helping them clarify the psychosocial and ethical aspects of these decisions. Clinical standards and case law will further define whether HPN in advanced cancer is futile treatment. Broader social issues of rationing, access to HPN, and costs must be addressed. Further research on outcomes and patient/family decision making on HPN are needed.

Home parenteral nutrition--a 3-year analysis of clinical and laboratory monitoring

We report a 3-year analysis (1986 to 1989) of the management of 63 home parenteral nutrition patients, 40 with short-bowel syndrome and 23 with chronic intestinal obstruction with or without intestinal resection. Intravenous fluid requirements varied from 0.9 to 6 L/day, and the content of glucose varied between 46 and 531 g/day, protein varied from .0 to 85 g/day, fat from .0 to 100 g/day, sodium from 37 to 695 mEq/day, potassium from 30 to 220 mEq/day, chloride from 60 to 760 mEq/day, and acetate from 0 to 200 mEq/day. Body weight was normalized and well maintained in the majority of patients, but using the strict definition of deficiency as the presence of one abnormal value during 3 years, more than half had abnormal plasma chloride, glucose, alkaline phosphatase, serum glutamic oxaloacetic transaminase, total protein, albumin, selenium, and iron concentrations, and more than a third had low calcium, magnesium, vitamin D, and vitamin C levels. Normochromic anemia was seen in 73% and high blood creatinine associated with low urine volumes in 42%. Most (78%) returned to relatively normal lifestyles, but employability was occasionally impaired by loss of third-party insurance coverage resulting from a therapy that may cost $100,000 per year. Overall mortality was low (5% per year), but 73% needed readmission to hospital, mainly for suspected catheter sepsis. The results indicate that home parenteral nutrition has allowed many patients to survive gut failure and return to work but problems with chronic fluid, electrolyte and micronutrient deficiencies, catheter sepsis, and insurance coverage often restrict optimal rehabilitation.

Home parenteral nutrition in chronic intestinal failure

In children with severe failure of intestinal function, intravenous nutrition is at present the only treatment able to maintain adequate nutrition for prolonged periods of time. Over the last five years we have discharged 10 patients home on parenteral nutrition for a total of 25 patient years and here the outcome of these children is presented. Of the 10 patients, one has discontinued home parenteral nutrition (HPN), seven patients remain well, one patient has recently moved to the USA, and one patient has died after major abdominal surgery. All children had either normal or an accelerated rate of growth on HPN and developmentally all have progressed well. All the children over 5 years attend normal schools. The major complication of treatment was line sepsis with an overall rate of one episode in 476 days and a total of nine central lines (five patients) have required replacement giving an average line life of 680 days. For those children unfortunate enough to suffer from severe intestinal failure, HPN is preferable to prolonged hospital treatment and offers the chance of a good quality of life with prolonged survival.

Safe harbor rules create infusion confusion. Physician ties may put business in a bind

Home infusion has been one of healthcare's healthiest businesses, but providers are concerned about the future in light of new "safe harbor" guidelines and recent crackdowns by the HHS inspector general's office. Despite that uncertainty, the industry continues to prosper: Revenues have risen at an estimated 25% annual rate, thanks to home infusion's ability to get patients out of hospitals quicker.