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|Research: Oley Publishes Research on Cost-Benefit of HPEN Therapy|
Oley Publishes Research on Cost-Benefit of HPEN Therapy
Total parenteral nutrition (TPN) became available in the hospital setting in the early 1960s. A few patients with extreme short bowel syndrome, usually due to Crohn’s disease or mesenteric infarction, were sent home on this therapy 10 years later. By the middle 1980s, home parenteral nutrition (HPN) therapy had become widely established and its use had been extended to a variety of clinical situations, including patients with short life expectancy as in active cancer.
During this same period, traditional tube feeding (HEN) also underwent a technical revolution making it more effective and user-friendly. This led to a much broader clinical application for tube feeding both in the hospital and at home.
But home nutrition support, especially when administered parenterally, is very costly and in an era of health-care spending restraint, the cost-benefit of these two therapies needs to be clearly defined.
To help resolve the issue, a research team led by Dr. Lyn Howard, medical and research director of the Oley Foundation and head of the division of clinical nutrition at Albany Medical College, began studying the use of these therapies and their clinical outcome across the United States in 1985.
The results of this study were published in Gastroenterology (Vol. 109, No. 2, Aug. 1995). Medicare data were reviewed to determine the use, growth and costs of home parenteral and enteral nutrition (HPEN). Medicare pays for 25 percent of all patients on HPN and 50 percent of patients on HEN. Data from the North American HPEN Patient Registry were also examined to assess disease distribution and therapy outcomes. Until recently, approximately 25 percent of Oley’s budget has gone toward the national HPEN registry which has longitudinal clinical outcome information on more than 12,000 patients managed by 217 nutrition support programs across the United States.
The Gastroenterology paper, which was co-authored by Dr. Marvin Ament of UCLA, Dr. C. Richard Fleming of the Mayo Clinic, Dr. Moshe Shike of the Memorial Sloan-Kettering Cancer Center and Dr. Ezra Steiger of the Cleveland Clinic, was abstracted in the September 1995 American Journal of Managed Care, and has been selected for the 1996 Year Book of Medicine and the 1996 Year Book of Digestive Diseases.
HPEN Cost and Use
This research found that in 1992 there were 40,000 patients using home parenteral nutrition and 152,000 patients using home enteral nutrition in the U.S. The use of both therapies doubled over the four-year period from 1989 to 1992. The total costs of HPN and HEN in the United States in 1992 were $780 million and $357 million respectively. Specialized nutrition in hospital and nonhospital settings has been estimated at more than one percent of all healthcare dollars, 20 percent of which is spent outside hospitals on patients at home, in nursing homes and in dialysis clinics. HPN costs $100,000 for one year of treatment, and HEN costs one-tenth of that. This cost includes only the nutrition solution, administration sets and home delivery; it does not include the costs of medical monitoring or readmission for therapy-related complications.
While homePEN costs are considerably less then PEN therapies delivered in hospitals, it is significant that the United States uses HPN 10 times more frequently and HEN four times more frequently than other medically advanced countries. This obviously raises issues about medical appropriateness versus cost-shifting and entrepreneurial marketing skills in the U.S.
Cancer was the most common diagnosis for both HPN and HEN-treated patients followed by neurological disorders of swallowing (HEN) and Crohn’s disease (HPN). Patients with Crohn’s disease, ischemic bowel disease, motility disorders or congenital bowel defects who were receiving HPN had relatively good outcomes; their survival was measured in years and their rehabilitation was excellent. In contrast, only 50 percent of patients with cystic fibrosis, 20 percent with cancer and 10 percent of those with acquired immune deficiency syndrome who were receiving HPN were still alive after one year. Relative to older patients, younger HPN patients had better survival rates on the therapy, had a greater likelihood of resuming full oral nutrition and experienced more complete rehabilitation.
Both therapies were shown to be relatively safe. Of the patients who died on parenteral treatment, the therapy was reported as the cause of death less than five percent of the time. Similarly, less than three percent of the enteral patients who died did so because of treatment complications. In addition, therapy-related complications resulting in rehospitalization were infrequent. Half of these complications involved sepsis, but the home sepsis rate was much lower than that for hospital-based parenteral therapy.
When Is HPEN Appropriate?
From this outcome analysis, Dr. Howard and her colleagues concluded that HPEN is justified for patients with severe gastrointestinal disease when home care is acceptable to the patient and his or her family, when the medical condition and home environment is stable enough to permit home management without undue hazard and when there is a predictable quality survival for several months. Although HPEN outcome is strongly related to the underlying diagnosis, in all diagnostic groups some patients survive long term and therefore the primary diagnosis should not preclude HPEN. Similarly age, per se, is not a reason to deny the more complex parenteral treatment.
It was estimated that about half the patients sent home in the U.S. either were in the terminal phase of their disease and died within a few weeks of discharge or had malnutrition not caused by primary gastrointestinal disease. The appropriateness of the use of HPEN in these conditions needs further evaluation.
Adapted from an article published in BioFocus, a research publication of the Wadsworth Center and the Albany Medical College.
Copyright © 1995 The Oley Foundation
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Oley exhibit at A.S.P.E.N.'s Clinical Nutrition Week
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