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The rise of enteral feeds expenditure
- Duncan Short (5 October 1998)
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Untitled
- Louise McCombie (7 April 1999)
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Duncan Short, Research Assistant Department of Medicines Management, University of Keele
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Potter et al in their paper on supplementary feeding state that "...there are implications in terms of cost... if nutritional supplementation were to become a routine part of hospital prescribing."(1) Whilst we agree with this statement, we believe that the issue is far wider than that of hospital prescribing, as primary care prescribing of enteral feed products is one of the most rapidly increasing areas of drug expenditure. As part of a study for the NHS Executive(2), we have recently analysed PACT data for the West Midlands Region for enteral feed products from the quarter January-March 1995 to March-June 1997. Starting from different baselines, there were year on year increases for both the cost and volume of products prescribed, varying from 39-142% and 43-135% respectively (Table 1). Price increases and changes in product mix accounted for only a small part of the rise in expenditure, suggesting that the main driver behind this trend was the increase in prescribing volume. The assertion of Potter et al that "...analysis of the subgroups showed that the benefits of routine nutritional supplementation were not restricted to particular subgroups or trials." is unsafe because of the clinical heterogeneity of the group as a whole.(1) The odds ratios in Figure 3 indicate statistically significant benefits on case fatality for a number of groups, including those either nourished, aged over 70 or having non-neoplastic disease. Qualitative findings of our work suggest that a significant proportion of current prescribing is for uses other than the defined clinical circumstances identified to date. Indeed there is inadequate evidence to support some current usage, particularly in terms of cost benefits, since the outcomes used in trials to date may not be those of greatest importance. For example improved quality of life or reductions in morbidity may be of greater clinical significance than improved muscle tone or immune function(3-5). Furthermore usage for some patients with terminal illness or severe neurological damage poses ethical dilemmas not yet adequately addressed. The conclusion of the paper could have been more definitive; enteral feeding should be prescribed only for those patients for whom, on current evidence, there is benefit, albeit of limited definition. We strongly endorse the conclusion that large pragmatic trials are required since we have recommended to the NHSE that enteral feeding be evaluated within the HTA programme. In the interim, clear national guidance is required on both initiation and exit criteria. The research has been funded by the NHS Executive Prescribing Branch and none of the authors have any conflict of interest. (word count 398) Dr J Norwood Consultant in Public Health Medicine Mr Duncan Short Research Assistant Dr N Dakhill Research Assistant Corresponding author and person dealing with the paper at all stages: Mr Duncan Short Norwood J, Short D, Dakhill N. Department of Medicines Management University of Keele 1. Potter J, Langhorne P, Roberts M. Routine protein energy supplementation in adults: systematic review. BMJ 1998;317:495-501 2. Short D, Norwood J. An exploration of the factors influencing the rise of enteral feeds expenditure in primary care - a study of the West Midlands Region. Report to the NHS Executive, August 1998. 3. Chandra RK. The relation between immunology, nutrition and disease in elderly people. Age and Ageing 1990;19:25-31. 4. Lopes J, Russell D, Whitwell J, Jeejeebhoy KN. Skeletal muscle function in malnutrition. Am J Clin Nutr 1982;36:602-10 5. Lesourd B. Protein undernutrition as the major cause of decreased immune function in the elderly: clinical and functional implications. Nutr Rev 1995;53:S86-94. Table 1: Increase in the costs and volume of enteral feeds prescribed in primary care between March 1994 and June 1997 W Midlands Heath Authorities change in costs (%) change in volume (%) Health Authority 1 72 53 Health Authority 2 53 43 Health Authority 3 73 53 Health Authority 4 81 60 Health Authority 5 79 59 Health Authority 6 94 77 Health Authority 7 39 76 Health Authority 8 113 100 Health Authority 9 99 81 Health Authority 10 81 58 Health Authority 11 142 135 Mean 84 72 |
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Louise McCombie
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Editor Norwood et al note the increase in enteral feed products in Primary Care. A similar pattern of increase in this area of prescribing has also been seen across all Health Boards in Scotland (Table 1). There is general agreement that inadequate nutritional intake will have a detrimental effect on clinical outcomes and Potter et al1 rightly identify the need for large pragmatic randomised controlled trials of routine oral or enteral nutritional supplementation. As these are a relatively high cost treatment (Table 2) there is also a clear need to demonstrate where such products have significant clinical benefit over appropriate dietary advice for particular patient groups. Potter's systematic review recognises the lack of studies examining the value of dietary advice, or appropriately modified catering provision, for patients identified as requiring nutrition support. Although various guidelines are available for this particular area of care, the overlap between diet and nutritional supplementation continues to leave clinicians unsure of what constitutes optimal patient care, which is also cost effective. Training initiatives should be targeted towards district nursing services as they are frequently responsible for recommending oral sip feed prescribing for patients living at home. Of note, is that at current NHS prices, prescribing costs for 10 patients receiving 2 sip feeds per day for one month would pay for approximately 20 dietetic sessions or 22 practice nurse sessions, potentially freeing up resources to provide dietary advice and follow up. In relation to ensuring optimal food provision in hospitals dietitians are involved in the Scottish Catering Initiative, seeking to ensure that the flexibility is available to allow food intakes to be maximised within environments where institutional catering is used. This would have particular relevance to the nursing home environment where sip feeds are provided at non-discounted NHS prices. The impact of such an initiative on the use of oral sip feeds would obviously be worthy of further investigation. Louise McCombie State Registered Dietitian GGHB Prescribing Advisers Department Glasgow Royal Infirmary 84 Castle Street GLASGOW Dr Catherine Hankey Research Dietitian University Department of Human Nutrition Glasgow Royal Infirmary 1 Potter J, Langhorne P, Roberts M. Routine protein energy supplementation in adults: systematic review. BMJ 1998; 317: 495-501. Table 1. Enteral Nutrition Costs per Quarter / Scotland. Date Total Cost (L's) Jan- Mar 1993 690786.5 Apr- Jun 1993 740271.1 Jul- Sep 1993 806456.9 Oct- Dec 1993 840499.1 Jan- Mar 1994 861330.1 Apr- Jun 1994 932750.9 Jul- Sep 1994 1025287 Oct- Dec 1994 1054013 Jan- Mar 1995 1082388 Apr- Jun 1995 1143644 Jul- Sep 1995 1258915 Oct- Dec 1995 1242661 Jan -Mar 1995 1275783 Apr- Jun 1996 1364388 Jul- Sep 1996 1430624 Oct- Dec 1996 1488513 Jan- Mar 1997 1414862 Apr- Jun 1997 1518809 Jul- Sep 1997 1561414 Oct- Dec 1997 1631072 Jan- Mar 1998 1602055 Apr- Jun 1998 1699403 Jul- Sep 1998 1832567 Oct- Dec 1998 1794897 Table 2. Cost per Item Major BNF Sections Oct- Dec 1998 Scotland Section Cost per Item (L's) Enteral Nutrition 40.20 Lipid Lowering 32.96 Ulcer- Healing Drugs 25.31 Corticosteroids (respiratory) 23.67 Antihypertensive Therapy 18.74 Antidepressant Drugs 17.28 Nitrates etc. BNF 2.6 13.47 Drugs Used in Psychosis 12.38 Bronchodilators 9.78 Vaccines 9.18 Drugs use in Rheumatic Disease 8.17 Antibacterial drugs 4.41 Beta- adrenoceptor Blockers 4.14 Hypnotics and Anxiolytics 1.78 Diuretics 1.71 Antiplatelet Drugs 1.26 |
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