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MNT: Cost Effectiveness, Cost-benefit, or Economic Savings of MNT (2009)

Citation:

DeLegge MH, Basel MD, Bannister C, Budak AR. Parenteral nutrition use for adult hospitalized patients: a study of usage in a tertiary medical center. Nutr Clin Pract. 2007; 22: 246-249. 

PubMed ID: 17374799
 
Study Design:
Prospective Cohort Study
Class:
B - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To determine the appropriateness of PN usage according to the ASPEN guidelines and the associated costs for patients at a tertiary medical center with an associated medical school, a full complement of residency and fellowship training programs and postgraduate physician education on topics including nutrition support.

Inclusion Criteria:

Adult patients admitted (in a six-month period) to the Medical University of South Carolina (MUSC) hospital on the cardiothoracic surgery, general surgery and transplant surgery services.

 

Exclusion Criteria:

None stated.

Description of Study Protocol:

Recruitment

Any patient receiving PN therapy on the cardiothoracic surgery, general surgery and transplant surgery units in a six-month period at a University Hospital.

Design

Prospective cohort study.

Intervention

Registered Dietitians logged patients receiving PN into a database over a six-month period. 

Statistical Analysis

Hospital PN cost information was obtained through a query of the MUSC Keane and Trendstar financial databases that allowed an analysis of PN therapy costs attached to individual inpatient billing accounts. An average PN daily hospital cost was compiled according to this financial analysis. The total number of inappropriate PN days was multiplied by the calculated average PN daily hospital cost to obtain a calculation of total cost for inappropriate PN therapy.

Data Collection Summary:

Timing of Measurements

Six-month period of data collection.

Dependent Variables

  • Demographic 
  • Patient primary medical diagnosis
  • The referral physician and their associated medical or surgical service
  • Appropriateness of PN therapy as per the ASPEN guidelines
  • Initiation and termination dates of PN therapy
  • Nutrition assessment information
  • Laboratory values associated with PN monitoring
  • PN cost.  

Independent Variables

Patients receiving PN therapy logged into database.

 

 

Description of Actual Data Sample:
  • Initial N: 1,383 patients were admitted to the identified services over the six-month time period, and 139 (49% male) received PN therapy
  • Attrition (final N): 139.

Age

  • Mean age: 50 to 59 years
  • 15 to 18 years: 2%
  • 19 to 29 years: 9%
  • 30 to 39 years: 14%
  • 40 to 49 years: 20%
  • 50 to 59 years: 25%
  • 60 to 69 years: 14%
  • 70 to 79 years: 13%
  • 80 to 89 years: 2%.

Ethnicity

  • Asian: 0.7%
  • Black: 28%
  • Hispanic: 1.4%
  • White: 69%.

Location

South Carolina, US.

 

Summary of Results:

PN Appropriateness Cases Mean Cost/Day in Dollars Total Costs, Dollars
Appropriate
78
293.40
22,885
Inappropriate
56
212.04
11,874
Unknown
5
433.20
2166

Other Findings

  • Of the 139 new PN initiations, 40% were deemed inappropriate according to the ASPEN guidelines
  • Of these 40% inappropriate cases, 11 patients were discharged home, receiving PN
  • Total PN hospital cost of $80,000 and 573 PN-days could have been avoided if PN therapy had been used appropriately (this cost only reflects PN solution and not additional cost related to laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management)
  • Laboratory monitoring  for inappropriate PN-days was $11,874.

 

 

Author Conclusion:

This study illustrated that PN was not always being provided according to ASPEN guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who met these guidelines. 

Funding Source:
University/Hospital: Medical University of South Carolina
Reviewer Comments:

Authors note weaknesses of not including all hospitalized patients at MUSC, therefore overestimating or underestimating the true percentage of inappropriate PN use and likely underestimating the total number of inappropriate PN days.

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? N/A
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? N/A
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? N/A
  8.3. Were statistics reported with levels of significance and/or confidence intervals? N/A
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes