A global perspective of home parenteral and enteral nutrition

Abstract

For patients with severe or permanent dysphagia, nutrition support through a gastrostomy, pharyngostomy, or large-bore nasogastric tube has been available for more than a century. Such treatment, however, was not palatable for the patient, family, or doctor. Home parenteral nutrition (HPN) was first tried in the late 1960s.1 Although the first patient was not a long-term success, the attempt was repeated by several academic centers, and over the next several years there was a flurry of publications reporting good rehabilitation and relatively few complications in patients with extreme short-bowel Crohn’s disease and mesenteric ischemia.2–7 It soon became evident that home management of long-term parenteral and enteral nutrition was more cost effective than inhospital treatment. Thus, in 1976 Medicare developed a reimbursement mechanism under the part-B prosthetic-device benefit for parenteral and enteral nutrition in the non-hospital setting. Private health-insurance companies and state Medicaid programs rapidly followed suit. The reports of good rehabilitation and the existence of a reimbursement mechanism had an explosive effect on the use of HPN and home enteral nutrition (HEN). The number of Medicare beneficiaries receiving HPN and HEN and the dollars spent between 1989 and 1992 are shown in Figure 1. During this period, there was a 25% increase in both usage and dollars spent per year. This growth was accompanied by several improvements in both the hardware used for nutrition infusion and home-nursing services. Soft, biologically inert, silastic tubes and catheters became available, along with portable pumps. For enteral patients, convenient, ready-made commercial formulas became available, many of which were tailored to specific underlying diseases. By 1992 it was estimated that there were 40 000 HPN and 152 000 HEN patients in the United States, corresponding to a yearly prevalence of approximately 140 HPN patients per million persons and 400 HEN patients per million persons.8 At the same time that use of HPN and HEN was growing, specialized nutrition support increased in other non-hospital settings. Tube feeding was provided to 4% of nursing-home residents in the 1970s; this figure rose to 9% in the 1990s, at least in New York (Michael Lindsey, New York State Long Term Care Bureau, personal communication, 1997). Intradialytic parenteral nutrition was rarely provided to hemodialysis patients in the early 1980s, but by 1992 this therapy accounted for 23% of Medicare parenteral-nutrition beneficiaries in a non-hospital setting.8 The dollars spent on these therapies mirrored this growth in utilization. The money spent for all parenteral and enteral nutrition in a non-hospital setting in 1992 was $1.6 billion.8 However, this figure includes only the direct costs of the nutrient solutions and infusion equipment and not the costs of laboratory monitoring, outpatient follow-up visits to a physician, and rehospitalization for therapy-related complications, which are reimbursed by separate mechanisms. IS THIS LARGE EXPENDITURE JUSTIFIED?