Cost-benefit and cost-effectiveness analysis ofhome artificial nutrition: reappraisal of available data

Abstract

The prevalence of home parenteral nutrition (HPN) has been estimated to be around 2 4 per million in Europe (UK, France, Italy) 1-5 and around 80 per million in the USA, 6 where its growth has been supported by health regulations favouring patient discharge from hospital. In these same countries, the prevalence of home enteral nutrition (HEN) is much greater than that of HPN, accounting for about 8090% of all home artificial nutrition (HAN) treatment. s-8 In the USA, the incidence of HAN is increasing at a rate of about 25% per year. 4 Most new cases are cancer patients, but patients infected with HIV are increasingly being provided with HAN. In Europe, the use of HAN is also increasing, but indications differ between countries. In Italy, 5 like the USA, cancer patients constitute most of the new HAN cases. In France, 2 patients with malignancy represent about 10-20% of HPN patients and protocols for AIDS patients have been developed. 9 In the UK, a different approach to terminally-ill patients has limited to a few cases the use of HAN for these categories of patients, t,4 HAN is expensive, especially HPN which is one of the most costly home therapies. The rapid growth of HAN, the difference in indications between various countries and its high cost render the definition of cost-benefit and cost-effectiveness of treatment essential. A reappraisal of data on cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA) published from January 1970 to April 1994 is reported in this paper. Data were obtained using a computerised literature search (Medline ®, on Silver Platter, US National Library of Medicine), by selecting the single and multi-centre surveys published on clinical nutrition, considering the Italian registers of HAN, and reviewing major nutrition texts. The computerised search was performed using the keywords 'home enteral nutrition', 'home parenteral nutrition' and 'economics'. The data obtained were analysed for a breakdown of costs of HAN and the major factors which influence total expenditure including identification, demonstration and quantification of benefits. Ad hoc designed studies were also included. Figure 1 shows the number of papers found with-the computerised search. The number of papers per year parallels the developing trend towards t tAN since its inception. Most papers have appeared during the last decade, following technological and scientific growth and the increased use of HAN during the 1980s. The Figure also demonstrates that publications on HEN are consistently fewer than those on HPN. Notwithstanding the increase in the total number of publications since 1970, the number of papers per year addressing the problem of CBA and CEA remained stable and represented a small proportion of the total number.