Abstract
BackgroundThe multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. This study describes the cost-effectiveness of this new nutritional strategy.MethodsDirect medical costs were calculated with use of a micro-costing approach. We compared the costs of late versus early initiation of PN (n = 673 versus n = 670 patients) in the Belgian and Dutch study populations from a hospital perspective, using Student’s t test with bootstrapping. Main cost drivers were identified and the impact of new infections on the total costs was assessed.ResultsMean direct medical costs for patients receiving late PN (€26.680, IQR €10.090–28.830 per patient) were 21% lower (-€7.180, p = 0.007) than for patients receiving early PN (€33.860, IQR €11.080–34.720). Since late PN was more effective and less costly, this strategy was superior to early PN. The lower costs for PN only contributed 2.1% to the total cost reduction. The main cost driver was intensive care hospitalisation costs (-€4.120, p = 0.003). The patients who acquired a new infection (14%) were responsible for 41% of the total costs. Sensitivity analyses confirmed consistency across both healthcare systems.ConclusionsLate initiation of PN decreased the direct medical costs for hospitalisation in critically ill children, beyond the expected lower costs for withholding PN. Avoiding new infections by late initiation of PN yielded a large cost reduction. Hence, late initiation of PN was superior to early initiation of PN largely via its effect on new infections.Trial registrationClinicalTrials.gov, NCT01536275. Registered on 16 February 2012.
Highlights
The multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN
We explored the cost-effectiveness of late initiation of PN, using the number of patients with a new infection prevented in the intensive care unit (ICU) as an effect measure
Total healthcare costs and evaluation of cost drivers Late initiation of PN, as compared with early initiation of PN, reduced the mean total direct medical costs by €7.180 (95% confidence interval (CI) (-€12.920; -€1.880), p = 0.007) per patient, which is a saving of 21% (Table 2)
Summary
The multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. Intensive care costs are largely dependent on length of stay (LOS) in the intensive care unit (ICU), Recently, a multicentre, randomised, controlled, parallel-group, superiority trial, with the acronym PEPaNIC (n = 1.440) concluded that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing PN within 24 hours when enteral nutrition was insufficient [6], resulting in fewer patients with new infections. Aside from this clinical benefit, an additional economic benefit van Puffelen et al Critical Care (2018) 22:4 of late PN would be an extra argument for implementation of this new nutritional strategy. With this method of calculating hospital costs, all relevant cost categories are included and costs are calculated at the most detailed level per patient, in contrast to the gross-costing approach, whereby the cost categories are highly aggregated or only hospitalisation costs are included
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