Specialized feeding in hospital and home: computers, regulations and reimbursement issues.

Abstract

The level of scientific investigation in nutrition achieved in developed countries is remarkable and has contributed to the establishment of clinical nutrition as a science. It is interesting to note, however, that in the clinical setting the doubts and challenges faced every day by the practitioner are quite similar in different countries and continents. The nutrition team members, in their clinical rounds, still debate whether a catheter should or should not be removed in a febrile patient, whether a gastrostomy should be performed instead of insertion of a nasogastric tube, and whether an in-line filter should be used or whether a renal or hepatic formula should be chosen. Even the amount, route and source of calories that should be administered to a hypermetabolic patient is still a matter of controversy at bedside. Some of these topics were included last year in Current Opinion in Clinical Nutrition and Metabolic Care, in the ‘Technical aspects of nutritional support’ section that we edited. As we observed in our previous editorial, by publishing only technical problems there is a danger that an erroneous impression is created that provision of nutritional support is dogged with dangers and practical difficulties [1]. Indeed, numerous serious and life-threatening complications associated with nutritional therapy have been published in the literature. Because of the dramatic nature and the notoriety that they attract, many of these incidents have appeared as single case reports. We have also pointed out [2] that, although occurring infrequently, the morbidity and mortality of such incidents may be extremely high. In contrast, the main problems associated with nutrition therapy are probably not the dramatic ones, but those that are related to ordinary daily problems. Because of their low mortality they command little attention, but they are important because of their high frequency. It is therefore of great importance to determine how best to prevent and treat them. In this issue, Chowdhary and Parashar (pp. 217-219) describe central venous access in neonates through the peripheral route, as a way to avoid the potential risks of serious complications associated with the percutaneous puncture of the internal or subclavian vein. The technique is described in detail. It is interesting to note that the peripheral lines are usually introduced in the ward, under sedation with oral chloral hydrate only. By percutaneous puncture of the cephalic, basilic, superficial temporal, saphenous or external jugular veins, the catheter is introduced to a premeasured distance, and the position of the line tip in the right atrium or superior vena cava is confirmed by radiography. The most common problems reported by the authors are catheter displacement, occlusion and sepsis. Therefore, satisfactory positioning, adequate fixation, continuous infusion, staff training and usage of in-line filters are considered the key points for success. Curiously, there is little recent literature on this topic. In their excellent review, Thomas and Akobeng (pp. 221-225) describe the most common feeding problems that are encountered in children with neurological impairment. They carefully describe the reasons why eating may be a distressing and time-consuming experience to many disabled children and their carers. In particular, they reviewed the causes, diagnostic methods, treatment and prevention of aspiration of food into the airways or lungs, which may result in recurrent chest infection. Chronic aspiration is usually secondary to uncoordinated swallowing or due to gastroesophageal reflux. Whereas esophagitis is best demonstrated by endoscopy, 24-hour pH monitoring is considered the most sensitive indicator of gastroesophageal reflux. Videofluoroscopy may help in the diagnosis and in determining the optimal consistency of foods. Clinical treatment consists of changes in positioning, use of feeding devices and changes in food texture. Enteral nutrition is reserved for situations in which oral feeding is unsafe, distressing, inadequate or very time-consuming. The surgical treatment of gastroesophageal reflux in disabled children is also discussed. In particular, the authors review the indications for performing a fundoplication at the time of gastrostomy tube insertion in those children with symptomatic reflux and with indication for gastrostomy. They also comment on the new technique of oesophagogastric dissociation with Roux-en-Y oesophagojejunostomy as an alternative to fundoplication. In preliminary studies, this technique has achieved good results. Despite decades of investigation, nutritional support in patients with chronic liver disease is still a matter of debate. Gopalan et al. (pp. 227-229) review the evidence in the literature for the usefulness of enteral and parenteral nutrition supplementation in patients with chronic liver failure. Although most studies have shown that nutrition supplementation does not significantly influence either short-term or long-term survival, recent studies suggest that enteral nutrition may improve the short-term survival of these patients. Although the use of branched-chain amino acid-enriched formulas in the treatment of hepatic encephalopathy remains controversial, it appears that such formulas are able to improve hepatic protein synthesis and to reduce catabolism. A better outcome after liver transplantation has been reported in previously well-nourished patients. The routine use of either parenteral or enteral nutrition before or after liver transplantation has not yielded uniformly better results, however. Newer therapeutic modalities such as the use of growth hormone alone or in combination with immunoglobulin F1 are being investigated in children to improve their growth after liver transplantation. In his very interesting paper, Ball (pp. 231-235) reviews the use of computers in clinical nutrition. He makes an interesting analogy by stating that both parenteral nutrition and personal computers became available at about the same time and ‘grew up’ together. The first reports of the use of computers in parenteral nutrition date from around 1975. The first nutrition support software applications were written by amateurs, and were progressively replaced by professional software. In Ball's opinion, however, despite the enormous increase in the power and flexibility of computers, their usefulness in clinical nutrition has not increased to the same proportion as portable computers. Despite a variety of commercially available programs for parenteral nutrition calculation, formulation and management, with extensive facilities for data storage and retrieval, it is pointed out that there is no report in the literature of the data recorded by such system being employed. Finally, an interesting overview is provided of the potential benefits of the wide availability of multimedia facilities, of the use of e-mail and of the internet, and the conclusion is drawn that nutritional support practitioners are generally not exploiting the potential benefits of the new computer technology. Outcome and costs of home parenteral nutrition are major ethical and economic issues, and are discussed by Colomb (pp. 237-239). The author estimates a growth rate of home parenteral nutrition of 25% per year. Children account for 15 and 22% of the cases in the USA and Europe, respectively. Although home parenteral nutrition is one of the most expensive ambulatory therapies, cost-benefit studies have demonstrated that home parenteral nutrition is about 50-75% more cost-effective than hospital parenteral nutrition. Factors that influence the cost of home parenteral nutrition are the number and duration of hospitalizations, usually due to catheter sepsis. Home parenteral nutrition is an excellent alternative to the more expensive and distressing long-term hospitalizations. In selected patients intestinal transplantation may become an appropriate indication. By applying a broader definition to ‘technical aspects of clinical nutrition’, one can draw the conclusion that the economics and regulation policies associated with the delivery of nutrition therapy may be a limiting factor and, consequently, may be included as a technical aspect of clinical nutrition. In Brazil, for example, we have everything necessary for the delivery of safe and efficient nutrition therapy, including catheters, tubes, bags, pumps and a myriad of products for both parenteral and enteral nutrition. Approximately one-quarter of our population has private health insurance that covers those costs. Until recently, however, three-quarters of the population had no access to enteral nutrition because the public health system considered enteral nutrition to be included in the alimentation fee paid to the hospital for each patient. It was a great achievement of the Brazilian Society of Parenteral and Enteral Nutrition (SBNPE) to obtain from the Ministry of Health the inclusion of enteral nutrition as a distinct therapeutic modality, to be paid separately. This was possible because we have demonstrated a high prevalence of hospital malnutrition throughout the country and by showing the cost-benefit data available in the literature. This was approved in October 1999 and gave access to enteral nutrition to over 120 million Brazilians. Similarly, we are negotiating with the government to obtain the reimbursement for home parenteral and enteral nutrition, which is still covered only by some private health insurance companies. Another issue that needs to be examined in greater detail is the regulation of the delivery of both parenteral and enteral nutrition. On the one hand regulations need to ensure the delivery of safe nutrition for every patient, either in the hospital or at home. On the other hand, regulations cannot be so strict as to deny the benefits of nutrition therapy in many clinical settings. The regulations for both parenteral and enteral nutrition were a subject of hot debate between the SBNPE and the Ministry of Health in Brazil. The discussion is now beyond the stage of establishing guidelines, and is involved in developing feasible, ethical, practical and yet safe regulations. Physicians, pharmacists, dieticians and nurses from SBNPE worked in close collaboration with the government during the years 1998 and 1999 to approve a modern and well-balanced legislation to regulate the delivery of nutrition therapy. Within the areas covered by the Latin American Federation of Parenteral and Enteral Nutrition (FELANPE) and the European Society of Parenteral and Enteral Nutrition (ESPEN), we have found that several countries face similar problems. Consequently, the Latin American Federation of Parenteral and Enteral Nutrition recently embarked upon a multinational study to evaluate the existing policies for both regulation and reimbursement of nutritional therapy in the different countries in Latin America. The ultimate goal is to offer the results of this study to national parenteral and enteral nutrition societies around the world in order to assist them to implement similar regulation and reimbursement policies in their countries. As the Journal of Parenteral and Enteral Nutrition and other major journals prepare to go ‘online’ [3], nutrition support techniques and practices are beginning to evolve in a truly international manner. It is our belief that the leaders in clinical nutrition throughout the world need to go beyond science and become involved with politics in order to ensure that every patient has access to optimum nutrition support.