Home Nutrition Support Research Articles

Overview of Considerations for the Pediatric Patient Receiving Home Parenteral and Enteral Nutrition

Pediatric home nutrition support is a common practice used to provide children with impaired gastrointestinal function and their caregivers a therapeutic environment for the delivery of needed nutrition for proper growth and development. Specialized teams and equipment are now available to make this a successful experience for all involved. This paper will review items specific to the care of infants and children receiving both enteral and parenteral nutrition.

Clinical Research: Benefits of a Nutrition Support Service in an HMO Setting

In an effort to improve long‐term follow‐up and to provide an integrated approach to the care of patients receiving home parenteral nutrition (HPN), a home nutrition support service (HNSS) was formed in 1993 at a large not‐for‐profit Midwest Health Maintenance Organization (HMO). Because the coordination of care for these patients is managed within the HMO setting, rather than contracting this service out, continuity of care is maintained and provides ease of communication with the physicians and access to patient information. By using a case management approach with the HPN patients, the average cost of HPN per day has decreased by 54% over the past six years. The home nutrition support service in the HMO setting has been cost effective and provides a unique setting for comprehensive patient care.

Recent developments in home total parenteral nutrition.

Home parenteral nutrition (HPN) support has been an advancing therapy in the past 30 years. Patients who previously had no options to sustain their lives are now able to live at home, maintain employment, and continue with most daily activities. Although this therapy has been innovative and successful, it requires great financial and professional resources. The expense of HPN makes most patients dependent on third-party payment, and the complications can result in frequent hospitalizations and may be life-threatening. For these reasons, extensive training of the patient and caregivers is necessary. Thorough and time-consuming monitoring by a multidisciplinary team of professionals is also essential. Home care and supply companies offer services that make the process of home TPN easier for the patient and the healthcare team. Advances in the area of home nutrition support are expected to continue as the demand for this therapy rises.

The Role of Advanced Practice Skills for Nutrition Support Dietitians in Home Care

Home care encompasses services such as the provision of supplies and durable medical equipment to the provision of high tech home infusion therapy (home chemotherapy and home nutrition support). The nutrition support dietitian (NS-RD) experienced in working with the hospital nutrition support team can be a valuable asset to the home infusion provider. We collated information from a large home infusion therapy provider (90 branches across the US) to provide insight into the qualifications, roles and responsibilities, and impact of the NS-RD in the provision of home nutrition support. More than half of the NS-RDs are certified nutrition support dietitians and all had been in practice greater than 2 years. The NS-RDs qualifications indicate that advanced practice skills are essential to performing the clinical management required for home nutrition support patients. The responsibilities of the NS-RD identified which would be considered advanced practice skills were: clinical management of home parenteral nutrition patients, participation on the home nutrition support team, and home visits to patients providing nutrition focused physical ^assessment. Other identified roles of the NS-RD were support and assistance to the reimbursement staff, sales support for joint sales calls, development of continuing education presentations for patients and customers, and community involvement in both professional and patient oriented activities. This information has assisted us in recognizing the need for the advanced level skills of a NS-RD in managing home nutrition support patients. By better identifying the contributions of the NS-RD, the clinical and sales staff to better utilize the NS-RD. Finally, this has demonstrated to senior management the valuable role the dietitian plays in the overall success of the business - by facilitating improved clinical outcomes with cost effective high quality care. Advanced level skills make the NS-RD a valuable asset to the home nutrition support provider and patient.

Are Home Nutrition Support Patient Outcomes Defined by the Practice Settings of the Prescribing Physicians?

This study was done to determine if the practice settings of home parenteral nutrition (HPN) prescribing physicians (MDs) effected patient outcomes. Practice settings were defined as either university/teaching hospitals (Gp 1) or private physician practices (Gp 2). Data was derived from a single home care provider and stratified as adult or pediatric (<16 years old). HPN patient outcomes studied were: length of therapy (LOT), rate of catheter related infections(CRI) per 1000 catheter days, and re-hospitalizations (within 30 days of HPN initiation). Pediatric data: Gp 1 top 3 diagnoses were malabsorption, BMT, and nutritional deficiency and for Gp 2 were malabsorption, nutritional deficiency and BMT. Of the 492 pediatric patients (50% male, age 6.4 ± 4.8 years {mean ± SD}), the LOT for Gp 1 was 110 ± 117 days compared to 117 ± 128 days for Gp 2. Gp 1 experienced a CRI of 1.9% (0.712/1000 catheter days) while Gp 2 experienced a 0.58% rate (0.025/1000 catheter days). The rate of rehospitalization was 38.1% for Gp 1 and 29.1% for Gp 2. Adult data: The top 3 diagnoses for the Gp 1 patients were malabsorption, BMT and Crohn's and in Gp 2 were malabsorption, nutritional deficiency and Crohn's. Of the 3056 adult patients (40% male, age 51 ± 17 years) the LOT for Gp 1 patients was 111 ± 123 days compared to Gp 2 of 91 ± 108 days. Rehospitalizations occurred in 23.5% of the Gp 1 patients and 20.2% of the Gp 2 patients. Gp 1 CRI rate was 0.9% (0.737/1000 catheter days) and for Gp 2 patients was 1.1% (0.846/1000 catheter days). These data indicate that patient outcomes are different. University/teaching hospital MDs may be caring for more complex patients than private practice MDs. In the future more home nutrition support patients will be followed by MDs not affiliated with university or teaching hospitals. To attain positive patient outcomes, the home infusion agency should use a team approach including a nutrition support dietitian to assist in the management of complex HPN patients.

Standards for Home Nutrition Support

Nutrition in Clinical PracticeVolume 14, Issue 3 p. 151-162 Article Standards for Home Nutrition Support A.S.P.E.N. Board of Directors, A.S.P.E.N. Board of DirectorsSearch for more papers by this author A.S.P.E.N. Board of Directors, A.S.P.E.N. Board of DirectorsSearch for more papers by this author First published: 01 June 1999 https://doi.org/10.1177/088453369901400318Citations: 17AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume14, Issue3June 1999Pages 151-162 RelatedInformation

Clinical Management of the Adult Home Nutrition Support Patient

Nutrition Support Consultant features issues pertinent to the clinical aspects of pharmacy nutritional support practice. The column is edited by Roland N. Dickerson, PharmD, BCNSP, CNS, FACN, Associate Professor of Clinical Pharmacy, University of Tennessee, Memphis.

Cost and outcome analysis of home parenteral and enteral nutrition.

Previous estimates of the cost of home parenteral and enteral nutrition (HPEN) have excluded hospitalization costs or were conducted abroad and have limited applicability in the United States. Few studies have used validated measures to determine the effect of home nutrition support on quality of life. A cost and clinical outcome analysis was performed by retrospective review of charts of patients receiving HPEN from 1991 to 1996. Questionnaires to determine the influence of therapy on lifestyle (n = 41) and a general health status questionnaire, the short form 36-item survey (n = 39), were mailed to patients. The annual cost per patient for parenteral solutions was $55,193 +/- 30,596 (mean +/- SD) based on Medicare charges and for enteral tube feedings was $9605 +/- 9327. The annual cost of hospitalization ranged from zero to $140,220 in the parenteral nutrition group and from zero to $39,204 in the enteral nutrition group. The annual number of hospitalizations per patient for patients receiving parenteral nutrition ranged from 0.52 to 1.10, compared with 0 to 0.50 in the enteral nutrition population. The health status of HPEN patients was significantly lower (p < .05) in five of the eight short-form 36 health domains compared with the general population. The areas of lifestyle most frequently affected were travel, sleep, exercise and leisure. The majority of the cost of therapy was associated with the direct provision of nutrition, although in some patients the hospitalization expenditure exceeded this cost. Home nutrition support had a significant negative impact on a patient's quality of life and lifestyle.

Clinical Pathways in Home Nutrition Support

In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home.

Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States

Background & Aims: Home nutrition support, especially when delivered parenterally, is very costly. The aim of this study is to examine current usage of home parenteral and enteral nutrition (HPEN) in the United States and the quality of therapy outcome. Methods: Medicare HPEN use from 1989 to 1992 was analyzed to assess use, growth, and costs. National Registry information collected on 9288 patients treated with HPEN from 1985 to 1992 was used to assess disease distribution and therapy outcome. Results: In the United States, there were approximately 40,000 parenteral and 152,000 enteral home patients in 1992. The usage of HPEN doubled between 1989 and 1992, and a large proportion was in patients with short survival. The prevalence of HPEN in the United States was 4–10 times higher than in other Western countries. Outcome data showed both therapies were relatively safe. The primary disease strongly influenced survival and rehabilitation, and age, per se, was not a reason to deny HPEN. Conclusions: Predicted quality survival at home for several months, rather than a specific diagnosis, seems to be the soundest justification for HPEN. Its role in terminal conditions and patients without primary gastrointestinal diseases needs further evaluation.

Home nutrition support materials.

The provision of enteral and parenteral nutrition to patients in the home setting continues to be an expanding area of practice throughout the US and Canada. The need for specialized training of patients and family members to safely administer these nutrition therapies at home following hospital discharge also continues to grow. In 1993, written materials designed for this purpose were gathered from institutions throughout the US and listed in a directory of Home Nutrition Support Patient Education Materials. Many nutrition support teams and health care organizations have been undergoing reorganization and streamlining during the past several years. As a result, resources for the creation and distribution of home nutrition support (HNS) education materials are diminished in many areas. An updated version of this directory has therefore been compiled to facilitate the exchange of these training items between institutions and teams across the country.

The use of indirect calorimetry in the assessment of energy expenditures in patients receiving home nutrition support

The use of indirect calorimetry in the assessment of energy expenditures in patients receiving home nutrition support

Position of the American Dietetic Association: Nutrition monitoring of the home parenteral and enteral patient

Home parenteral and enteral nutrition support has enabled more patients to be discharged from hospitals who would otherwise have endured longer inpatient stays and increased health care costs ( 1. Compher CW Colaizzo TM Rieke S Changes in nutrition support services between 1984 and 1986. J Am Diet Assoc. 1989; 89: 1452-1457 Google Scholar , 2. 10th ed. OASIS Annual Report: 1988 Data. Home Nutrition Support Patient Registry. The Oley Foundation, and Silver Spring, Md: American Society for Parenteral and Enteral Nutrition, Albany, NY1990 Google Scholar , 3. Howard L Heaphey LL Fleming CR Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. JPEN. 1991; 15: 384-393 Google Scholar , 4. J Am Diet Assoc. 1985; 85: 981-982 Google Scholar , 5. Smith AE Smith PE Reimbursement for clinical nutrition services: a 10-year experience. J Am Diet Assoc. 1992; 92: 1385-1388 Google Scholar , 6. Raymond JL State and Federal reimbursement for home nutrition support. Caring. 1990; (Oct): 16-18 Google Scholar ). Home parenteral and enteral medical nutrition therapies require coordination and management by the family or caregiver and by the health care team. A registered dietitian with expertise in nutrition support is qualified and trained to assess the nutritional status and monitor the nutrition regimen of these patients. The need for comprehensive nutrition monitoring by a team of qualified nutrition professionals is imperative.

Home parenteral and enteral nutrition in cancer patients.

The clinical outcomes of 2968 patients with active cancer receiving home nutrition support are described. Of these patients 1672 were receiving home parenteral nutrition and 1296 were receiving home enteral nutrition. The outcomes of these active cancer patients are compared to those of 123 radiation enteritis ("cured" cancer) and 480 Crohn's disease patients receiving home parenteral nutrition and 918 noncancer dysphagic patients receiving home enteral nutrition. This longitudinal clinical information was reported to the North American Home Parenteral and Enteral Nutrition Patient Registry between 1985 and 1990. Evidence indicates that the number of home parenteral and enteral nutrition patients has increased nationally by about 25% each year between 1989 and 1990. In a subsample of 37 home nutrition support programs that have consistently reported their data to the registry since 1985, more than 90% of their program growth was accounted for by new patients with active cancer. This is now the largest single diagnosis of patients starting home parenteral and enteral nutrition. The mean survival time of cancer patients is 6 months after starting home parenteral and enteral nutrition, but 25% live beyond a year and 20% resume full oral nutrition. Although most active cancer patients experience only partial rehabilitation, for those patients with longer survival, rehabilitation is more complete. The outcome is relatively better for children and for patients whose neoplasm is leukemia, lymphoma, small bowel, or liver. In comparison, 96% of home parenteral nutrition Crohn's patients, 80% of home parenteral nutrition radiation enteritis patients, and 60% of home enteral nutrition noncancer dysphagic patients survive at least 1 year. Adult active cancer home parenteral and enteral nutrition patients do not have a greater incidence of therapy-related readmissions than other patient groups, however, their overall rehospitalization rate is much more frequent. This article discusses factors that may have contributed to this growth in home nutrition support in active cancer patients. It attempts to clarify where this therapy is clearly justified and where more information is needed. It emphasizes some of the special issues that need to be addressed in treating these vulnerable patients.

Home health care: A new worksite for dietitians monitoring nutrition support

Dietitians have been practicing in the home setting for many years. However, monitoring patients receiving home parenteral and enteral nutrition has been performed primarily on an outpatient basis by dietitians affiliated with hospital-based nutrition support teams. Changes in physician familiarity with these specialized therapies and expansion of the home infusion therapy industry have resulted in oppurtunities for dietitians to monitor nutrition support in a patient's home. This article describes the role of the home nutrition support dietitian, the work environment, and the training needed to prepare the practitioner for effective work in this field. Practical concerns of interest to the dietitian monitoring home nutrition support include equipment, resources, and communication tools. Home visits impart several benefits to dietetics practice by enriching the contact between patient and dietitian. A case study describes a dietitian's involvement in and potential cost-effectiveness of treatment of a patient whose parenteral nutrition therapy was initiated and completed without hospitalization. The home is emerging as a worksite for dietitians who monitor nutrition support. As providers of home infusion therapy continue to expand, widespread availability of dietitians' services for patients receiving parenteral and enteral support at home must be ensured.

Home nutrition survey in the UK: The patient's perspective

A detailed survey questionnaire compiled by the executive committee of Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT) was circulated in November 1991 to the postal addresses of all full (patient) members of PINNT in the UK. The objective of the survey was to identify current practices and problems of home nutrition support as seen from the patients perspective. 128 questionnaires were distributed. 87 (68%) analysable questionnaires were completed and returned. 77 were for parenteral nutrition (HPN) patients and 10 for patients on enteral nutrition (HEN). Areas of concern for patients include the practicalities of administration of lipid and additives, and problems associated with the appearance of air in infusion bags. Although most patients appeared happy with the home nutrition support services 18% commented on particular negative aspects. This survey highlights such areas which may not be identified during routine patient/clinician contact.

Home nutrition support patient education materials.

The practice of providing specialized enteral and parenteral nutrition to patients in the home setting has expanded nationwide during the past decade. Accompanying this growth has been an increased need for education of patients, families, and care providers in techniques of administering intravenous and tube feedings safely after discharge from the hospital. To meet this demand for information, written home nutrition support (HNS) education materials have been developed by hospital nutrition support teams, patient education specialists, home care providers, and formula manufacturers. The time and financial costs of developing these materials may be prohibitive in certain institutions that need HNS education resources. A directory of the printed materials available has been compiled to facilitate communication and exchange of HNS education information among institutions. The directory is presented with this article, with important characteristics to consider in the development of HNS education materials.

Home nutrition support in HIV disease

There exists a strong interrelationship between the nutritional status of PWAs and the effectiveness of the immune system. Nutritional deficiency or a malnutritioned state often accompanies AIDS, thus further compromising the function of the patient's immune system. Nutritional intervention is essential at all levels of the HIV/AIDS disease process, from the asymptomatic phase to the terminal. Each phase is compli cated by the involvement of various organ systems in the disease process. The authors offer information on additional variables to investigate during the nutritional assessment and on the importance of inclusion of the patient in the team planning process. The major roles of oral, enteral, and parenteral nutritional support are addressed, with a focus on the last two. The complexities of the ethics of the continuation/termination dilemma are concretely addressed. This article supports the vital role of the nutritionist in the home health care team.

Changes in billing for nutrition support services and dietetics staff resources between 1984 and 1986

Changes in hospital funding resulting from the Prospective Payment System have been recognized as a major force in hospitals in the 1980s. The Dietitians in Nutrition Support (DNS) Practice Group examined these changes using a survey sent to 1,000 clinical nutrition managers at American Hospital Association (AHA) hospitals. The goals of the survey were (a) to evaluate changes in billing for nutrition services and (b) to evaluate changes in resources available to dietetics staff members. Although income from nutrition services to inpatients had increased only 18% since 1984, 45% of respondents reported an increase in payment for outpatient services. Prior to 1984, larger hospitals reported screening for malnutrition more often than smaller hospitals, and the responsibility for screening was handled more often by dietetic technicians than by RDs. Larger hospitals also reported establishment of a home nutrition support company more often than smaller hospitals. Computer and academic course costs were paid more frequently by nonprofit and tertiary hospitals. Although the number of hospitals billing for nutrition services to patients was small, most reported receiving payment. We conclude that charges for nutrition services by dietitians to outpatients have increased, and that most dietitians who bill for services receive payment. Academic and technological resources for RDs have increased in general, though smaller primary-care and for-profit hospitals report such supports less consistently than larger, tertiary-care, and not-for-profit hospitals.

Five Years of Experience in Patients Receiving Home Nutrition Support with the Implanted Reservoir: A Comparison with the External Catheter

This study examines 5 years (1983-1988) of home parenteral nutrition (HPN) experience in 27 patients using the implanted reservoir for venous access. Their catheter-related complications are compared to two control populations using the external catheter. Group I compares the 46 patients who all started HPN in the same 5-year period, group II compares 17 patients with experience of both types of venous access. For the entire 58 patients the average infusion time was 22 months (1 month-8.2 yr) and the average complication rate was about one complication every 2 years. Analyzing the separate groups however, group I implanted reservoir patients did better than those with the external catheter (p less than 0.05) and group II external catheter patients did better than those with the implanted reservoir (p less than 0.05). A possible explanation for this discrepancy is the greater medical competence of group I patients selecting the reservoir. The data show a clear separation of patients into those who have minimal complications with either device and others who have several complications with both. Two-thirds of the complications were infectious, one third mechanical. The infectious complications were similar with both catheters; clotting was more common with the external catheter and skin erosion was seen only with the reservoir. Eighty % of patients with experience with both type of venous access preferred the implanted reservoir.