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• W2087538211 abstract "This article summarizes what is known about which factors influence survival of patients on home parenteral nutrition, the costs related to this therapy, and the quality of life for patients living on home parenteral nutrition. The article refers to both North American and European experiences with this complex therapy. This article summarizes what is known about which factors influence survival of patients on home parenteral nutrition, the costs related to this therapy, and the quality of life for patients living on home parenteral nutrition. The article refers to both North American and European experiences with this complex therapy. Home parenteral nutrition (HPN) has been an available therapy for patients with intestinal failure for about 30 years. More recently, small-bowel transplantation has become a second treatment option, affording reasonable survival. There now are sufficient outcome data from both of these therapies that survival, cost, and quality of life can be compared.This article describes outcome in patients on HPN managed in North America and Europe. Later articles in this issue describe outcomes after intestinal transplantation.Survival on HPNA number of factors have been shown to effect survival of patients on HPN.Influence of the Primary DiagnosisHPN is not so much a disease treatment as a treatment of a disease complication, notably intestinal failure. This complication occurs in a wide spectrum of gastrointestinal diseases. The disease itself may stabilize as in most individuals with short-bowel syndrome (<150 cm of small intestine; normal small bowel, 600 cm) due to result of resection for Crohn’s disease, mesenteric ischemia, or a congenital disorder. Conversely, the disease may progress, as in bowel obstruction, from an unresectable cancer. Table 1 lists the primary diagnoses from 2 large multicenter HPN sources in the United States and Europe.1North American Home Parenteral and Enteral Nutrition RegistryAnnual reports 1992. Oley Foundation, Albany, NY1994Google Scholar, 2Van Gossum A. Bakker H. Bozzetti F. Staun M. Leon-Sanz M. Hebuterine X. Pertikiewicz M. Shaffer J. Thul P. Home parenteral nutrition in adults a European multicenter survey in 1997.Clin Nutr. 1999; 18: 135-140Abstract Full Text PDF PubMed Scopus (236) Google Scholar Table 2 shows percent survival at 1, 3, and 5 years for persons who stay on parenteral therapy.3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholar, 4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar, 5Scolapio J.S. Fleming C.R. Kelly D.G. Wick D.M. Zinsmeister A.R. Survival of home parenteral nutrition–treated patients 20 years of experience at the Mayo Clinic.Mayo Clin Proc. 1999; 74: 217-222Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar As shown in Table 3, a large percentage of patients who require HPN improve over time and are able to resume full oral nutrition.3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholar This is true for 75% of short-bowel patients with a nonmalignant underlying diagnosis.6Carbonnel R. Cosnes J. Chevret S. Beaugerie L. Ngo Y. Malafosse M. Parc R. Le Quintrec Y. Gendre J.P. The role of anatomic factors in nutritional autonomy after extensive small bowel resection.JPEN J Parenter Enteral Nutr. 1996; 20: 275-280Crossref PubMed Scopus (204) Google Scholar The recovery of enteral autonomy, if it occurs, almost always is in the first 2 years of HPN therapy in adults, but in children recovery can take much longer. This may in part reflect the higher nutritional demands per kg of body weight of a growing child, hence nutritional autonomy is delayed until these growth demands subside. Because the survival data in Table 2 largely describe adults, permission was obtained (V. Colomb, Necker-Enfants Malades Hospital, Paris, France) to present unpublished overall survival rates in a large pediatric cohort of 302 children managed by an HPN specialist center. More than 95% of children with inflammatory bowel disease, 85% with short-bowel syndrome, and 80% with pseudo-obstruction survived 15 years. (Note that the overall survival rate is different from the survival rate on HPN shown in Table 2 because the overall survival rate includes children who came off HPN.) The mean duration on HPN for the French children was 2.6 years; ultimately, 22% required indefinite HPN therapy.Table 1The Primary Diagnoses in which HPN Is UsedUnited States (85–92), %Europe (97), %Cancer4239Crohn’s disease1119Ischemic bowel615Motility disorder6NDAcquired immune deficiency syndrome52Congenital bowel4NDRadiation enteritis37Other2318NOTE. European data refer to adults only.2Van Gossum A. Bakker H. Bozzetti F. Staun M. Leon-Sanz M. Hebuterine X. Pertikiewicz M. Shaffer J. Thul P. Home parenteral nutrition in adults a European multicenter survey in 1997.Clin Nutr. 1999; 18: 135-140Abstract Full Text PDF PubMed Scopus (236) Google Scholar US data refer to all age groups.1North American Home Parenteral and Enteral Nutrition RegistryAnnual reports 1992. Oley Foundation, Albany, NY1994Google Scholar US data collected annually over 8 years (1985–1992). This is the distribution (%) diagnosis of 5481 HPN patients entered in the registry during their first year of therapy. European data collected in 1997 on 494 HPN patients.ND, no data. Open table in a new tab Table 2Survival on HPN TherapyDiagnosis% Survival1 yaNorth American Home Parenteral and Enteral Nutrition Registry, n = 4350.33 yaNorth American Home Parenteral and Enteral Nutrition Registry, n = 4350.35 ybFrance/Belgium, n = 217.45 ycMayo, n = 225.5Crohn’s96878292Ischemia87845660Congenital9480——Motility8762—48Radiation87585254Chronic obstruction8340——Cancer20———a North American Home Parenteral and Enteral Nutrition Registry, n = 4350.3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholarb France/Belgium, n = 217.4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholarc Mayo, n = 225.5Scolapio J.S. Fleming C.R. Kelly D.G. Wick D.M. Zinsmeister A.R. Survival of home parenteral nutrition–treated patients 20 years of experience at the Mayo Clinic.Mayo Clin Proc. 1999; 74: 217-222Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar Open table in a new tab Table 3Summary of Outcome on HPNDiagnosis/therapyNo. of patientsAge, y (SD)Survival on therapy (% observed deaths/expected deaths)aSurvival rates on therapy are values at 1 year calculated by the life-table method. This will differ from the percentage listed as died under therapy status because all patients with known end points are considered in this latter measure. The ratio of observed vs expected deaths is equivalent to a standard mortality ratio.Therapy status at 1 year, % (SEM)bNot shown are those patients who were readmitted to the hospital or who had changed the type of therapy by 12 months.Rehabilitation status in first year, % (SEM)cRehabilitation is designated complete, partial, or minimal relative to the patient’s ability to sustain normal age-related activity.ComplicationsdComplications refer only to those complications that resulted in rehospitalization. (per patient y)Full oral nutritionContinued on HPN therapyDiedCompletePartialMinimalHPNNon-HPNCrohn’s disease56236 (17)96 (31/2.9)70 (2)25 (1)2 (1)60 (5)38 (5)2 (NA).91.1Ischemic bowel disease33149 (24)87 (81/7.5)27 (3)48 (4)19 (3)53 (4)41 (4)6 (2)1.41.1Motility disorder29945 (22)87 (81/3.1)31 (3)44 (4)21 (3)49 (4)39 (4)12 (3)1.31.1Congenital bowel defect1725 (14)94 (20/1.6)42 (6)47 (6)9 (3)63 (6)27 (5)11 (4)2.11.0Hyperemesis gravidarum11228 (5)100 (0/.1)100 (NA)0 (NA)0 (NA)83 (4)16 (4)1 (NA)1.53.5Chronic pancreatitis15642 (17)90 (9/.6)82 (3)10 (3)5 (2)60 (5)38 (5)2 (NA)1.22.5Radiation enteritis14558 (15)87 (47/3.2)28 (5)49 (5)22 (4)42 (6)49 (6)9 (3).81.1Chronic adhesive obstructions12053 (17)83 (30/1.1)47 (6)34 (5)13 (4)23 (7)68 (7)10 (NA)1.71.4Cystic fibrosis5117 (10)50 (254/.05)38 (7)13 (5)36 (7)24 (6)66 (7)16 (5).83.7Cancer212244 (24)20 (1336/8.7)26 (1)8 (1)63 (1)29 (3)57 (3)14 (2)1.13.3Acquired immune deficiency syndrome28033 (12)10 (182/.8)13 (3)6 (2)73 (4)8 (NA)63 (7)29 (6)1.63.3Data from the North American Home Parenteral and Enteral Nutrition Patient Registry.1North American Home Parenteral and Enteral Nutrition RegistryAnnual reports 1992. Oley Foundation, Albany, NY1994Google Scholara Survival rates on therapy are values at 1 year calculated by the life-table method. This will differ from the percentage listed as died under therapy status because all patients with known end points are considered in this latter measure. The ratio of observed vs expected deaths is equivalent to a standard mortality ratio.b Not shown are those patients who were readmitted to the hospital or who had changed the type of therapy by 12 months.c Rehabilitation is designated complete, partial, or minimal relative to the patient’s ability to sustain normal age-related activity.d Complications refer only to those complications that resulted in rehospitalization. Open table in a new tab The influence of the underlying disease on survival is sufficiently strong that broad international agreement has been reached to describe HPN outcome in terms of a specific primary disease, for example, Crohn’s disease, ischemic bowel, radiation enteritis, and so forth.2Van Gossum A. Bakker H. Bozzetti F. Staun M. Leon-Sanz M. Hebuterine X. Pertikiewicz M. Shaffer J. Thul P. Home parenteral nutrition in adults a European multicenter survey in 1997.Clin Nutr. 1999; 18: 135-140Abstract Full Text PDF PubMed Scopus (236) Google Scholar, 3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholar, 4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar, 7Howard L. Home parenteral nutrition a transatlantic view.Clin Nutr. 1999; 18 (Editorial): 131-133Abstract Full Text PDF PubMed Scopus (22) Google ScholarHPN has been proven to be a fairly safe therapy and if death occurs it usually is not because of an HPN complication. This is especially true for short-term users (<1 y). For example, cancer patients by and large have a short prognosis of 2–6 months8Howard L. Home parenteral and enteral nutrition in cancer patients.Cancer. 1993; 72: 3531-3541Crossref PubMed Scopus (65) Google Scholar (the prognosis may be 2–3 years in women with metastatic ovarian cancer). Most deaths (99%) are caused by progression of the primary disease or another medical condition; only 1% of deaths are caused by an HPN complication. In long-term HPN users, such as those with short bowel as a result of Crohn’s or mesenteric ischemia, survival on HPN is measured in decades. Death, if it occurs (20%–25% of those starting HPN), happens after many years, and again the primary diagnosis or another medical illness accounts for the majority of these deaths (80%–85%). However, long-term patients may die from an HPN complication (sepsis, liver failure, thrombosis, and so forth). These therapy complications eventually account for 15%–20% of all deaths.9Richards D.M. Carlson G.L. Nightingale J.M.D. Quality of life assessment and cost effectiveness, Intestinal Failure. Greenwich Medical Media Limited, London2001: 447-457Google Scholar, 10Messing B. Crenn P. Beau P. et al.Long term survival and parenteral nutrition dependence in adult patients with short bowel syndrome.Gastroenterology. 1999; 117: 1043-1050Abstract Full Text Full Text PDF PubMed Scopus (482) Google Scholar, 11Howard L. Michalek A.V. Home parenteral nutrition.Ann Rev Nutr. 1984; 4: 69-99Crossref PubMed Scopus (20) Google ScholarInfluence of AgeIn both European4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar and North American outcome data3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholar younger patients on HPN have better survival than older patients. Figure 1 shows the influence of age on survival of long-term French HPN patients and Figure 2 shows the influence of age on US HPN patients. In the US study, an attempt was made to compare patients with similar diagnoses because the primary diagnosis independently influences survival. The 3 diagnoses chosen were Crohn’s disease, ischemic bowel disorders, and a motility disturbance. These diagnoses occur in all 3 age groups, pediatric, middle-aged, and geriatric, and generally are associated with a good outcome. Figure 2 confirms better survival rates in younger patients. An arrow indicates the expected mortality rate for each age group in the general population. Clearly, the higher mortality in the geriatric patients is not explained by an expected higher mortality in this age group. This suggests older patients have greater accumulated medical fragility and have less ability to withstand intestinal failure. Despite this, the geriatric patients did not have more therapy complications and most experienced good rehabilitation, therefore initiating HPN in this age group seems justified if the patient and family agree. This is an important issue because over the years there has been a widening of the age spectrum of patients who start HPN3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholar and both the young and old are significantly dependent on family and professional support. It should be noted that there are few nonacute institutional settings capable of long-term parenteral nutrition, a factor that needs to be broached with all families taking responsibility for an older HPN relative.Figure 2Survival according to age at start of HPN. Patients studied had Crohn’s disease, ischemic bowel, or a motility disorder. The arrows indicate the expected mortality rate in the general population. Reprinted with permission from Howard et al.3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google ScholarView Large Image Figure ViewerDownload (PPT)Influence of Length and Type of Remaining BowelCarbonnel et al6Carbonnel R. Cosnes J. Chevret S. Beaugerie L. Ngo Y. Malafosse M. Parc R. Le Quintrec Y. Gendre J.P. The role of anatomic factors in nutritional autonomy after extensive small bowel resection.JPEN J Parenter Enteral Nutr. 1996; 20: 275-280Crossref PubMed Scopus (204) Google Scholar studied 103 short-bowel patients (small bowel, <150 cm) and found 25% required indefinite HPN. That was true for end jejunostomy patients with less than 115 cm of small bowel, for those with a jejunocolic anastomosis with less than 60 cm of small bowel, and for those with a jejunoileal anastomosis with less than 35 cm of small bowel. These data underline the important contribution that the colon and terminal ileum make to achieving short-bowel adaptation and autonomy. In a similar vein, Messing et al4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar have shown that patients with an end jejunostomy have a higher HPN mortality rate than those with an in-continuity colon as shown in Figure 3. Messing et al4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar also showed how chronic bowel obstruction adversely effects survival, increasing the risk for death 2.6-fold (Figure 4). This may be due to a greater likelihood of sepsis in bowel-obstructed patients. In the North American Home Parenteral and Enteral Nutrition Registry,1North American Home Parenteral and Enteral Nutrition RegistryAnnual reports 1992. Oley Foundation, Albany, NY1994Google Scholar patients with chronic adhesive bowel obstruction were hospitalized for sepsis .87 times per year, compared with Crohn’s patients who were hospitalized for sepsis only .46 times per year.Figure 3Survival rates of 124 adult bowel patients with nonmalignant short-bowel syndrome. In patients with colon in continuity the 5-year survival rate is 80%, in patients with an end-jejunostomy the 5-year survival rate is 44%. Reprinted with permission from Messing et al.10Messing B. Crenn P. Beau P. et al.Long term survival and parenteral nutrition dependence in adult patients with short bowel syndrome.Gastroenterology. 1999; 117: 1043-1050Abstract Full Text Full Text PDF PubMed Scopus (482) Google ScholarView Large Image Figure ViewerDownload (PPT)Figure 4Survival according to the presence of chronic intestinal obstruction in 217 patients on HPN. The risk for death was 2.6 times higher (95% CI 1.1, 5.8) in obstructed patients. Reprinted with permission from Messing et al.4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google ScholarView Large Image Figure ViewerDownload (PPT)Influence of Experience of the Supervising ClinicianEuropean data4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google Scholar show that survival improved as the experience of the supervising clinicians increased (Figure 5). In France’s designated HPN centers the professional turnover has been modest, hence the improved survival over a 20-year period may reflect a professional learning curve, emphasizing the importance of clinical supervision, at least for long-term patients, in expert centers. This lesson has great importance to the United States where any physician can initiate HPN and there is no central mechanism for tracking outcome. The North American Home Parenteral and Enteral Nutrition Registry compared the mortality rate in 407 HPN Crohn’s patients managed in either large teaching programs or smaller nonteaching programs (Table 4). The average mortality rate per year was significantly higher in the smaller programs. This again suggests the importance of clinical experience for optimal survival.Figure 5Survival according to the date of inclusion in an HPN program. Reprinted with permission from Messing et al.4Messing B. Lemann M. Landais P. Gouttebel M.C. Gerard-Boncompain M. Saudin F. Vangossum A. Beau P. Robert D. Matuchansky C. Leverve X. Lerebours E. Carpentier Y. Rambaud J.C. Prognosis of patients with nonmalignant chronic intestinal failure receiving long term parenteral nutrition.Gastroenterology. 1995; 108: 1005-1010Abstract Full Text PDF PubMed Scopus (209) Google ScholarView Large Image Figure ViewerDownload (PPT)Table 4Mortality Rate of Crohn’s Disease Patients in Teaching Programs Vs Nonteaching ProgramsTeaching programsNonteaching programsNumber of patients32879Average HPN duration, y1.8Deaths177Average mortality rate/yraP < .025.5.2%12.5%Data from the North American Home Parenteral and Enteral Nutrition Registry.1North American Home Parenteral and Enteral Nutrition RegistryAnnual reports 1992. Oley Foundation, Albany, NY1994Google Scholara P < .025. Open table in a new tab Influence of Narcotics and Social SupportThese 2 factors have been shown to effect the frequency of line sepsis and may as a consequence influence survival, although this has not yet been tested critically. Richards et al,12Richards D.M. Scott N.A. Shaffer J.L. et al.Opiate and sedative dependence predicts a poor outcome for patients receiving home parenteral nutrition.JPEN J Parenter Enteral Nutr. 1997; 21: 336-338Crossref PubMed Scopus (51) Google Scholar working in the United Kingdom, showed narcotic-dependent patients had significantly more septic events and required significantly more hospital care than patients not using narcotics.Smith et al,13Smith C.E. Curtas S. Werkonitch M. et al.Home parenteral nutrition does affiliation with a national support and education organization improve patient outcome?.JPEN J Parenter Enteral Nutr. 2002; 26: 159-163Crossref PubMed Scopus (75) Google Scholar working in the United States, found that affiliation with an HPN peer-support and education organization greatly reduced the incidence of sepsis (Table 5). This was a case-controlled study of patients matched for diagnosis, duration on HPN, sex, and age. The benefit of peer support and education was equally true for patients supervised in large or small programs. As Smith et al13Smith C.E. Curtas S. Werkonitch M. et al.Home parenteral nutrition does affiliation with a national support and education organization improve patient outcome?.JPEN J Parenter Enteral Nutr. 2002; 26: 159-163Crossref PubMed Scopus (75) Google Scholar pointed out, the benefits of peer support and education also have been shown in other chronic disorders.Table 5Affiliation With Peer Support Organization Improves Outcomes in HPN PatientsHPN PatientsCRBSI incidence over 18 moLarge program1 Affiliated (n = 24).10 ± .3aP = .01. Nonaffiliated (n = 28).60 ± .55aP = .01.Small programs2 Affiliated (n = 21).10 ± .3bP = .02. Nonaffiliated (n = 22).71 ± .64bP = .02.NOTE. Large programs had ≥25 HPN patients, small programs had <5 HPN patients.CRBSI, catheter-related bloodstream infections.Data from Smith et al.13Smith C.E. Curtas S. Werkonitch M. et al.Home parenteral nutrition does affiliation with a national support and education organization improve patient outcome?.JPEN J Parenter Enteral Nutr. 2002; 26: 159-163Crossref PubMed Scopus (75) Google Scholara P = .01.b P = .02. Open table in a new tab Cost of HPNAfter a number of academic centers reported good rehabilitation of chronic intestinal failure patients on HPN,14Shils M.E. Wright W.L. Turnbull A. et al.Long term parenteral nutrition through external arteriovenous shunt.N Engl J Med. 1970; 283: 341-344Crossref PubMed Scopus (96) Google Scholar, 15Shils ME. Home TPN registry annual reports. New York: New York Academy of Medicine, 1978–1983.Google Scholar, 16Jeejeebhoy K.N. Zohrab W.J. Langer B. et al.Total parenteral nutrition at home for 23 months, without complications and with good rehabilitation.Gastroenterology. 1973; 65: 811-820PubMed Google Scholar, 17Broviac J.N. Scribner B.H. Prolonged parenteral nutrition in the home.Surg Gynecol Obstet. 1974; 139: 24-28PubMed Google Scholar, 18Jeejeebhoy K.N. Langer B. Tsallas G. et al.Total parenteral nutrition at home studies in patients surviving 4 months to 5 years.Gastroenterology. 1976; 71: 943-953PubMed Scopus (166) Google Scholar, 19Fleming C.R. McGill D.B. Berkener S. Home parenteral nutrition as primary therapy in patients with extensive Crohn’s disease of the bowel and malnutrition.Gastroenterology. 1977; 73: 1077-1081PubMed Google Scholar, 20Heizer W.D. Orringer E.P. Parenteral nutrition at home for 5 years via arteriovenous fistulae.Gastroenterology. 1977; 72: 527-532PubMed Scopus (26) Google Scholar, 21Ladefoged K. Jarum S. Long term parenteral nutrition.BMJ. 1978; 2: 262-266Crossref PubMed Scopus (31) Google Scholar, 22Steiger E. Srp F. Morbidity and mortality related to home parenteral nutrition in patients with gut failure.Am J Surg. 1983; 145: 102-105Abstract Full Text PDF PubMed Scopus (54) Google Scholar Medicare devised a reimbursement mechanism under the Prosthetic Device Benefit23Viall C.D. Home parenteral nutrition finances.in: Rombeau J.L. Rolandelli R.H. Clinical nutrition parenteral nutrition. 3rd ed. Saunders, 2001: 512-528Google Scholar and Medicaid and private insurance companies followed suit. Although this was an expensive home technology, providing PN at home, rather than in the hospital, appeared to cut the total management cost by about half.Until the mid-1980s Medicare was paying for HPN through its many regional offices and the reimbursement amounts varied widely. To achieve better control of this uncommon but expensive therapy, HPN and enteral nutrition payments were centralized first under an East and West carrier, and subsequently under the 4 national sites administrating Medicare’s durable medical equipment.Direct Costs of HPNThe direct costs of HPN involve the nutrient solution, dressing kits, administration sets, and infusion pump. In 1992 the Medicare-allowable charge for HPN therapy ranged between 238 and 390 dollars per day, depending on the grams of amino acids and lipids prescribed (Table 6). This translated into 86 to 140 thousand dollars per annum. Medicare reimbursed 80% of this allowable charge and the remaining 20% was paid by secondary insurance or directly by the consumer. Few consumers could afford to pay the 20%. If they were willing to fill out a financial statement showing financial hardship, the 20% could be forgiven legally. Medicare is the primary payer for 25% of all new HPN patients and eventually covers the costs for more than 60% of all long-term survivors.Table 6Medicare-Allowable Charges for HPN Therapy in 1992ItemParenteral (per day)Nutrient solution Glucose$158–$298 Amino acids Lipids$30–$40 Additives$7Dressing kit$7Administration set$22Pump loan (15 mo only)$12MeanaThe mean daily Medicare-allowable change was calculated from actual Medicare reimbursement of 1000 days for Medicare patients receiving HPN. This mean daily reimbursement was increased from 80% to 100% to derive the mean daily Medicare allowable charge. (range)$280 ($238–$390)NOTE. Medicare paid 80% of the allowable charges.Data from Howard et al.3Howard L. Ament M. Fleming C.R. Shike M. Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States.Gastroenterology. 1995; 109: 355-365Abstract Full Text PDF PubMed Scopus (450) Google Scholara The mean daily Medicare-allowable change was calculated from actual Medicare reimbursement of 1000 days for Medicare patients receiving HPN. This mean daily reimbursement was increased from 80% to 100% to derive the mean daily Medicare allowable charge. Open table in a new tab Managed-care contracts slowly reduced HPN reimbursement to approximately 70% of the Medicare-allowable charge. Medicare, in turn, has followed this price-cutting trend and by 2002 the allowable charge ranged from 75 to 122 thousa" @default.
• W2087538211 created "2016-06-24" @default.
• W2087538211 creator A5029397447 @default.
• W2087538211 date "2006-02-01" @default.
• W2087538211 modified "2023-10-11" @default.
• W2087538211 title "Home Parenteral Nutrition: Survival, Cost, and Quality of Life" @default.
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