| Background & AimsThe patients at nutritional risk have a higher probability to benefit from nutritional support by the reports from ESPEN Experts Group in 2003 (Europe). But there is still a lack of data about the prevalence of nutritional risk and malnutrition from China and the prospective study to evaluate the association of nutritional risk, nutritional support and clinical outcomes in internal medicine patients. There are seldom reports about the cost-effectiveness of nutrition support from China up to now. However these studies had methodological flaws. In fact, the economical studies are still lack even from the worldwide. The present study aims to (1) investigate the prevalence of nutritional risk and malnutrition in internal medicine patients in Beijing and Baltimore, and (2) to examine the clinical outcomes of nutrition support in the gastroenterology patients at nutritional risk identified by NRS-2002 and to compare the "cost/effectiveness" of parenteral nutrition, enteral nutrition, parenteral combined enteral nutrition support with non-nutrition support.Methods(1)The descriptive study:A total of 1277 patients who were consecutively admitted to the gastroenterology unit, pulmonary medicine unit and neurology unit of Peking Union Medical College Hospital (PUMCH) and the internal medicine unit of Johns Hopkins Hospital (JHH) were enrolled in this prospective cohort study. Nutritional risk was determined by NRS-2002 on admission. The information with respect to nutritional support and complications during hospitalization was monitored and recorded. Estimate of association between nutritional risk, nutritional support and complications was carried out.(2)A prospective cohort study was designed. The patients who were consecutively admitted to the gastroenterology wards and with certain predetermined diagnoses were screened for nutritional risk. Those who were identified as at nutritional risk were the candidates of this study. The information with respect to nutrition support, complication occurrence and treatment, length of hospital stay was monitored and recorded of these patients in the whole course of hospitalization. The direct costs of nutrition support, the costs of diagnosing and treating complications were calculated in detail. The impact of nutrition support on the infectious complications was evaluated by multivariate statistical analysis. The "rate of infectious complication-free patients" was used as the index of effectiveness. The cost-effectiveness ratios of four different cohorts were calculated.Results(1) Descripitive research--the prevalence of nutritional risk and the clinical practice of nutritional support. 1277 patients were included The prevalence of nutritional risk in patients with digestive disease, respiratory disease and stoke was 49.24%,29.36% and 41.62% respectively. The prevalence of nutritional risk in internal medicine patients of Johns Hopkins Hospital was 55.47%. The patients with inflammatory bowel disease, pancreatic disease and gastrointestinal hemorrhage or obstruction had the highest prevalence of nutritional risk.45.99% of the digestive medicine patients,15.84% of the respiratory medicine patients,28.57% of the patients with stroke, and 36.62% of the internal medicine patients in Johns Hopkins Hospital who were at nutritional risk received nutritional support.15.57% of the digestive medicine patients who were not at nutritional risk were also applied nutritional support.(2) Cohort studyTotal 623 patients who were consistent with the four predetermined diagnoses groups were screened for nutritional risk by NRS-2002. Of these patients,289 (46.4%) who were identified as at nutritional risk were enrolled in this cohort study and were tracked in the course of hospitalization. Finally,275 cases were involved in the analysis.8 patients in the cohort with nutrition support encountered infectious complications while 31 patients in the patients without nutrition support had infectious complications. The patients with nutrition support had lower incidence of infectious complications than the patients without nutrition support (6.8% vs.19.6%, x2=9.0, P=0.003).The adjusted (by ANCOVA) costs of PN cohort, EN cohort, PN combined EN cohort and the cohort without nutrition support were USD 869,187,805,207 (CNY 5635,1212,5220 and 1339), and the rates of "infectious complication-free patients" were 92.3%,96.4%,91.9% and 80.4% respectively. Cost-effectiveness ratios adjusted by ANCOVA were USD 942,194,876, 257 (CNY 6105,1257,5680, and 1664) respectively. Enteral nutrition support had the lowest cost-effectiveness ratio in this study.Conclusion(1) A large number of internal medicine patients were at nutritional risk or malnourished. Only a proportion of them received nutritional support.(2) Nutritional support had a protective effect from infectious complication. Nutrition support for gastroenterology patients at nutritional risk improved clinical outcomes. Enteral nutrition was the most cost-effective way of nutrition support for the gastroenterology patients at nutritional risk in this cohort study. Further multi-center cohort studies will be needed. |
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