Patients often are at risk of being overfed or underfed when prescribed home nutrition doesn’t meet their needs, according to research presented recently at the American Society for Parenteral and Enteral Nutrition (ASPEN) Clinical Nutrition Week (CNW) conference.
Research presented by Option Care, a provider of home and alternate treatment site infusion services indicates that orders upon discharge from the hospital for home parenteral (intravenous) nutrition (HPN) did not meet the patients’ needs nearly one-quarter of the time. Nutrition needs were more likely to be met for home enteral (tube-fed) nutrition (HEN) patients, but even with those patients, 38% of orders did not meet hydration needs. The research involved an analysis of nutrition orders for 187 HPN patients and 349 HEN patients who were discharged from hospitals that did not have dedicated nutrition support teams to guide the order writing.
Registered dietitians from Option Care reviewed orders, performed nutritional assessments when the patients were discharged to home care, and made recommended changes to the nutrition order if warranted, based on the patient’s lab values, activity level, and overall medical condition, explains Noreen Luszcz, RD, MBA, CNSC, lead author of the study and nutrition program director for Option Care.
She notes that overfeeding can lead to metabolic problems and cause excess weight gain, as well as increasing costs by providing more nutrition than required. Underfed patients may not gain weight adequately or heal as quickly as they should.
For the 187 HPN patients, the researchers determined the original orders did not meet the patients’ needs 23% of the time on average. In particular, 22% did not meet fluid needs, 26% did not meet amino acid (protein) needs, 21% did not meet dextrose (carbohydrate) needs, 34% did not meet lipid (fat) needs, and 27% did not meet total caloric needs.
In addition, 13% were inappropriately prescribed HPN when they should have received nutrition via other, less costly routes such as HEN and/or oral intake. HPN should only be prescribed for patients whose gastrointestinal systems cannot adequately process nutrients, Luszcz explains. The top two prescribing physicians were internal medicine specialists (29%) and gastroenterologists (19%).
Regarding protein, patients were provided initial orders that would have led to overfeeding 48% of the time and underfeeding 52% of the time. In the remaining categories, patients were much more likely to be given initial orders that would have led to underfeeding. The researchers estimate the average amount of overprescribed protein would result in an extra $179,837 per patient who received HPN for 90 days, the average length of time on the therapy. They determined that correcting the protein prescription in 12% of HPN orders alone would result in $5.2 million in saved healthcare costs.
The researchers note that a variety of factors may lead to hospital discharge nutrition orders not meeting the patient’s needs. For starters, they often are prescribed by physicians who may lack specialized nutrition expertise and do not have a qualified nutrition support team — including a registered dietitian, nurse, and pharmacist — to guide them, the researchers say. Nutritional needs also change over time, and a patient with an acute injury might require more protein while healing, but less by the time the patient is discharged. They also note that there is a high level of scrutiny when qualifying a patient for home nutrition support, especially with Medicare, whereas hospitals are not under that same level of review.
