EAL

MNT: Cost Effectiveness, Cost-benefit, or Economic Savings of MNT (2009)

Citation:

Kennedy JF, Nightingale J. Cost savings of an adult hospital nutrition support team. Nutrition. 2005; 21: 1,127-1,133.

PubMed ID: 16308136

Study Design:

Retrospective Cohort Study

Class:

B - Click here for explanation of classification scheme.

Quality Rating:

POSITIVE: See Quality Criteria Checklist below.

Research Purpose:

Primary purpose was to determine whether tangible cost savings could be demonstrated in the first year after the formation of a hospital-based adult Nutrition Support Team (NST).

The secondary purpose was related to quality of care issues and included changes in the place where a parenteral nutrition (PN) catheter was inserted, catheter-related sepsis (CRS), duration of PN and mortality.

Inclusion Criteria:

Any patient receiving PN feeding in the hospital from Pre-NST year (September, 1998 to August, 1999) to NST Year (November, 1999 to October, 2000).

Exclusion Criteria:

Any patient not receiving PN feedings.

Description of Study Protocol:

Recruitment

Pre-NST Year: There was no formal process for selecting patients for PN. The medical or surgical team requested PN feeding for the patients and the dietitian and pharmacist chose the PN regimen.
NST Year: The hospital staff caring for the patient or the pharmacy department notified the NST of all patients for whom PN feeding was being considered.

Design

Retrospective and prospective cohort study. Comparative data about all patients given parenteral nutrition were collected for two consecutive years (a retrospective pre-Nutrition Support Team year and a prospective Nutrition Support Team year).

Intervention

Treatment by a NST for patients receiving PN feedings.

Statistical Analysis

Fisher exact test using two-sided P values. Statistical significance was accepted as P<0.05.

Data Collection Summary:

Timing of Measurements

Pre-NST Year: September, 1998 to August, 1999
NST Year: November, 1999 to October, 2000.

Dependent Variables

Number of patients receiving PN
PN catheter placement
Catheter-related sepsis rate
Duration of PN
Mortality
Tangible cost savings included equipment and medication costs but excluded nursing, medical and laboratory time and bed occupancy costs
Full cost savings (intangible cost savings plus tangible cost savings).

Independent Variables

PN feeding management by a Nutrition Support Team.

Description of Actual Data Sample:

Initial N

Pre-NST Year: 54 patients (41 males), with 82 PN episodes
NST Year: 75 patients (47 males), with 78 PN episodes.

Attrition (final N)

Same as initial N.

Age

Pre-NST Year: 61 years
NST Year: 58 years.

Location

United Kingdom, Leicester Royal Infirmary.

Summary of Results:

Variables	Pre-NST Year Measures and confidence intervals	NST Year Measures and confidence intervals	Statistical Significance of Group Difference
PN Episodes	82 episodes (1.54 episodes per patient)	78 episodes (1.04 episodes per patient)
PN Catheter Placement in Radiology	19 placed in radiology (28%)	8 placed in radiology (10%)	P<0.05
Number of Single Lumen Catheters Used	44 (67%)	63 (81%)	P<0.05
Number of Tunneled Catheters Used	19 (28%)	42 (54%)	P<0.05
Catheter-Related Sepsis	Mean 7.06 per 100 PN days (71%)	Mean 3.26 per 100 PN days (29%)	P<0.05
Duration of PN Feedings	Mean duration: 8 days	Mean duration: 10 days	P not significant

Other Findings

Tangible cost-savings for the NST year were derived from 55 avoided PN episodes (£42,741) and 35 avoided CRS episodes (£7,974)
Total tangible cost savings for decreased infection rate and avoided PN episodes:£50,715 (£318 per patient referred for PN)
Total cost savings (tangible plus intangible costs) = £301,052 (£2,264 per patient referred for PN)
39% of PN catheters were inserted by the NST with no insertion-related complications
Competency-based training of ward nursing staff decreased the CRS rate
In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P<0.05).

Author Conclusion:

Although the number of PN days increased with an NST, tangible cost savings were demonstrated within the Nutrition Support Team year by avoiding parenteral nutrition episodes and decreasing incidence of catheter-related sepsis. These savings can justify the salaries of a nutrition nurse specialist and a senior dietitian.

Funding Source:

University/Hospital:

Leicester Infirmary (UK)

Reviewer Comments:

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		Yes
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	Yes
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	No
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	Yes
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		Yes
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	Yes
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	Yes
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	N/A
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	N/A
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes