Early introduction of a semi-elemental formula may be cost saving compared to a polymeric formula among critically ill patients requiring enteral nutrition: a cohort cost–consequence model

Abstract

ObjectivesGastrointestinal (GI) intolerance is associated with adverse outcomes in critically ill patients receiving enteral nutrition (EN). The objective of this analysis is to quantify the cost of GI intolerance and the cost implications of starting with semi-elemental EN in intensive care units (ICUs).Study designA US-based cost–consequence model was developed to compare the costs for patients with and without GI intolerance and the costs with semi-elemental or standard EN while varying the proportion of GI intolerance cases avoided.Materials and methodsICU data on GI intolerance prevalence and outcomes in patients receiving EN were derived from an observational study. ICU stay costs were obtained from literature and the costs of EN from US customers’ price lists. The model was used to conduct a threshold analysis, which calculated the minimum number of cases of GI intolerance that would have to be avoided to make the initial use of semi-elemental formula cost saving for the cohort.ResultsOut of 100 patients receiving EN, 31 had GI intolerance requiring a median ICU stay of 14.4 days versus 11.3 days for each patient without GI intolerance. The model calculated that semi-elemental formula was cost saving versus standard formula when only three cases of GI intolerance were prevented per 100 patients (7% of GI intolerance cases avoided).ConclusionIn the US setting, the model predicts that initial use of semi-elemental instead of standard EN can result in cost savings through the reduction in length of ICU stay if >7% of GI intolerance cases are avoided.

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial

“…Semi-elemental formulae appear to have no beneficial impact on outcome including gastrointestinal tolerance when prescribed in unselected ICU patients, and were shown to require a decrease of at least 7% in the number of cases of gastrointestinal intolerance in order to be cost-effective in ICU patients [ 8 , 21 ]. Considering the lack of a clearly demonstrated clinical benefit, and the higher price compared to polymeric formula, the ESPEN guidelines recommend that semi-elemental formulae should not be prescribed as first-line EN solution in ICU patients, but deserve further investigation in patients at high risk of gastrointestinal dysfunction [ 18 ].…”

“…The prescription of a standard isotonic polymeric formula is recommended as the first-choice solution in unselected critically ill patients requiring EN, considering its cost-effectiveness compared to semi-elemental formula [ 5 , 8 ]. However, semi-elemental solutions containing small peptides and predominantly medium chain triglycerides (MCTs) might theoretically improve gastrointestinal tolerance [ 9 – 15 ].…”

Real‐World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide‐Based Diets in the United States

“…w-PB ETF formulas have previously been shown to be more effica- cious and better tolerated than whole-protein formulas in patients with acute and chronic medical conditions in both the acute and postacute care settings. [22][23][24][25][26]28,29 The data indicate that utilization of w-PB ETF leads to a statistically significant improvement in GI tolerance compared with standard ETF in clinical practice in patients in the postacute care setting. More than half of the adult patients in the study experienced no intolerance events after w-PB diets were used.…”

“…28 Across various diseases, formulas offer similar or improved tolerance, digestion, and nutrient assimilation compared with free amino acid-based or polymeric formulas. [22][23][24] PB ETF formulas have also been shown to be more efficacious and better tolerated by patients in the postacute setting compared with standard whole-protein formulas. 29 Despite the need for well-tolerated ETF formulas for use in the postacute setting, limited data are available in relation to the use of PB diets for HEN.…”

Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study

“…The causes of disease-related malnutrition are multifactorial [ 8 ] and can include severe maldigestion and malabsorption of nutrients (including protein and fat), reduced gut motility, inflammation of the gut that leads to poor appetite, metabolic stress with high nutrient needs and an inability to take or tolerate oral feeding or some enteral tube feeds [ 10 ]. Intolerance to enteral tube feeding with polymeric whole protein and long-chain triglyceride fat-containing feeds is common, occurring in approximately 27–60% [ 11 , 12 ] and 30–40% [although anecdotal] of patients in critical care and community settings, respectively. Intolerance issues are likely a consequence of impaired feed assimilation due to inflammation, insufficient secretion of pancreatic enzymes or bile and/or reduced surface area for nutrient absorption, and patients commonly present with nausea, diarrhoea and abdominal distension [ 13 ].…”