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Journal of Parenteral and Enteral Nutrition
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Presentations

Economic Study in Surgical Patients of a New Model of Nutrition Therapy Integrating Hospital and Home vs the Conventional Hospital Model

Yara Carnevalli Baxter, RD, PhD, Maria Carolina G. Dias, MS, RD, Janete Maculevicius, RD, Ivan Cecconello, MD, PhD, Bernard Cotteleng, PhD and Dan Linetzky Waitzberg, MD, PhD

From the Laboratório de Fisiologia e Distúrbios Esfincterianos, Departemento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Correspondence: Dan L. Waitzberg, GANEP, R. Maestro Cardim 1175, SP, CEP 01323.001, Brazil. Electronic mail may be sent to dan{at}ganep.com.br.

Background: Dehospitalization is a trend in the health sector justified by humanitarian and socials aspects for the patient and relatives. From the financing institutions' perspective, whether government or third party, the positive results arise from an optimization of hospital bed use and favorable cost-benefit ratio. The "integrated home-hospital" model was created with the purpose of optimization of resources without detriment to the patients' nutritional care. The objective of this study was an economic evaluation regarding nutrition therapy of the integrated hospital-home model in comparison with an exclusively hospital model. Methods: A retrospective controlled study, paired (age, sex, disease, and surgical procedure), was performed on 56 digestive surgery patients divided into 2 groups: study (SG; n = 30) and control (CG; n = 26). The data collected included total expenses with hospitalization, nutritional benefits, minimization cost analysis, cost-effectiveness ratio analysis, cost-benefit ratio analysis, hospital length of stay, and hospital-bed optimization. Results: The patients from the SG achieved the same nutritional benefits as those in the CG, but with expenses 3 times lower (median Brazil Reals (R)$3237.18 vs R$8647.93; p < .05). The new model resulted in economic benefit to the institution, as shown by the cost-effectiveness ratio, mainly resulting from the savings of the days of hospitalization avoided. The cost-benefit ratio showed an important savings per patient for the institution (US $3100). Conclusions: The home-hospital model also reduced length of hospital stay 2.7 times and optimized the hospital bed usage, as it promoted higher hospital-bed rotation (3 times greater).

In recent decades, new techniques and technologies have become available that offer considerable benefits for health programs. Paradoxically the resources available for their acquisition are progressively less. In the Brazilian public health sector, the financial resources, personnel, and material are severely limited or inadequately managed.1 The Brazilian public health sector, known as the Single Health System, depends on only 10% of the resources of a country such as Canada, a situation exacerbated by inefficient distribution mechanisms.2 Thus, the optimization of health care is imperative because the potential demand is endless, and the resources are generally limited.3,4

Applying economic principles to health policies does not necessarily mean spending less but that resources should be used as efficiently as possible.5 The application of health resources should represent benefits for patients or be accompanied by an important social objective.5 Therefore, it is part of the health professionals' task to seek optimal results from a strictly necessary investment, a favorable cost-benefit ratio, the greatest territorial coverage, improvement in the assistance rendered, and an appropriate quality-control program.3

The tendency in the health sector to increasingly treat patients out of the hospital environment has created the jargon dehospitalization. Technological progress has favored this new process through miniaturization of equipment, such as mechanical ventilators, infusion pumps, and dialysis machines, which have facilitated the placing of patients in the home environment.6 The development of less-invasive methods, exemplified by surgical interventions using laparoscopy, have also contributed to this scenario by offering benefits such as less discomfort and shorter hospital stay.7–10 Arguments valorizing social and humanitarian aspects for the patient and their family justify the practice of home care.11 From an economic perspective, it is justified by optimization of hospital bed usage, resources, and favorable cost-benefit ratio for the financing entities, whether these be public or private.12 This optimization of resources is manifested by a greater availability of beds and health workers. In purely monetary terms, this translates into greater profits for private institutions, whereas for beneficent or public institutions, the savings can be applied in implementing community programs, teaching, or research.12

Malnutrition significantly increases the risk of complications, duration of hospital stay, and incurs other expenses, thereby elevating further the cost of hospitalization.13 Funds reimbursed by the state, in these conditions, are insufficient to cover the additional expenses, leading to losses reflected in a lack of resources for health care.13–15

However, it is not always easy to demonstrate the impact of nutrition therapy (NT) on modifying the patient's clinical course. The base disease, associated diagnoses, extremes of age, and immunodepression are just some of the confounding factors that can impede a visualization of the effect of NT.16

The skepticism that involves the theme of NT expenses raises questions such as "Which is the best model of attendance?" and "What is the best way to maintain the patient under nutritional care, as an in-patient or an out-patient?" Clinical specialists have dedicated their efforts to answer these questions in various socioeconomic scenarios.17–19

One of the cost components of NT is the expense of applying this therapy to a hospitalized patient. Providing the same NT in the home environment reduces the cost by eliminating those expenses arising specifically from maintaining the patient in the hospital unit.20–23

The objective of the present research was to compare the new integrated hospital-home model with intrahospital NT for surgical patients with digestive diseases in terms of cost, cost-benefit, cost-effectiveness, and cost minimization. In addition, the occupancy rate of hospital beds and its optimization was also studied.


   MATERIALS AND METHODS
Top
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 
A retrospective, paired, and controlled study was performed on 56 patients receiving enteral or parenteral NT in the preoperative or in the pre- and postoperative state of surgical intervention of the digestive tract, attended by the Gastroenterology Department of the Central Institute of the Clinicas Hospital, University of São Paulo Medical School (ICHC-FMUSP), Departamento de Gastroenterologia do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. The characteristics of these patients are shown in Table I. The NT therapy followed 2 models of attendance: integrated hospital-home model (study group, SG; n = 30), and the conventional intrahospital model (control group, CG; n = 26). The integrated hospital-home model was instituted by the Domiciliary Enteral Support Program (PROSNED) of ICHC-FMUSP. The 2 models were analyzed and compared, with a focus on economic aspects and function of the nutritional benefits achieved by the patients of each group.


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  		Table I Comparison of study and control groups, according to age, height, normal weight, sex, disease and type of surgical procedure

 

The nutritional benefits were evaluated by anthropometric, dietary, and laboratory indicators. The economic study was carried out by calculating the unitary cost of the benefit, cost-effectiveness, cost-benefit, and optimization of hospital bed usage. NT received (planning of the study) by the patients is described in Figure 1.


Figure 1
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  		FIG. 1. Economic evaluation study design.

 

Inclusion and Exclusion Criteria
Patients met the following criteria were included: age ≥ 18 years;

indication for surgery of the upper digestive tract (principally those with esophageal disease);

presentation in the preoperative phase of oral caloric ingestion <60% of the estimated daily caloric requirement with at least moderate malnutrition (recent loss of 10% from normal weight) and indication for enteral or parenteral NT;24,25

institution of enteral and or parenteral NT in the pre- or postoperative stage;

hospitalization for surgical intervention; and

suitable pairing of the sample between cases and controls (as described below) in terms of age group, height, sex, and type of surgical procedure.

Exclusion criteria were the following:

having been submitted to an esophageal prosthesis;

failure to comply with at least 70% of the NT prescribed in the preoperative stage because of abandoning the treatment or death;

not hospitalized for surgical intervention;

presentation of chronic renal or hepatic disease; and

incomplete medical records, nurses' or physicians' notes were incomplete or did not coincide with those of the nutrition team.

The present study was approved by the Ethics Commission for Analysis or Research Projects of the Clinical Directorship, HC-FMUSP. The domiciliary and hospitalized patients were provided, at no charge, the appropriate quantity of the same type of industrialized, polymeric formula for enteral nutrition.

The data were collected from various sources: medical records, nutritional attendance form, Division of Medical Files and closed files, Departments of Human Resources, Finances, Superintendence, and Pharmacy Division for Esophageal Surgery. The data provided indicators for economic and nutritional benefits, as shown in Table II.


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  		Table II Data collected for determining indicators of study

 

Nutritional Therapy
Nutritional care and prescription. Both the SG and CG received the same nutritional care, including the phases of nutritional attendance, calculation of the diet, and method for establishing the diet therapy prescription. There were no significant differences regarding the type of evaluation and nutritional attendance between the 2 groups. The indication for enteral NT or enteral plus parenteral NT was determined by the multidisciplinary team of the Esophageal Surgery Service, according to clinical judgment and by well established and widely accepted criteria in daily clinical practice.

Complications in NT. Complications that occurred in the pre- or postoperative stage were registered in the NT. The method used to classify the complications of NT was the same as the classifications and definitions proposed by Cataldi-Belcher et al26 and Coppini and Waitzberg.27

Economic Study
To compare the economic scenario between the 2 attendance models, the following indicators were calculated: unitary cost of the benefit, cost reduction analysis, cost-effectiveness analysis (CEA), and cost-benefit analysis (CBA). The calculations necessary to obtain these economic indicators were in accordance with the recommendations of the specialized literature.8, 28–34

The present economic analysis was conducted from the perspective of the patient (nutritional benefits and length of hospitalization) and the institution (cost, optimization of hospital bed usage, and optimization of resources). Both conditions were studied through the analysis of unitary cost of benefit, cost reduction, and cost-effectiveness and cost-benefit ratios.

The cost of care was defined as the total cost of treatment (TCTr). TCTr comprises the expenses of nutritional care and pharmacologic therapy, together with the cost of the health team and daily hospital costs. A component of TCTr is cost of nutrition treatment (CNT), which includes only the direct expenses of nutritional care.

Calculation of the TCTr
For each group, the expenses related to NT, medications, and the hospital bed were considered for calculation of the TCTr. Expenses arising from the following items were calculated:

preparation of industrialized enteral formulas administered to patients during hospitalization;

industrialized enteral formulas supplied to domiciliary patients;

medications for hospitalized patients;

hospital bed; and

health team (physician, nutritionist, nurse).

The TCTr was thus obtained in the studied sample by the sum of the costs with the NT (Cnutr), medication (Cmed), hospital bed (Cbed), and multidisciplinary NT team (CNTT), resulting in the formula:

Formula

The TCTr considered the expenses involved with each of the patients according to their total time of treatment, whether they were at home or hospitalized. Expenses were not included that arose from surgical procedures, operating theater, personnel involved solely with the surgery, anesthetic medication, and equipment, because it was assumed there would be no significant difference between the groups in this respect due to statistical homogeneity in the pairing. All calculations for cost of consumer goods and personnel were adjusted for 2001, according to the hospital inflation index for the corresponding period.

Nutritional Benefits
Nutritional benefits were evaluated using the adapted index of nutritional rehabilitation and were expressed by units of benefit.

To calculate this index, clinical criteria were used as standardized by Baxter et al,35,36 a dietetic indicator (positive when the daily caloric ingestion was <60% of the individual requirements); an anthropometric indicator (BMI); a laboratorial indicator (dosage of serum albumin), and a clinical criterion that was subjective and based on the annotations in the medical records by the physician with regard to alimentation, disposition, and general well-being of the patients.

Cost Reduction (Minimization Cost) for the Institution (CRI)
The cost reduction for the institution calculation points to the lower cost, as far as possible, to achieve the same benefits. In the present study, this was calculated by the difference in the values found between the SGs and CGs for each cost variable involved. The following formula was applied:

Cost reduction (R$) of the variable = cost of highest variable – cost of lowest variable.

Optimization in the Use of Hospital Beds: Duration of Treatment
To study the time a patient spent in each of the treatment phases, medical records were consulted and number of days were noted for home attendance, pre- and postoperative hospitalization, and in the intensive care unit. Complete and or partial days were considered.

Rate of Hospital Bed Occupation (RHBO)
The RHBO per patient, in days, was calculated using the following formula:

Formula
where TTOTHOSP = time of total hospitalization.

Cost-effectiveness and CBA
The schematic model for cost-effectiveness analysis (CEA) and CBA identify the "economy" that the institution achieved by the days of hospitalization that were avoided (CEA), and how much the institution saved (or even earned) in monetary terms with this new treatment proposal (CBA; Fig. 2).


Figure 2
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  		FIG. 2. Economical study of the two models of treatment.

 

CEA
The CEA from the institution's standpoint considered the variables of cost of treatment and benefits, "benefit" defined as a shorter length of stay and lower rate of complications (Fig. 2). The following formula was applied:

Formula
where

TCstudy = treatment cost per patient in the SG (R$)

TCcontrol = treatment cost per patient in the CG (R$)

TTOTHOSP-study = total length of hospitalization per patient in the SG (days)

TTOTHOSP-control = total length of hospitalization per patient in the CG (days)

CBA for Institution
To calculate the cost-benefit ratio between the distinct forms of treatment, the formula added the differences in the cost of nutritional therapy (CNT) to the difference in cost of hospitalization (CPHLOS). The total CBA represents the advantages of the two benefits together:

Formula
where

CNTstudy = median cost of nutritional therapy per patient of the study group (R$)

CNTcontrol = median cost of nutritional therapy per patient of the control group (R$)

CPHLOS study = cost of patient per day in study group (R$), equivalent to median length of hospitalization per patient in study group multiplied by the cost of the hospital bed

CPHLOS control = cost of patient per day in control group (R$), equivalent to median length of hospitalization per patient in control group multiplied by the cost of the hospital bed

Statistical Analysis
{chi}2 Or Fisher's exact test was used for the qualitative variables. For the quantitative variables, the data normality test was applied (Kolmogorov-Smirnov test with Lilliefors correction) and the homogeneity of variance test (Levene test). For the data that satisfied these 2 principles, a parametric test was used (t test); otherwise, nonparametric tests were performed (Mann-Whitney U test). The level of significance was set at 95% (p < .05).37 The software Statistics for Windows, version 5.0 (Chicago, IL), was used to analyze the data.


   RESULTS
Top
MATERIALS AND METHODS
 RESULTS
DISCUSSION
 
Both groups achieved the same nutritional benefits considering the number of patients that have reached the objectives of the NT (28 SG vs 26 CG patients; p > .05). The rate of complication of the NT was similar between the 2 groups.

Our work showed that the SG, which was submitted to home-based NT in the preoperative and posthospital discharge periods, resulted in a 2.7-fold cost reduction compared with the conventional intrahospital group (R$3237.18 vs R$ 8647.93 respectively; p < .001; Figure 3). Considering the cost variables involving the multidisciplinary team, length of hospital stay, and NT, a cost reduction was observed in the order of R$5413.92 for each patient in the SG model (Fig. 4). The length of stay of the SG was 2.7 times less than the conventional model, and as a consequence, the SG also presented the best RHBO. The CBA showed an economic benefit to the institution from "days of hospitalization avoided" (R$163.40 per day), generating an overall economic benefit for the institution in the order of R$9,132.83 (US$3132) for each patient in the SG (Fig. 5).


Figure 3
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  		FIG. 3. Total cost of treatment. SG, study group; CG, control group.

 

Figure 4
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  		FIG. 4. Cost reduction (CR) per patient per total treatment (median).

 

Figure 5
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  		FIG. 5. Cost-benefits analysis (CBA).

 


   DISCUSSION
Top
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 
Health attendance involves therapeutic procedures documented in the medical records of the patient, analyzed and reimbursed by sources of funding belonging to the SUS. Fund providers (Medical Health Systems or medical insurance companies) observe this process according to their own interests. The health service provider also seeks to analyze investment and results, with a view to certifying that the monetary resources transferred are being allocated in a safe, efficient, and effective manner in the appropriate amount and without waste. The hospital administrator receives the funds and has the responsibility of optimizing these resources. Thus, the institution receiving these resources must determine a balance between the length of hospital stay and resulting cost, and also whether the services rendered by the hospital are guaranteeing its financial stability.38 The relationship between the manager of health services and the direct provider of health services is, in general, conflicting. The former wants to spend the least finds possible, whereas the latter aspires to use leading-edge technology to treat patients. The health service provider that manages to demonstrate the value of the service rendered can receive reimbursement for services that are increasingly closer to the real costs of the procedures performed. For example, in the US the reimbursement for NT represents 30% of the expenses effectively involved in the service, although after elaboration of a series of economic studies, the reimbursement begins to cover up to 80% of the real costs.39

Keeping a patient in a hospital bed for longer than absolutely necessary implies proportionally higher direct and indirect expenses.8 Higher direct costs, in this sense, arise because of the cost of physical space, university and nonuniversity labor, occupation of equipment, basic utilities, and technology. In addition to these, there are other costs incurred by prolonged hospital stay; for example, the greater risk of acquiring hospital infection, thus generating additional costs in medicines, laboratory examinations, and prolonging still further the duration of hospitalization. Furthermore, lengthy hospitalization causes delays in attending new patients that can result in irremediable damage to the health of these patients on the waiting list, given the implacable advance of certain consumptive diseases.

There is a direct relationship between the degree of malnutrition not treated in an early manner and the onset of postoperative complications.40–44 Undernourished patients tend to require longer hospitalization45–47 and higher hospital costs.48,49 Ignoring the undernourishment of patients indicated for surgical interventions and referring them immediately to surgery results in a higher incidence of general and infectious complications and greater mortality when compared with those in good nutritional state at the time of surgery.43,44

At first sight, it may seem redundant to highlight that nutritional risk has a direct relationship with the onset of complications and increment in costs. Nevertheless, it is unfortunate that even today, most patients are not evaluated from the nutritional point of view and NT is prescribed too late.16,50–52 Thus, we turn a blind eye to the "cost of not prescribing NT."

Conventionally, NT has been instituted for the majority of hospitalized patients but without a home-based follow-up after hospital discharge. Clearly, hospital discharge almost always does not coincide with nutritional discharge, and there are many cases of interruption in nutritional care because there is no integrated model to ensure a posthospital discharge follow-up.

At the University of Illinois at Chicago, the nutritional state of 404 patients was documented during hospitalization. The prevalence of moderate and severe malnutrition increased from 54% at admission to 59% at discharge. The greatest risk of complications was associated with those that passed from eutrophic state to severely undernourished (3.8 times greater than the reference group) and those that were admitted with severe malnutrition and worsened while in the hospital (3.1 times more than the reference group). costs The were also proportionally greater.53

Mughal and Meguid46 affirmed it is a myth to believe that patients submitted to abdominal operations recovered their habitual ingestion of foods by the second postoperative week because, according to their study, this only occurred 36 days on average after the surgical event. This underscores the need for backup home-based NT in the care of hospitalized patients, as proposed by the present study.

Among the components of the cost involved with NT is the expense of applying this therapy in the hospital environment because cost is lower if the patient is treated at home.20–23 The present study corroborates others that demonstrated cost advantages arising from treating patients at home compared with in hospitals, as shown in Table III.


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  		Table III Review of articles comparing cost of home-based NT with cost of hospitalized patients

 

The US government medical health care system (Medicare) has created a financial incentive for hospitals to discharge hospitalized patients earlier.58 Probably because of this initiative, the US has seen a significant decrease in active hospital beds between 1994 and 1999 (from 1.2 million to 425,000). Van Way19 has pointed out that over the last 10–15 years many US hospitals have been closed and downsized, but many experts feel there should be a further decrease. This is still not the reality in countries such as Brazil, where, paradoxically, there has been a 30% increase in the number of beds during the same period.6

At a teaching hospital in Spain, it was observed that the mean value of attending patients at home was 4.17 times less than the expenditure in the same conditions when hospitalized.55 Thus, the attendance model proposed in this study, designated "integrated hospital-home model," is an organized application of the home model. The patients, by turns hospitalized and at home, do not have interruption in their nutritional care. A physical flow is enabled for the patients, and their respective nutritional information allows a complete follow-up and optimization of their nutrition care. There are evident advantages in the management and attendance with the implantation of this model. There is no interruption in the nutritional care of the patients, such that it is possible to consider them from the point of view of treatment cost alone. The "integrated hospital-home model" allows a standardization of the nutritional service, the use of the same nutritional service protocol, and the same selection criteria for enteral and parenteral formulas. This confirms the equality and solidity of the nutritional service provided in the eyes of the patient and family, besides offering greater security.

This innovative alternative for nutritional care of patients in pre- and postoperative digestive surgery resulted in comparable nutritional benefits for the patients, but with significant economic advantages for the institution, as observed in this study. A service model similar to this was implanted in the New England Medical Center (Boston, MA), where it maximized efficiency of the patients' attendance, diagnostic services, and therapeutics rendered to children with cancer.17

The purpose of experience with this model in Brazil was to optimize the use of surgical beds and to provide nutritional service in the perioperative period. This model was supported by the PROSNED at the Hospital das Clinicas of São Paulo. The objective of NT was focused on the nutritional preparation of the patient for surgical intervention and on the postoperative adaptation period.59–62

Preoperative NT has already been the object of economic studies at various centers of attendance. Flynn and Leightty63 reported a reduction in the postoperative complications and in the duration and cost of hospitalization when 61 undernourished patients were given home-based enteral nutrition in preparation for head and neck surgery. The benefits of postoperative home nutritional supplementation were also studied by Beattie et al64 in 101 undernourished surgical patients who were randomized and controlled every 2 weeks for a 10-week period. The authors observed that the group with nutritional supplementation presented less weight loss, better muscular force, and more favorable indicators for quality of life. Furthermore, fewer patients necessitated antibiotic therapy. These authors were in agreement with the present work when they suggested that NT should be continued in the postoperative of medium to major surgeries in order to reduce the postoperative morbidity and to achieve nutritional recovery earlier.

The present study underscores that surgical patients can benefit from a nutrition intervention in both pre- and postoperative periods, without necessarily being hospitalized. Surprisingly, it is not common practice to initiate NT in surgical patients as part of the perioperative preparation, not even in countries where reimbursement of home NT is already allowed. Howard et al65 criticized the system of reimbursement in the US, through Medicare, as it does not allow the inclusion of surgical patients in the perioperative phase of NT as a short-term home-based model. The US model only reimburses long-term home services and consequently impedes the adoption of NT models for surgical patients as proposed in the present study.

Considering the results obtained in the present study and those before our group in Brazil,59–62,66,67 and the tendency to maintain the patient out of the hospital environment whenever the clinical situation allows, we suggest the expansion of the home service as a support for hospitalization, thereby guaranteeing appropriate nutritional care for the patient and a significantly reduced financial burden for the institution.

In conclusion, under the conditions of the present study, the integrated hospital-home model achieved nutritional benefits comparable to those of the conventional intrahospital model but with significantly lower costs. The hospital-home model presented a significant reduction in the costs involved in the treatment, mainly because of the shorter hospital stay. In addition, it provided cost savings to the institution, as demonstrated by the CEA, through the avoidance of hospital days and prevention of surgical complications. It also resulted in lower cost of the NT combined with shorter length of stay, along with optimization in the usage of hospital beds by generating a surgical-bed occupancy superior to that of the conventional intrahospital model.

Finally, these economic tools are an indispensable aid to optimizing resources and clinical-surgical results. Everybody stands to gain from their use, including the patient, health professionals, fund provider, and institution.


  
Top
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 
This economical study evaluated the nutrition therapy of the integrated hospital-home model (study group) in comparison with an exclusively hospital model. The study group achieved the same nutritional benefits but with expenses 3 times lower, reduction in length of hospital stay, and higher bed rotation.

Received for publication October 8, 2004. Accepted for publication October 14, 2004.

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Journal of Parenteral and Enteral Nutrition, Vol. 29, No. 1 suppl, S96-S105 (2005)
DOI: 10.1177/01486071050290S1S96
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