A Survey of Home Enteral Nutrition Practices and Reimbursement in the Asia Pacific Region

Literature regarding the use of home enteral nutrition (HEN) and how it is reimbursed in the Asia Pacific region is limited. This research survey aims to determine the availability of HEN, the type of feeds and enteral access used, national reimbursement policies, the presence of nutrition support teams (NSTs), and clinical nutrition education in this region. An electronic questionnaire was sent to 20 clinical nutrition societies and leaders in the Asia Pacific region in August 2017, where thirteen countries responded. Comparison of HEN reimbursement and practice between countries of different income groups based on the World Bank’s data was investigated. Financial support for HEN is only available in 40% of the countries. An association was found between availability of financial support for HEN and health expenditure (r = 0.63, p = 0.021). High and middle-upper income countries use mainly commercial supplements for HEN, while lower-middle income countries use mainly blenderized diet. The presence of NSTs is limited, and only present mainly in acute settings. Sixty percent of the countries indicated an urgent need for funding and reimbursement of HEN. This survey demonstrates the varied clinical and economic situation in the Asia Pacific region. There is a lack of reimbursement, clinical support, and inadequate educational opportunities, especially for the lower-middle income countries

Economic Evaluation of Nutrition Support in the Prevention and Treatment of Pressure Ulcers in Acute and Chronic Care Settings: A Systematic Review

Background: Recent developments in nutrition intervention indicated clinical effectiveness for pressure ulcer (PU) prevention and treatment, but it is important to assess whether they are cost-effective. The aims of this systematic review are to determine the cost-effectiveness and clinical outcomes of nutrition support in PU prevention and treatment. Methods: A systematic search of randomized controlled trials, observational studies, and statistical models that investigated cost-effectiveness and economic outcomes for prevention and/or treatment of PUs were performed using standard literature and electronic databases. Results: Fourteen studies met the inclusion criteria, which included 3 randomized controlled trials with their companion economic evaluations, 4 model-based, 2 cohort, 1 pre and post, and 1 prospective controlled trial. Risk of bias assessment for all of the uncontrolled or observational trials revealed high or serious risk of bias. Interventions that incorporated specialized nursing care appeared to be more effective in prevention and treatment of PUs, compared with single intervention studies. There is a trend of improved PU healing when additional energy/protein are provided. PU prevention ($250–$9,800) was less expensive than treatment ($2,500–$16,000). Nutrition intervention for PU prevention was cost-effective in 87.0%–99.99% of the simulation models. Conclusions: There is potential cost-saving and/or cost-effectiveness of nutrition support in the long term, as predicted by the model-based PU prevention studies in the review. Prevention of PU also appears to be more cost-effective than treatment. A multidisciplinary approach to managing PU is more likely to be cost-effective

Improving nutrition care and intake for older hospital patients through system-level dietary and mealtime interventions

Background & aims: Interventions such as oral nutritional supplements (ONS), fortified meals and mid-meals, feeding assistants and Protected Mealtimes have shown some impact on nutritional intake in research studies, but embedding them in practise remains challenging. This study monitored nutritional intake of older medical inpatients as dietary and mealtime interventions were progressively implemented into routine practise. Methods: Series of three prospectively evaluated patient cohorts allowed comparison of nutritional intake of 320 consented medical inpatients aged 65 + years: cohort 1 (2007–8), cohort 2 (2009) and cohort 3 (2013–14) as nutrition care interventions were progressively introduced and embedded. Interventions focused on ‘assisted mealtimes’ fortified meals and mid-meals, and ONS. Energy and protein intake were calculated from visual plate waste of individual meal and mid-meal components on day 5 of admission. Nutrition care processes were evaluated by mealtime audits of diet type, assistance and interruptions on the same day. One-way ANOVA and chi square tests were used for comparison between cohorts. Results: Significant, progressive improvements in energy and protein intake were seen between cohorts (energy: cohort 1: 5073 kJ/d; cohort 2: 5403 kJ/d; cohort 3: 5989 kJ/d, p = 0.04; protein: cohort 1: 48 g/d, cohort 2: 50 g/d, cohort 3: 57 g/d, p = 0.02). Greater use of fortified meals and mid-meals and sustained improvements in mealtime assistance likely contributed to these improvements. Conclusions: Multi-faceted system-level approach to nutrition care, including changes to dietary and mealtime care processes, was associated with measureable and sustained improvements in nutritional intake of older inpatients over a seven year period

The costs arising from pressure ulcers attributable to malnutrition

Background & aims: To estimate the economic consequences of pressure ulcer attributable to malnutrition

Home enteral nutrition in Singapore's long-term care homes—incidence, prevalence, cost, and staffing

: Data on home enteral nutrition (HEN) in long-term care facilities (LTCF) in Singapore is scarce. This study aims to determine the prevalence and incidence of chewing/swallowing impairment and HEN, and the manpower and costs related. A validated cross-sectional survey was sent to all 69 LTCFs in Singapore in May 2019. Local costs (S$) for manpower and feeds were used to tabulate the cost of HEN. Nine LTCFs (13.0$799.47 (interquartile range (IQR): 692.11, 940.30). Nursing costs for feeding contributed to 63% of total HEN costs. The high usage and length of time on NGT feeding warrants exploration and education of PEG usage. A national HEN database may improve the care of LTCF residents

Adult malnutrition, nutritional interventions and outcomes in Singapore: a scoping review of local studies for the past 20 years

Background: There is currently no review published on the prevalence and incidence of malnutrition in Singapore across various populations, or what interventions or policies are in place for preventing/treating malnutrition.Objectives: This review aims to determine the: (a) incidence and prevalence of malnutrition in the community, and in acute, intermediate and long-term care facilities; (b) interventions implemented for screening, assessing and treating/preventing malnutrition; (c) specific clinical populations investigated for malnutrition or nutritional therapy; and (d) implications of malnutrition and effectiveness of treating malnutrition or using nutritional therapy in Singapore.Methods: A structured search strategy was applied to available electronic databases (MEDLINE/PubMed, EMBASE, CINAHL, the Cochrane Library and Google Scholar) using selected search terms, with additional reports and grey literature identified using iterative searches.Results: Forty-two articles were found, with the majority of research performed in the community and acute care settings. Malnutrition screening and assessment is the most common nutritional research performed in Singapore. Approximately 14.7% to 65.0% of acute care and 2.8% to 31.5% of community populations are found to be malnourished. Limited interventional and economic-related studies are available.Conclusion: Malnutrition rates in Singapore appear to be similar to other developed countries. Future studies will need to focus on nutritional intervention, cost-effectiveness analyses and specific populations such as the underprivileged, chronically ill and those dependent on nutritional support

Encouraging, assisting and time to EAT: improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

Background & aims: Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. Methods: Pre-post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM+AIN: combined intervention. Dietary intake of 254 patients (pre: n=115, post: n=141; mean age 80±8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded. Results: Mealtime assistance levels significantly increased in all interventions (

Medical nutrition reimbursement in Singapore: who are the patients receiving MediFund assistance? An audit of clinical outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore

Financial reimbursement (MediFund) of medical nutrition products (MNP) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy, and the benefits conferred.A one-year retrospective audit of patients in a tertiary hospital who received MediFund was performed. Demographics, pre and post support clinical outcomes, and cost of support was determined and analyzed.A total of 129 patients received MediFund for MNP. The median length of financial support was 115 days (IQR: 37, 269). Overall, body mass index (BMI) increased after nutritional support (20.9 ± 5.1 vs 20.4 ± 5.3 kg m , p = 0.012). There was a significant decrease in the number of malnourished patients (Final: 55.1% vs Initial: 86.8%,

Randomised controlled trial of early prophylactic feeding vs standard care in patients with head and neck cancer

Weight loss remains significant in patients with head and neck cancer, despite prophylactic gastrostomy and intensive dietary counseling. The aim of this study was to improve outcomes utilising an early nutrition intervention.Patients with head and neck cancer at a tertiary hospital in Australia referred for prophylactic gastrostomy prior to curative intent treatment were eligible for this single centre randomised controlled trial. Exclusions included severe malnutrition or dysphagia. Patients were assigned following computer-generated randomisation sequence with allocation concealment to either intervention or standard care. The intervention group commenced supplementary tube feeding immediately following tube placement. Primary outcome measure was percentage weight loss at three months post treatment.Recruitment completed June 2015 with 70 patients randomised to standard care (66 complete cases) and 61 to intervention (56 complete cases). Following intention-to-treat analysis, linear regression found no effect of the intervention on weight loss (10.9±6.6% standard care vs 10.8±5.6% intervention, P=0.930) and this remained non-significant on multivariable analysis (P=0.624). No other differences were found for quality of life or clinical outcomes. No serious adverse events were reported.The early intervention did not improve outcomes, but poor adherence to nutrition recommendations impacted on potential outcomes