Table 2.
Detailed overview of identified articles with respect to key study items
| Authors and reference | Disease area and classification | Intervention | Model design | Health care setting and perspective | Health economic endpoints and results |
|---|---|---|---|---|---|
| Abou-Assi et al40 | Acute pancreatitis | Initial 48-hour IV fluids and analgesics. After patients improved, they were restarted on oral feeding. The remaining patients were randomized to nasojejunal (EN group) or parenteral feeding (TPN group). Comparison: EN versus TPN |
RCT in one center | Hospital perspective in the US | Average hospitalization cost: US $11,183. For the sicker patients needing nutritional support, those given enteral feeding had lower total average hospitalization costs: US $26,464 versus US $34,530 per patient. Average nutritional costs: US $394 (EN) versus US $2,756 (TPN) per patient. |
| Freijer and Nuijten41 | Abdominal surgery GI surgery |
ONS versus no ONS Comparison: ONS versus no ONS |
Cost-effectiveness model | Hospital, national perspective | Budget impact: cost saving (in favor of ONS) of €12,986 million. |
| Gianotti et al23 | Surgery in GI cancer patients GI surgery |
Perioperative administration of enteral IN or standard enteral diet Comparison: ONS + EN IN versus SoC |
Calculation based on RCT and cost data | Hospital perspective | Cost per patient: €347 (ONS) versus €103 (SoC). Cost per complication (for all study patients): €78,336 (ONS) versus €243,882 (SoC). Cost-effectiveness (not incremental): €1,339 (ONS) versus €3,725 (SoC). |
| Kruizenga et al20 | Malnourished hospitalized patients with different diseases Malnutrition |
Intervention group: patients admitted to two mixed medical and surgical wards, and who received both malnutrition screening at admission and standardized nutritional care (TF and parenteral feeding). Control group received the usual hospital clinical care. Comparison: EN versus PN |
Controlled trial with a historical control group | Hospital, societal perspective | Length of stay: 11.5 days versus 14 days. Cost-effectiveness: EN more costly, less effective. |
| Neelemaat et al19 | Malnourished hospitalized patients (newly admitted to the wards of general internal medicine, rheumatology, gastroenterology, dermatology, nephrology, orthopedics, traumatology, and vascular surgery) Malnutrition |
Intervention group: nutritional supplementation (energy- and protein-enriched diet, ONS, calcium-vitamin D supplement, telephone counseling by a dietician) until 3 months after discharge from hospital. Patients in the control group received usual care (control). Comparison: ONS into diet protocol versus SoC |
Randomized clinical trial in one center | Hospital, societal perspective (one hospital center) | Direct cost: €8,773 versus €8,332. Indirect cost: €356 versus €352. Total: €9,129 versus €8,684. ICER: €26,962/QALY. |
| Norman et al21 | Malnourished hemodialysis patients Malnutrition |
Oral supplementation early in the course of malnourished hemodialysis patients Comparison: ONS in mild hemodialysis patients versus ONS in moderate/severe hemodialysis patients |
RCT (pilot) study | Outpatient, hemodialysis centers in the US | Length of stay: 71 days versus 107 days versus 208 days. |
| Wilson et al38 | Advanced dementia Eating problems |
TF versus hand-feeding nursing Comparison: TF (EN) versus SoC (including normal food intake with nurse help) |
Retrospective cohort study | NH residents, long-term care facility in the US | Daily costs of NH care: US $4,219 (without feeding tubes) versus US $2,379 (with feeding tubes). |
| Mitchell et al39 | Disease-related malnutrition Malnutrition |
ONS (intervention) versus no ONS Comparison: ONS versus no ONS |
Budget impact | Community, national perspective | Budget impact: cost savings of €12,986 million. |
| Freijer et al27 | CVA Dysphagia |
ETF in NH versus at home Comparison: ETF in different health care settings: home versus NH |
Cost-utility model | Outpatient, perspective not reported | Cost/QALY (ETF at home): £12,817. Cost/QALY (in NH): £10,304–£68,064. |
| Elia and Stratton42 | Acute pancreatitis | PN versus EN Comparison: PN versus EN |
Randomized clinical trial | Hospital, health authority in Canada | Average cost per patient: US $1,375 (EN) versus US $2,608 (PN). Other cost categories were equivalent. |
| Louie et al24 | Lower GI tract surgery GI surgery |
Oral supplements (Fortisip; Nutricia Advanced Medical Nutrition Schiphol, the Netherlands) both before and after surgery. Patients were randomized to the following groups: 1) no nutritional supplements; 2) supplements both before and after surgery; 3) postoperative supplements only; 4) supplements only before surgery Comparison: ONS versus +/− ONS before/after surgery |
Two-phase, randomized clinical trial | Hospital perspective | Total cost per patient: ONS pre- and postsurgery: £2,289. ONS presurgery: £2,286. ONS postsurgery: £2,324. No ONS: £2,618. |
| Smedley et al29 | Patients after discharge from hospital Malnutrition |
Elderly malnourished subjects were randomized to 8 weeks of supplementation (Ensure® Plus tetrapak, Abbott Laboratories, Enlive® tetrapak; Formance® Pudding; or Ensure® bars, Abbott Laboratories, Abbott Park, IL, USA) or no supplementation postdischarge, and followed up for 24 weeks Comparison: ONS versus no ONS |
Multicenter prospective open label, RCT | Outpatient, NHS perspective | Cost changes within the study period: Prescriptions: £92 versus £28. Consultations: −£11 versus £16. Appointments: £28 versus £14. Hospital admissions: −£326 versus −£2,703. Hospital stays: −£326 versus −£2,703. |
| Edington et al43 | 1) Well-nourished surgical patients 2) Malnourished surgical patients 3) Trauma patients 4) Medical ICU patients, GI surgical and ICU patients |
Immune-modulating formulations could be either: 1) Impact (Novartis AG, Basel, Switzerland), or 2) Immonaid (Braun GmbH, Kronberg, Germany) Comparison: ONS versus no ONS |
Database analysis | Hospital (before/after surgery – after trauma/ICU admission) US hospital for patients covered by Medicare or Medicaid services |
Cost of complications normally higher for the intervention group (ONS). Break-even infection rates calculated to define the efficiency point for ONS treatment. |
| Strickland et al30 | Cancer of the stomach, pancreas, or esophagus GI surgery |
Randomization into two groups receiving postoperative TPN or EEN Comparison: EN versus PN |
Prospective, randomized clinical trial | Hospital, department of surgery in an Italian university hospital | Mean cost per day: $25 versus $90 (USD). Prescriptions represent 73.2% of the mean daily cost in TPN and 22% in EEN. The costs of the other variables were similar in the two groups. |
| Braga et al22 | GI cancer GI surgery |
1) Preoperative group receiving Oral Impact® (Nestlé SA, Canton of Vaud, Switzerland) for 5 days before surgery; 2) perioperative group receiving the same preoperative treatment plus jejunal infusion of Impact for 7 days after surgery; and 3) a conventional group Comparison: IN oral or enteral versus SoC in a pre- or perioperative regimen |
Clinical study | Hospital perspective | Total cost of nutrition: €3,407 (conventional) versus €14,729 (preoperative). Cost of in-hospital routine care was similar in both groups. Mean cost of complication: €6,178 versus €4,639€. Total cost of patients with complications: €535,236 versus €334,148. Cost-effectiveness: €6,245 versus €2,985. |
| Braga and Gianotti25 | GI cancer GI surgery |
Preoperative IN versus no nutritional support Comparison: preoperative IN (oral) versus no ONS support |
Review | Hospital, perspective NA | Cost of nutrition: €144–€347 versus €33–€103. Cost of complications: €768–€1,728 versus €2,345–€3,089. Cost-effectiveness: €1,339–€2,985 versus €3,587–€6,244. |
| Braga and Rocchetti26 | GI cancer GI surgery |
Oral preoperative specialized diet versus conventional treatment (no supplementation) Comparison: Preoperative IN (oral) versus no ONS support |
Prospective, randomized clinical trial | Hospital, Italian university hospital | Mean cost per day per patient (without complications): €3,622 versus €3,588. Mean cost per day per patient (with complications): €10,494 versus €8,793. Mean total cost per patient: €7,092 versus €5,668. |
| Braga et al26 | Critically ill patients | PN versus EN Comparison: EN versus PN |
Systematic review and cost analysis | Hospital (ICU), perspective NA | Cost savings per patient (due to EN): US $2,473. Budget impact: switching 10% of PN patients to EN saves US $57 million annually. |
| Cangelosi et al44 | Patients with risk of disease-related malnutrition Malnutrition |
ONS versus no ONS Comparison: ONS versus no ONS |
Linear decision analytic model | Hospital, perspective not reported | Total cost: €1,482 versus €1,717. Budget impact: cost savings (in favor of ONS): €603,539 million. |
| Nuijten and Mittendorf45 | Malnutrition patients Malnutrition |
Two groups of physicians were selected based on historical prescribing practice: group 1 with rare prescription of ONS and group 2 with frequent prescription of ONS (only an HEHP nutritional supplement that has a pharmaceutical status on the French market) Comparison: ONS versus no ONS |
Observational, prospective, longitudinal, cohort study | Community, physician perspective | Length of stay: 4.3 days versus 5.6 days. Cost per patient: Oral supplementation: €565 versus €37. Hospital admissions: €1,572 versus €2,123. Nurse visits: €217 versus €362. GP visits: €32 versus €42. Total: €2,499 versus €2,694. |
| Arnaud- Battandier et al6 | GI cancer GI surgery |
Oral or enteral dietary supplementation with arginine, omega 3 fatty acids, and nucleotides (known as IN) Comparator: IN perioperative (EN or ONS) versus SoC |
Database analysis | Hospital perspective | Cost savings per patient (in favor of IN): $3,300 (reduction in infectious complications) and $6,000 (length of hospital stay) (USD). |
| Mauskopf et al28 | Disease-related malnutrition Malnutrition |
ONS ONS (no comparator) |
Cost review | Hospital and community perspective | Additional ONS cost for individuals: Hospital inpatients: £3,194. Long-term care: £1,646. GP visits: >£43. Hospital outpatients: >£43. Artificial nutrition and ONS in hospital: £54. Artificial nutrition and ONS in the community: £149. Total: >£5,280. |
| Russell46 | Malnutrition patients Malnutrition |
Disease-specific medical nutrition Comparators and treatments not specified |
Database-matched analysis | Community, physician perspective | Total 6-month cost per patient: £1,003. Budget Impact: £615 million–£3,695 million. |
| Guest et al32 | CMPA | Treatment data and, hence, split of patient groups according to UK market data | Computer-based budget impact model | Community, perspective not reported | Total cost of managing CMA per patient (first 12 months): £1,381. Budget impact: £25.6 million (for an annual cohort of 18,350 infants) |
| Sladkevicius et al33 | CMPA | Soy, eHF, neocate AAF based on assumptions and the literature | Decision budget impact model | Community, KELA (health insurance), patient and society | KELA’s total expenditure on clinical nutrition preparations for 1,443 new CMA sufferers is expected to fall by 34% (from €47,930–€31,666). |
| Guest and Valovirta31 | CMPA | Soy, eHF, AAF | Decision budget impact model | Community, publicly funded health care system | Expected 6-monthly health care cost per CMA infant: AU $1,150. |
| Guest and Nagy34 | CMPA | Soy, eHF, AAF | Decision budget impact model | Community health care insurers | Expected budget impact (4,382 new CMA sufferers up to 1 year of age): €11.28 million. |
| Sladkevicius and Guest35 | CMPA | Soy, eHF, AAF | Decision budget impact model | Community, insurer, parents/carer perspective | Expected 12-monthly cost (insurance perspective): 2,430 South African (private sector) versus 1,073 R (public sector). Expected 12-month cost (parents/carers): 43,563 R (private sector) versus 24,899 R (public sector). Budget impact (annual cohort of 18,270 newly diagnosed infants): 22.1 million R for health care insurers and 489.1 million R for parents/carers. |
| Sladkevicius and Guest36 | CMPA | eHF versus AAF | Decision analytic model | Community | 12-month NHS cost: £1,853 and £3,161 per patient in the eHF and AAF groups, respectively. Total incremental 12-month NHS cost: £1,308 (AAf versus eHF). |
| Taylor et al47 | Malnutrition patients in a gastroenterology ward Malnutrition |
Nutritional support (including oral supplements, parenteral feeding, parenteral TF) Comparison: ONS; EN; and PN |
G-DRG-relevant variables were prospectively collected | Inpatient, hospital perspective | Direct cost for 50 patients: ONS: €618. EN: €2,772. PN: €4,002. |
| Ockenga et al37 | Pancreatitis | EN versus PN support Comparison: EN versus TPN |
Retrospective review of preexisting database | Inpatient, hospital in the USA | No significant difference was found in terms of cost, even though meaningful: US $22,277 (TPN) versus US $16,724 (EN). Reason: most likely due to the small sample size. |
Abbreviations: IV, intravenous; EN, enteral nutrition; TPN, total parenteral nutrition; GI, gastrointestinal; ONS, oral nutritional supplements; IN, immunonutrition; SoC, standard of care; RCT, randomized controlled trial; TF, tube feeding; PN, parenteral nutrition; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year; NH, nursing homes; CVA, cerebrovascular accident; ETF, enteral tube feeding; NHS, National Health Service; ICU, intensive care unit; EEN, early enteral nutrition; NA, not applicable; HEHP, high-energy, high-protein; GP, general practitioner; CMPA, cow’s milk protein allergy; CMA, cow’s milk allergy; eHF, extensively hydrolyzed formula; AAF, amino acid formulas; KELA, Social Insurance Institution in Finland; AU, Australian; R, rand; G-DRG, Diagnosis-related Groups Germany.