Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States
Review Article

Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States

Jose M. Pimiento1, David C. Evans2, Renay Tyler3, Albert Barrocas4, Beverly Hernandez5, Krysmaru Araujo-Torres6, Peggi Guenter7; ASPEN Value Project Scientific Advisory Council

1Gastrointestinal Oncology Department, H. Lee Moffitt Cancer Center, Tampa, FL, USA; 2Ohio Health Trauma and Surgical Services, Columbus OH, USA; 3University of Maryland Medical Center, Baltimore, MD, USA; 4Surgery Department, Tulane School of Medicine, New Orleans, LA, USA; 5Nutrition Services. Tampa General Hospital, Tampa, FL, USA; 6Nestlé Health Science Bridgewater, NJ, USA; 7American Society for Parenteral Nutrition, Silver Spring, MD, USA

Contributions: (I) Conception and design: JM Pimiento, DC Evans, R Tyler, A Barrocas, B Hernandez, KA Torres, P Guenter; (II) Administrative support: P Guenter; (III) Provision of study materials or patients: P Guenter; (IV) Collection and assembly of data: P Guenter; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Jose M. Pimiento, MD, FACS. Associate Professor Gastrointestinal Oncology, Director of Surgical Inpatient Services, H. Lee Moffitt Cancer Center, Tampa, FL, USA. Email: Jose.pimiento@moffitt.org.

Abstract: Malnutrition, particularly under-nutrition, is highly prevalent among adult patients with a diagnosis of gastrointestinal (GI) cancer and negatively affects patient outcomes. Malnutrition is associated with clinical and surgical complications for patients undergoing therapy for GI cancers and the costs associated with those complications is a high burden for the US health system. Our objective was to identify high-quality evidence for nutrition support interventions associated with cost savings for patient care, followed by a complex economic value analysis to project cost savings for the US health system. A narrative literature search was conducted in which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area [GI cancer (esophageal, gastric, gallbladder, pancreatic, liver/hepatic, small and large intestine, colorectal)], and clinical outcomes and healthcare cost, to look for nutrition interventions that could significantly improve clinical outcomes. Medicare claims data were then analyzed using the findings of these identified studies and this modeling exercise supported identifying the cost and healthcare resource utilization implications of specific populations to determine the impact of nutrition support on reducing these costs as reflected in the summary of the evidence. Eight studies were found that provided clinical outcomes and health cost savings data, 2 of those had the strongest level of evidence and were used for Value Analysis calculations. Nutrition interventions such as oral diet modifications, enteral nutrition (EN) supplementation, and parenteral nutrition (PN) have been studied especially in the peri-operative setting. Specifically, peri-operative immunonutrition administration and utilization of enhanced recovery pathways after surgery have been associated with significant improvement in postoperative complications and decreased length of hospital stay (LOS). Utilizing economic modeling of Medicare claims data from GI cancer patients, potential annual cost savings of $242 million were projected by the widespread adoption of these interventions. Clinical outcomes can be improved with the use of nutrition interventions in patients with GI cancers. Healthcare costs can be reduced as a result of fewer in-hospital complications and shorter lengths of hospital stay. The application of nutrition intervention provides a positive clinical and economic value proposition to the healthcare system for patients with GI cancers

Keywords: Health economics; value; enteral nutrition (EN); immunonutrition; oral nutrition supplements (ONS); outcomes; malnutrition

Submitted Aug 12, 2020. Accepted for publication Jan 17, 2021.

doi: 10.21037/jgo-20-326

Introduction

Malnutrition is an epidemic that plagues patients with a diagnosis of gastrointestinal (GI) malignancies, as reported in the US and the international setting (1). The incidence of severe malnutrition in patients with GI cancers ranges from 9% to 20% (2). Further, studies estimate a 70% prevalence of malnutrition in upper GI cancers and pancreatic cancer, and 40% in colorectal cancer patients (1). Malnutrition in cancer patients is multifactorial and is caused by a myriad of physiologic and mechanical problems especially in patients with GI malignancies (3-7). See Table 1.

Table 1
Table 1 Factors associated with malnutrition in cancer patients (1-5)
Full table

Malnutrition is associated with increased morbidity and mortality in patients undergoing surgery for GI malignancies (8-11). Poor nutrition among surgical candidates has emerged as a prominent modifiable pre-operative risk factor that negatively impacts postoperative complication rates and severity of illness. Additionally, malnourished patients are at increased risk for prolonged length of hospital stay (LOS), infectious complications, need for hospital readmission, and early death after surgery (9-11). Surgical complications in cancer patients are particularly devastating as they can delay or preclude the administration of adjuvant therapy, negatively impact tumor biology, inflammation, and host immune response. Some complications may also negatively impact nutrition status (e.g., GI leak or fistula). Therefore, an early surgical complication can reduce long-term survival; reductions of 20–35% are reported in colorectal cancer, for example (12).

Emerging evidence suggests nutritional interventions can significantly decrease the incidence of these adverse outcomes (13,14). While the true economic impact of malnutrition in this population is difficult to calculate, it does contribute to excess costs for health systems (11,14,15). Moreover, the concept of multidisciplinary nutrition support teams including physicians, nurses, dietitians, and pharmacists has been adopted by high performing institutions in order to maximize the impact of nutritional support in patients at malnutrition risk (16-19).

In the current environment of at-risk reimbursement models for hospitals and preventable patient complications, it is fundamental to define value in healthcare delivery (20-22). To this end, value analysis is one of the instruments that can be utilized. Value analysis is used to adjudicate potential cost or cost savings to a clinical intervention that focuses on specific clinical outcomes that go beyond immediate therapeutic outcomes such as quality of life and complication rates (23). The ASPEN Value Project was developed to focus on the cost savings associated with improved clinical outcomes (see Figure 1).

Figure 1 Value analysis of nutrition support equation.

We present the study in accordance with the Narrative Review reporting checklist. Available at http://dx.doi.org/10.21037/jgo-20-326.

Methodology

The American Society for Parenteral and Enteral Nutrition (ASPEN) Value Project Scientific Advisory Council was tasked with evaluating clinical evidence and assigning potential cost savings that could impact healthcare delivery. The approach taken was to model nutrition interventions that could significantly improve clinical outcomes. Specifically, the GI cancer workgroup, a multidisciplinary section of the ASPEN value project, evaluated a targeted review of the literature which combined keywords in the areas of therapeutic nutrition (nutrition, malnutrition), a specific therapeutic area of GI cancers, study parameters (clinical outcomes, healthcare costs) previously conducted by the Value Project team, the complete list of terms used is in Table 2 (24). This search was conducted using PubMed and Google Scholar in 5-year look-back period, for human trials and papers in English, published in both her US & International. The GI cancer workgroup, then searched for more recent [2018–2019] high-evidence papers [meta-analyses of randomized controlled trials (RCTs), narrative/systematic reviews of RCTs, recent individual RCTs], using human studies, and papers in English. A literature assessment rubric that was developed by the ASPEN Value Project group was used to evaluate each article identified in the search to select publications for inclusion in the final analysis (24). The rubric, consisted of 4 domains with a point-based scoring system: (I) level of evidence using the GRADE evidence scale (1 to 5), (II) outcomes of interest (0 to 3), (III) type of nutrition intervention (0 to 4), (IV) scalability (1 to 4) (24). The initial ASPEN Value Project search 2012–2018 yielded 10 qualifying studies in this population, 7 of which used oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN), as nutrition support (23,24). The additional search in 2019 yielded one additional clinical trial (25) (Figure 2). Narrative analysis of the qualifying papers was performed. Of the eleven papers only 2 received the highest marks across the 4 domains and were selected to be used in the Medicare claims data analysis described below.

Table 2
Table 2 Specific terms query
Full table
Figure 2 Targeted literature search design.

Value analysis methodology

An analysis of potential cost savings of nutrition interventions for the Medicare population was conducted using the methodology published previously by our group (24); initially the papers with the strongest evidence for cost savings were selected and analyzed. The objective of the analysis was to model the effects of the specific nutrition interventions studied on the specific GI cancer population. This modeling exercise consisted on identifying the cost and healthcare resource utilization implications on the GI cancer population, with the goal of determining the impact of nutrition support on reducing these costs as reflected in the summary of the evidence, and identify the maximum potential savings to the Medicare program as demonstrated by modeling the findings described in the studies if all patients with the diagnoses of GI cancers received the beneficial nutrition intervention, annualized savings were projected (24). The Medicare data Source was Avalere Health, a Washington, DC-based health policy firm who on behalf of ASPEN obtained the appropriate human participant approvals to analyze the Medicare fee-for-service Parts A and B claims 5% sample dataset according to Medicare requirements (24). These claims include information on procedures, diagnoses, and payments organized by individual beneficiary. The 5% sample is recognized as being statistically representative of the entire Medicare population and can be roughly adjusted to the full 100% population by multiplying raw results by 20 (24). Relevant ICD-10 codes were used for the different GI cancer diagnosis. For each included study, findings were applied to the defined population and savings associated with reduced adverse outcomes or healthcare resource utilization were measured [such as, shorter length of stay (LOS) or reduced complications].

Results

Evidence narrative review

The literature search of nutrition support, GI cancers, and clinical outcomes yielded 7 usable papers through 2018 and one additional trial published since then. For the value analysis modeling articles were excluded where studies reported on conditions, procedures, or populations that could not be observed in the Medicare claims data or focused on an outcome like mortality or nonspecific complications that cannot be accounted for in the Medicare claims. Other studies that compared and contrasted EN vs. PN interventions were excluded as well because this analysis was focused on the impact of singular intervention approaches (Figure 2). Table 2 summarizes the study findings relevant to this analysis. The literature is presented based on three types of nutrition interventions, ONS, EN, and PN. Patients also received nutrition in the pre-operative period, post-operative, or both. In a few studies, they also received supplemental nutrients, primarily those that have been shown to be immunomodulating, while other studies examined therapy timing with early vs. later in the post-operative period.

In reviewing the 8 studies (Table 3), the following was observed. Oral supplements including those with immunonutrition decreased hospital LOS as compared to standard care (25,26). In those receiving EN via feeding tube, those that received an enriched formula had decreased mortality rate in the short term (27). When EN was provided early in the post-operative period, LOS and hospital expenditures were decreased (27,28). When EN was compared to PN in these patients with GI cancer, several factors were examined including pre-operative EN vs. PN (29), standard EN vs. immunonutrition EN vs. PN (29,30), post-operative EN vs. PN (31) and early EN vs. early PN in the post-operative period (32). In all of these studies, EN was associated with improved clinical outcomes including better GI function, fewer post-operative complications, and shorter LOS.

Table 3
Table 3 Summary of the literature review
Full table

Value analysis

Specific cost savings from all of the reviewed literature cannot be fully ascertained as the papers do not provide specific financial data. With the reduction in complications and LOS with specific nutrition interventions, cost savings can be assumed as demonstrated in the two modeled studies below (24,26,28). See Table 4.

Table 4
Table 4 Medicare claims data modeling analysis results
Full table

Discussion

GI malignancies and impaired nutritional intake with related malnutrition has been associated with poor surgical outcomes such as infections, increased postoperative complication, prolonged hospital stays and increased readmission rates. Timely and appropriate nutrition support may improve nutrient intake, decrease risk of associated complications, and improve quality of life. Using the existing literature that specifically shows evidence that nutrition support in this population improves clinical outcomes, this Value Project demonstrated that modeling those findings using the Medicare Claims database, revealed potentially significant cost savings. Although is beyond our analysis to exhaustively review specific interventions this current research shows the potential cost savings associated with interventions and the necessity to adopt these interventions as a cost saving initiative in the care of cancer patients. In this context, value analysis for interventions such as early EN (within 48 h of surgical intervention) for patients undergoing esophagectomy for cancer, is associated with 3 to 6 day decrease in LOS (28) which corresponds to $18 million in savings, calculated as a $5,000 decrease in cost per patient treated. Value analyses also indicate that cost savings can be gained by the adoption of an ERAS bundle with immunonutrition ONS for colorectal cancer patients (26), with a decrease in LOS for patients receiving the intervention that corresponds to potential savings of $4,000 per patient, or $224 million a year for the Medicare program. This $4,000 per patient savings is similar to that reported for immunonutrition alone by Mauskopf et al. Using a national inpatient data sample, they estimated immunonutrition use resulted in $1,200 to $6,300 (2008 US dollars) hospital costs reduction per patient depending on GI cancer patient population (upper vs. lower GI) and the analysis methodology used (33).

Our cost savings estimates likely underappreciate the true impact of nutrition, as reductions in surgical complications may result in improved quality-adjusted life-years for patients that are not quantified in our analysis. Recent Washington State data demonstrated that oral immunonutrition supplements reduced average hospitalization costs by $2,500 per patient during the surgical hospitalization but continued to demonstrate value benefits after hospitalization. After 180 days, patients who received preoperative immunonutrition had overall less healthcare costs $5,300 than patients who did not (34).

Similar calculations could be performed for each of the reviewed studies with the overarching concept behind this value analysis being to provide the clinicians that are on the “front-lines” taking care of patients with GI cancers, with hard numbers that can help articulate the need for nutritional interventions for cancer patients.

Patients with GI malignancies have significant metabolic challenges and associated increased metabolic demands where the need for nutrition intervention becomes even more pronounced (4,6). A principal goal of nutrition therapy is to provide adequate calories and protein to support optimal metabolic function and immune response (4). Immunonutrients have been shown to produce remarkable effects beyond nutritional value (35,36). There is emerging consensus on the benefits associated with nutrient mixtures that include glutamine, arginine, omega-3 fatty acids, as well as nucleotides addition, used to address immune defects and improve metabolic derangements (37,38). Depleted glutamine stores may lead to severe post-surgical impediments hindering healing and increasing infectious complications. Arginine supports blood flow, protein metabolism, and wound healing while nucleotides help rebuild cells. Replicating cells support immune function and cell growth. Omega-3 minimizes inflammatory response and increases immune response by enhancing lymphocyte action, while decreased availability of nucleotides is associated with impaired T-cell function and weakened killer cell activities (37,38). These formulas of immunonutrient combinations appear to significantly improve outcomes through decreased complications, improved immune function, improved healing and decreased hospital stays (27,38,39).

Despite an abundance of literature, widespread malnutrition can be found in patients with GI malignancies (5). One of the myths that has limited more aggressive nutritional therapy in cancer patients is the concept of “feeding the cancer” (40). The misnomer that nutritional supplementation will increase tumor burden, impedes the more significant improved oncologic outcomes with the implementation of nutrition support (40,41). Another potential inhibitor of widespread adoption of immunonutrition interventions is the cost. Clinicians need to understand the cost/benefits of enhanced nutrition therapies and feel empowered to advocate for what organizations may perceive inappropriately as “expensive” therapies (24,42).

This targeted literature review and modeling analyses combined with national and international guidelines demonstrates interventions that will significantly impact cancer patient care. Translating these findings and guidelines to inventions in everyday clinical practice is critical.

Clinical application

ASPEN and ESPEN are two internationally recognized expert groups with published guidelines to assist with consistent and appropriate intervention to help ameliorate risk of malnutrition among vulnerable cancer patients (3). Current ASPEN and ESPEN guidelines cover most aspects of nutritional support therapy for patients with malignant diagnoses. These recommendations are included in Table 5 (3,41).

Table 5
Table 5 Clinical recommendations: harness the value of nutrition for patients with GI cancer
Full table

Summary

This paper demonstrates the value that nutrition support therapy provides in improving clinical outcomes in patients with GI cancers. The model creates cost savings when nutrition support is appropriately used. Clinicians caring for patients with GI cancer should always consider nutrition support as a routine therapeutic tool.

Acknowledgments

The authors would like to thank the full Value Project Scientific Advisory Council (SAC) for their support. They would also like to thank Cecilia Hofmann, PhD (C. Hofmann and Associates, Western Springs, IL, USA), and Kathryn Hennessy, MS, RN, FASPEN (KAH Healthcare Consulting, LLC) for editorial assistance, reference management, and communications advice.

Funding: Funding for the ASPEN Value Project was contributed by Nestlé Health Science, Abbott Nutrition, Cardinal Health, and B. Braun Medical, Inc.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at http://dx.doi.org/10.21037/jgo-20-326

Peer Review File: Available at http://dx.doi.org/10.21037/jgo-20-326

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (Available at http://dx.doi.org/10.21037/jgo-20-326). Dr. DCE reports grants and personal fees from Abbott Nutrition, personal fees from Coram/CVS, personal fees from Alcresta, personal fees from Fresenius Kabi, outside the submitted work. Dr. KAT serves as an employee of Nestle Health Science (Head of Medical Affairs, USA). Dr. PG reports grants from Nestlé Nutrition Institute, grants from Abbott Nutrition, grants from Cardinal Health, grants from B. Braun Medical, Inc., during the conduct of the study. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Pimiento JM, Evans DC, Tyler R, Barrocas A, Hernandez B, Araujo-Torres K, Guenter P; ASPEN Value Project Scientific Advisory Council. Value of nutrition support therapy in patients with gastrointestinal malignancies: a narrative review and health economic analysis of impact on clinical outcomes in the United States. J Gastrointest Oncol 2021;12(2):864-873. doi: 10.21037/jgo-20-326

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