Early versus late parenteral nutrition in ICU patients: cost analysis of the EPaNIC trial

Abstract

Introduction: The EPaNIC randomized controlled multicentre trial showed that postponing initiation of parenteral nutrition (PN) in ICU-patients to beyond the first week (Late-PN) enhanced recovery, as compared with Early-PN. This was mediated by fewer infections, accelerated recovery from organ failure and reduced duration of hospitalization. Now, the trial's preplanned cost analysis (N = 4640) from the Belgian healthcare payers' perspective is reported.

Methods: Cost data were retrieved from individual patient invoices. Undiscounted total healthcare costs were calculated for the index hospital stay. A cost tree based on acquisition of new infections and on prolonged length-of-stay was constructed. Contribution of 8 cost categories to total hospitalization costs was analyzed. The origin of drug costs was clarified in detail through the Anatomical Therapeutic Chemical (ATC) classification system. The potential impact of Early-PN on total hospitalization costs in other healthcare systems was explored in a sensitivity analysis.

Results: ICU-patients developing new infection (24.4%) were responsible for 42.7% of total costs, while ICU-patients staying beyond one week (24.3%) accounted for 43.3% of total costs. Pharmacy-related costs represented 30% of total hospitalization costs and were increased by Early-PN (+608.00 EUR/patient, p = 0.01). Notably, costs for ATC-J (anti-infective agents) (+227.00 EUR/patient, p = 0.02) and ATC-B (comprising PN) (+220.00 EUR/patient, p = 0.006) drugs were increased by Early-PN. Sensitivity analysis revealed a mean total cost increase of 1,210.00 EUR/patient (p = 0.02) by Early-PN, when incorporating the full PN costs.

Conclusions: The increased costs by Early-PN were mainly pharmacy-related and explained by higher expenditures for PN and anti-infective agents. The use of Early-PN in critically ill patients can thus not be recommended for both clinical (no benefit) and cost-related reasons.

Trial registration: ClinicalTrials.gov NCT00512122.

Figure 1

Cost tree (cost allocation in the form of a decision tree). Costs are allocated by studied randomly assigned treatment (first branch), by the acquisition of a new infection (second branch), and by prolonged intensive care unit (ICU) stay, defined as an ICU stay beyond 8 days (third branch). The percentages represent the proportion of patients for the entire study population in each branch. The costs in euros (EUR) represent the total costs for all patients in each branch and - between brackets - mean cost per patient. Costs reported in euros are rounded at zero decimals. Early PN, parenteral nutrition administered during the first week of critical illness when enteral nutrition is insufficient; Late PN, no parenteral nutrition administered before day 8 of critical illness.

Figure 2

Pareto chart of the costs for the total EPaNIC trial population. The histogram depicts the relative size of each cost category in comparison with the total cost. The line graph shows their cumulative contribution. Important cost drivers for total hospital stay in the EPaNIC trial population are highlighted. EPaNIC, Impact of Early Parenteral Nutrition completing enteral nutrition In Critical illness; PD, per diem.