Cost-Effectiveness of Parenteral Nutrition: A Systematic Literature Review

Management of patients with disease-related malnutrition imposes a significant economic burden to societies worldwide. Parenteral nutrition (PN) is a commonly applied feeding route in severely malnourished cancer patients and those with intestinal failure. This study aimed to establish cost-effectiveness of PN based on the systematic review and qualitative synthesis of published evidence. Literature review was performed in PubMed/Medline and Tufts registry for economic evaluations published since 2000 through 2017 using terms related to PN and economic evaluations. Full economic evaluations that assessed PN in malnourished adults published in English were included. Two independent reviewers performed the screening and data extraction using the 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement for quality assessment. Forty-seven potentially relevant articles were found, with 12 satisfying predefined inclusion criteria. The studies evaluated different PN protocols (n=7), PN compared to enteral nutrition (EN) (n=3), intestinal transplantation (n=1), and no treatment (n=1). Most studies were cost-effectiveness analyses (n=8) from a healthcare provider perspective (n=4) analyzing context of European (n=5) or East Asian (n=4) countries. Nine studies were model-based economic evaluations with five of them applying discrete event simulation. Only two studies reported cost per quality-adjusted life year. Study population consisted of predominantly critically ill patients. When compared to EN, PN was a dominated alternative. Certain PN formulations (omega-3 lipids, glutamines or structured triglyceride-based emulsions) appeared to be cost-effective when compared to standard PN. The CHEERS assessment resulted in total score of 15.8 (SD=4.23), with a lack of reports on discount rates, heterogeneity and uncertainty characterization. The heterogeneity of treatments and populations and limited quality of evidence, precluded definite conclusions regarding the cost-effectiveness of PN. The present evidence gap in the care of malnourished adults highlights the need for further economic evaluations, to better enable healthcare stakeholders making informed, cost-effective treatment decisions.