Clinical nutrition: The view from Europe
2
OUTCOMES RESEARCH Nutrition Vol. 12, No. 4, 1996 GUEST EDITORS: ANN COBLE VOSS, PHD, RD Manager, Outcomes Research Ross Products Division Columbus, Ohio, USA SIMON ALLISON, MD, FRCP Consultant Physician Department of Medicine Queens Medical Centre Nottingham, United Kingdom Clinical Nutrition: The View From Europe SIMON ALLISON, MD, FRCP From Department of Medicine; University Hospital, Queens Medical Centre, Nottingham, UK In my last column,’ I mentioned that I had invited a number of colleagues throughout Europe to contribute reviews of outcome research in their own particu- lar field. It will be some time before these come through, but I thought it would be of interest to subscribers to Nutrition to know the subjects I hope to cover in fu- ture issues. I have invited contributions from colleagues in France and the United Kingdom concerning home parenteral and enteral nutrition in both adults and children. The centralised services in France means that colleagues in Paris and Montpellier, in particular, have umi- valled experience in the field of home parenteral nutrition and have important data concerning longevity, quality of life and the complications and costs of this technology. A national register for those on home parenteral nutrition was estab- lished by the Salford group in the United Kingdom. This and the national register for home enteral nutrition established 4 years ago by the British Dietetic Associ- ation have now been brought under the umbrella of the British Association of Parenteral and Enteral Nutrition and re- designed to give cumulative data on both process and outcome over the next few years. I have invited a review concerning national registers and their importance. The Italian Society of Parenteral and Enteral Nutrition also carried out im- portant audits of both inpatient and home nutritional support, and I have invited colleagues there to report on this. The role of nutrition teams is controversial. Nutrition 12:287-288, 1996 OElsevier Science Inc. 1996 Printed in the USA. All rights reserved. There is a school of thought that says that they are now out of date, since individual departments, such as bum units and renal units, have their own teams. Others maintain that this is a dangerous turning back of the clock. I have invited an arti- cle to address this controversy from the European view. Significant studies have appeared in the European literature con- cerning nutrition in the elderly, perioper- ative nutritional support, the role of nu- trition in respiratory and renal disease and in intensive care. The involvement of schools of busi- ness administration in operational health research is symptomatic of the growing importance of the subject of health eco- nomics. Two recent studies by Master of Business Administration students at Lancaster University, United Kingdom, were sponsored by Nutricia Clinical Care. The first of these,* published in 1994, addressed the question of nutri- tional support teams and why so few hos- pitals in the United Kingdom have them. Payne-James and colleagues3 showed that despite the overwhelming evidence that nutrition teams improve patient se- lection and outcome and reduce morbid- ity and costs, only 27% of UK hospitals had access to a nutrition support team or advisory group in 1988. A repeat survey in 1991 4 showed that this figure had risen to 32.5%. Despite the findings of the King’s Fund Centre Report published in 1992, entitled “A positive approach to nutrition as treatment,’ ’ 5 a further survey undertaken in 19936 showed that the ELSEVIER number of hospitals with access to nutri- tion support teams had risen to only 37.3%. The importance of nutrition teams in determining outcome from nutritional support will be addressed in a future review in this section. The first of the Lancaster studies addressed the factors inhibiting the implementation of more ef- fective management of clinical nutrition. It argued, among other things, that if ef- fective nutritional support reduces length of hospital stay, the hospital’s hotel costs but not treatment costs are reduced, allowing either closure of beds or rede- ployment of beds for other purposes. The students conducted 76 telephone inter- views with personnel in UK hospitals and identified the main barriers to imple- mentation of the King’s Fund Report rec- ommendations as the doctors rather than the managers. They found that, whereas management was amenable to arguments concerning cost effectiveness, the doc- tors lacked awareness, interest and time. They found that conflicts of interest and differing perspectives were also im- portant. Doctors were reluctant to release the care of their patients and to share their clinical decision-making authority with others, such as dietitians or nutrition nurses. It was clear from this that much remained to be done to educate doctors that malnutrition worsens outcome and that intervention is not only effective but cost-effective. It was also evident that, even though colleagues may be con- vinced of the benefits of nutritional sup- 0899-9007/96/$15.00 PII: SO899-9007(96)00086-X
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Transcript of Clinical nutrition: The view from Europe
OUTCOMES RESEARCH Nutrition Vol. 12, No. 4, 1996
GUEST EDITORS:
ANN COBLE VOSS, PHD, RD Manager, Outcomes Research
Ross Products Division Columbus, Ohio, USA
SIMON ALLISON, MD, FRCP Consultant Physician
Department of Medicine Queens Medical Centre
Nottingham, United Kingdom
Clinical Nutrition: The View From Europe SIMON ALLISON, MD, FRCP
From Department of Medicine; University Hospital, Queens Medical Centre, Nottingham, UK
In my last column,’ I mentioned that I had invited a number of colleagues throughout Europe to contribute reviews of outcome research in their own particu- lar field. It will be some time before these come through, but I thought it would be of interest to subscribers to Nutrition to know the subjects I hope to cover in fu- ture issues. I have invited contributions from colleagues in France and the United Kingdom concerning home parenteral and enteral nutrition in both adults and children. The centralised services in France means that colleagues in Paris and Montpellier, in particular, have umi- valled experience in the field of home parenteral nutrition and have important data concerning longevity, quality of life and the complications and costs of this technology. A national register for those on home parenteral nutrition was estab- lished by the Salford group in the United Kingdom. This and the national register for home enteral nutrition established 4 years ago by the British Dietetic Associ- ation have now been brought under the umbrella of the British Association of Parenteral and Enteral Nutrition and re- designed to give cumulative data on both process and outcome over the next few years. I have invited a review concerning national registers and their importance.
The Italian Society of Parenteral and Enteral Nutrition also carried out im- portant audits of both inpatient and home nutritional support, and I have invited colleagues there to report on this. The role of nutrition teams is controversial.
Nutrition 12:287-288, 1996 OElsevier Science Inc. 1996 Printed in the USA. All rights reserved.
There is a school of thought that says that they are now out of date, since individual departments, such as bum units and renal units, have their own teams. Others maintain that this is a dangerous turning back of the clock. I have invited an arti- cle to address this controversy from the European view. Significant studies have appeared in the European literature con- cerning nutrition in the elderly, perioper- ative nutritional support, the role of nu- trition in respiratory and renal disease and in intensive care.
The involvement of schools of busi- ness administration in operational health research is symptomatic of the growing importance of the subject of health eco- nomics. Two recent studies by Master of Business Administration students at Lancaster University, United Kingdom, were sponsored by Nutricia Clinical Care. The first of these,* published in 1994, addressed the question of nutri- tional support teams and why so few hos- pitals in the United Kingdom have them. Payne-James and colleagues3 showed that despite the overwhelming evidence that nutrition teams improve patient se- lection and outcome and reduce morbid- ity and costs, only 27% of UK hospitals had access to a nutrition support team or advisory group in 1988. A repeat survey in 1991 4 showed that this figure had risen to 32.5%. Despite the findings of the King’s Fund Centre Report published in 1992, entitled “A positive approach to nutrition as treatment,’ ’ 5 a further survey undertaken in 19936 showed that the
ELSEVIER
number of hospitals with access to nutri- tion support teams had risen to only 37.3%.
The importance of nutrition teams in determining outcome from nutritional support will be addressed in a future review in this section. The first of the Lancaster studies addressed the factors inhibiting the implementation of more ef- fective management of clinical nutrition. It argued, among other things, that if ef- fective nutritional support reduces length of hospital stay, the hospital’s hotel costs but not treatment costs are reduced, allowing either closure of beds or rede- ployment of beds for other purposes. The students conducted 76 telephone inter- views with personnel in UK hospitals and identified the main barriers to imple- mentation of the King’s Fund Report rec- ommendations as the doctors rather than the managers. They found that, whereas management was amenable to arguments concerning cost effectiveness, the doc- tors lacked awareness, interest and time. They found that conflicts of interest and differing perspectives were also im- portant. Doctors were reluctant to release the care of their patients and to share their clinical decision-making authority with others, such as dietitians or nutrition nurses. It was clear from this that much remained to be done to educate doctors that malnutrition worsens outcome and that intervention is not only effective but cost-effective. It was also evident that, even though colleagues may be con- vinced of the benefits of nutritional sup-
0899-9007/96/$15.00 PII: SO899-9007(96)00086-X
288 OUTCOMES RESEARCH
port, they are unclear about how to obtain funding to implement a proper service within their institution.
In a second study carried out in 1995,’ 16 studies from the world litera- ture on the effect of nutritional support and/or nutrition support teams in reduc- ing length of hospital stay were re- viewed. It was concluded that there was a substantial body of literature supporting this relationship. A cost model was de- scribed in which the initial implementa- tion costs of a nutrition support service were offset against long-term cost sav- ings due to improved outcome and de- creased hospital stay. The mechanisms whereby funding could be obtained for this service were then analysed. It was believed that although priming funds could be obtained from a number of “soft money” sources, such as research and development funds, audit funds, and
so on, the main effort should be directed at putting a strong case directly to pur- chasers of health services. In the case of the United Kingdom, this is the District Health Commissions and General Prac- titioner fundholders. By this means, ap- propriate contracts can be obtained and the provider units (i.e., the hospitals) can obtain the funds to develop nutritional support services in a well-organised and appropriately audited manner. Health service managers are demanding that doctors practice evidence-based medi- cine. We have nothing to lose by asking for evidence-based management as well.
REFERENCES 1. Allison S. Recent outcomes research in Brit-
ain. Nutrition 1996; 12:133 2. The Management of Clinical Nutrition in
NBS Hospitals. Lancaster University Full- Time MBA Project 1994. Report obtainable
from Burson-Marsteller, 24-28 Bloomsbury Way, London WC1 2PX. Reoort obtainable from Burson-Marsteller, 24-28 Bloomsbury Way, London WC1 2PX.
3. Payne-James JJ, De Gara CJ, Grimble GK, et -al. Nutritional support in hospitals in the United Kinadorn-1988: National Survev. Health Trends 1990,22:9.
4. Payne-James JJ, De Gara CJ, Grimble GK, et al. Artificial nutrition support in hospitals in the United Kingdom-1991: Second Na- tional Survev. Clin Nutr 1992: 11: 187
5. King’s Fund Centre Report. .Itu Lennad
Jones JB, ed. A positive approach to nutrition as treatment. London: King’s Fund Centre, 1992.
6. Payne-James JJ, De Gara Cl, Grimble GK, et -al. Artificial nutrition support in hospitals in the United Kingdom-1994: Third Na- tional Survey. ClinwNutr 1995; 14:329 Financial Issues for Clinical Nutrition in NI-IS Hospitals. Lancaster University Full-Time MBA Project 1995. Report obtainable from Burson-Marsteller, 24-28 Bloomsbury Way, London WC1 2PX.
7.
