OUTCOMES RESEARCH Nut&ion Vol. 12, No. 9, 1996

GUEST EDITORS:

ANN COBLE VOSS, PHD, RD Manager, Outcomes Research and

Long Term Care Services Ross Products Division

Abbott Laboratories Columbus, Ohio, USA

SIMON ALLISON, MD, FRCP Consultant Physician

Department of Medicine Queens Medical Centre

Nottingham, United Kingdom

View From Eastern Europe SIMON ALLISON, MD FXCP

From the Department of Medicine, Queen’s Medical Centre, Nottingham, UK

With the new political freedoms of the last few years there has been a release of energy in all aspects of life. On a re- cent visit to the Czech Republic, I was impressed by the signs of renewal every- where: the rebuilding of the infrastruc- ture, the refurbishment of housing, and developments in medicine and science. As well as attending the Czech Society of Parenteral and Enteral Nutrition, I had the opportunity to visit Professor Zdenek Zadak in Hradec Kralove, the first unit in the Czech Republic to develop a nutri- tional support service. I also visited Dr. Zdenek Rusavy in Pilsen, and talked with Dr. Michal Andel from Prague. They are developing nutritional support services and undertaking research work of a high standard with an enthusiasm and com- mitment that was most impressive.

The Czech Republic shares with other countries all the problems of health eco- nomics. Their reimbursement system was initially rather cumbersome, with money being taken at source from in- come and with employer contributions paid to over 20 different insurance com- panies who administered the reimburse- ment for health care. This resulted in a very high percentage of funds being taken up with administration and a smaller percentage available for patient care. This process is being modified, and no doubt after the current election there will be further changes. This structure meant that doctors had to negotiate reim- bursement contracts with a large number

Nutrition 12547-648, 1996 QElsevier Science Inc. 1996 Printed in the USA. All rights reserved.

of purchasers and to demonstrate the cost effectiveness of any proposed new ser- vices before they could be funded. De- spite the fact that the first patient was treated with home parenteral nutrition in 1987, it was only 2 y ago that reimburse- ment could be obtained for this service. In contrast, they are still negotiating for finance to treat patients requiring home enteral nutrition. Within hospitals there is a similarly mixed picture. Reimburse- ment is available for parenteral nutrition on the general wards but not in the inten- sive care unit. Our colleagues in the Czech Republic have used results of out- comes research from the rest of Europe and the United States to argue their case, but have realised the importance of carrying out their own work in this field to establish their services on a proper footing.

The Czech Society of Parenteral and Enteral Nutrition was created 8 y ago, and one of its projects has been to sup- port a register of patients on home nutri- tional support. Reports are made from all parts of the country to Michal Andel’s group in Prague, who input the informa- tion on a national data base. This has allowed them to highlight areas of the country where there is underprovision of service and has also allowed them to be- gin to monitor the quality of the services provided. They currently have 20 pa- tients on home parenteral nutrition and 80 on home enteral nutrition, although these numbers are growing fast. One

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would expect that, because the total pop- ulation is 10 million, and the rest of Europe has 4-5 patients per million of population on home parenteral nutrition, their numbers will double in the next 5 Ye

Doctor Bures and colleagues from Hradec Kralove have carried out a qual- ity-of-life study on patients receiving home enteral nutrition by continuous na- sogastric tube feeding for mainly gastro- intestinal problems. Using WHO quality of life criteria, they studied the patients before treatment and again after a mean of 1 y upon beginning such nutritional support; they obtained an 80% response rate to their enquiries. On a 7-point scale from -3 to +4, the score increased from an average of -2 pretreatment to +2.5 after treatment for 1 y. Dr. Tesinsky from Pilsen reported a study of enteral nutri- tion in 50 patients developing pancreatic pseudocysts after the acute phase of pan- creatitis. Previous practice had included total parenteral nutrition (TPN) for a pe- riod of 18 d. Using 29 historical controls treated in this manner, Tesinsky’s group studied a further 64 patients treated with enteral nutrition. Twelve of these pa- tients were withdrawn from the study as they required surgery, but 52 completed the study using mainly nasojejunal tubes. The polyurethane or silicone tubes were of Czech design, with small umbrella projections that appear to enhance their spontaneous progress from the stomach into the jejunum beyond the ligament of

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Treitz. By this means, stimulus to the pan- creas was avoided, and delayed gastric emptying was bypassed. Fourteen patients were sent home on this treatment, which was wntinued for a mean of 29 days. In both the historical controls receiving TPN and the patients treated enterally, there was resolution of pseudocysts from an average

of 5.8 cm to 1.5 cm in diameter. None of the 52 patients required surgery. This compares with a reported spontaneous resolution of pseudocysts in this group in the region of 20%. Although them was no difference in outcome between those treated with enteral and those treated with TPN, the fact that such patients could be treated equally well

VIEW FROM EASTERN EUROPE .

with the safer and cheaper method, and some even allowed home on treatment, meant a considerable saving in costs.

These studies illustrate the remarkable progressthathasbeenmadeinthelast5y in one wuntty in Eastern Europe that is now experiencing the problems of provid- ing evidence-based medicine.