Hip fracture patients are now routinely cared for by hospitalists with orthopedic consultation. Demographically, these patients tend to be elderly and frail with multiple medical comorbidities. Much has been published about minimizing the use of feeding tubes in this demographic, specifically in individuals with advanced dementia, and hospitalists have wisely begun to avoid placement of percutaneous feeding tubes in end of life patients. However, these recommendations have unintentionally influenced use of temporary feeding tubes in patients with acute issues who are otherwise receiving full medical treatment, resulting in inappropriate withholding of enteral nutrition. Since inadequate inpatient nutrition is itself shown to worsen clinical outcomes, this has the potential to negatively impact patient outcomes, length of stay and overall cost of care.
To explore the quality and financial impact of withholding temporary assisted enteral nutrition, a retrospective cohort study was conducted of 100 sequential hip fracture patients at a community‐based tertiary care center in Salem, OR. The outcome considered was average length of stay (ALOS) with the exposure length of post‐operative time without enteral nutrition. Means and relative risk were calculated with 95% confidence intervals. Financial analyses were conducted using publically available data on Medicare DRG reimbursement, and published estimates on hospital cost of care for hip fracture patients and daily costs of enteral nutrition.
The overall ALOS for this population of hip fracture patients was 4.78 days (4.35‐5.21, 95% CI) with an average age of 83.03. Length of stay for patients who received no enteral nutrition for more than 1 day post‐operatively was 7.67 (5.80‐9.54, 95% CI) with an average age of 85.63; for patients receiving enteral nutrition within 24 hours of surgery, the ALOS was 4.43 (4.05‐4.81, 95% CI). The relative risk for prolonged hospital stay (ALOS≥5) if enteral nutrition was delayed was significantly increased at 4.14 (1.76‐14.59, 95% CI). Mortality in the delayed enteral nutrition group was 18% compared to 9% in those who received early nutrition although sample sizes were too small to draw meaningful conclusions.
With an average daily estimated cost of inpatient care of $4,530 and enteral nutrition via nasogastric tube of $34.40, the potential savings with early initiation of enteral nutrition is enormous. Given an ALOS of 7 days without intervention, an early 3‐day trial of enteral nutrition could save the hospital between $2,939 and $12,065 for ALOS reduction of 1‐4 days, respectively. Assuming a utility of 100%, the cost per outpatient day gained for the patient varies from $25‐$100 for a range of 4 to 1 days gained. If early enteral nutrition is responsible for the reduction in ALOS, less than a tenth of a cent is spent to garner one dollar in reduced inpatient costs.
Early initiation of enteral nutrition can potentially provide significant financial benefit to the hospital by reducing ALOS while potentially improving outcomes for the patient. The daily cost of enteral nutrition is approximately $30‐35 and, as demonstrated above, is remarkably cost‐effective even if it reduces LOS by only one day. The most compelling limitation of this study is that association does not demonstrate causality. A randomized clinical trial would be appropriate to determine whether early enteral nutrition in patients unable to effectively take PO would indeed reduce ALOS.
To cite this abstract:Wallace C. Outcome and Cost Ramifications of Delayed Enteral Nutrition and Medications in Hip Fracture Patients. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 144. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/outcome-and-cost-ramifications-of-delayed-enteral-nutrition-and-medications-in-hip-fracture-patients/. Accessed May 26, 2019.