Artificial Nutrition Support Home Parenteral Nutrition and Home Enteral Tube Feeding

Patients suffering from chronic conditions often prefer to be treated in the familiar surroundings of their home rather than in hospital. When the treatment involves sophisticated techniques, it is essential that either the patient or the caregiver is adequately trained to distinguish between problems that can be easily remedied at home and those that need expert advice and treatment in hospital. With the increasing pressure for hospital beds and the increasing cost of hospital care, many forms of treatment that were previously restricted to the hospital environment have extended to the community, including renal dialysis, cytotoxic drug therapy, HETF, and HPN. HETF has grown rapidly so that its prevalence in several developed countries is now several times greater than in hospital. In contrast, PN is still practiced less commonly outside hospital than in hospital and is likely to remain so in the foreseeable future. Both forms of treatment have led to the development of professional teams specialising in nutritional support in both the hospital and the community. These teams deal with problems ranging from simple day-to-day management issues to difficult ethical problems, such as concerning withholding or withdrawing nutritional support.

Origins and Development

The first report of HPN appeared in 1970 in North America, and in Europe the first reports appeared in the late 1970s. The number of people receiving HPN has increased considerably since then but remains substantially lower than for HETF (Figure 2).

HETF is a much older technique than HPN, with the first reports appearing centuries ago. Accurate information on the numbers of people receiving HETF is difficult to obtain because HETF tends to be initiated from many centres and centralized reporting and record keeping in most countries are not fully established. There has been rapid growth in HETF attributable to developments in tube technology (flexible fine bore tubes) and endoscopic procedures for placement of gastrostomy tubes (facilitating easier initiation and management of long-term feeding), as well as the development of home care services provided by commercial enteral

30 000 25 000

5000 0

30 000 25 000

5000 0

1985 1992 1996 1997 1998 1999 2000 2002 2003 Year

Figure 2 Estimated growth in point prevalence (amount of feeding taking place at a given point in time) in home enteral tube feeding (HETF) and home parenteral nutrition (HPN) in the United Kingdom.

feeding companies. In many developed countries there is considerably more ETF taking place in the community than in hospital. In Britain, there continues to be steady growth (10-20% per year) in the numbers of people receiving HETF, and in 2003, 21 527 people were registered with the British Artificial Nutrition Survey (BANS), with an estimated total number receiving HETF in excess of 25 000. As with HPN, HETF is less common in Europe than in North America and is practised much less in Eastern Europe, India, and China than in industrialized Western countries.

In addition to the differences in prevalence of HETF and HPN between countries, there may also be marked variations within countries. Even within one region of the United Kingdom (south and west regions) the number of individuals receiving HETF in 2002 within different primary care trusts varied from 82 to 632 per 1 million people. Similarly, considerable variation in the point prevalence of HPN was found to exist in different regions of the United Kingdom in 1999 (0 to 36per 1 million). This large variation, which is unlikely to be due to chance, can be explained by variations in the availability of expertise and support staff, resources to fund such treatment, or local differences in attitudes/policies toward the use of artificial nutrition.

The wide variations in the prevalence of home artificial feeding throughout the world are related to health care economies. There is a relationship between expenditure on health care, as a percentage of gross domestic product (GDP), and the incidence of HPN and HETF. In India, Pakistan, and Africa, where spending on health is low, home artificial nutrition is less common. In Western Europe, where health care accounts for a greater proportion of GDP, home artificial nutritional support is more common. In the United States, with an even greater expenditure on health care, the prevalence of HPN and HETF is higher than anywhere else in the world.

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