Introduction Immunonutrition (IN) containing arginine has been demonstrated to decrease complications as well as length of hospital stay in surgical patients in numerous meta-analyses of randomised clinical trials (Drovers et al 2011; Cerantola et al 2011). Its impact on hospital costs has already been assessed in gastrointestinal (GI) cancer surgery based on Swiss, US, Italian and German hospital costs (Mauskopf et al 2011; Chevrou-Séverac et al 2011; Braga et al 2005; and Senkal et al 1999). The objective of this study is to assess whether IN is a cost-effective option in hospitals of the British National Health System (NHS) for upper GI cancer patients undergoing surgery.
Methods Based on the Cerantola et al (2011) meta-analysis, the RR of complications of IN vs control were computed. Hospital cost and length of hospital stay (LOS) of upper GI cancer patients undergoing major surgery were retrieved from the HRG (healthcare resource group) database of 2010. Then an average cost per stay for patients presenting with post-surgical complications and without were computed. Two approaches to compute the difference in costs per patient were performed: one based on cost of stay related to the LOS of patients of each group (IN vs control); and another based on a weighted cost of stay link to the rate of patients with and without complications of each group.
Results The RR of complications was 0.69 (95% CI 0.58 to 0.83) for pre-operative use of IN, demonstrating a decrease in post-operative risk of complications due to the use of IN. When running cost-effectiveness analysis, the NHS recommends using the average cost per day of £675. This value was used into the LOS approach. The HRG costs of stay were calculated for different upper GI cancers (oesophagus, small intestine, stomach, duodenum, liver and pancreas) and different level of complications, ranging from £968 to £2395 per hospital stay. When considering the LOS approach, £1585 were saved per patient-stay. When considering the complication approach, savings reached £176 per patient for patients with oesophagus cancers, £201 for stomach and duodenum cancers, £394 for small intestine cancers, and £608 for pancreas cancer.
Conclusion Costs of IN are more than offset by the savings linked to decrease in LOS and to avoided costs of treatment for complications. Thus, as in the USA, Switzerland, Italy and Germany, in the NHS hospital setting, IN is a cost-effective and cost-saving nutritional intervention.
Competing interests H Chevrou-Severac Employee of: Nestle Health Science, L Weijers Consultant for: Nestle Health Science, I Eijgelshoven Consultant for: Nestle Health Science.
References 1. Cerantola, et al. Immunonutrition in gastrointestinal surgery. Br J Surg 2011;98:37–48.
2. Drover JW, et al. Perioperative use of arginine-supplemented diets: a systematic review of the evidence. J Am Coll Surg 2011;212:385–99, 399.e1.