CLINICAL ECONOMICS REVIEW - NUTRITIONAL SUPPORT

Nutritional support currently accounts for about 1% of the total healt h care costs in the USA. Interestingly, most of the prospective random ized controlled trials to date have not been able to demonstrate that this therapeutic intervention alters morbidity or mortality. In fact, parenteral nutritional support may predispose the recipients to develo ping systemic infections. There have been a few areas in which nutriti onal support may be of benefit. Enteral supplements given to underweig ht women who suffer hip fractures reduce the hospital stay and, presum ably, overall cost. Preoperative parenteral nutritional support may pr oduce a small absolute reduction in post-operative morbidity, but its cost becomes prohibitive. Preoperative enteral nutritional support, es pecially if carried out in the home, may be of benefit (using the most optimistic interpretation of a small number of trials); if so, it is an economically defensible intervention. Particular nutrients or diets may have specific effects on certain disease processes. Indirect comp arisons have suggested that elemental diets can be used to treat flare s of Crohn's disease (perhaps because putative food antigens are remov ed). However, corticosteroid therapy is more efficacious. Furthermore, it is less expensive to employ 6-mercaptopurine as the next modality in steroid failures. Branched-chain amino acid infusions may have some effect on hepatic encephalopathy, but again, lactulose is less expens ive. Nutritional support is one area of medicine in which there has be en far more enthusiasm than the data justify. Disease-associated malnu trition probably is a secondary phenomenon, not an important cause of morbidity. The widespread use of this modality cannot be justified in a cost-constrained health care system.