Economics of home parenteral nutrition.

The past 30 years have seen long term parenteral nutrition evolve from a novel technique to an accepted intervention for gastrointestinal failure. The development of home parenteral nutrition (HPN) has parallelled a shift in resources from hospital to community care and has been driven by technological advances, the growth of commercial home care companies and patient choice. Costs for HPN per patient year have been estimated to range from $US 150,000 to $US 250,000 in the US, and are around 55,000 pounds in the UK, perhaps only 25 to 50% of in-hospital costs. In the absence of any alternative treatment for many patients with gastrointestinal disease, parenteral nutrition is life saving and offers the prospect of maintaining a good quality of life. The cost of 1 quality-adjusted life-year for HPN has been estimated as 69,000 pounds in the UK (1995 values), and $Can 14,600 in Canada (1984 values), making HPN relatively cost effective compared with other ways of spending money to improve health. HPN is also given to patients in whom life expectancy is unlikely to be influenced, such as those with cancer or AIDS. Although there is considerable heterogeneity between countries in the proportion of HPN patients with a particular disease, malignancy is now the single most common indication. HPN can be expected to improve quality of life over a short period of terminal care, and whilst a strong case can be made for use of HPN in some of these patients, its use has not been subjected to detailed medical or economic appraisal.