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| Journal of the New Zealand Medical Association,
17-October-2008, Vol 121 No 1284
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Benchmarking home parenteral nutrition in Scotland
and New Zealand: disparities revealed
Lyn Gillanders, Janet Baxter, Patrick Ball, Arend Merrie,
Ruth F McKee
Home parenteral nutrition (HPN) is a low-volume
high-expenditure treatment which allows some patients with inadequate intestinal
function or an inaccessible intestinal tract to sustain nutritional and fluid
status while remaining at home.1 Monitoring
characteristics, standards of care, and outcomes of HPN patients varies
worldwide with some European centres maintaining comprehensive ongoing records
through to no national reporting in other countries with similar health
standards.2
The Scottish Home Parenteral Nutrition Managed Clinical
Network (SHPNMCN) has been in existence since 2000 and has maintained an HPN
register as part of its activities.1 The New
Zealand (NZ) register was started in 2004 as part of an initiative by the
Australasian Society of Parenteral and Enteral Nutrition (AuSPEN) to develop an
Australasian HPN register.3
The AuSPEN Register was developed in conjunction with the
SHPNMCN to allow annual benchmarking. The NZ portion of the register obtained
ethical approval in NZ for patients to consent to annual data collection.
Early comparison of register data between NZ and Scotland
revealed that patient numbers were much greater in Scotland. This survey was
designed to see if underlying diseases leading to provision of HPN were
different between Scotland and NZ.
MethodHPN registers for Scotland and NZ were examined early
in 2006 for patients who received HPN in each country during 2005 together with
the indications for provision of HPN.
To allow direct comparison rates of utilisation, the
underlying diseases were mapped to the relevant
ICD-104 diagnostic classification for digestive
diseases. Although both registers include children only adults (18years and
over) were included in this analysis.
ResultsRates of provision of HPN in 2005 were much higher in
Scotland (71 patients vs 14 patients) as shown in Table 1.
Table 1. Rates of provision of home parenteral
nutrition (HPN) in Scotland vs New Zealand
The diagnostic categories for the 2005 HPN patients were
similar in both countries (Figure 1)
Figure 1. Comparison of the diagnostic
categories between Scotland and New Zealand (NZ) HPN patients
 DiscussionThere is wide variation in practice throughout the world in
relation to patient selection for HPN. Within Scotland and NZ patient referral
patterns appear to be inconsistent. Some regions in both countries have very few
HPN patients. This variation may reflect availability of treatment as well as
differences in prevalence of diseases such as Crohn’s disease in different
areas.
The prevalence of HPN patients in the UK as a whole is
approximately 5/million, although this is probably under-reported according to
the British Artificial Nutrition Survey (BANS)
Register.5 The BANS Register also shows that
the prevalence of HPN patients in Scotland is similar to regions in the United
Kingdom which have recognised intestinal failure units. The UK prevalence varies
from 6.2/million to 16.2/million patients. In Scotland the prevalence is
14/million5 and in NZ it is
3.4/million.3
The requirements for the safe delivery of HPN have been
outlined both by the National Institutes for Clinical
Excellence6and the
SHPNMCN.1 Patients should be supervised in
units where there is experience in the management of HPN, as well as knowledge
and experience in the management of intestinal failure. Units providing this
service should have a nutrition support team with at least a clinician,
pharmacist, specialist nurse, and dietitian.
The widespread geographical areas of Scotland and NZ make it
difficult for patients to travel to recognised centres of expertise for their
treatment and some large centres have developed outreach services including
protocols and standards of care. When the NZ arm of the Australasian HPN
register was established, the SHPNMCN was recognised as a model with established
expertise in collection and publication of standards of care and HPN
protocols.
Scotland and NZ have similar public health systems,
demographics, and population (Table 2). In addition, in NZ the Health
Practitioners Competency Assurance Act (2004) introduced the ‘comparable
health system’ path to registration of medical practitioners—a list
of 22 countries (including Scotland) regarded as similar to NZ on indicators
such as life expectancy and infant mortality.7
The similar population sizes in each country together with these other factors
thus make inter-country benchmarking for a specialist service such as HPN a
reasonable process, particularly from the NZ perspective.
Table 2. Demographics compared: New Zealand and
Scotland
The diagnostic categories for the 2005 HPN patients were
similar in both countries and are also broadly similar to some other European
countries according to older data in a survey preformed by the ESPEN-HAN group
between December 1998 and March 1999.10 Nine
centres in five European countries participated in this study including only
patients with benign diseases who had been receiving HPN for at least 2 years.
This survey included 228 adult patients including 141 females and 87 males, with
a median age of 49 (19–92) years. The underlying conditions were:
Crohn’s disease was the leading
diagnostic category for both Scotland and NZ, although the small numbers in NZ
make this a more uncertain conclusion. The nature of Crohn’s disease can
lead to many surgical resections and thus intestinal failure as a result of
short bowel syndrome.11 Some studies have
reported an incidence of short bowel syndrome associated with Crohn’s
disease of between 0.1 and 4%.12,13
Inflammatory bowel disease, especially Crohn’s disease
has increased greatly over the last 50 years. It was estimated recently that the
incidence of Crohn’s disease was 0.7–14.6 per 100,000 population in
Europe and North America.14 A recent survey in
NZ has shown that Crohn’s disease incidence and prevalence in the
Canterbury region are amongst the highest ever
reported.15 Scottish data is
older16 but the pattern appears similar in the
north-eastern region of Scotland (Table 3). A more recent review of
Crohn’s disease in the east of Scotland confirms this
data.17
There are large differences in the rates of provision
between Scotland and NZ which are difficult to explain on the basis of
demographics, healthcare systems, and population. Crohn’s disease is most
likely the leading cause of intestinal failure in both countries and the
prevalence and incidence is high in both countries. Whilst enteral feeding is a
common method of nutrition support it is not a successful means of support in
the setting of intestinal failure and therefore cannot account for the disparity
seen. Thus the indications are similar and in comparison with other European
countries such as Italy18 provision of HPN for
cancer is rare.
Table 3. Comparison of point prevalence of
Crohn’s disease
On this basis, it would be reasonable to assume that HPN use
should be similar, particularly for Crohn’s disease. These results lead to
the question of whether there is over-utilisation of HPN in Scotland or
under-utilisation of HPN in New Zealand.
This is not a straightforward question to answer. The
Scottish HPN network has adhered well to guidelines about patient selection for
HPN.19 The prevalence of HPN in Scotland is
also similar to that in the areas around the two large intestinal failure
centres in England and Wales.5
Although it may be that the lower prevalence in New Zealand
is due to more emphasis on enteral feeding, it is possible that there is
under-utilisation of HPN in New Zealand. This might be due to a lack of
recognition of the indications for HPN, conservative attitudes on the part of
clinicians or under-resourcing of nutrition support and nutrition support teams.
Conclusions:
Despite similar demographics, healthcare systems, and
population size, HPN is utilised to a significantly lesser extent in NZ compared
to Scotland. The reasons for this difference are not clear. There may be
different rates of the underlying indications for HPN although they are similar
for Crohn’s disease.
It is possible that there is lack of recognition of the need
for HPN and/or under provision of HPN, which may lead to poorer treatment
outcomes for New Zealanders. Ongoing prospective registration of HPN cases and
benchmarking with networks such as the SHPNMCN will clarify this situation
further.
Competing interests: None known.
Author information: Lyn Gillanders, Senior
Clinical Dietitian, Nutrition Services, Auckland City Hospital, Auckland, New
Zealand; Janet Baxter, Network Manager and Dietitian, Scottish HPN Managed
Clinical Network, Ninewells Hospital, Dundee, Scotland; Patrick Ball, Foundation
Professor of Pharmacy, Charles Sturt University, Wagga Wagga, NSW, Australia;
Arend Merrie, Consultant Colorectal Surgeon, Auckland City Hospital, Auckland,
New Zealand; Ruth F McKee, Consultant Colorectal Surgeon, Glasgow Royal
Infirmary, Glasgow, Scotland
Correspondence: Lyn Gillanders,
Senior Clinical Dietitian, Nutrition Services,
Private Bag 92024, Auckland Mail Centre,
Auckland 1142, New Zealand. Fax: +64 (0)9 3775075;
email: lynng@adhb.govt.nz
References:
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