Gestión de la nutrición enteral: factores clave en las mejores guías de práctica clínica y brechas en su aplicación / Enteral nutrition management: key factors and application gaps in the best clinical practice guidelines

Introducción: Una adecuada práctica clínica en soporte nutricional requiere de recomendaciones basadas en la mejor evidencia disponible, para apoyar a los profesionales en salud en la toma de aquellas decisiones concernientes al manejo del soporte nutricional enteral en las patologías de interés. Objetivo: Identificar los factores clave en la gestión de la nutricion enteral para prevenir y tratar la malnutrición a partir de las recomendaciones establecidas en las mejores Guías de Práctica Clínica (GPC). Métodos: Se realizó una búsqueda estructurada de las GPC en soporte nutricional. La selección de las guías se llevó a cabo de forma independiente por cinco evaluadores, que incluyeron las GPC basadas en la evidencia publicadas entre 2005 y 2015. La evaluación de la calidad se llevó a cabo mediante la herramienta AGREE II. Se seleccionaron las GPC teniendo en cuenta que la calificación de los dominios rigor metodológico e independencia editorial, fuera como mínimo 60% cada uno.Se compararon los hallazgos con la práctica en Colombia. Resultados: Se evaluaron 24 GPC, de las cuales 79.1% (n=19) desarrolladas por sociedades científicas, 12.6% (n=3) por entidades gubernamentales y 8.3% (n=2) por organismos desarrolladores de GPC. Las GPC seleccionadas fueron la elaborada por NICE con puntuación global de 92%, y dos guías elaboradas por CENETEC, que puntuaron 79.7% y 81.9%. Discusión: Con el fin de disminuir la heteroge - neidad en la práctica, abordar nuevas opciones terapéuticas y brindar una atencion con calidad, se sugiere adoptar las mejores GPC, las cuales son desarrolladas por entidades gubernamentales y organismos desarrolladores de guías como CENETEC y NICE respectivamente, las cuales son poco estudiadas e implementadas en Colombia, donde las más consultadas son las ASPEN y ESPEN. Conclusión: Los factores claves recomendados en las mejores GPC de nutrición son: tamizaje nutricional de ingreso, seguimiento del riesgo nutricional, apoyo nutricional en el paciente desnutrido y/o malnutrido, soporte nutricional en el paciente con limitación de ingesta de alimentos, soporte nutricional especializado, educación en nutrición y creación del comité institucional de nutrición. Estos factores son útiles para generar confianza en la sociedad sobre la práctica asistencial. Debería incentivarse la consulta de GPC en Nutrición de alta calidad científica, con el fin de optimizar las capacidades técnicas ante las limitaciones en el sector salud (AU)

Introduction: Adequate nutrition-support clinical practice requires recommendations based on the best available evidence, in order to help health professionals making decisions concerning the management of enteral nutritional support in pathologies of interest. Objective: To identify the key factors in the management of enteral nutrition, in order to prevent and treat malnutrition based upon the recommendations made in the best Practice Guidelines (CPG). Methods: A structured search of nutritional support in CPG was performed. Five referees independently selected the CPG among those published between 2005 and 2015. They used AGREE II in order assess quality and selected those CPG with a score no lower than 60% in the domains of methodological rigor and editorial independence. The findings were compared to the Colombian clinical practice. Results: 24 GPC were evaluated, of which 79.1% (n = 19) were developed by scientific societies, 12.6% (n = 3) by government agencies and 8.3% (n = 2) by CPG developing bodies. Selected CPG were those produced by NICE (global score 92%), and those developed by CENETEC, which scored 70.89% and 87.2%.8. Discussion: In order to decrease clinical-practice heterogeneity, take into account new therapeutic options and provide quality care, it is suggested to adopt the best CPG, such as those developed by governmental institutions and CPG developing agencies like CENETEC and NICE. Attention and implementation of their recommendations in Colombia has been poor, as the most consulted CPG are the ASPEN and ESPEN ones. Conclusion: Key elements recommended in the best nutrition CPG, are: income nutritional screening, nutritional risk monitoring, nutritional support for malnourished patients, nutritional support for patients with limiting food intake, specialized nutritional support, nutrition education, and creation of institutional nutrition committees. These elements would be useful to build societal trust in clinical practice. Encouraging consultation of high quality nutrition CPG would help to optimize capacities in the face of technical limitations in the health sector (AU)

Cost-effectiveness of iso- versus low-osmolality contrast media in outpatients with high risk of contrast medium-induced nephropathy.

INTRODUCTION: Contrast media can cause acute renal failure by direct toxic effects on the tubular cells and kidney ischemia. Diabetics and hospitalized patients have a greater risk of developing contrast-induced nephropathy than the general population. OBJECTIVE: The cost effectiveness of iso and low-osmolality contrast media was assessed in high risk outpatients. MATERIALS AND METHODS: The analysis was based on a systematic literature review comparing the nephrotoxic effects of iso- to low-osmolality contrast media. Only direct costs were considered; these were obtained from the official tariff manual. Incremental cost-effectiveness ratios, efficiency curves and acceptability curves were calculated. Univariate sensitivity analyses were performed for costs and effects, as well as probabilistic analyses. Zero and 3% discounts were applied to results. The cost-effectiveness threshold was equal to the per capita GDP per life-year gained. RESULTS: Alternatives with Iopamidol and Iodixanol are preferable to the others, because both reduce risk of contrast-induced nephropathy and are less costly. The incremental cost-effectiveness of the Iodixanol alternative compared to the Iopamidol alternative is US$ 14,660 per additional life year gained; this is more than twice the threshold. CONCLUSION: The low-osmolality contrast medium, Iopamidol, appears to be cost-effective when compared with Iohexol or other low-osmolality contrast media (Iopromide, Iobitridol, Iomeprol, Iopentol and Ioxilan) in contrast-induced nephropathy, high-risk outpatients. The choice of the iso-osmolality contrast medium, Iodixanol, depends on its cost per vial and on the willingness to pay.

Cost-effectiveness of iso- versus low-osmolality contrast media in outpatients with high risk of contrast medium-induced nephropathy / Costo-efectividad de medios de contraste isoosmolales e hiposmolales en pacientes con alto riesgo de nefropatía inducida por medio de contraste

Introduction. Contrast media can cause acute renal failure by direct toxic effects on the tubular cells and kidney ischemia. Diabetics and hospitalized patients have a greater risk of developing contrast-induced nephropathy than the general population. Objective. The cost effectiveness of iso and low-osmolality contrast media was assessed in high risk outpatients. Materials and methods. The analysis was based on a systematic literature review comparing the nephrotoxic effects of iso- to low-osmolality contrast media. Only direct costs were considered; these were obtained from the official tariff manual. Incremental cost-effectiveness ratios, efficiency curves and acceptability curves were calculated. Univariate sensitivity analyses were performed for costs and effects, as well as probabilistic analyses. Zero and 3% discounts were applied to results. The cost-effectiveness threshold was equal to the per capita GDP per life-year gained. Results. Alternatives with Iopamidol and Iodixanol are preferable to the others, because both reduce risk of contrast-induced nephropathy and are less costly. The incremental cost-effectiveness of the Iodixanol alternative compared to the Iopamidol alternative is US$ 14,660 per additional life year gained; this is more than twice the threshold. Conclusion. The low-osmolality contrast medium, Iopamidol, appears to be cost-effective when compared with Iohexol or other low-osmolality contrast media (Iopromide, Iobitridol, Iomeprol, Iopentol and Ioxilan) in contrast-induced nephropathy, high-risk outpatients. The choice of the iso-osmolality contrast medium, Iodixanol, depends on its cost per vial and on the willingness to pay.

Introducción. Los medios de contraste pueden provocar falla renal aguda por toxicidad directa sobre las células tubulares e isquemia medular renal. Los pacientes diabéticos y los hospitalizados presentan mayor riesgo de desarrollar nefropatía inducida por medios de contraste que la población general. Objetivo. Establecer el costo-efectividad de los medios de contraste isosmolales e hiposmolales en pacientes con alto riesgo. Materiales and métodos. El análisis se basó en una revisión sistemática de la literatura científica, comparando los efectos nefrotóxicos de los medios isosmolales e hipoosmolales. Se consideraron sólo los costos directos, obtenidos del manual tarifario. Se calcularon las tasas del incremento del costo-efectividad, las curvas de eficiencia y de aceptabilidad. Se hicieron análisis univariados de sensibilidad para costos y efectos, así como probabilísticos. Se aplicaron tasas de descuento de 0 y 3 % a los resultados. Se usó como umbral de costo-efectividad por año de vida ganado, el producto interno bruto per cápita. Resultados. Las alternativas con Iopamidol y Iodixanol dominan a las demás porque reducen el riesgo de nefropatía inducida por contraste a un menor costo. La razón del incremento del costo-efectividad del iodixanol comparado con el iopamidol es de US$ 14.660 por año de vida ganado que más que duplica el umbral. Conclusión. El medio de baja osmolalidad, iopamidol, parece ser costo-efectivo comparado con iohexol u otros medios hiposmolares (iopromide, iobitridol, iomeprol, iopentol y ioxilan), en pacientes con alto riesgo de nefropatía inducida por contraste. La elección del medio hiposmolar, depende de la disponibilidad a pagar o del costo por ampolleta.