Economic Analysis of a Ketoanalogue-supplemented Very Low-protein Diet in Patients With Chronic Kidney Disease in Vietnam.

PURPOSE: The aim of this study was to estimate the cost-effectiveness of a very low-protein diet (VLPD) supplemented with ketoanalogues of essential amino acids compared with a conventional low-protein diet (LPD) in Vietnam. METHODS: The study was conducted from payer (base case), patient, and societal perspectives. A Markov model simulated costs and quality-adjusted life-years (QALYs) for patients with chronic kidney disease stage 4 or 5 (CKD4+) who were followed up during their lifetimes. Patients received a VLPD (0.3- to 0.4-g/kg/d diet) supplemented with ketoanalogues (5 kg/d [1 tablet]) versus LPD (0.6 g/kg/d, mixed proteins). In each model cycle, patient transitions among the health states-CKD4+ (nondialysis), dialysis, and death-were based on transition probabilities taken from the published literature. The time horizon covered the cohort's lifetime. Utilities and costs were estimated from literature review and projected for the lifespan considered in the model. Probabilistic and deterministic sensitivity analyses were performed. FINDINGS: The ketoanalogue-supplemented VLPD increased survival and QALYs compared with the LPD. From a payer's perspective, total cost of care in Vietnam was ₫216,854,268 (€8684/$9242) per patient with LPD versus ₫200,928,819 (€8046/$8563) per patient with a supplemented VLPD (sVLPD) (difference, -₫15,925,449 [-€638/-$679]). From a patient's perspective, total cost of care in Vietnam was ₫217,872,043 (€8724/$9285) per patient with LPD versus ₫116,015,672 (€4646/$4944) per patient with sVLPD (difference, -₫101,856,371 [-€4,079/ -$4341]). From a societal perspective, total cost of care in Vietnam was ₫434,726,312 (€17,408/-$18,527) per patient with LPD versus ₫316,944,491 (€12,692/ $13,508) per patient with sVLPD (difference, -₫117,781,820 [-€4716 €/$5020). IMPLICATIONS: Ketoanalogue-supplemented VLPD lowered costs compared with LPD in all 3 perspectives considered.

Omega-3 fatty acids in parenteral nutrition - A systematic review with network meta-analysis on clinical outcomes.

BACKGROUND & AIMS: Accumulating scientific evidence supports the benefits of parenteral nutrition (PN) with fish oil (FO) containing intravenous lipid emulsions (ILEs) on clinical outcomes. Yet, the question of the most effective ILE remains controversial. We conducted a network meta-analysis (NMA) to compare and rank different types of ILEs in terms of their effects on infections, sepsis, ICU and hospital length of stay, and in-hospital mortality in adult patients. METHODS: MEDLINE, EMBASE, and Web of Science databases were searched for randomized controlled trials (RCTs) published up to May 2022, investigating ILEs as a part of part of PN covering at least 70% of total energy provision. Lipid emulsions were classified in four categories: FO-ILEs, olive oil (OO)-ILEs, medium-chain triglyceride (MCT)/soybean oil (SO)-ILEs, and pure SO-ILEs. Data were statistically combined through Bayesian NMA and the Surface Under the Cumulative RAnking (SUCRA) was calculated for all outcomes. RESULTS: 1651 publications were retrieved in the original search, 47 RCTs were included in the NMA. For FO-ILEs, very highly credible reductions in infection risk versus SO-ILEs [odds ratio (OR) = 0.43 90% credibility interval (CrI) (0.29-0.63)], MCT/soybean oil-ILEs [0.59 (0.43-0.82)], and OO-ILEs [0.56 (0.33-0.91)], and in sepsis risk versus SO-ILEs [0.22 (0.08-0.59)], as well as substantial reductions in hospital length of stay versus SO-ILEs [mean difference (MD) = -2.31 (-3.14 to -1.59) days] and MCT/SO-ILEs (-2.01 (-2.82 to -1.22 days) were shown. According to SUCRA score, FO-ILEs were ranked first for all five outcomes. CONCLUSIONS: In hospitalized patients, FO-ILEs provide significant clinical benefits over all other types of ILEs, ranking first for all outcomes investigated. REGISTRATION NO: PROSPERO 2022 CRD42022328660.

Assessing the Effect of Nutrition Therapy on Rehospitalization Rate in Malnourished Pediatric Patients With Chronic Diseases.

BACKGROUND: Malnutrition is common among hospitalized children with chronic diseases and increases hospital care needs. The aim of this study is to estimate the clinical consequences of nutrition therapy (NT) after discharge. METHODS: A retrospective analysis of all pediatric inpatients with diagnosis of malnutrition hospitalized at our center from January 2017 to February 2018 was conducted. Malnutrition was assessed according to body mass index (BMI) z-score, routinely recorded in patient's files. The treatment group consists of all patients referred to nutrition assessment and treated by the clinical nutrition team; all the other patients not receiving NT are selected as the control group. The effect of NT on rehospitalization rates, length of stay (LOS), and emergency room (ER) visits was estimated for the total cohort and in a propensity score (PS) matched sample. RESULTS: 277 malnourished pediatric inpatients were enrolled and analyzed. NT was prescribed in 111 patients (40%). Rehospitalization rate was lower in the treated group (rate ratio [RR] = 0.797; 95% CI, 0.630-1.009); particularly, nonelective hospital admissions are considerably lower (RR = 0.556; 95% CI, 0.325-0.952). The strength of this association increased in the PS-matched sample. There is no clear evidence of NT's effect on ER visits (RR = 0.892; 95% CI, 0.580-1.373) or LOS per episode (Δ = 1.46 days; 95% CI, -3.39 to 6.31). CONCLUSIONS: Detecting and treating malnutrition seems to promptly improve the patients' clinical course after discharge, reducing the number of subsequent hospitalizations, particularly nonelective ones, probably caused by unresolved, ongoing malnutrition.

Acute cough in Italian children: parents' beliefs, approach to treatment, and the family impact.

BACKGROUND: Acute cough is the most common symptom among children in primary care, but the impact of cough episodes was never investigated in Italian families. METHODS: A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population; a specific and validated questionnaire was used. RESULTS: The sample (604 calls) was uniform by geographical distribution, and by children age and gender. Mean cough episode was 3.1/year, they were short lasting (only 4.7% > 2 weeks). Independent predictors of children cough episodes were parents' active smoking habit and work (p < 0.05). The mean nursery/school absenteeism was mostly < 7 days, but of a 7-15-day duration in near 30% of cases. The pediatrician was contacted immediately only by 25% of parents and a second consultation (mostly a lung physician) usually occurred after 2-3 weeks of cough. Meanwhile, home/pharmacist suggested remedies were adopted in 50-70% of cases. Usual prescriptions were mucolytics (85.8%), antitussive agents (55.6%), non-steroideal anti-inflammatory drugs (33.8%), antibiotics (regularly or episodically 80%), and corticosteroids (systemic steroids in less than 50%, but via aerosol in more than 80% of cases). Moreover, pediatricians claimed to use homeopathic drugs regularly or episodically in almost 50%. The respondents' willingness to spend out-of-pocket for an "effective remedy" against cough was of € 20 (>€ 30 in 18.4% of cases). CONCLUSIONS: Parents' actions against cough episodes were variable, depending on their beliefs, smoking habit, and occupational status. The parents' perceived efficacy of usual prescriptions is poor, and their willingness to pay out-of-pocket for an "effective remedy" against cough is high. The interest for alternative treatments is not negligible in these circumstances.

Influenza and influenza-like syndromes: the subjects' beliefs, the attitude to prevention and treatment, and the impact in Italian general population.

BACKGROUND: Influenza and influenza-like syndromes (I-LSs) are infectious diseases occurring on a seasonal basis which can lead to upper (URTI) and lower respiratory tract illness (LRTI) of different severity. The approach to these disorders is unfortunately not uniform. Aim of the study was to investigate real-life people beliefs, the attitude to their prevention and treatment, and their impact in general population. METHODS: A cross-sectional survey via Computer Assisted Telephone Interview (CATI) was carried out using a specific questionnaire investigating influenza episode rates, subjects behavior in case of influenza and I-LSs, and prescribed therapy. RESULTS: 1,202 subjects completed the questionnaire: median age was 46, 49% male, 20% active smokers. 57% of respondents experienced at least one episode of influenza or I-LS in the previous 12 months; episodes were usually home-managed, shorter than 2 weeks and more frequent in fall and winter (73% of the total). GP resulted the first health-care option (56%); almost 3% of respondents referred to the emergency room, and hospitalization occurred in 1%. Mucolytics resulted the most prescribed drugs (55%) followed by antibiotics and aerosol therapy (37-38%). Even if more than 70% of subjects considered vaccination essential, only 14% received influenza vaccination yearly and almost 60% had never received vaccination. Approximately 36% of respondents regarded homeopathy (namely Oscillococcinum) as an helpful alternative because of perceived as safer. CONCLUSIONS: Seasonal prevalence of I-LSs and influenza partially overlap. As virus identification is not a common procedure in daily practice, only a clinical discrimination is possible. Antibiotic prescription is still too high and largely inappropriate. Influenza vaccination is strongly encouraged, but different strategies are also used. Other approaches are receiving increasing attention in general population, and subjects' willingness to spend out-of-pocket for effective remedies is also increasing. The discrepancy between subjects' beliefs and health care actions likely reflects the insufficiency of institutional preventive strategies. In general, the approach to influenza and I-LSs appear variable and highly dependent of subjects' and their GPs' cultural beliefs.

Cost-effectiveness of omega-3 fatty acid supplements in parenteral nutrition therapy in hospitals: a discrete event simulation model.

BACKGROUND & AIMS: A recent meta-analysis showed that supplementation of omega-3 fatty acids in parenteral nutrition (PN) regimens is associated with a statistically and clinically significant reduction in infection rate, and length of hospital stay (LOS) in medical and surgical patients admitted to the ICU and in surgical patients not admitted to the ICU. The objective of this present study was to evaluate the cost-effectiveness of the addition of omega-3 fatty acids to standard PN regimens in four European countries (Italy, France, Germany and the UK) from the healthcare provider perspective. METHODS: Using a discrete event simulation scheme, a patient-level simulation model was developed, based on outcomes from the Italian ICU patient population and published literature. Comparative efficacy data for PN regimens containing omega-3 fatty acids versus standard PN regimens was taken from the meta-analysis of published randomised clinical trials (n = 23 studies with a total of 1502 patients), and hospital LOS reduction was further processed in order to split the reduction in ICU stay from that in-ward stays for patients admitted to the ICU. Country-specific cost data was obtained for Italian, French, German and UK healthcare systems. Clinical outcomes included in the model were death rates, nosocomial infection rates, and ICU/hospital LOS. Probabilistic and deterministic sensitivity analyses were undertaken to test the reliability of results. RESULTS: PN regimens containing omega-3 fatty acids were more effective on average than standard PN both in ICU and in non-ICU patients in the four countries considered, reducing infection rates and overall LOS, and resulting in a lower total cost per patient. Overall costs for patients receiving PN regimens containing omega-3 fatty acids were between €14 144 to €19 825 per ICU patient and €5484 to €14 232 per non-ICU patient, translating into savings of between €3972 and €4897 per ICU patient and savings of between €561 and €1762 per non-ICU patient. Treatment costs were completely offset by the reduction in hospital stay costs and antibiotic costs. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS: These results suggest that the supplementation of PN regimens with omega-3 fatty acids would be cost effective in Italian, French, German and UK hospitals.