Quality, clinical outcomes and treatment costs in acute intestinal failure
Type 1 and type 2 intestinal failure (IF) are associated with significant morbidity and mortality, with little published data reporting outcomes from clinical practice. This thesis will therefore examine the definitions, quality of care, clinical outcomes and treatment costs of these conditions within the setting of an acute hospital which cares for many type 1 IF patients as well as running a regional intestinal failure service for type 2 and 3 IF patients.Observational studies were conducted to examine; the parenteral nutrition (PN) care provided to patients with all types of IF, screening tools and criteria to identify type 2 IF in clinical practice and an assessment of clinical outcomes and treatments costs in this complex patient group.The multidisciplinary nutrition and intestinal failure team were involved in 90% of decisions regarding initiation of PN in this hospital compared to only 52.7% reported by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report. Standards of assessment, monitoring and catheter complications were also better than those in the NCEPOD report. Rates of catheter related sepsis were lower in patients managed within a specialised IF unit compared to other wards; 1.8 episodes/1000 PN days versus 8.21 episodes/1000 PN days (p 28 days had a 91% sensitivity and 96% specificity for identifying type 2 IF but a low positive predictive value of only 59%. IF surgery criteria had a sensitivity of 96% and a positive predictive value of 100% for identifying type 2 IF.Mortality during an acute admission for type 2 IF patients (n=44) was 4.2%. Following reconstructive surgery (n=37) there were no post-operative deaths, no readmissions within 30 days and only one post-operative fistula recurrence. After surgery 94% of patients were independent of artificial nutrition. The median calculated treatment costs per day for patients with type 2 IF was £572. Current funding mechanisms within the NHS only allow hospitals to recover 44.7% of the treatment costs in type 2 IF.These studies confirm that standards of PN care in IF can be high within a regional specialist centre, with low rates of mortality, fistulae recurrence and PN dependence in type 2 IF. Criteria for screening and defining type 2 IF are relevant to clinical practices and their wider use could result in earlier access to specialist treatment, improvements in outcome reporting and a mechanism for establishing future IF funding.