Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis.

BACKGROUND: Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas. METHODS: Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay. RESULTS: 3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001). CONCLUSIONS: Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study.

BACKGROUND & AIMS: Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization. METHODS: A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions. RESULTS: Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001). CONCLUSIONS: Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.

Healthcare Resource Utilization and Cost Comparisons of High-Protein Enteral Nutrition Formulas Used in Critically Ill Patients.

Background: High-protein enteral nutrition is advised for patients who are critically ill. Options include immunonutrition formulas of various compositions and standard high-protein formulas (StdHP). Additional research is needed on the health economic value of immunonutrition in a broad cohort of severely ill hospitalized patients. Objective: The study goal was to compare healthcare resource utilization (HCRU) and cost between immunonutrition and StdHP using real-world evidence from a large US administrative database. Methods: A retrospective cohort study was designed using the PINC AI™ Healthcare Database from 2015 to 2019. IMPACT® Peptide 1.5 (IP) was compared with Pivot® 1.5 (PC), and StdHP formulas. Inclusion criteria comprised patients age 18+ with at least 1 day's stay in the intensive care unit (ICU) and at least 3 out of 5 consecutive days of enteral nutrition. Pairwise comparisons of demographics, clinical characteristics, HCRU, and costs were conducted between groups. Multivariable regression was used to assess total hospital cost per day associated with enteral nutrition cohort. Results: A total of 5752 patients were identified across 27 hospitals. Overall, a median 7 days of enteral nutrition was received over a 16-day hospital and 10-day ICU stay. Median total and daily hospital costs were lower for IP vs PC ($71 196 vs $80 696, P<.001) and ($4208 vs $4373, P=.019), with each higher than StdHP. However, after controlling for covariates such as mortality risk, surgery, and discharge disposition, average total hospital cost per day associated with IP use was 24% lower than PC, and 12% lower than StdHP (P<.001). Readmissions within 30 days were less frequent for patients receiving IP compared with PC (P<.02) and StdHP (P<.001). Discussion: Choice of high-protein enteral nutrition for patients in the ICU has implications for HCRU and daily hospital costs. Considering these correlations is important when comparing formula ingredients and per unit costs. Among the enteral nutrition products studied, IP emerged as the most cost-saving option, with lower adjusted hospital cost per day than PC or StdHP. Conclusions: Using a select immunonutrition formula for critically ill patients may provide overall cost savings for the healthcare system.

Trends in the outpatient treatment of atrial fibrillation in the USA from 2001 to 2010.

PURPOSE: Several clinical trials have shown that rhythm-control drugs have serious adverse events and no survival advantage over rate-control drugs in patients with atrial fibrillation. The objectives were to determine and explain the recent trends in outpatient prescribing of both drug classes. METHODS: Data were obtained over 10 years from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Visits by patients with atrial fibrillation were identified by ICD-9 diagnosis code 427.31. Trend lines were estimated for drug prescribing and comorbidities. A multinomial logistic model was estimated to predict treatment on the basis of visit characteristics. RESULTS: The percentage of visits mentioning only a rate-control medication trended upward (p = 0.07) from 41.9% in 2001 to 47.3% in 2010; the percentage mentioning both rhythm-control and rate-control drugs also had an upward trend (p < 0.05) from 3.1% to 12.5%; finally, the percentage mentioning rhythm-control drugs alone remained steady (p = 0.37). Consistent with the increase (p = 0.10) in the percentage of visits mentioning hypertension, there was a statistically significant (p < 0.01) rise in the prescribing of ß-blockers from 20.5% to 43.4%. The odds that a patient aged 65 years or younger was prescribed a rhythm-control medication were significantly higher (p < 0.01) than those for a patient older than 65 years. The estimated odds that a diabetic patient was prescribed both rhythm-control and rate-control medications was only 0.269 (p < 0.05). CONCLUSIONS: This study documents change in the outpatient treatment of atrial fibrillation in the USA from 2001-2010. In clinical practice, there has been a growing reliance on rate-control medications.