Despite the constantly growing expenditure on hospital care in Poland, we still struggle with insufficient access to treatment. With this in mind, the National He alth Fund, following a pattern proven in many European countries, adopted in its strategy for 2022-2023 the direction of shifting the burden of he althcare from hospitals to outpatient clinics and home. During the debate "NFZ strategy and treatment at home", which took place on March 7, 2022 as part of the 4th Congress of He alth Challenges in Katowice, experts discussed the benefits of such an approach, its impact on access, as well as the quality of medical services in our country. One of the solutions already provided at the patient's home that meets these expectations is enteral nutrition.

Where is the NHF strategy going?

The key elements of the NHF's strategy for 2022-2023 include not only increasing the access and quality of services provided, but also improving communication with the patient, both on the part of the payer and service providers1. This is especially important for the chronically ill who still require specialist care after the end of hospital treatment. A way to optimize the cost of the treatment process is to reduce the number of hospitalizations by allocating funds towards outpatient and home care.

There are already procedures that have been successfully transferred from hospital conditions to home conditions. An example is enteral nutrition, which is a medical procedure that provides specialized nutrients through a gavage directly into the stomach or intestine. This type of nutrition is intended for patients who cannot eat traditional (oral) nutrition and are struggling with such difficulties as, inter alia, swallowing properly, obstruction of the upper gastrointestinal tract or they are unconscious.

The second example of an economically justified and patient-beneficial benefit discussed by experts during the debate was home ventilation. In many cases, both enteral nutrition and mechanical ventilation do not require hospitalization, and the patient can successfully use the service at home, which at the same time increases the availability of places in the hospital for people with a real clinical need.

How To Ensure Effective Treatment Inhome?

- More than 20 years ago, many patients, due to the need for enteral nutrition, were sentenced to several weeks or even months in hospital. Thanks to the reimbursement of the procedure of enteral nutrition at home and its efficient organization, today patients can stay with their loved ones, and often learn, play, pursue their work and lead a social life despite the limitations resulting from the disease. The effectiveness and safety of nutritional treatment at home is greatly influenced by a qualified team (doctors, nurses, nutritionists, psychologists) who not only cares about the appropriate selection of diet and equipment, but is able to minimize the risk of complications, including those related to access nutritional - said prof. dr hab. Janusz Książyk, specialist pediatrician, head of the Department of Paediatrics, Nutrition and Metabolic Diseases of the "Monument - Children's He alth Center" Institute, President of the Polish Society of Clinical Nutrition for Children in Warsaw.

Professor Książyk also emphasized that the success in effective nutrition at home depends on many factors: First of all, it is the proper preparation of the patient and his family to perform daily duties related to nutritional treatment outside the hospital and ensuring a sense of security . Proper communication and trust between medical staff and parents is a prerequisite for effective home treatment. You should also remember that your child cannot wait "in line" for access to home nutritional treatment.

Financial savings and nutritional treatment at home

The numbers speak for themselves. As explained by Edyta Grabowska-Woźniak, President of the Association of Nutritional Treatment Providers in Home Conditions, the cost for the National He alth Fund of 30-day enteral nutrition at home is a maximum of PLN 2,760, while the average value of hospitalization is PLN 3,459, and in clinical hospitals even PLN 1,000 more2 . It is worth noting that, according to the Organization for Economic Cooperation and Development (OECD), the average length of stay in a hospital in Poland is 6.7 days, i.e. a week of hospitalization is much more expensive than the monthly provision of home nutrition3 .

The National He alth Fund is aware of the financial benefits of bringing home treatment procedures. According to Appendix 4 to the Order of the President of the National He alth Fund of October 18, 2011, the total cost of living a patient who requires enteral nutrition at home is 70-80% lower than in hospital4 . In 2022, expenditure on the provision of enteral nutrition at home accounted for approx. 5% of the budget allocated toseparately contracted services, and the needs in this area will undoubtedly increase in the coming years. The development of services provided at home is beneficial for all participants of the system.

Availability of home enteral nutrition and reality

It is a fact that the payer systematically increases outlays for home benefits, but the needs still significantly exceed the available funds. The average waiting time in 2022 for nutrition counseling services in various voivodeships ranged from 1 to 24 months. In the previous year, there were queues in as many as 13 voivodeships. Limiting the provision of enteral nutrition at home is arguing, inter alia, with the concept of oncology package.

- Cancer patients have full access to diagnostics and treatment thanks to the oncology package - unfortunately, in practice there are procedures not covered by the DILO card, which are limited, e.g. home enteral nutrition. It is worth emphasizing that the treatment of most cancers involves the risk of malnutrition and the need to implement nutritional treatment - in cancers of the digestive system it may affect up to 80% of patients. After the end of hospitalization or during breaks between individual stages of treatment, patients should be smoothly taken into the care of a nutritional clinic, while waiting in queues lasting several weeks or even several months. Many of them, as a result of the disease's progression, will not even have a chance to benefit from the service, explained Tomasz Olesiński, MD, PhD, general and oncological surgery specialist at the Department of Oncological Gastroenterology, Oncology Center - Institute. Maria Skłodowskiej-Curie in Warsaw.

The expert emphasized that a patient waiting in the queue to be admitted to the procedure of home enteral nutrition often develops many complications, including those related to improper care and care of the nutritional access, which often leads to the need for another hospitalization and the need to replace access to the home enteral nutrition. digestive tract. However, complications related to malnutrition itself are the most burdensome. In many cases, it is not possible to provide an oncological patient with the right amount of energy and necessary nutrients through a traditional diet. It may end with infection, bedsores, the necessity of hospitalization very often, or even postponing or giving up a given method of treatment, which at the same time reduces the chances of recovery. Therefore, it is necessary to implement nutritional treatment at the earliest possible stage with the use of industrial diets, consistent with the needs of oncological patients and adapted to the supply through a tube.

- Modern oncological therapy is extremely expensive. We spend billions on modern drugs while reducing their effectiveness by not fighting malnutrition. Numerous clinical studies show that a malnourished patient is not only associated with a greater number of complications, including postoperative mortality, but also a worse response to chemotherapy, radiotherapy and worse long-term results. Proper dietary management in all cost analyzes significantly reduces the costs of treatment. From a purely economic point of view, if we are looking for money to introduce new anti-cancer drugs, we should save where it is obvious and easy to achieve - concluded the expert.

Oncology is just an example of an area where nutritional treatment is an integral part of patient care. Most of the patients under the long-term care of nutritional clinics are people with stroke and other neurological diseases.

Psychological costs of living with illness

Currently, research is conducted in the world and in Poland on the perception of differentiation in the quality of life of patients treated in a stationary and home treatment. In a 2006 study, psychologists - Dr. Romuald Derbis and Anna Machnik-Czerwik - proved that the quality of life of cancer patients under the care of a home hospice is higher than that of patients staying in an inpatient hospice. Quality of life was assessed on the basis of factors such as the will to live, happiness, functioning and activity of the patient5 .

- Home is the basic environment of every human being. Care at home means safety, acceptance, peace and psychological comfort for the patient. Returning to this place after a mentally and physically exhausting stay in the hospital is a return to "normality", the possibility of being with relatives and participating in family life - said Edyta Kochan, psychologist, Nutrimed Food Clinic.

During the debate, it was emphasized that in the NHF strategy, the patient's needs are to be the most important - for the patient, especially the chronically ill, the feeling of comfort and security is crucial, while being able to function in their own environment. So if it can be effectively treated at home, you should bet on it.

Sources:

1. Assumptions for the National He alth Fund strategy for 2022-2023, published on November 8, 2018: http://www.nfz.gov.pl/aktualnosci/aktualnosci-centrali/zalozenia-do-strategii-nfz-konsultacje-spoleczne,7236.html

2. Report on the activities of the National He alth Fund for 2022,published on 06.2018: http://nfz.gov.pl/gfx/nfz/userfiles/_public/bip/dzialalnosc_nfz/sprawozdania_z_dzialalnosci_nfz/sprawozdanie_z_dzialalnosci_nfz_za_2017_rok.pdf

3. Length of hospital stay; https://data.oecd.org/he althcare/length-of-hospital-stay.htm

4. Annex 4 to the Order of the President of the National He alth Fund of October 18, 2011 http://www.nfz.gov.pl/zarzadzenia-prezesa/zarzadzenia-prezesa-nfz/zarzadzenie-nr-672011dsoz,4632.html

5. Derbis R., Machnik-Czerwik A. (2006): Differentiation in the quality of life in cancer patients from inpatient and home hospice. Scientific Works of the Academy of Jan Długosz in Częstochowa. Series: Psychology, issue 13, pp. 5-14.

Category:

Geriatrics