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Cost-effectiveness of preoperative parenteral nutrition in patients undergoing major gastrointestinal surgery.

We used cost-effectiveness analysis to compare three strategies for reducing the incidence of severe nutrition-associated complications (eg, would dehiscence) in patients undergoing major gastrointestinal surgery: treat all patients with parenteral nutritional support for 10 days before surgery, treat no patients with preoperative parenteral nutritional support, or perform a test which stratifies patients (treating only the "high risk" or "malnourished" patients). The "test" strategy results in the lowest total hospital complication rate when the overall incidence of postoperative nutrition-associated complications is greater than 4% and less than 39%. However, the cost minimizing strategy is "treat none" as long as the overall incidence is less than 78%. In moving from the "treat none" to the "test" strategy, the incremental cost per complication avoided varies from $11,515 (for a 20% overall incidence), to $1,031 (for a 60% overall incidence). These cost-effectiveness ratios for incidence rates above 20% compare favorably to the use of routine screening tests performed on preoperative patients. However, the cost-effectiveness ratios are quite sensitive to the assumptions made concerning the effectiveness of parenteral nutritional support and the predictive properties of the test (derived from previous clinical studies). We conclude that further research is needed to study the overall incidence of severe postoperative nutrition-associated complications for various surgical procedures, to confirm the accuracy of stratification techniques and to confirm previous studies of the effectiveness of preoperative parenteral nutritional support in order to permit third party payers to evaluate the consequences of adopting this intervention as a standard clinical practice.