Socioeconomic effects on home parenteral nutrition.

The paper by Chang et al in this issue of JPEN reports an analysis of the effects of various socioeconomic risk factors upon catheter infections in home parenteral nutrition (HPN) patients, using the 2 largest provincial HPN programs in Ontario and British Columbia. One is tempted to call this East vs West, but because the Canadian health care system is federally mandated, the analysis actually represents 2 different flavors of the same basic program. The analysis was fairly complex and is admittedly limited by the relatively small sample sizes and the retrospective nature of the data-gathering instrument. Nonetheless, the authors have indeed found some effects. One might observe that the design of the Canadian system inherently limits the amount of effect that socioeconomic status has on health care. In this connection, it is important to note that neither the level of income nor the level of education appeared to significantly affect line sepsis. Yet, other socioeconomic factors were important. Some of these were counterintuitive. Patients who cared for their own catheters and HPN seemed to do better than those who relied on family members. Why should people whose family members cared for their HPN be at higher risk? Patients on social assistance or welfare were at higher risk. Yet, in an egalitarian health care system, why should that make a difference? Perhaps the common factor here is the degree of involvement of the individual patient. Are patients who take responsibility for their own care and who are competent to do so likely to fare better? We have all observed that patients vary widely in their desire and ability to be involved in their own care, with some patients passive to the point of denial, whereas others are involved in the management of their own diseases. There has been woefully little in the literature addressing the effect of socioeconomic factors on measurable aspects of nutrition support. One might cite a paper by Detsky et al, published in 1987. The intent of the study was to evaluate methods (subjective global assessment, serum albumin) for predicting complication rates in patients undergoing gastrointestinal surgery. But as an incidental finding, the overall complication rates in patients from 2 teaching hospitals were found to be much lower than had been found in previous studies, such as the then-recent study in the American Veterans Administration health system. It was suggested that this might represent an effect of lower socioeconomic status in previous studies. Any of us who have worked in hospitals caring for the indigent can testify to the greater risk of complications and other adverse events. Everyday clinical experience seems to indicate that Chang et al are on to something. The infection rate from a chronic tunneled venous catheter is the product of a complex series of interactions among the patient’s disease, his or her ability to deal with that disease and the needed therapy, and support provided by the health care system, the family, and the community. Anyone who has dealt with a long-care home PN patient can attest to the self-discipline and organization that characterizes such remarkable individuals. On the other hand, some of us have had experiences with individuals who seem unable to take the responsibility of caring for their own catheters or their HPN regimen. Such patients, unhappily, do not live long. Much of the medical literature, especially the quality literature, assumes that patients are relatively homogeneous. That is, all patients have, for example, the same risk of getting a complication after an operation. To be sure, one has to stratify patients by type, duration, and degree of contamination of the operation. But we now know that other diseases and poor general health may increase that risk. The nutrition literature has shown repeatedly that severe nutrition depletion also increases the risk. Those of us who have worked in both “safety net” hospitals and private hospitals can attest to the validity of Dr Detsky’s observation: there are real differences among patients, and this is especially evident when we try to carry out a stressful intervention, such as an operation—or such as HPN. This may not be a popular concept, and it may lead to uncomfortable conclusions. Yet, anything that affects outcome should be fair game for investigation. Much of the current thinking on outcome studies is directed toward their use as a measure of quality of health care. That’s certainly valid, but perhaps not enough. Consider our experience with malnutrition Received for publication August 9, 2005. Accepted for publication August 9, 2005. Correspondence: Charles W. Van Way III, MD, UMKC Department of Surgery, 2301 Holmes Street, Kansas City, MO 64108. Electronic mail may be sent to charles.vanway@tmcmed.org. 0148-6071/05/2906-0456$03.00/0 Vol. 29, No. 6 JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A. Copyright © 2005 by the American Society for Parenteral and Enteral Nutrition