Original articleThe costs of disease related malnutrition in hospitalized children☆
Introduction
Malnutrition is a continuously huge global problem with substantial clinical as well as economic consequences. Despite the fact that the term malnutrition literally comprises both overnutrition (too many nutrients) and undernutrition (too little nutrients), an etiology-related definition of pediatric malnutrition (undernutrition) has been formulated as follows: an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes [1]. Based on its etiology, malnutrition is either illness related (secondary to one or more diseases/injury), non-illness related (caused by environmental/behavioral factors), or both. For the purposes of this article the term malnutrition is used only for the illness related undernutrition, also known as disease related malnutrition (DRM) as only somatically ill children were included.
Although the criteria for defining malnutrition in pediatric patients are used inconsistently, the WHO cut-off measures of <−2 standard deviation scores for weight and/or height compared to age-adjusted references are the most frequently used [2]. These criteria are based on the fact that growth assessment is the best indicator for the nutritional status of a child, as growth (height and weight) is steadily affected by disruption of health and nutrition irrespective of the cause [3]. International studies have shown a DRM prevalence rate in European hospitalized children from 7% up to 45%, with the highest prevalence rate in children with infections, gastro-intestinal disease, mental and behavioral disorders and those with endocrine, nutritional or metabolic diseases [4], [5], [6], [7], [8], [9], [10]. DRM is associated with unfavorable outcomes, including increased rates of infection, increased medical and surgical complications, poor wound healing and increased hospitalization [1], [11]. This association with negative clinical consequences has recently been confirmed in a large multicenter prospective European study, showing DRM was associated with an increased occurrence of diarrhea and vomiting, augmented length of hospital stay (LOS) and a decreased quality of life [4]. Studies in adults have shown that DRM is costing the society billions of euros, leading to an estimated annual cost for European governments of up to € 170 billion (€ 120 billion for EU countries) based on a DRM prevalence rate of 33 million patients (about 20 million in EU countries) [12], [13]. In children however, there is a lack of data about the additional costs due to malnutrition for hospitalized children in Europe, but it is presumed that costs will be substantial [4].
As no cost-of-illness data for malnourished children in The Netherlands exist, the objective of the current study was to calculate the annual additional costs due to DRM for these pediatric patients as was done for adults [14].
Section snippets
Cost-of-illness study
A cost-of-illness analysis has been performed similar to the study that estimated the annual additional costs due to malnutrition in adult patients in The Netherlands [14]. Thus, a total cost per patient group was assessed, in which only hospital costs (direct costs) were used due to lack of data on the indirect costs. Direct health care costs include all costs directly related to the use of care, such as prevention, diagnostics, therapy, rehabilitation and care of the considered disease or
Results
The total additional hospital costs of managing pediatric patients with DRM in 2013 in the age of 1 month up to and including 17 years, were estimated to be € 51 million for acute malnutrition, € 46 million when focused on chronic malnutrition and € 80 million in case of overall malnourished pediatric patients (Table 3). This means that 5.6% of the total Dutch hospital costs for hospitalized children relevant for the patient group in this analysis (€ 1433 million) appear to be related to DRM.
Discussion
To the best of our knowledge, this is the first cost-of-illness study for DRM in hospitalized children in Europe, showing DRM is associated with 40% increase in hospital costs compared to children without suffering from DRM. In the US, hospital costs for children with an ICD coding for malnutrition were calculated to be 3 times higher than those not diagnosed with malnutrition [24] and a study in children under five years old in Thailand showed a 25% increase in hospital costs for malnourished
Statement of authorship
KF and MAK designed the research; KF, EvP and MAK conducted the research, analyzed data and wrote the paper. KJ and JH provided their research data of their follow-up study in Dutch malnourished hospitalized children and critically reviewed and revised the total content of this manuscript where needed. All authors have read and approved the final manuscript.
Conflict of interest
EvP, KJ, JH and MAK have no conflicts of interest. KF receives salary as an employee of Nutricia Advanced Medical Nutrition (NAMN) and is affiliated to the University of Maastricht in The Netherlands. NAMN has an unrestricted agreement with the Maastricht University to enable KF to do research.
Funding sources
This research was funded unrestrictedly by Nutricia Advanced Medical Nutrition (NAMN), The Netherlands; MAK was paid to conduct the analyses as a consultant. The contents of this article are not contingent on approval of NAMN.
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The publication of the study results was not contingent on the sponsor’s approval