A systematic review with meta-analysis of survival, quality of life and cost-effectiveness of home parenteral nutrition in patients with inoperable malignant bowel obstruction

Background and aims: Inoperable bowel obstruction is the most common and judicious indication for long term parenteral nutrition in patients with palliative malignancy. Considerable uncertainty exists about the survival length, quality of life (QOL) and associated health economics of home parenteral nutrition (HPN) for this patient group.

Methods: A systematic review was carried out for survival length and QOL of adult patients treated with HPN due to malignancy causing inoperable bowel obstruction in the palliative phase. Whenever possible, individual patient data were extracted to allow meta-analyses. Health economic evaluation was undertaken to calculate cost and incremental cost effectiveness ratio (ICER).

Results: Twelve studies involving 437 patients, met the inclusion criteria. Meta-analyses of extracted survival length data, representing the largest published cohort of HPN patients with palliative malignancy and inoperable bowel obstruction (n = 244 patients), revealed a mean survival of 116 days, median 83 days, with 45% and 24% still alive at 3 and 6 months, and only 2% survival at one year. Limited evidence suggests QOL deteriorated before death in a highly symptomatic group. The ICER is £176,587 per quality adjusted life year.

Conclusions: This is the first health economic evaluation and systematic review of survival and QOL for patients with inoperable bowel obstruction receiving HPN during the palliative phase of malignancy. Meta-analyses reveal a short survival and health economic analysis demonstrates high associated costs. This information can be used by clinicians to inform and guide selection of patients in this cohort for HPN treatment.