Community-Based Appraisal of the Effects of Parenteral Nutrition Versus Enteral Nutrition on the Quality of Care for Patients With Acute Pancreatitis

BACKGROUND: Enteral nutrition (EN) rather than parenteral nutrition (PN) has been advocated in treatment guidelines for acute pancreatitis (AP) as endorsed in randomized studies or meta-analyses. The findings derived from those studies would recognize the criticism of smaller sample sizes or limited patient case-mixes. To determine the generalizability of those findings, community-based appraisal on the advantages of EN over PN is required. Using a Japanese administrative database between 2006 and 2010, we determine whether EN is superior to PN in the real clinical settings. METHODS: A total of 24,913 patients diagnosed with AP at admission in 1,000 hospitals were identified. Among them, we analyzed 1,803 patients of ≥ 15 years who received EN or PN for AP across 480 hospitals. Among three nutrition categories of PN only, EN only and PN with EN, we examined patient characteristics, comorbidities, complications, AP severity score determined by the Ministry of Health, Labor and Welfare, surgical procedures for the biliary/pancreatic system, use of artificially assisted ventilation and hemodialysis proxy of multiple organ failures and hospital teaching status. To identify the variables associated with PN use, a logistic regression model was used and the propensity score (PS) was calculated to control for the selection bias of patient case-mix preferring PN use. Then, we compared mortality, length of hospital stay (LOS), total charges (TC) and commencement day of oral food intake between EN and PN. RESULTS: A total of 1,191 PN patients, 330 EN patients and 282 mixed EN and PN patients were identified. EN was indicated for patients with mild AP and procedures for the pancreas. PS matching analysis indicated that PN had a higher mortality compared with EN, and PN significantly increased LOS and TC compared with EN. PN deterred the commencement of oral food intake. CONCLUSIONS: Community-based study has shown that EN was employed in the less severe case-mixed. Even though considering that selection bias, EN was still superior to PN in AP. Physicians should be aware of the guidelines for the advocacy of EN and need to carefully consider the indications for EN to optimize the quality of AP care.