ASPEN Enteral Nutrition by The Numbers EN Data Across The Health

ASPEN Enteral Nutrition
by the Numbers
EN Data Across the Healthcare Continuum
Authors and Contributing Staff:
JoAnn Read RD
Research Consultant
Peggi Guenter, PhD, RN, FAAN, FASPEN

Senior Director of Clinical Practice, Quality, and Advocacy
American Society for Parenteral and Enteral Nutrition

Copyright © 2017 American Society for Parenteral and Enteral Nutrition
All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted in any form or by any means—electronic, Published by American Society for
mechanical, photocopy, recording, or any other—except for brief quotations Parenteral and Enteral Nutrition
in printed reviews, without the prior permission of the publisher.
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Photo credits: (lower left) Bodenham, LTH NHS Trust/Science Source; (lower right) Robert and Silver Spring, MD 20190
Chace Selby; credit: Robert Selby. Used with permission.
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ISBN 978-1-889622-33-8 www.nutritioncare.org
ASPEN Enteral Nutrition
by the Numbers
EN Data Across the Healthcare Continuum
About ASPEN
ASPEN is dedicated to improving patient care by advancing the science
and practice of clinical nutrition and metabolism. Founded in 1976,
ASPEN is an interdisciplinary organization whose members are involved
in the provision of clinical nutrition therapies, including parenteral and
enteral nutrition. With more than 6,500 members from around the world,
ASPEN is a community of dietitians, nurses, pharmacists, physicians,
scientists, students, and other health professionals from every facet of
nutrition support: clinical practice, research, and education.
For more information about this report, please contact Peggi Guenter at peggig@nutritioncare.org.
Table of Contents
Executive Summary �� 1
Introduction�� 2
EN Overview�� 2
Objectives � �� 3
Patients in the Healthcare System � �� 3
Methodology �� 6
Data Sources: Big Data Sets� �� 6
Data Sources: Large EN Studies in the Literature� �� 10
Data Source: ASPEN Survey�� 10
Results �� 11
Segmentation by Healthcare Setting�� 11
Acute Care Hospitals � ��12
Acute Care Hospital Data from Big Data Sources��12
Acute Care Hospital Data from the Literature ��16
Acute Care Hospital Data from ASPEN Survey � ��19
Analysis of the Acute Care Hospital Setting��19
Nursing Homes ��20
Nursing Home Data from Big Data Sources��20
Nursing Home Data from the Literature ��21
Nursing Home Data from the ASPEN Survey ��22
Analysis of the Nursing Home Setting � ��22
Home Care ��22
Home Care Data from Big Data Sources��23
Home Care Data from the Literature � ��24
Home Care Data from the ASPEN Survey��26
Analysis of the Home Care Setting ��26
Long-Term Acute Care Hospitals (LTCH) ��27
LTCH Data from Big Data Sources��27
LTCH Data from the Literature ��28
LTCH Data from the ASPEN Survey ��29
Analysis of the LTCH Setting � ��29
Inpatient Rehabilitation Facilities (IRF)��30
IRF Data from Big Data Sources��30
IRF Data from the Literature � ��31
IRF Data from the ASPEN Survey ��31
Analysis of the IRF Setting ��31
Segmentation by Product Type and Delivery Methods �� 32
Types of Feeding Tubes��32
Feeding Tube Types in Acute Care��32
Feeding Tube Types in Post-Acute Care��34
Analysis of Feeding Tubes ��36
Types of Formula Administered��37
Types of Formulas Used Across Healthcare Settings ��37
Use of Modular Components � ��40
Analysis of Formula Types � ��40
EN Delivery Methods � ��41
Open vs. Closed Delivery Systems � ��43
Water Flushes � ��44
Analysis of Administration Methods � ��44
Malnutrition and EN�� 45

Acute Care Hospitals�� 45
Post-acute Care�� 48
Market Drivers, Trends, and Challenges �� 50

Growing Awareness of the Role of Nutrition �� 50
Aging Population and Malnutrition Risk� �� 51
Healthcare Delivery and Reimbursement Policies � �� 52
Coverage Policies for EN�� 53
Greater Involvement in Self Care �� 57
EN Order Writing: Changes in Prescribers � �� 58
Opportunity for Future Research �� 60
Conclusion �� 60
Appendices�� 61
Glossary of Abbreviations and Terms �� 61
References � �� 65
Acknowledgements �� 70
Tables �� 71
Table A. Discharge Status for Hospital Discharges 2014 ..................................................................................71
Table B. Prevalence of Clinical Measures in Nursing Home Residents By Age, by Percent, 2014.............................71
Table C. Health Care Settings, Enteral Nutrition Coverage and Payer Policies.......................................................72
Table D. EN Payer Mix per Healthcare Setting .................................................................................................73
Table E. ASPEN Clinical Practice Committee Enteral Nutrition Survey Instrument .................................................73
Table F. ICD-9-CM Diagnosis Codes for Malnutrition Used in HCUP Data Analysis.................................................78
Executive Summary
More than 250,000 hospital patients each year in the United Notable concepts include:
States, and many more in long-term care and home settings,
rely on nutrition provided directly into the gastrointestinal • Number of patients on EN by healthcare setting
tract through a feeding tube.1 There is a growing awareness
• How EN use in children and infants differs from adults
of, and intense demand for this therapy, known as enteral
nutrition (EN). Due to its complexity, there is not a stan- • Demographic and diagnostic data on patients
dardized data collection tool or central registry for patients receiving EN
receiving EN that consistently captures data in every care • How factors such as the aging population, healthcare
setting. Thus, it has been extremely difficult to gather compre- delivery, reimbursement policies, and increased consumer
hensive information and key data about EN in every health self-care affect the EN market
care setting. Until now.
• Which patient populations have increased or decreased
use of EN
The American Society for Parenteral and Enteral Nutrition
(ASPEN) has created the most comprehensive report ever • The relationship of nursing home EN patients and pressure
compiled on the topic of EN. It accurately captures the use ulcer prevalence.
and practice of this therapy across the US healthcare con- • The types of tubes and administration methods used across
tinuum over the past several years from available sources the healthcare continuum
including government agencies, payers, current literature, and
organization surveys. The report brings together data sources, comparing and
confirming those findings as much as possible while allowing
users to interpret and use the information for their own plan-
The report is intended to be a thorough review of available
ning and policy development purposes. The report identifies
resources for those looking to better understand the reach
gaps in the data and helps identify ways to fill those gaps with
and impact of EN across the care continuum. It serves as a
future research. By using this information, stakeholders will
resource for clinicians, healthcare administrators, supply chain
be better positioned to have patients across the healthcare
personnel, safety and regulatory organizations, payers, manu-
continuum receive the most appropriate clinical nutrition and,
facturers and policy makers, among others.
ultimately, achieve better outcomes.
In addition to outlining EN marketing drivers, challenges,
and trends, the report segments data by:
1. Healthcare setting: Incorporating information

from acute care hospitals, nursing homes, home care
settings, long-term acute care hospitals, and inpatient
rehabilitation facilities.
2. Product type and delivery methods: Accounting

for specifics such as tube types, formula mix, and
administration methods.
3. Malnutrition and EN: Providing information collected in

acute care hospitals and post-acute care.
Enteral Nutrition by the Numbers: ASPEN Data Use Report Across the Healthcare Continuum 1
Introduction
EN Overview
Enteral nutrition (EN) refers to the system of providing nutrition directly into the gastrointestinal (GI)
tract, bypassing the oral cavity.2 For purposes of this report, EN data does not include nutrition formulas
administered orally unless specifically noted. EN will include those nutrient formulas and human breast
milk delivered through an enteral access device (EAD). EN is widely used in the acute and post-acute
settings, which include subacute, rehabilitation, long-term care, and home settings. The EN use process
as seen in Figure 1, is the system within which EN is used.3 This involves a number of major steps: the
initial patient assessment, the recommendations for an EN regimen, the selection of the EAD, the EN
prescription, the review of the EN order, the product selection or preparation, the product labeling and
dispensing, the administration of the EN to the patient, and the patient monitoring and reassessment,
with documentation at each step as required. This process requires a multidisciplinary team of compe-
tent clinicians working in concert to provide safe nutrition care.4 More information on the specifics of
EN care can be found in the recently published ASPEN Safe Practices for Enteral Nutrition Therapy.3
FIGURE 1
Enteral Nutrition Use Process
Prescribe an Review the

EN Regimen EN Order
Assess the
Patient’s Enteral Procure,
Access and Select/Prepare,
Recommend an Label, and
EN Regimen Dispense EN
Monitor and Administer

Re-assess EN Regimen
the Patient
Adapted from Boullata JI, Carrera AL, Harvey L; Escuro AA; Hudson L, Mays A, et al. ASPEN Safe Practices for Enteral Nutrition Therapy
JPEN J Parenter Enteral Nutr. 2017; 41:15-103. Copyright © 2016 The American Society for Parenteral and Enteral Nutrition
2 © 2017 ASPEN www.nutritioncare.org

Data on the use of enteral nutrition are influenced by many Patients in the Healthcare System
factors including the medical literature, societal influences such
as aging of the population and ethical considerations, the vari- The US healthcare system is complex, and while EN can be
ety of healthcare settings, and healthcare and reimbursement initiated in many healthcare settings, it is most often started
policies that drive insurance coverage for this therapy. The use in acute care hospitals.1 To best understand the transition of
of EN is not unique to any one population, since the medical patients across the healthcare continuum, it is important to
need can present in the neonatal, pediatric, adult, and older see what care settings they move into following hospital stays.
adult populations. These dynamic factors are addressed in this They may also at any time move from a post-acute care setting
report and need to be considered with any review of the enteral back to the hospital or from one post-acute care setting to
nutrition market in the United States. another. It is not the care setting but the medical necessity that
dictates the indication for EN. Patients who receive EN can
Little comprehensive published data are available about the be captured in this data report in any of these post-acute care
size, practice, and other demographic details about patients categories, including routine discharge and home health care.
receiving EN. No single source for information is currently Figure 2 illustrates the dynamic flow of patients in the health-
available; thus, various data sources are needed to access or care system. Changes from one setting to another may happen
extrapolate information about this therapy in the United States. many times during a data collection period.
Variables such as patient demographics and EN administration
are not standardized across data reports and the literature, and
often the same patients are reported multiple times. This report
captures the use and practice of EN in the United States across
the healthcare continuum, providing the best available collec- FIGURE 2
tion of data in one document. This report offers stakeholders, Variety of Healthcare Settings
including clinicians, healthcare administrators, supply chain with EN Patients
personnel, safety and regulatory organizations, payers, manu-
facturers, and policy makers, a view of the EN market over the
past few years.
Acute Care
Hospital
Objectives
The specific objectives of this report are to: Inpatient
Rehab Home
Facility
1. Provide the stakeholder with a comprehensive collection of
data on EN use and practice in the United States including
demographic and current practice information on tube-
fed patients,
2. Discuss the data findings in the context of current nutrition

and healthcare issues such that stakeholders can utilize this Long-term
Nursing
data for planning and policy purposes, and Acute Care
Home
Hospital
3. Determine gaps in available data and suggest plans
to address those gaps with research and other data
collection initiatives.
To best explore the use of EN, one needs to understand where all patients are in the healthcare system.
In Figure 3, see 2014 acute care hospital discharges and where all patients go post discharge. Routine
discharge is defined as discharge to home without the need for home health care services. Discharge to
another institution includes transfers to long-term acute care hospitals (LTCH), nursing homes (NH),
and inpatient rehabilitation facilities (IRF).5 Discharge data by age can be found in Appendix Table A.
Overall, most patients leave the hospital with a routine discharge.
FIGURE 3
Discharge Status for Hospitalized Patients 2014
25000000
70%
20000000
15000000
10000000
14%
5000000 11%
2% 2% 1%
0
In-hospital Routine To Another Another Home AMA-missing
Deaths Discharge Short-term Hospital Institution Health Care
AMA = leave against medical advice. Data from AHRQ HCUPnet National Inpatient Sample 20141 www.hcupnet.ahrq.gov

Figures 4 and 5 illustrate the differences in hospitalized patients’ discharge status for 2014 by
age. Most pediatric and neonatal patients have routine discharges, many of which are perina-
tal discharges of newborns. Older adults, defined as those aged 65 years and older, have higher
in-hospital death rates, require more home healthcare services, and have more stays in post-acute
care institutions.
FIGURE 4
Discharge Status for Pediatric Hospitalized Patients 2014
In-hospital Deaths 0.3%

Routine Discharge 94.8%
At Another
Short-term Hospital 1.7%
Another Institution 0.7%
Home Health Care 2.4%
AMA-missing 0.1%
0 1000000 2000000 3000000 4000000 5000000 6000000
FIGURE 5
Discharge Status for Hospitalized Older Adults 2014
In-hospital Deaths 3.7%

Routine Discharge 43.9%
At Another
Short-term Hospital 2.5%
Another Institution 29.8%
Home Health Care 19.5%
AMA-missing 0.5%
0 1000000 2000000 3000000 4000000 5000000 6000000
Methodology
Data from big data sources and large enteral studies, as well recovery from surgery. Care for acute health conditions is
as from a more granular survey were analyzed for use in this materially different from the treatment for chronic care condi-
report. Data were derived exclusively from US sources and tions, or longer-term care. Hospital-based acute inpatient care
included patients of all ages and across all healthcare settings. typically has the goal of discharging patients as soon as they
When available, data points included total number of tube-fed are deemed healthy and stable to their home or to a lower level
patients in various care settings, patient age, type (category) of institutional care such as LTCH, IRF, or NH.8
of formula, method of administration, duration of therapy,
diagnoses, and payer mix. Payer policies on coverage are also The primary reference used to obtain demographic infor-
included in this report. Data presented by healthcare setting, mation about tube-fed patients in the acute care setting was
EN delivery method and products, are broken down by data the Agency for Healthcare Research and Quality (AHRQ)
source: big data sources, literature, and then survey findings. Healthcare Cost and Utilization (HCUP) National Inpatient
Sample (NIS) database (will be called HCUP data throughout
The goal of this report was to collect as much information this report).1 NIS is the largest all-payer (Medicare, Medicaid,
about the enteral (tube-fed) population in the United States private insurance, and the uninsured), inpatient healthcare da-
by channel or healthcare delivery setting, specifically: acute tabase that includes discharge information from US communi-
care hospitals, nursing homes and home care. These 3 set- ty hospitals, excluding rehabilitation and long-term acute care
tings represent the majority of the enterally fed population, hospitals, Indian Health, VA, and other government hospitals.
however long-term acute care hospitals (LTCHs) and inpa- Also available from that family of HCUP databases is the Kid’s
tient rehabilitation facilities (IRF) were also included, as data Inpatient Database (KID), which specifically houses data on
were readily available to provide a more complete view of the patients age 0-17 years. Another database called the Hospital
enteral market. Readmissions Summaries, houses information on readmissions
to the hospital within 30 days of discharge. Data on ambulato-
ry surgery and emergency departments, along with individual
Data Sources: Big Data Sets state data, are also available. For the most part, the source of
the data in this report is the NIS.1 The number of tube-fed
Big data is defined as extremely large data sets that may be patients reported is the number of patients discharged with
analyzed computationally to reveal patterns, trends, and as- ICD-9 procedure code: 96.6 Enteral Infusion of Concentrated
sociations, especially relating to human behavior and interac- Nutrition Substances and was compared to the total number of
tions.6 The NIH explains that big data refers to the complexity, hospital discharges for the same period of time. The most re-
challenges, and new opportunities presented by the combined cent data available is from 2014, and some of the data elements
analysis of data. In biomedical research, these data sourc- go back to 1993.1
es include the diverse, complex, disorganized, massive, and
multimodal data being generated by researchers, hospitals, and
Nursing Homes
mobile devices around the world.7 The big data from this report
on EN comes from government, payer, and member associ- Nursing homes (NH) are defined as a place for patients who do
ation reports. It is further explained based on the healthcare not need to be in a hospital but cannot be cared for at home.9
setting and source. Most nursing homes have nursing aides and skilled nurses on
hand 24 hours a day. There are two levels of care within nurs-
Acute Care Hospitals ing homes; skilled nursing and custodial care. Skilled nursing
facility residents are covered by Medicare (Part A) for a period
Acute care hospitals provide treatment for a severe injury or of time if the stay is deemed medically necessary to improve
episode of illness, an urgent medical condition, or during or to maintain the quality of health of patients or to slow the

deterioration of a patient’s condition. Custodial care is the Nutrition benefit applies to beneficiaries in both nursing
provision of services and supplies for activities of daily living homes and the non-institutional setting.
(not medically necessary), that can be provided safely and
reasonably by individuals who may not be skilled or licensed Since the Compendium does not report the distribution of
medical personnel.10 enteral formulas used, nor could other sources that directly
report this information be found exclusively for this setting,
Similar to acute care, Medicare Part A reimburses skilled data from the 2013 Medicare Provider Utilization and Pay-
nursing facilities a lump sum based on the acuity of the patient ment Data Public Utilization File, otherwise known as PUF
for up to 100 days if the conditions of participation are met.11 Data, were used to estimate the distribution of formulas used
Tube-fed residents in skilled nursing facilities have enteral nu- by Medicare Part B beneficiaries.15 It is important to note,
trition covered during the initial 100 days of a qualified stay by however, that PUF data are reported comprehensively for both
Medicare Part A’s facility payment. If there is a continued med- the home care and nursing home settings, not separately. See
ical need for tube feeding beyond the first 100 days, the therapy Medicare Part B National Coverage Determination for Enteral
may be covered by Medicare Part B under the prosthetic device and Parenteral Nutritional Therapy (180.2).16 See more infor-
benefit to qualified beneficiaries. State Medicaid programs cov- mation on PUF Data in the home care section below.
er nursing home services for all eligible beneficiaries and pay
a monthly lump sum.12 EN is covered as part of the lump sum Home Care
paid to the NH by Medicare Part A and Medicaid.
For the purposes of this report, the term “home care” refers to
NH data comes primarily from the Nursing Home Data Com- the non-institutionalized setting where the individual resides
pendium 2015 Edition published by the Centers for Medicare in their own home, group home, board and care, or assisted
and Medicaid Services.13 The Certification and Survey Provider living facility. These individuals may or may not be receiving
Enhanced Reporting (CASPER) and clinical data from the “home health care services,” since receiving EN does not neces-
Minimum Data Set are the data sources for this compendium. sarily justify the need for home health services. They admin-
Since CASPER data can be modified by administrators, the ister the EN by themselves or with the assistance of a family
analysis of the same data element may yield slightly different member or caregiver. Home care supplies in the United States
results depending on when the data were retrieved. Thus, are delivered by many different systems, including durable
variations in survey results or facility counts may be apparent medical equipment (DME) providers, home infusion provid-
when comparing data. The Nursing Home Data Compendium ers, consumer self-purchase of products, and visiting nurses,
contains figures representing all Medicare and Medicaid-certi- among others. In most cases, patients who reside in this setting
fied NHs in the United States. The report provides information receive their formulas and/or supplies from a DME provider or
about resident-specific clinical measures such as the presence infusion provider.
of a feeding tube (nasogastric or abdominal), pressure ulcers,
and recent falls. It is important to note that while the compen- Not enough comprehensive demographic data exists about en-
dium is published by CMS, the patient data are not limited to teral patients at home to verify the total number of patients on
the Medicare or Medicaid population, but rather all residents tube feeding in this setting. Based on available data, this report
in Medicare- and Medicaid-certified NHs. presents the information from various sources independently
for the reader to extrapolate data based on their own needs. Se-
While enteral data are reported by healthcare settings else- lected big data sources are available, but some are older (earlier
where in this report, data from the Medicare Part B Durable than 2010) and thus, results need to be interpreted with cau-
Medical Equipment, Prosthetics, Orthotics and Suppliers tion. Sources such as the National Home Infusion Association
(DMEPOS) program were included as it is likely one of the (NHIA) survey, Medi-Cal, and Medicare PUF Data are used.17-
most robust resources when it comes to EN data in the NH and
19
It can be assumed that that the delivery of EN at home has
home care settings. In 2015, 70% of the 55,000,000 individuals grown in the United States over the years based on the shift in
in the Medicare population were enrolled in the Medicare Fee- care from acute care hospitals to the community setting and
for-Service program.14 The Medicare Part B DMEPOS Enteral the number of companies that provide enteral therapy at home.
The 2010 NHIA Provider Survey Comprehensive Aggregate Long-Term Acute Care Hospitals
Analysis Report is a collection of data representing the alter-
Long-term acute care hospitals (LTCH), also known as long-
nate site infusion industry member participation in the 2010
term care hospitals, provide long-term acute care to patients
NHIA Provider Survey.17 NHIA conducted this survey to gain
who continue to be medically complex and require an extend-
an understanding of the size and scope of the home infusion
ed stay in an acute care hospital setting. LTCHs provide care
industry. With 39% of NHIA members responding, NHIA
to patients who need hospital-level care for relatively long
extrapolated data from this survey to their other member
periods. Under Medicare’s conditions of participation, the pa-
organizations with statistical confidence. The results are limited
tient must have a length of stay of greater than 25 days.22 Data
in that they reflect only the NHIA membership and do not
on the use of EN in long-term acute care hospitals were based
include home infusion companies that were not members of
on data from the CMS 2014 Admission LTCH Continuity
NHIA in 2009, other suppliers of EN such as DME companies,
Assessment Record & Evaluation (CARE)23 data set purchased
or other “home care” suppliers.17 Older studies such as those
from Fleming-Advanced Outcomes Design, Inc., Silver Spring,
from the Oley Foundation OASIS home EN and PN registry
MD.24 This data set contained patient age, payer, and admitting
from the 1980s-1990s were excluded due to the age of these
diagnosis, based on an admission assessment and filtered for
data. However, these studies are important to review from a
use of enteral and/or parenteral nutrition.
historical perspective.20
2015 data from the Medi-Cal (California State Medicaid) Inpatient Rehabilitation Facilities
fee-for-service program were included to provide a glimpse of Inpatient rehabilitation facilities (IRF) provide intensive reha-
enteral formula utilization by Medicaid beneficiaries at home, bilitation services (such as physical or occupational therapy,
which includes all ages. Data was reported from Medi-Cal as it rehabilitative nursing, speech language pathology, prosthetic
is the largest state Medicaid program in the country.21 or orthotic devices) after injury, illness, or surgery. Medicare
requires that the beneficiary must actively participate and
The 2013 Medicare Provider Utilization and Payment Data benefit from therapy to qualify for this level of care.22 Use of
Public Utilization File was used to estimate the distribution of EN data from IRFs were based on data from the 2014 Amer-
formulas and supplies used by Medicare Part B beneficiaries in ican Medical Rehabilitation Providers Association (AMPRA)
both the nursing home and home care setting.19 This DMEPOS Database of Inpatient Rehabilitation Facilities Patient Assess-
Public Use File includes data on utilization and supplier counts ment Instrument.25 This data set represented about 36% of the
organized by Healthcare Common Procedure Coding System total patients in this healthcare setting. Patients were filtered
(HCPCS) codes. This public utilization file is based on infor- on patient assessment instrument Question 27: Swallowing
mation from CMS administrative claims data for Medicare status and selected based on the answer of enteral/parenteral
beneficiaries enrolled in the fee-for-service program available nutrition, which could have been checked either on admission
from the CMS Chronic Condition Data Warehouse. It is esti- or discharge from the facility.
mated that there were at least 3,978 enteral suppliers servicing
the Medicare DMEPOS enteral program in 2013.15 This figure
represents the number of suppliers who dispensed nutrition
Segmentation by Product Type and Delivery Methods
formulas found in HCPCS code B4150, the highest utilization HCPCS codes are used by Medicare Part B and some other
EN HCPCS code during 2013. There is no total number of sup- payers to classify and reimburse for DMEPOS, including EN.26
pliers reported for the therapy; rather, the number of suppliers In the section of this report on Segmentation by Product Type
who provide each HCPCS code is reported. Medicare PUF and Delivery Method, HCPCS codes will be used. Table 1 is
Data on types of tubes, delivery methods, and specific formulas a description of these codes for formula, pump, and supply
will be discussed in the section on segmentation by product kit categories.
type and delivery method.

TABLE 1
Description of HCPCS Codes for Formula Categories and Enteral Supplies

HCPCS HCPCS Description
B4034 Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4036 Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
B4081 Nasogastric tubing with stylet
B4082 Nasogastric tubing without stylet
B4083 Stomach tube - levine type
B4087 Gastrostomy/jejunostomy tube, standard, any material, any type, each
B4088 Gastrostomy/jejunostomy tube, low-profile, any material, any type, each
B4149 Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4150 Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, adminis-
tered through an enteral feeding tube, 100 calories = 1 unit
B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1. 5 kcal/ml) with intact nutrients, includes proteins, fats, carbohy-
drates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals,
may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of
proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids
(e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit
B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates,
vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include
fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals,
may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0. 7 kcal/ml) with intact nutrients, includes proteins,
fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include
fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B9000 Enteral nutrition infusion pump - without alarm
B9002 Enteral nutrition infusion pump - with alarm
SOURCE: https://www.dmepdac.com/
Data Sources: Large EN Studies Data Source: ASPEN Survey
in the Literature ASPEN conducted a member survey in January-February 2017
to gather more granular data from US-based members who
Using “enteral nutrition” as a search term, a Pub Med search
represent clinicians and other stakeholders such as service pro-
was conducted. Studies reviewed were published between 2011
viders. The data collected encompassed patient and institution-
and 2016 in English and with US patient cohorts. Abstracts
al demographic percentages, EN administration methods, and
from the ASPEN Clinical Nutrition Week meeting were also
current practices, including tube types, formulas, and flushing
searched and included if they met the criteria. Use of this
techniques. The ASPEN Clinical Practice Committee reviewed
US-based search criteria allows for comparison with the big
and approved the survey. The survey study was approved by the
US data sets. Studies were selected if they had greater than 50
University of Oklahoma Health Sciences Center Institutional
patients to provide more generalizability as to what patients
Review Board. The survey was administered using Survey
looked like in that healthcare setting. The healthcare settings
Monkey,® and statistical analysis was completed by ASPEN
ranged from critical care to home care with a few studies in
staff. Data were completely patient and institutional de-identi-
nursing homes, long-term acute care hospitals, and inpatient
fied and aggregated for this report. Many of the questions were
rehabilitation facilities.
similar across settings so that data between settings could be
compared. Respondents were all ASPEN members, and there-
fore may not represent all clinicians caring for all patients who
receive EN. While there was an approximate 10% response
rate for this survey, there are limitations to the generalizability
of this data. To view the full survey instrument, see Appendix
Table E, ASPEN Clinical Practice Committee Enteral Nutrition
Survey January-February 2017.

Results
The data and analyses in this report are divided into findings based on healthcare setting and then by
EN delivery practice. Each section will include results from big data sets, studies from the literature,
and survey results as available. Data are primarily displayed in tables and figures, augmented by text
and analysis. Additional findings and related topics are included to add context to the discussion.
Segmentation by Healthcare Setting

Table 2 provides an overall summary of EN use in all settings for 2014 as an overview of the EN
market. This table is a compilation of many sources, and adding the various healthcare setting totals
together should be discouraged, as patients often transitioned from one healthcare setting to another
and may be counted multiple times if all sources are simply totaled up.
TABLE 2
Enteral Nutrition Data by Healthcare Setting for 2014

Acute Care Nursing Home Home Care LTCH IRF
Number of Facilities/ 4,926a 15,640b Total Number Unknown 391d 1,180d

Providers in US 3978 DMEPOS EN
suppliersc
Number of Beds 786,874a 1,663,000b NA 27,000d NA
Percentage of Beds NA 82.4%b NA NA 64d

Occupied
Number of Residents/ 35,358,818 dischargese 1,406,220 residentsb Unknownf 179,560 dischargesd 627,000 dischargesd
Patients/Discharges
Patients/Discharges 255,140 e 75,936b 437,882g 72,360h 13,125i

on EN
Average LOS of all 4.6 Dayse 41.5 Daysd Unknown length of service 26.3 Daysd 12.8 Daysd
Patients
a
Number of hospitals from 2016 AHA Fast Facts of 2014 data27
b
Data from Nursing Home Compendium13
c
This figure represents the number of suppliers rendering nutrition formulas found in HCPCS code B4150, the highest utilization code during 201315
d
Data from MedPAC report of 2014 data22 (376,000 Medicare = 60% of total IRF discharges; 134,000 Medicare=66% of LTCH discharges)
e
From HCUP NIS 2014 data1
f
Home DME, Infusion, and Other Source supplied patients and EN patient numbers vary widely depending on source of data
g
2013 data estimated by Mundi28
h
Calculated on 36% of patients found in LTCH data23,24
i
Calculated on 2.1% of patients found in IRF data25
NA = Not available
To obtain a good overview of the healthcare settings and what eye, ear, nose, and throat; rehabilitation; orthopedic; and other
happens to patients post-hospital, the HCUP Statistical Brief individually described specialty services. Community hospitals
#205 All Payer View of Hospital Discharge to Post Acute Care, include academic medical centers or other teaching hospitals if
2013 provides valuable information.29 It reports that 70.2% of they are nonfederal short-term hospitals. Excluded are hospi-
discharges are routine, but 22.3% require post-acute care. This tals not accessible by the general public, such as prison hospi-
post-acute care in 2013 included discharges to home; health tals or college infirmaries. In 2014, these US community hospi-
agencies: 3,987,900; skilled nursing facilities: 3,219,800; IRF: tals, in 2014, had 786,874 staffed beds with 33,066,720 annual
576,700; and LTCH: 171,300. In 2014, post-acute care was admissions, and reported total expenses of $808,869,209,000.27
provided in 1,177 IRFs, 422 LTCHs, 15,173 skilled nursing
facilities, and at home through 12,461 home health agencies.22 Payment of EN therapy in the acute care setting is included
Of note, this AHRQ Statistical Brief #205 data is from 2013,29 in the Medicare Diagnostic Related Group (DRG) lump sum
while Table 2 above reflects 2014 data. The discharges in 2013 payment, which most accurately reflects the patient’s condition
to skilled nursing facilities were much higher in this HCUP and medical diagnoses. Thus, if the hospital provides more
NIS report, at 3,219,80029; notably, the nursing home compen- services or the patient’s stay is longer than expected, the hos-
dium data states that the number of nursing home residents is pital stands to lose money. If the patient’s stay is shorter than
only 1,406,220.13 The difference might be explained by the fact expected, the hospital receives the same amount of money and
that a Resident Assessment Instrument must only be complet- stands to come out ahead. Many payers mimic Medicare’s mod-
ed for any individual residing more than 14 days on a unit of el for payment. Some private payers may negotiate a rate with
a facility that is certified as a long-term care facility for partic- the hospital, while uninsured patients, and “self pay” patients
ipation in the Medicare or Medicaid programs.30 Additionally, must pay 100% of charges out of pocket. In summary, EN in
nursing home residents may be admitted and discharged mul- acute care is not specifically reimbursed but is covered under
tiple times during 1 calendar year. For example, in 2013, there the DRG or other negotiated payment rate.
were 1,800,000 hospital readmissions of patients on Medicare.31
Acute Care Hospital Data from Big Data Sources
The most recent AHRQ HCUP data available are from 2014.
Acute Care Hospitals
This database records the number of acute care discharges
Acute care hospitals provide treatment for a severe injury or where EN was coded.1 Table 3 illustrates the number and per-
episode of illness, an urgent medical condition, or during cent of hospital discharges by age, and the number and percent
recovery from surgery. According to the American Hospital of those hospital discharges where the patient received EN.
Association (AHA) in 2014, there are 5627 registered US hospi- Figure 6 illustrates the growth in hospital discharges where pa-
tals.27 Most are community hospitals (4926) and are defined as tients received EN from 1993 to 2014. According to this HCUP
all non-federal, short-term general, and other special hospitals. NIS data, less than 1% of all hospital discharges have EN as a
Other special hospitals include obstetrics and gynecology; coded procedure.
TABLE 3
Patients on EN in Acute Care Hospitals in 2014

ACUTE CARE
Age Group (Years) Total <1 1-17 18-44 45-64 65-84 85+
Total number of hospital discharges by age 35,358,818 4,247,755 1,347,359 8,714,895 8,709,298 9,490,054 2,837,716
Percent of all discharges by age 100% 12.01% 3.81% 24.65% 24.63% 26.84% 8.03%
Number on EN (0.72% of all discharges) 255,140 41,050 22,065 22,985 61,020 83,040 24,785
Percent of discharges on EN by age 100% 16.09% 8.65% 9.01% 23.92% 32.55% 9.71%
SOURCE: HCUP National In-Patient Samples 20141

FIGURE 6
Number of Hospital Discharges Where EN Was Coded 1993-2014
300000
250000
Total # of Discharges
200000
150000
100000
50000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
SOURCE: HCUP National In-Patient Sample1
There was significant growth in the coding of EN in patients in acute care hospitals from 1993 to
about 2006, at which point the growth curve decreased and has remained relatively flat over the last
8 years, as seen in Figure 6. However, when normalized per number of hospital discharges per year,
as shown in Figure 7, the trend is actually rising and has almost tripled over this time period, from
0.25% to 0.72% of all discharges.
FIGURE 7
Use of EN as a Percentage of Total Hospital Discharges in the US from 1993-2014
0.8
0.7
% of Total # of Discharges
0.6
0.5
0.4
0.3
0.2
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
SOURCE: HCUP NIS 1
When exploring these data by age population, some interesting trends are evident. First, examine
Figure 8, which illustrates a comparison of all hospital discharges to discharges on EN by age group.
Infants, pediatric patients, and older adults have a higher proportion of patients on EN as compared
to all hospital discharges in their age group.
FIGURE 8
Comparison of Discharges with EN with All Discharges by Age Group
50
40
Percent
30
20
10
0
Less than 1 year of age 1-17 years 18-64 years 65 years of age and older
Percent of hospital discharges Percent of EN patients
SOURCE: HCUP NIS1
As a percentage of total discharges, the pediatric age group, which includes both neonates and pedi-
atric patients through age 17, is increasing, as seen in Figure 9, while the older adults, aged 65 years
and older, remain the majority but are clearly trending down as a percent of the total.
FIGURE 9
EN Use as a Percent of Total Discharges in That Age Group Over Time

70
60
50
40
% of Total EN
30
20
10
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
Peds % of total EN Older Ad % of total EN
SOURCE: HCUP NIS1

These trends can be better appreciated when the data are normalized for all hospitalized patients in
that age range, as seen in Figure 10. It is interesting that EN use as a percentage of the total discharg-
es in that age range is increasing in pediatrics while decreasing and then remaining steady for older
adults. Some potential explanations for this change in EN use in older adults are explored further in
the discussion on nursing homes.
FIGURE 10
EN Use as a Percent of Total Discharges in That Age Group Over Time

1.2
1.0
0.8
% of Total EN
0.6
0.4
0.2
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
Peds-EN as % of discharges Older Ad-EN as % of discharges
SOURCE: HCUP NIS1
A driver for the growth in EN use in pediatric patients may be explained by examining those
patients under the age of 1 year. Actual numbers of discharges of patients on EN who are less than
1 year of age have increased by 43% over the past 10 years, while the total number of all patients
that age has decreased by 11%, going down from 4,818,678 (12.73% of total discharges) in 2005 to
4,247,755 (12.01% of total discharges) in 2014 (see Figure 11).1 There may actually be more infants
in hospitals receiving EN than are captured in the HCUP NIS database. Many neonates receive
breast milk via a nasogastric tube, and since this may not necessarily be considered enteral feeding
in that it is not a commercial infant formula, it may not have been coded using the ICD-9 code of
96.6. For full data on acute care discharges, see Appendix Table A, Discharge Status for Hospital
Discharges 2014.
FIGURE 11
Infants on EN in Acute Care Hospitals Over Time
45000
40000
35000
30000
# of Discharges
25000
20000
15000
10000
5000
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
SOURCE: HCUP NIS1
Acute Care Hospital Data from the Literature

Table 4 provides a summary of the literature of the hospitalized patient population receiving EN.
Fourteen studies of adult patients met the search criteria. Most were ICU patients with a variety of
critical illnesses, and most were mechanically ventilated. The average age of the patients across stud-
ies was 50 years to their early 60s. Overall patients received about 60% of their required nutrition
with short EN duration.
TABLE 4
Summary of EN by Type of Patient in Acute Care Hospitals from the Literature

Setting in Acute Care Number of Patients Mean Age Diagnoses Comments
Adult Acutely Ill Patients Ranged from 77-3343 52-63 years of age Most with respiratory insufficien- EN duration 3-11.8 days
(14 studies) cy on mechanical ventilation; EN adequacy 52.3-64.3%
diagnoses: neurologically injured,
post-surgical, trauma, sepsis, or
cardiac failure
Pediatric/Infant/NICU Ranged from 163-8333 31 weeks gestational All pediatric hospitalized patients or NICU GI surgery infants; time to
age – 14 months GI surgery NICU patients full EN was 15 days

Table 5 contains the full details of each study. Only 2 studies were available for pediatric and
neonatal patients. The first study looked at the percentage of feeding tubes placed, and the second
study reviewed improved days to full enteral regimen in surgical neonates. There are limitations to
generalizing hospitalized EN populations from the literature. However, it is likely that most patients
on EN are in intensive care units and that they have a mean duration of EN therapy from 3 to 12
days. When adequacy of the EN therapy is measured, defined as the percent of received formula as
compared to required formula, these studies reveal that EN adequacy is only about 55%. This is of
concern as it may contribute to ongoing disease and hospitalized patient malnutrition and should
be addressed with more aggressive feeding protocols. More studies are needed, and those should
include representative surveys of patients on EN across the acute care setting.
TABLE 5
Literature on Acute Care EN by Individual Studies

Citation Study Purpose Population (n) Patient Age Diagnoses Other Notes
Adult Acutely Ill Patients
Dijkink S, et al. Nutrition in the surgical To determine what proportion Adult surgical ICU Mean age 60.9 APACHE II score 14.0 EN duration 8.7 days
intensive care unit: the cost of starting of total SICU calorie/protein patients (n=109) years Reason for SICU admission RAMP-UP Calorie deficit
low and ramping up rates. Nutr Clin Pract. deficit is attributable to Trauma 35 (32.1%) significantly less than standard
2016;31:86-90. 32 RAMP-UP. Emergency surgery 16 (14.7%) protocol
Elective surgery 23 (21.1%)
Nonoperative 35 (32.1%)
Fuentes E, et al. Hypophosphatemia in en- To investigate the incidence Adult, surgical ICU Median age 63 Elective surgery 28% EN duration at least 72 hours
terally fed patients in the surgical intensive of refeeding hypophosphate- patients (n=213) years Emergency surgery 17% with actual caloric intake 17.8
care unit common but unrelated to timing mia (RH) in the surgical inten- Medical issues 25% kcal/kg/day and 1 g/kg/day
of initiation or aggressiveness of nutrition sive care unit (SICU) and its Trauma 30% of protein
delivery. Nutr Clin Pract. 2017;32(2): association with early enteral Median APACHE II score =14
252-257.33 nutrition (EN) administration
and clinical outcomes.
Gungabissoon U, et al. Prevalence, risk fac- Determine the incidence Adult, critically ill, me- Mean age 57.6 The most frequent Percent caloric adequacy
tors, clinical consequences, and treatment of enteral feed intolerance chanically ventilated years admission diagnosis was respi- ranged from 55.6-64.3%
of enteral feed intolerance during critical and factors associated with patients (n=1888) ratory, accounting for 30.8%
illness. JPEN J Parenter Enteral Nutr, 2015; intolerance and to assess (581/1,888) of the patients,
39(4):441-448.34 the influence of intolerance next was neurologic at 16.5%
on nutrition and clinical
outcomes
Haskins IN, et al. A volume-based Study clinical outcomes Adult ICU patients Median age Not specifically noted, median Median days on EN 11.4-11.8
enteral nutrition support regimen in ICU patients receiving (n=77) range 58-61 APACHE II score ranged from days
improves caloric delivery but may not rate-based or volume-based 90% were mechanical- years of age 10-17
affect clinical outcomes in critically ill enteral feedings. ly ventilated
patients. JPEN J Parenter Enteral Nutr. doi:
0148607115617441, first published on
November 12, 2015.35
Kozeniecki M, et al. Process-related To investigate barriers to Adult critically ill Mean age 61.8 Severe sepsis 28 (36%) Continuous feedings- after
barriers to optimizing enteral nutrition in a reach and maintain >90% patients (n=78) years Respiratory failure 36 (46%) day 1, received about 60% of
tertiary medical intensive care unit. Nutr prescribed EN among Neurologic failure 7 (9%) prescribed EN
Clin Pract. 2016;31:80-85.36 critically ill medical intensive Cardiac failure 2 (3%)
care unit (ICU) patients. Other 5 (6%)
Metheny NA, et al. Relationship between Determine the extent to Adult, mechanically Mean age 51.8 Neuromedicine/neurosurgery EN duration at least 3 days
feeding tube site and respiratory outcomes. which aspiration and pneu- ventilated intensive years 29.9% Less complication
JPEN J Parenter Enteral Nutr. 2011;35(3): monia are associated with care unit patients Trauma/surgery 42.5% With duodenal feeding
346-355.31 feeding site (controlling for (n=428) General medicine 27.6%
the effects of severity of ill- Mean APACHE II scores 20.2-
ness, degree of head-of-bed 22.5
elevation, level of sedation,
and use of gastric suction).
Rice TW, et al. Randomized trial of initial Conducted this randomized, Adult, mechanically Mean age Most frequent ICU diagnosis: EN duration just over 5 days
trophic versus full-energy enteral nutrition open label study to test ventilated intensive range 53-53 Respiratory illness or injury 38% Trophic feeds associated with
in mechanically ventilated patients with the hypothesis that initial care unit patients years Second most frequent was fewer GI intolerances
acute respiratory failure. Crit Care Med. low-volume (i.e., trophic) (n=200) neurologic
2011 ;39(5):967-974.38 enteral nutrition would APACHE II scores 26.9
decrease episodes of
gastrointestinal intolerance/
complications and improve
outcomes as compared to
initial full-energy enteral
nutrition in patients with
acute respiratory failure.
Roberts S, et al. Delivery of the enteral To determine if Volume Adult ICU patients Mean age 58.2 Primary top 3 diagnoses: 5.8 days on EN; Percent of
nutrition prescription and incidence of based EN led to delivery that (n=117) years respiratory (n = 44, 37.6%), ordered EN received: 67%
feeding intolerance in critically ill patients met the EN target (≥ 65% neurologic (n = 19, 16.2%) or
on volume-based enteral nutrition. according to the ASPEN/ trauma (n = 18, 15.4%);
ASPEN Clinical Nutrition Week LONG SCCM guidelines) for the first
BEACH FEB 2015 week in the ICU.
http://journals.sagepub.com/pb-assets/
cmscontent/PEN/CNW15_Posters_S1-
S98.pdf.39
Saran D, et al. Gastric vs small bowel To evaluate gastric compared Adult critically ill, Mean age Medical or surgical neurological EN adequacy ranged from
feeding in critically ill neurologically injured with small bowel feeding neurologically injured across two illness Mean APACHE II scores 52.3-60.2%
patients: results of a multicenter observa- on nutrition and clinical patients (n=1495) groups ranged 19.1-20.2
tional study. JPEN J Parenter Enteral Nutr. outcomes in critically ill, neu- from 52.7-57
2015; 39(8): 910-916.40 rologically injured patients. years
Taylor B, et al. Improving enteral delivery To determine the effect of Adult critically ill Age data not Trauma (41%) Received bolus and continuous
through the adoption of the “feed early “volume-based” feeding on patients (n=110) expressed Non-trauma surgical (59%) feeding methods
enteral diet adequately for maximum effect adequacy of EN delivery
(feed me)” protocol in a surgical trauma and provision of calories and
icu: a quality improvement review. Nutr Clin protein in a surgical/trauma
Pract. 2014;29:639-648.41 ICU (STICU).
Wood JD. Current postoperative enteral To provide an understanding Adult post op cardiac Mean age 61 Post-op cardiac surgery 100% Post-op cardiac surgery 100%
nutrition support trends after cardiac sur- of current practice in a high surgery hospitalized years Reasons for EN: Reasons for EN:
gery. ASPEN Clinical Nutrition Week LONG volume university cardiac patients (n=73) 22 (30.1%) dysphagia, 56 22 (30.1%) dysphagia, 56
BEACH FEB 2015 surgery program, with (75%) mechanical ventilation, (75%) mechanical ventilation,
http://journals.sagepub.com/pb-assets/ specific attention to EN, and 8 (11.1%) mental status and 8 (11.1%) mental status
cmscontent/PEN/CNW15_Posters_S1- formula used, enteral ac- changes changes
S98.pdf 42 cess, presence of pressors,
complications, and success
at achieving target volumes.
Studies Containing ICU and non-ICU Patients
Aloupis M, et al. Use of an adjusted enteral To assess the effectiveness Adult acute hospital Mean age 60.3 Not specifically noted All received pump adminis-
nutrition feeding goal to improve enteral of using an adjusted feeding and LTCH patients years tered feedings
nutrition delivery. ASPEN Clinical Nutrition goal to increase EN delivery n=109
Week Long Beach, CA 2015 by providing 125% of ICU 65(59.6%)
http://journals.sagepub.com/pb-assets/ patient specific estimated Floor 28 (25.7%)
cmscontent/PEN/CNW15_Posters_S1- energy needs. LTCH 16 (14.7%)
S98.pdf.43
Chaudhry R, et al. Trends and outcomes of Studied TBI hospitalized 96,625 TBI patients Not specified Traumatic brain injury (TBI) Only 3.5% of TBI patients had
early versus late percutaneous endoscopic patients 2011-2013 cohorts n=3343 had PEGs PEGs placed. Placement timing
gastrostomy placement in patients with to identify early, standard, (3.5%) of 7-14 days was associated
traumatic brain injury: Nationwide and late PEG placement and with best outcomes
population-based study. J Neurosurg association with outcomes.
Anesthesiol. 2017 Apr 28. DOI:10.1097/
ANA.0000000000000434 (epub ahead
of print).44
Pash, E, et al. Attainment of Enteral To review tube feed flush or- Hosp. patients n=393 Not specifically Not specifically noted 89% continuous
Nutrition Water Flush Orders Using Manual der practices and determine noted 11% intermittent pump
Syringe versus Automated Pump Delivery adherence to prescribed or- 53% ICU 2/3 manual flush, 1/3 auto-
ASPEN Clinical Nutrition Week poster ders and nationally accepted 47% non-ICU mated flush
Austin, TX 2016. JPEN Supplementary files standards of practice.
http://journals.sagepub.com/pb-
assets/cmscontent/PEN/CNW16_
Monday_Poster_Abstracts_revised.pdf.45

Pediatric and Neonatal Acute Care Hospitalized Patients
Lyman B, et al. Use of temporary enteral Conduct a multicenter 63 hospitals Mean age 14 All pediatiric hospitalized Verification of EAD placement
access devices in hospitalized neonatal 1-day prevalence study. Par- 1991 EADs in patients months patients. The neonatal intensive per site:
and pediatric patients in the United ticipating hospitals counted (24% of 8333 care unit (NICU) had the highest aspiration from the tube
States. JPEN J Parenter Enteral Nutr; the number of NG, OG, and patients ) prevalence (61%), followed (n=21/ 33%),
2016;40(4):574-580.46 PP tubes present in their by a medical/surgical unit auscultation (n=18/29%),
pediatric and neonatal inpa- (21%) and pediatric intensive measurement (n=8/13%),
tient population. Additional care unit (18%) pH (n=10/16%), and
data collected included age, X-ray (n=6/9%)
weight, and location of the
patient, type of hospital,
census for that day,
and the method(s) used to
verify initial tube placement.
Neonatal ICU (NICU)
Savoie KB, et al. Standardization of feeding To compare the surgical Infants (n=163) The median 85 infants (52%) had NEC, Time to full EN was 15 days
advancement after neonatal gastrointes- infants who were cared for gestational age 52 (32%) had gastroschisis, post implementation of
tinal surgery: does it improve outcomes? before and after the imple- ranged from 25 (15%) had an intestinal protocol
Nutr Clin Pract. 2016;31(6): 810-818.47 mentation of the first version 31-33.5 weeks atresia, and
of the feeding guideline 1 (1%) had malrotation and
based on data collected volvulus
retrospectively.
Acute Care Hospital Data from ASPEN Survey

Of the 492 respondents to the ASPEN EN Survey, 389 (or 79%) reported working exclusively in the
acute care hospital setting. In terms of facility size, 18% reported a facility with less than 100 beds,
38% worked in a 100-250 bed facility, 32% worked in a 251-500 bed facility, and 11% in a facility
with more than 500 beds. The average number of patients on EN was 22 (range 1-300); see Table 6
for number per size of facility. It appears that as the size of the hospital increases, so does the per-
cent of patients on EN. This is consistent with HCUP data as well when comparing EN use in small,
medium, and large hospitals.1 In acute care hospitals, the respondents reported that on average,
83% of patients were adults, 5% were pediatric patients, and 9% were neonatal patients. Data on
types of tubes and EN delivery can be found in the section on segmentation by product type and
delivery methods.
TABLE 6
Number of EN Patients per Size of Acute Care Hospital

Bed Size of Hospital Average number of EN patients Range EN Patients as Percent of Beds
Less than 100 (n=19) 3.8 0-28 0-3.8%
100-250 (n=57) 11.6 0-100 4.6-11.6%
251-500 (n=51) 23.6 4-75 4.7-9.4%
Greater than 500 (n=20) 94 18-300 9.4-18.8%a

a
Based on bed size 501-1000
SOURCE: ASPEN Survey 2017
Analysis of the Acute Care Hospital Setting

More than 35 million hospital discharges occurred in 2014, and less than 1% of patients during
a hospital stay received EN. This therapy was provided most often in adult patients (ages 18-64),
although the large percentage of older adults who have received EN in the past is decreasing, EN in
the pediatric patient population is growing, driven primarily by an increase in infants receiving EN.
Some of the most vulnerable individuals, including children Nursing Homes
and the elderly, are the most impacted by EN. This therapy is
provided often in critically ill, mechanically ventilated patients In the United States in 2014, there were 15,640 nursing facili-
and in a wide variety of hospital sizes, but most often in large ties with 1,663,000 certified NH beds with an 82.4% occupan-
urban teaching medical centers. cy rate.13 Similar to acute care, Medicare Part A reimburses
skilled nursing facilities a lump sum based on the acuity of the
patient for up to 100 days if the requirements of participation
Data Highlights Include: are met.11 If there is a continued medical need for tube feeding
beyond the first 100 days, or if the patient never qualified for
• Use of EN has almost tripled from 1993 to 2014, from Part A coverage, the therapy may be covered by Medicare Part
0.25% to 0.72% of all acute care discharges. B under the prosthetic device benefit to qualified beneficia-
ries.12 EN is covered as part of the lump sum paid to the NH by
• EN, as a procedure, is used in less than 1% of
acute care hospital discharges, indicating that it Medicare Part A and Medicaid.
may be undercoded.
• Pediatric use, particularly for those under the age of Nursing Home Data from Big Data Sources
one, is increasing in acute care hospitals with 5,595,114 Nursing home data comes primarily from the Nursing Home
children on EN in acute care hospitals in 2014. Data Compendium 2015 Edition published by the Centers for
• EN use in older adults remains the highest proportion Medicare and Medicaid Services.13 This report provides trends
but is decreasing as a percent of the total. over time in terms of EN use. Patients reported here are all
residents of nursing homes certified by Medicare and Med-
• It appears that as the size of the hospital increases, so
icaid, regardless of payer or age. In 2014, there were 75,936
does the percent of patients on EN. This is consistent
with several data sources. NH residents with a feeding tube, or 5.4% of the NH popula-
tion. The number of nursing homes, nursing home beds, and
• ICU patients on EN receive, on average, 60% of residents has decreased slightly over this 4-year period, as seen
required formula.
in Table 7. The number of residents with feeding tubes has de-
creased, as has the percentage of residents with tubes, at a rate
of 9% over this 4-year period.
TABLE 7
Nutrition Related Data from Nursing Home Data Compendium 2015 Edition
2011 2012 2013 2014
Number of Nursing Homes in US 15,673 15,630 15,638 15,640
Total Number of Certified NH Beds 1,668,000 1,665,000 1,662,000 1,663,000
Number of Certified NH Beds Occupied 1,388,000 1,380,000 1,370,000 1,370,000
Percentage of Beds Occupied 83.2% 82.9% 82.4% 82.4%
Number of Residents 1,431,730 1,409,749 1,404,949 1,406,220
Feeding Tubes Prevalence
Residents with Feeding Tubes 84,472 80,356 78,677 75,936
Percentage Feeding Tubes 5.9% 5.7% 5.6% 5.4%
Trends in Prevalence: 2011 to 2014 -9.0%
SOURCE: Nursing Home Data Compendium 2015 Edition published by the Centers for Medicare and Medicaid Services.13

Table 8 displays the use of EN in this healthcare setting by age. In NHs, a higher percentage of
younger residents have feeding tubes (ages 0 to 30 years of age) although the total number of res-
idents in this age category is relatively low. Older adults, aged 65 years and greater, make up 66%
of all EN in the nursing home setting but represent 3.6% of all nursing home residents. Additional
data on clinical measures in nursing home residents were available in the Compendium and will be
presented in section on malnutrition in this document.13 For full data on NH clinical measures by
age, see Appendix Table B, Prevalence of Clinical Measures in Nursing Home Residents by Age, by
Percent, 2014.13
TABLE 8
Prevalence of EN Use in Nursing Home Residents by Age, by Percent, 2014

Age Group (Years) Total 0-21 22-30 31-64 65-74 75-84 85-94 95+
Total number of residents by age 1,406,203 2,758 4,509 210,655 232,077 371,295 475,050 109,859
Percent of total residents by age 100% 0.02% 0.30% 15.00% 16.50% 26.40% 33.80% 7.80%
Feeding Tube
Number of patients with a feeding 76,089 2,005 1,560 22,540 15,781 18,193 14,252 1,758
tube
Percent of residents with a feeding 5.4% 72.7% 34.6% 10.7% 6.8% 4.9% 3.0% 1.6%
tube by age
SOURCE: Nursing Home Data Compendium 2015 Edition published by the Centers for Medicare and Medicaid Services.13
Nursing Home Data from the Literature

Only 2 studies of patients on EN in nursing homes were found to meet the search criteria, as seen in
Table 9. An additional study was included and published in 2009 by Kuo.48 This report was a classic
presentation of the history of feeding tubes in nursing home patients and clearly illustrates the tran-
sition from acute care to the nursing home. The study by Burgermaster is related to nursing home
admission criteria regarding the type of tube,49 and the Kuo and Mitchell studies are related to the
feeding tube insertion rate in advanced dementia.48,50
In the early to mid-2000s, clinicians and researchers began to more closely examine the use of EN
and permanent feeding tubes in the elderly, particularly those with advanced dementia.51-54 This be-
gan a trend in considering alternatives to feeding tube placement. The Kuo study illustrated a sharp
decline in feeding tube placement in this population, as the tube insertion rate in the year 2000 was
11.7% and decreased to 5.7% in 2014 in patients with advanced dementia.48
TABLE 9
Literature That Met Criteria from Nursing Home Settings

Nursing Homes
Citation Study Purpose Population (N) Age Diagnoses
Burgermaster M, et al. Regional comparison Compared nursing home EN–related SNF residents Primarily 62% of facilities nationwide accepted
of enteral nutrition–related admission admission policies in New York City (n=164 SNF facilities) older adults patients with NG tubes, but only 18%
policies in skilled nursing facilities. and other regions of the United accepted those patients in the NYC
Nutr Clin Pract. 2016;31(3):342-348.49 States and explored motivations for area.
these policies.
Kuo S, Rhodes RL, Mitchell SL, Mor V, To examine the natural history of Nursing home residents with advanced 84 years Found 5.4% of nursing home facility
Teno JM. Natural history of feeding tube feeding tube insertion and utilization dementia (n=5209) also had aspiration residents had feeding tube. Tubes most
use in nursing home residents with in a national sample of nursing home pneumonia, dehydration, dysphagia, UTI, often placed in the acute care hospital.
advanced dementia. J Am Med Dir Assoc. residents with advanced cognitive malnutrition, CVA, and septicemia in the
2009;10(4):264 270.48 dementia. hospital at time of feeding tube placement.
Mitchell SL, Mor V, Gozalo PL, Servadio JL, To describe feeding tube insertion Nursing home residents with advanced 84 years Feeding tube insertion rates went from
Teno JM. Tube feeding in US nursing home rate from 2000-2014 among US dementia (n=71,251) 11.7% in 2000 to 5.7% in 2014.
residents with advanced dementia, 2000- nursing home residents with advanced
2014. JAMA 2016;316(7):769-770.50 dementia. Used MDS assessments.
Nursing Home Data from the ASPEN Survey Home Care

This survey did not specifically seek information about nursing
Home care EN supplies and services for EN in the United
home patients.
States are delivered by many different provider systems, in-
cluding DME companies, home infusion companies, visiting
Analysis of the Nursing Home Setting nurses, consumer self-purchase of products, donations, or
The use of EN in nursing home patients has been gradually self-preparation of formulas. Little comprehensive current
declining over the past 4 years despite the steady rate of nurs- demographic data exists about enteral patients at home to be
ing home residents. This may be due to the continued trend of able to verify the total number of patients on tube feeding in
not placing feeding tubes in patients with advanced dementia, this setting. Historically, home care data have been difficult to
which started about 10 years ago. This is consistent with the capture. In the 1980s and 1990s, authors used Medicare and
decreased EN use in older adults in the hospitals as a percent Oley Foundation Registry data to analyze numbers of patients,
of total on EN by age and as a percent of hospital discharges cost, and outcomes. They reported that, on average, from
by age. 1989-1992 approximately 56,000 Medicare beneficiaries were
on home EN, including 73,000 in the single year of 1992.20 In
terms of payer policy, Medicare Part B covers EN supplies and
equipment (feeding pump) under the prosthetic device benefit
Data Highlights Include:
to qualified beneficiaries in the home care setting, as well as in
nursing homes (see above). See Appendix Table C for coverage
• Approximately 75,000 nursing home residents receive
EN (2014 data), a 9% decrease over the previous policies by healthcare setting.12 Coverage by state Medicaid,
four years. WIC, and private insurance varies.55,56
• About 5% of nursing home residents have feeding tubes,

a significant decrease from 11.7% in the year 2000.
• 62% of nursing home facilities nationwide accepted

patients with NG tubes.
• The largest proportion of those with feeding

tubes in nursing homes are those residents aged
75-84 years (24%).

Home Care Data from Big Data Sources
In an AHRQ HCUP Statistical Brief of 2013 hospitalizations, it was reported that 3,987,900 (or 11.2%
of all hospital discharges) were discharged to home health agencies.29 These patients had an average
hospital length of stay of 6.2 days. Sixty percent of these patients were 65 years old or older, and the top
5 diagnoses were joint replacement (MS-DRG 469,470), sepsis (MS-DRG 870-872), heart failure (MS-
DRG 291-293), COPD (MS-DRG 190-192), and pneumonia (MS-DRG 193-195).29
The National Center for Health Statistics, within the Centers for Disease Control and Prevention, con-
ducted a home care and hospice patient survey in 2000 and again in 2007.57 This survey report indicated
that in the year 2000, 1,355,300 US patients received home health care, while in 2007, that number rose
to 1,459,900 patients. The 2000 findings in this report also found that 60,200 patients received dietary
and/or nutritional therapy, but it was unclear which specific nutritional therapies were included in
this category.
In 2011, the National Home Infusion Association (NHIA) published findings from a 2010 survey of their
members.17 NHIA was able to extrapolate the survey data to a wider market, and the findings relative
to patients receiving EN from infusion providers can be found in Table 10. This NHIA survey report-
ed about 160,000 patients on home EN. This home EN population had a larger percentage of pediatric
patients as compared to older adults. Insurance coverage for these patients was Commercial Insurance/
HMO/PPO 40%, Medicaid 31%, Total Medicare 24%, and Other 5%. (NHIA).17
TABLE 10
NHIA Data on Enteral Nutrition Patients by Age

NHIA Data (2010) by Age Group (Years) Total 0 to 14/18 15/19 to 55 55 to 65 >65
Total - All Therapies 1,243,590 263,930 449,923 246,453 283,283
Number on EN (13% of all Patients) 162,581 72,001 33,363 19,249 37,969
Percent 100.0% 44% 21% 12% 23%

SOURCE: NHIA 17
The Medi-Cal (CA State Medicaid Program) program is the largest state Medicaid program in the
country.58 In December 2015 there were 13,303,206 certified eligible Medi-Cal beneficiaries (or 34% of
the number of residents residing in the state in July 2015).18,59 Of the 13,303,206 beneficiaries, 3,012,122
(23%) were enrolled in their Fee-for-Service (FFS) program and 10,291,084 (77%) in one of the state’s
Managed Care plans.18 The Medi-Cal FFS program may cover EN products upon authorization when
used as a therapeutic regimen to prevent serious disability or death in patients with medically diag-
nosed conditions that preclude the full use of regular food.60 Both tube feeding and oral supplements are
covered under this benefit.60 Medi-Cal data were obtained from the California Department of Health
Care Services, which manages the benefit for the Medi-Cal Fee-for-Service Program using the Califor-
nia Public Records Act process.61 The data obtained were from Medi-Cal paid claims, which provide a
glimpse of EN formula (tube-fed and oral nutrition) usage within the Medi-Cal Fee-for-Service program
from July 1, 2015 to June 30, 2016. The data reported represents formula reimbursed for both oral and
tube feeding. The number of beneficiaries receiving tube feeding was calculated based on the number of
beneficiaries receiving tube feeding administration sets during the same time period. Because Medi-Cal
uses NDC Formatted Codes to identify EN products for reimbursement purposes, the authors of this
publication converted the reported information to HCPCS codes to compare and contrast utilization by
this payer, compared to data from other available sources. See Table 11 for details.
TABLE 11
Medi-Cal Fee for Service Program (FY 2015)

State of CA Population 39,144,818
All Medi-Cal Beneficiaries 13,303,206 (34%)
FFS Beneficiaries 3,012,122 (23%)
Managed Care Beneficiaries 10,291,084 (77%)
Number of FFS Unique Beneficiariesa with an EN Formula (Oral or TF) paid claim 15,168
Number of FFS Beneficiaries with an EN Administration Set paid claim from 7/1/15 thru 6/30/16 5,206 (34%)
a
Unique Beneficiaries represents the number of beneficiaries who had an enteral nutrition product(s) paid claim during reported time period. A unique beneficiary may have more than
one formula with a paid claim therefore formula utilization number is more than the unique beneficiary number.
SOURCE: Medi-Cal61
Home Care Data from the Literature

There were 8 studies in the recent literature that met the search criteria, as can be seen in Table 12. Most
of these studies had a mix of pediatric and adult patients, and the number of patients observed ranged
from 52 to over 10,000. Most patients who required tube feeding were either younger than 8 years of
age or from mid-50s to mid-80s in age. Diagnoses varied greatly from feeding difficulties and congen-
ital heart disease in pediatrics, and from surgical oncologic conditions to dysphagia in adults. Types of
tubes, formula mix, and EN delivery methods will be discussed further in the section on segmentation
by product type and delivery method.

TABLE 12
Individual Studies of EN Patients in the Home Care Setting

Home Care Study Purpose Population (n) Patient Age Types of tubes Diagnoses Other Notes
Brettschneider AK, Reddick C, Emch VL. To collect Home EN 51% pediatric, Type of tube not Pediatric patients: Insurance coverage:
Apria Healthcare Inc., Characteristics demographic and patients (adults 48% adult with available. The leading diagnoses 25% pediatric patients have
of patients receiving home enteral prescription data and pediatrics) 19% older adult majority of patients are failure to thrive, Medicaid, 70% of those less
nutrition. ASPEN Clinical Nutrition Week on all patients n=10,000+ under the age of esophageal reflux, than 65 have commercial
Poster 2011 Vancouver, BC, CANADA over a 1 year 65 are pump fed, feeding difficulties insurance, 70% older adults
http://journals.sagepub.com/doi/ period from a and the majority and cerebral palsy; have Medicare Part B coverage
suppl/10.1177/ home infusion of patients age leading diagnosis Formula: Patients at age 5 or
0884533610397920/suppl_file provider. 65 or older are for adult patients is younger are prescribed formula
DS_10.1177_ fed via the bolus dysphagia listed as the “other category”
0884533610397921.pdf.62 (syringe) method. 42% of the time. This category
The gravity feeding includes metabolic formulas,
method is the modulars, and thickeners.
smallest population Standard intact protein formulas
of patients in each are most commonly prescribed in
age group the population of patients at age
6 or older.
Drake R, et al. Hospital inpatient To examine the Medicare Home Mean age = 72 PEG/ PEJ Those readmitted 37% (or 5500) were admitted
admissions with dehydration rate and cost of EN patients years had a primary with dehydration and/or
and/or malnutrition in Medicare Medicare patients n=15,000 diagnosis of malnutrition
beneficiaries receiving enteral on home EN who septicemia,
nutrition: a cohort study. JPEN are admitted to aspiration
J Parenter Enteral Nutr. 2017 a hospital with pneumonitis,
doi:10.1177/0148607117713479.63 dehydration and/ pneumonia, renal
or malnutrition. failure, or UTI
Epp L, et al. Use of blenderized tube To administer a Adult and Adult 42.2% of Type of feeding This variable Duration of home EN
feeding in adult and pediatric home validated survey pediatric patients patients tube devices not not noted 38% > 5 yrs
enteral nutrition patients. to home enteral (n=216) mean age 51.7 specifically noted 52% on EN from 1-5 yrs
Nutr Clin Pract. 32(2): 201-205.64 consumers years
to assess the Pediatric 57.8% BTF was used at least for part
prevalence of BTF. mean age 5.4 of the Home EN for 66-90% of
years these patients.
Hall BT, et al. Implementation of a To describe the (n=52) Age of patients Surgical feeding Surgical and Implementation of a dietitian-
dietitian-led enteral nutrition support development and not noted tubes, not specified oncology patients led nutrition support clinic
clinic results in quality improvement, validation of an resulted in improved quality, and
reduced readmissions, and cost enteral nutrition decreased costs.
savings. Nutr Clin Pract. 2014;29:649- support clinic
655.65 (NSC) with a focus
on prevention of
enteral access
complications.
Kranz E, et al. Trends in enteral tube To investigate Home adult and Age range 0-100 G-tubes Diagnoses not G-tubes most common
placement for utilization in the home home enteral pediatric patients Most patients J-tubes available J-tube second most prevalent G-J
setting. ASPEN Clinical Nutrition Week nutrition (HEN) (n=4672) were less than G-J tubes, exact and J tube use doubled over 6
2017 poster Orlando, FL 2017. JPEN J feeding tube 8 years old or number not available year period
Parenter Enteral Nutr.66 Supplementary utilization in from mid-50s to
material http://journals.sagepub.com/ patients residing mid-80s
page/pen/collections/abstracts/index in Montana,
Oregon, and
Washington State,
from 2010 to
2015.
Mundi MS, et al. Prevalence of home To ascertain the Adult Not provided Not provided Specific diagnoses Data extrapolated from Medicare
parenteral and enteral nutrition in the prevalence of HEN=248,846 not provided claims data and large DME
US. Nutr Clin Pract. 2017.28 HPEN patients in Pediatric providers patient payer statistics
doi:10.1177/0884533617718472 the US. HEN=189,036
Home Care Study Purpose Population (n) Patient Age Types of tubes Diagnoses Other Notes
Rosen D, et al. Home nasogastric To look at children Pediatrics (n=87) Average age NG tubes (100%) Diagnoses: Average feeding duration was
feeds: feeding status and growth discharged on 1.2 years congenital heart 4.8 months
outcomes in a pediatric population nasogastric (NG) disease (47%),
JPEN J Parenter Enteral Nutr. 2016; feeds to assess metabolic disease
40(3): 350-354.67 follow-up feeding (17%),
status and impact neurologic
on growth. impairment (10%),
liver disease (9%),
prematurity (8%),
and inflammatory
Vallumsetla N, et al. Effect of home To retrospectively Home adult EN Mean age 88 (48.6%) PEG Gastrointestinal Patients with diabetes who
enteral nutrition on diabetes and it review our patients 66.1 years tube, diseases (44.1%) received home EN did not
management. ASPEN Clinical Nutrition prospectively (n=181) 21 (11.6%) PEJ and Hematological experience worsening of their
Week 2016 Poster Austin, TX.68 http:// maintained tube, and malignancies HbA1C, and a majority of them
journals.sagepub.com/pb-assets/ HEN database 72 (39.7%) (24.3%) were well managed using insulin
cmscontent/PEN/CNW16_Monday_ to identify all jejunostomy tubes therapy.
Poster_Abstracts_revised.pdf patients who
had a diagnosis
of diabetes and
received HEN.
Home Care Data from the ASPEN Survey equal about 50,000 patients going home with this therapy
Of the 492 respondents to the ASPEN Survey, 44 (or 8.9%) per year. This differs from the NHIA data of 162,000 patients
reported caring for patients in the home setting. Of those on EN therapy.17 These patients, however, may have been on
respondents, 55% were reporting data for their agency based at service for some time and not newly discharged, as with the
the branch level, 5% on the regional level, 5% on the national HCUP data, and could represent an accumulation effect over
level, and 35% on the hospital or medical center-based home time. Another way to compare these numbers is to look at
care agency level. On average, the respondents reported caring those older adults on home EN. NHIA reports about 38,000
for 467 patients on EN with a range of 1 to 764 patients. Of older adult patients on EN at home,17 while Medicare PUF
those patients, 75% were adult patients, 22% pediatric patients, data reports 114,287 (represents both NH and home care).15
and 3% were neonates or infants. When those who care for Attempts were made to acquire information on the percent in
hospitalized EN patients were asked about what percentage of each care setting but there does not appear to be any published
those patients on EN are discharged to home, they reported data on this number. Over the years, estimates from the com-
that 23% of inpatients on EN go home with this therapy. Data munity range from 40%/60% to 50%/50% to 60%/40%. The
on types of tubes, delivery methods, and formulas will be recent study by Mundi et al., extrapolates the number of home
discussed in the section on segmentation by product type and patients receiving EN based on Medicare DME claims and per-
delivery method. cent of payers based on three large home care suppliers.28 This
is clearly an area that calls for a home EN registry to collect
data on these patients. In the past, patient registries may have
Analysis of the Home Care Setting not produced data that is truly representative of full home care
EN use in the home care setting is the most difficult to gather population, as they have been largely volunteer clinician input
data on for several reasons. There are a number of different efforts, and data have come from larger institutions and home
ways patients receive home care supplies, including DME, care agencies that value benchmarking data.20,69-71 Registries
home infusion providers, home health agencies, and self-pur- are an important data source going forward and may be a way
chase. There are a number of different payment models and no to look at this population, but there clearly are challenges and
1 registry of patients. The best way to estimate patient numbers obstacles to overcome. An innovative approach to automati-
is to compare various data sources and view those sources for cally download home care data from all patients on home EN
the type of data they are collecting. For example, the HCUP would certainly be welcome. Growth in pediatric patients on
data reports about 250,000 patients in the hospital on EN.1 EN and healthcare reforms are just two of many factors that
When you use the ASPEN Survey average percent (23%) of may influence growth in the home care sector.
patients going home on EN, this 23% can be extrapolated to

Data Highlights Include: with the HCUP data.29 (Note these are 2 different years of data
collection). In terms of payer policy, an LTCH stay is paid in a
• The home care setting is the most difficult environment similar fashion to the acute care hospital with the DRG system.
in which to capture an accurate measure of the number There is no explicit payment for EN specifically.
of patients on EN therapy.
• The Mundi paper estimated about 438,000 patients on LTCH Data from Big Data Sources
home EN.
The only large data set available for analysis that records nutri-
• The HCUP and ASPEN Survey data combined, project tion support use is from the 2014 Admission LTCH Continuity
about 50,000 patients discharged to home per year
Assessment Record & Evaluation (CARE) Data Set, which
on EN.
includes a question in the pre-assessment form on diet selec-
• 75% of those on home EN are adults, 25% children but tion.23,24 The answers to these questions included options listed
depends on data source. here: a) Tube/parenteral feeding (tube/parenteral feeding used
wholly or partially as a means of nutrition) or b) Total Parenter-
al Nutrition (tube/parenteral feeding used wholly as a means of
Long-Term Acute Care Hospitals nutrition). The total number of patients in this database in 2014
was 132,258, but only 22,466 had admission assessments upon
LTCHs provide care to patients who need hospital-level care for which these findings are based. The number of patients with
relatively long periods. Under Medicare’s conditions of partic- either of these diet selection answers of EN and/or PN were
ipation, the patient must have a length of stay in an LTCH for 8156 of 22,466 (or 36% of those with assessments). Table 13
more than 25 days. In 2014, 118,000 Medicare fee-for-service illustrates demographics and diagnoses for these patients who
beneficiaries had approximately 134,000 LTCH stays. Medi- were on EN and/or PN. Most of these patients had Medicare
care spent $5.4 billion on LTCH stays and accounted for about coverage. A limitation to this data set is that these 2 therapies
two-thirds of the LTCHs discharges with an average length of were not separated out, although based on the diagnoses listed
stay of 26.3 days.22 In the HCUP Statistical Brief #205 entitled below, one might assume that most of these patients were on
An All-Payer View of Hospital Discharge to Postacute Care, 2013, EN. Patients in LTCHs were on average 66.2 years old, although
it was reported that there were 171,000 discharges from acute the range of ages is wide.
care to 422 LTCHs in 2013.29 Using 134,000 Medicare patients
as two-thirds of the LTCH population,22 this roughly matches
TABLE 13
Selected Demographics and Diagnoses for Patients on EN in LTCH Setting

Patients Age on Mean 66.2 years Range 5-90 (>than 89 listed as 90)
Admission SD +/- 14.3 years
Patient Primary ICD-9 (Top 10, only 6039 had diagnosis listed) Number and percent of listed responses
Code and Diagnosis
518.81 (Acute respiratory failure not otherwise specified) 1916 (31.7%)
518.84 (Acute and chronic respiratory failure) 844 (13.9%)
998 (Other complications of procedures) 334 (5.5%)
38 (Septicemia) 308 (5.1%)
518.83 (Chronic respiratory failure) 294 (4.9%)
518.51 (Pulmonary insufficiency following trauma and surgery) 277 (4.6%)
V58 (Encounter for other and unspecified procedures and aftercare) 125 (2.1%)
Patient Primary ICD-9 (Top 10, only 6039 had diagnosis listed) Number and percent of listed responses
Code and Diagnosis
438 (Late effects of cerebrovascular disease) 121 (2%)
507 (Pneumonitis due to solids and liquids) 111 (1.8%)
996 (Complications peculiar to specified procedures) 75 (1.2%)
Insurance Coverage (Discharge Payer) n=13209 * some had more than one coverage Responses and % of responses
Medicare ( fee-for-service) 5391 (47.4%)
Medicaid (fee-for-service) 1852 (14%)
Private insurance/Medigap 1754 (13.3%)
Private managed care 1254 (9.5%)
Medicare (managed care/Part C/Medicare Advantage) 953 (7.2%)
Self-pay 651 (4.9%)
Medicaid managed care 629 (4.8%)
Other government (Tricare, VA, etc.) 342 (2.6%)
Other 230 (1.7%)
Unknown 88 (0.7%)
Worker’s compensation 19 (0.15%)
No payor source 16 (0.12%)
SOURCE: 2014 Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set / Fleming
23,24
LTCH Data from the Literature

Only 1 study was found that included patients on EN in an LTCH setting, (see Table 14 for the
study details). This was a study completed at the University of Pennsylvania, and only a portion
of the patients in this study were in this care setting. The small number of LTCH patients con-
tributed to a mean age of about 60 years and received pump administered feedings.

TABLE 14
Literature on EN in LTCH
Types of
Citation Study Purpose Population (n) Patient Age Tubes Diagnoses Other Notes
Long-Term Acute Care Hospital (LTCH)
Aloupis M, et al. S-39 - Use of an Adjusted Enteral Nutrition To assess the effective- Adult Hosp. and LTCH Mean age Not specifi- Not specifi- All received
Feeding Goal to Improve Enteral Nutrition Delivery ASPEN ness of using an adjusted patients n=109 60.3 years cally noted cally noted pump adminis-
Clinical Nutrition Week 2015 Long Beach, CA43 feeding goal to increase ICU 65 (59.6%) Floor tered feedings
http://journals.sagepub.com/pb-assets/cmscontent/PEN/ EN delivery by providing 28 (25.7%)
CNW15_Posters_S1-S98.pdf. 125% of patient-specific LTCH 16 (14.7%)
estimated energy needs.
LTCH Data from the ASPEN Survey Analysis of the LTCH Setting
Of the 492 respondents to the ASPEN EN survey, 32 of the re- Extrapolating from the LTCH big data set that found 36% of
spondents (or 6.5%) worked in LTCHs. In terms of facility size, patients in that care setting are on nutrition support therapy
65% reported a facility with less than 100 beds, 25% worked in and applying that to the 177,000 to 201,000 patients discharged
a 100-250 bed facility, and 10% in a facility with more than 250 to these facilities in 2014,1 this would predict that a large num-
beds. The number of patients on EN averaged 21.5, and 100% ber of patients (up to approximately 72,000) require EN/PN in
of those were considered adults. As with acute care hospitals, as LTCHs. In comparing these large data to the ASPEN Survey,
the facility size increased, the percent of those receiving EN in in which EN patients make up anywhere from 0 to 28% of the
LTCHs did as well, as seen in Table 15. The details on tube type, patients in these facilities, this population of patients on EN is
formula, and delivery methods are provided in the section on significant. Very little observational research on this population
segmentation by product type and delivery method. has been done, and with their long-term acute needs, there is
an opportunity to place additional focus on these EN patients
TABLE 15 in LTCHs. It would be important in future data collection to
separate EN from PN in the assessment data for these patients.
Number of EN Patients per Size of LTCH Facility
Bed Size of Average number EN Patients as
LTCH of EN patients Range Percent of Beds
Less than 100 16.5 1-60 0-16.5%
• Far more patients in long-term acute care hospitals
100-250 17.4 10-30 6.96-17.4% receive nutrition support than those in IRFs.
251-500 69.5 55-84 13.9-27.7%

• 36% of patients in a LTCH large data source required
nutrition support.
ASPEN EN Survey 2017
• Like acute care hospitals, as the size of the facility (in
terms of number of beds) grows, so does the percent of
patients on nutrition therapy.
• A large majority of these patients had

respiratory conditions.
Inpatient Rehabilitation Facilities IRF Data from Big Data Sources
The only large data set available for analysis that records EN
Inpatient Rehabilitation Facilities (IRF) provide intensive reha-
use was from the 2014 American Medical Rehabilitation
bilitation services (such as physical or occupational therapy, re-
Providers Association Database of Inpatient Rehab Facilities
habilitative nursing, speech language pathology, and prosthetic
Patient Assessment Instrument.25 This data represented about
or orthotic devices) after injury, illness, or surgery. Medicare
36% of the total patients in this healthcare setting. Patients
requires that the beneficiary must actively participate and
were filtered on patient assessment instrument Question 27:
benefit from therapy to qualify for this level of care. In 2014,
Swallowing status and selected based on the answer of enteral/
Medicare spent $7 billion on Medicare fee-for-service benefi-
parenteral nutrition, which could have been checked either
ciaries in 1,180 IRFs nationwide. About 339,000 beneficiaries
on admission or discharge from the facility. The total num-
had almost 376,000 IRF stays. On average, Medicare accounts
ber of patients in this database in 2014 was 221,216, which
for about 60% of IRF’s discharges.22 According to the HCUP
represented 36.4% of all patients in the IRF care setting.25 The
Statistical Brief #205 entitled An All-Payer View of Hospital
number of patients with answers of EN and/or PN were 4630,
Discharge to Postacute Care, 2013, it was reported that there
or 2.1% of those patients in this database. Table 16 illustrates
were 576,000 discharges from acute care to 1,177 IRFs in that
demographics and diagnoses for these patients who were on
year.29 Note that these 2 reports are not reporting data from the
EN and/or PN. Most of these patients had Medicare coverage.
same year, but when the 60% of Medicare stays are extrapo-
A limitation to this data set is that these 2 therapies were not
lated to all stays in 2014, it compares well to the 2013 data of
separated out, although based on the diagnoses listed below,
576,000 discharges. The primary diagnoses for IRF stays are
one might assume that most of these patients were on EN
primarily orthopedic procedures and stroke.29 In terms of pay-
secondary to their diagnoses and the usual indications for EN
er policy, an IRF stay is paid in a similar fashion to the acute
versus PN. Of note, most of these patients requiring nutrition
care hospitals in that they are paid a per diem based on the
support therapy had a neurological condition of some type.
level of acuity. There is no explicit payment for EN specifically
but is paid for as part of the lump sum payment.
TABLE 16
Demographics of Patients in IRF Care Setting on EN/PN Therapy

Patient Age on Admission Mean 63.8 years (SD +/- 17.8 years) Range <1-90 (>than 89 listed as 90)
Primary Diagnosis -Top 10 Intracerebral hemorrhage (431.0) 1182 (25.5%)

(ICD-9 codes)
Critical illness myopathy (359.81) 190 (4.1%)
Subdural hemorrhage following injury (852.2) 182 (3.9%)
Injury, other specified sites, including multiple (959.8) 175 (3.8%)
Cerebral embolism (434.11) 158 (3.4%)
Subarachnoid hemorrhage (430.0) 123 (2.7%)
Anoxic brain damage (348.1) 107 (2.3%)
Subarachnoid hemorrhage following injury (852.0) 76 (1.6%)
Cervical spondylosis with myelopathy (721.1) 53 (1.1%)

Insurance Coverage (Top 10) Medicare non-MCO 2195 (47.4%)
Not listed 753 (16.2%)
Medicare MCO 531 (11.4%)
Blue Cross 295 (6.4%)
Commercial Insurance 260 (5.6%)
Medicaid non-MCO 165 (3.6%)
Medicaid MCO 114 (2.5%)
MCO-HMO 105 (2.3%)
None 59 (1.3%)
SOURCE: 2014 American Medical Rehabilitation Providers Association (AMPRA) Database of Inpatient Rehab Facilities Patient Assessment Instrument25
IRF Data from the Literature

Only 1 study on patients receiving EN in an IRF that met the search criteria was found in the litera-
ture. This large study by Horn and colleagues observed patients with traumatic brain injury (TBI) (see
Table 17).72 After matching patients with a propensity score for the likely use of EN, they found that
patients who received standard or high-protein formula EN for greater than 25% of their rehabilitation
stay had better motor and cognitive scores at discharge and less weight loss than similar patients not
receiving EN.
TABLE 17
Literature on EN in the IRF Setting

Inpatient Rehabilitation
Study Purpose Population (n) Patient Age Types of Tubes Diagnoses Other Notes
Facility
Horn SD, et al. Enteral nutrition for To determine the association of EN Patients admitted for first full Mean age = Tube types not All had brain Mean dura-
tbi patients in the rehabilitation with patient pre-injury and injury inpatient rehabilitation after a 38.5 years specifically injury due to tion of EN
setting: associations with patient characteristics and outcomes for TBI index injury on EN (n=451) (patients 14 outlined. trauma. 16.6 days
pre-injury and injury character- patients receiving inpatient brain compared to 1250 patients who years and older
istics and outcomes. Arch Phys injury rehabilitation. did not receive EN. treated in adult
Med Rehabil. 2015; 96(8S): IRF)
S245–S255.72
IRF Data from the ASPEN Survey Analysis of the IRF Setting
Of the 492 respondents to the ASPEN EN survey, no respon- There was limited data and literature for EN in the IRF set-
dents worked in IRFs. ting. Overall, most patients who receive EN in these facilities
have neurological conditions that would preclude adequate,
if any, oral nutrition intake. Only a small percentage of the
IRF population appears to require EN, but little research has
been done to confirm these findings, and more information
is needed. A major limitation for this care setting is that PN and Feeding Tube Types in Acute Care
EN are categorized together, and while one might assume that
In the acute care hospital setting, there are data from big data
most of these patients are on EN, there are no data to confirm
sources such as HCUP data, studies in the literature, and the
that assumption. With just 1 paper on this population, very few
ASPEN Survey. The HCUP National Inpatient Sample tracks
conclusions can be made except that only a small percentage of
tube placement procedures from inpatient facilities. In 2014,
patients in this care setting receive EN.
over 260,000 tubes were placed and coded as feeding tube pro-
cedures.1 This did not include nasoenteric feeding tubes, as there
was not a specific code for this procedure in ICD-9CM coding.
Data Highlights Include: There is an ICD-10 code for NG tube placement, which began
to be used in the United States in 2015. A large majority of those
• Only 2.1% of patients in the IRF setting required tubes placed and coded for were PEG tubes as seen in Figure
nutrition support, and a majority of them had a 12. The majority of the tube procedures in acute care were also
neurological condition.
placed in older adults, as seen in Figure 13. In large clinical
• The percent of EN use was a much smaller percentage as studies of acute care hospitalized patients, most of those patients
compared to LTCH setting. had naso- or oroenteric short-term tubes. For types of feeding
tubes from the ASPEN Survey, hospital-based respondents
• The majority of these patients had Medicare coverage
and were 63.8 years old (SD +/- 17.8 years). reported that 41% of their patients receiving EN had short-term
nasogastric tubes, 17% had short-term nasoenteric (post-pylor-
ic) tubes [58% short-term], 27% had gastrostomy tubes, 5% had
gastrojejunostomy tubes, and 6% had jejunostomy tubes.
Segmentation by Product Type and

Delivery Methods
The purpose of segmenting findings by product type and deliv-
ery methods is to provide data on the practice of EN delivery
and the types of formulas used in various healthcare settings as
well as in total. Not all settings or types of data sets have all vari-
ables presented, but where data is available, it can be compared.
Types of Feeding Tubes

This section provides data on the types of tubes across care set-
tings from all data sources where this breakdown by percentage
of patients is available. In some settings, such as IRFs, these data
is not available and should be the topic of future investigations.
Feeding tube types can be categorized into naso- or oroenteric
(short-term) tubes, gastrostomy tubes to include PEGs, combi-
nation gastrostomy-jejunostomy tubes, and jejunostomy tubes,
no matter the insertion techniques.

FIGURE 12
Feeding Tube Procedures in Acute Carea

300000
100%
250000
200000
62.6%
150000
100000
50000
12.3% 12.9%
4
% 8.2%
0
PEG Other G-tube PEGJ/PEJ Other Enterostomy Replacement G-tube Total
a
Naso and Oro-enteric feeding tubes not coded for SOURCE: HCUP NIS 20141
FIGURE 13
Combined Feeding Tube Procedures in Acute Care by Age in 2014a
60 55%
50
37.3%
40
Percent of Procedures
30
20
10
3.7% 4%
0
Age less than 1 Age 1-17 Age 18-64 Age 65 and greater
a
Naso and Oro-enteric feeding tubes not coded for SOURCE: HCUP NIS 20141
Table 18 outlines feeding tube type in acute care from all data sources. It is difficult to compile a sum-
mary of tube use in acute care, as NG tube insertion is not captured in big data. In addition, comparing
100% of ICU patients who have short-term nasoenteric tubes with the 23% of patients who are prepar-
ing to be discharged and who may have had a more permanent tube placed for longer-term EN, is not
always an appropriate comparison.
TABLE 18
Feeding Tube Types in Acute Care

Study Source Patient Types Types of Tubes
2014 HCUP National Inpatient Mixed hospitalized Nasoenteric feeding tubes- data not available
Sample procedures1 PEG (ICD-9 43.11) 161,825
Other gastrostomy (ICD-9 43.19) 31,665
PEGJ and PEJ (ICD-9 46.32) 10,365
Other feeding enterostomy (ICD-9 46.39) 21,135
Replacement of gastrostomy tube (ICD-9 97.02) 33,370
Replacement of small bowel tube (ICD-9 97.03) 6,805
Total for 2014 = 265,165
Saran D.40 Adult critically Ill 100% nasoenteric (tip position not noted)
Gungabissoon U.34 Adult critically Ill 100% nasoenteric (tip position not noted)
Rice T.38 Adult critically Ill 100% nasogastric (tip position not noted)
Metheny N. 37 Adult critically Ill 100% nasoenteric (51% duodenum, 49% gastric)
Kozeniecki M.36 Adult critically Ill 100% nasoenteric (90% gastric, 10% small bowel)
Roberts S.39 Adult critically Ill 100% nasogastric (tip position not noted)
Pash, E.45 Adult mixed ICU and non-critically ill hospitalized patients 53% nasoenteric (79% gastric, 21% small bowel)
40% PEG
7% PEG-J/PEJ
Wood J.42 Adult post-op cardiac surgery 90.5% nasoenteric (73% gastric, 27% small bowel)
9.5% PEG-PEGJ
Lyman B.46 Pediatric- neonatal mixed ICU, non-ICU hospitalized 100% naso/oroenteric (87% gastric, 13% small bowel)
Savoie KB.47 Post-abdominal intestinal surgery (PAIS) neonates and infants in NICU 100% naso/oroenteric (tip position not noted)
ASPEN Survey Mixed ICU and non-ICU Hospitalized 62% nasoenteric (69% gastric, 31% small bowel)
23% gastrostomy
11% gastro-jejunostomy or jejunostomy
Feeding Tube Types in Post-Acute Care

Tube placement can also be performed in ambulatory surgery centers, nursing homes, clinics, physi-
cian offices, in the home, and in other post-acute care settings such as LTCHs, and IRFs. Nasoenteric
tube placement is not often tracked and is difficult to quantify. The HCUP Ambulatory Surgery data-
base provides data from 35 states and reports placement of gastrostomy tubes in 2012 in 1,676 patient
level encounters.1

A common belief is that patients in nursing homes need to Using the Medicare PUF data set for examining tubes pro-
have a more permanent gastrostomy type tube placed and vided to Medicare beneficiaries in home and nursing home
that they are not permitted to receive EN through an NG settings, Table 19 shows that tubes were provided to 11,176
tube. This is attributed to the fact that these patients may beneficiaries.15 These tubes were replacement tubes, and 99%
pull an NG tube out and need to have it replaced with X-ray of them were long-term feeding tube types. This data may
verification thus, a more permanent feeding tube is needed. not capture all tubes provided or purchased by this popula-
Also, many of these patients may need feeding for longer tion, as these patients may obtain replacement tubes from
than the 4 to 6 weeks that a short-term tube can stay in place. hospitals, clinics, and physician offices. This difference can
To test this belief, Burgermaster and colleagues compared be seen by looking at the variance between patients who re-
nursing home EN policies throughout the United States and ceive formula (114,287) and those who receive feeding tubes
received survey responses from 164 nursing home facilities.49 (~12,000) in the home care and nursing home settings.
They found that 62% of nursing homes nationwide accepted
patients with NG tubes, while in the New York City area this
rate was only 18.3%. TABLE 19
Types and Numbers of Tubes

In home care, more permanent feeding tubes are often pre- Provided to Medicare Beneficiaries
ferred, although the pediatric population will more often use
short-term nasoenteric tubes. In the study by Rosen, 100% of Number of
HCPCS Description Beneficiaries
the pediatric patients at home in this study used nasogastric
tubes.67 In a recent study by Northington, 144 parents and 66
B4081 Nasogastric tubing with stylet 33
homecare providers reported their experience with pediatric
patients receiving home EN via nasoenteric tubes.73
B4082 Nasogastric tubing without stylet 41
Kranz reported in 4672 adult and pediatric home patients

B4083 Stomach tube - levine type
that gastrostomy tubes are significantly the most common,
but gastrostomy-jejunostomy and jejunostomy tube use is
B4087 Gastrostomy/jejunostomy tube, standard, 7,584
growing.66 Vallumsetla reported on 181 adult home diabetic any material, any type, each
patients in whom 48.6% had gastrostomy tubes, 11.6% PEJ
tubes, and 39.7% jejunostomy tubes.68 The respondents to B4088 Gastrostomy/jejunostomy tube, low-profile, 3,518
the ASPEN EN Survey who practiced in the home set- any material, any type, each
ting reported that 7.9% of their patients receiving EN had

short-term nasogastric or nasoenteric (post-pyloric) tubes,
Total 11,176
75.4% had gastrostomy tubes, 8.6% had gastrojejunostomy
tubes, and 8.1% had jejunostomy tubes. In a recent analysis SOURCE: Data from the 2013 Medicare Provider Utilization and Payment Data Public Utilization File for
Referring Durable Medical Equipment, Prosthetics, Orthotics and Supplies.15
of Medicare data, fewer than 5% of white Medicare benefi-
ciaries with dementia received a feeding tube, compared to Data on feeding tube types from LTCHs were not available
more than 17% of black and nearly 13% of Hispanic patients through big data or literature sources, but the ASPEN Survey
with dementia, which equated to an odds ratio of 3 to 4.5.74 captured respondents who practice in this care site. They
This issue of EN indications in advanced dementia is one reported nasoenteric use in 15% of patients, gastrostomy in
that will alter the number of tubes placed in these patients in 75% of patients, gastro-jejunal tube 6%, and jejunostomy 4%.
all care settings. Figure 14 compares tube type between acute care, LTCHs,
and home care based on the ASPEN Survey Responses.
FIGURE 14
Type of Tube Used by Care Setting
80
70
60
50
Percent of tube types
40
30
20
10
0
Nasoenteric Gastrostomy Gastro-jejunostomy Jejunostomy
Acute Care Home Care LTCH
SOURCE: ASPEN EN Survey 2017
Analysis of Feeding Tubes

More research is needed to capture tube type in all care settings. Data Highlights Include:
The fact that nasoenteric feeding tubes were not tracked in hos-
pital big data sets using ICD-9 coding through early 2015 should • A majority of feeding tubes in the ICU setting are
be noted, as placement of these tubes is not without compli- nasogastric or nasoenteric tubes.
cations. Adverse events tracking and quality improvement
• Primarily gastrostomy tubes are placed in patients for
initiatives would benefit from the knowledge of the number and post-acute care. This is compared to gastro-jejunostomy
type of short-term tubes that are actually placed, which should or jejunostomy tubes.
now be done using ICD-10 coding. To make this issue even
more complicated, nasogastric tubes initially placed for gastric • The majority of long-term feeding tubes are placed in
older adults.
decompression are sometimes used for feeding, particularly in
ICU mechanically ventilated patients, in an attempt to monitor
GI tolerance to feedings prior to placement of a feeding-indicat-
ed tube. There is much need here for further investigation into
types of tubes used and comparison of complications associated
with each kind of tube.

Types of Formula Administered
Types of Formulas Used Across Healthcare Settings
In using big data to examine types of formulas, one can examine Medicare Part B PUF Data, which
covers home care and nursing homes.15 Formula types are identified using HCPSC codes (see Table 1
in Methodology for codes). Data in Table 20 show that Medicare beneficiaries receive most, but not all,
of each general category of formula. Sixty-eight percent of Medicare beneficiaries received nutritionally
complete formulas with intact nutrients, either standard concentration or calorically dense (B4150 and
B4152). Note the small number of pediatric beneficiaries, as most Medicare beneficiaries are 65 years
or older.
TABLE 20
2013 Medicare Part B (PUF) EN Usage by Formula Type

Formula Usage
HCPCS Formula Type Number of Claims by Percent
B4149 Blenderized natural foods with intact nutrients 351 0.3%
B4150 Intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber 43,705 33%
B4152 Intact nutrients, calorically dense (equal to or greater than 1. 5 kcal/ml) includes proteins, fats, carbo- 45,621 35%
hydrates, vitamins and minerals, may include fiber
B4153 Hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and 5,457 4%
minerals, may include fiber
B4154 For special metabolic needs, excludes inherited disease of metabolism, includes altered composition of 27,148 21%
proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber
B4155 Nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. Glucose 8,011 6%
polymers), proteins/amino acids (e.g. Glutamine, arginine), fat (e.g. Medium chain triglycerides) or
combination
B4157 For inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may 0 0%
include fiber
B4158 For pediatrics, intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may 0 0%
include fiber and/or iron
B4159 For pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohy- 0 0%
drates, vitamins and minerals, may include fiber and/or iron
B4160 For pediatrics, nutritionally complete calorically dense (equal to or greater than 0. 7 kcal/ml) with intact 157 0.1%
nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber
B4161 For pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, 81 0%
vitamins and minerals, may include fiber
B4162 For pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, 0 0%
carbohydrates, vitamins and minerals, may include fiber
Total 130,531
SOURCE: Data from the 2013 Medicare Provider Utilization and Payment Data Public Utilization File for Referring Durable Medical Equipment, Prosthetics, Orthotics and Supplies.15
Table 21 identifies the distribution of formula used by Medi-Cal Fee-for-Service program beneficiaries
according to HCPCS codes.60 In this data set, the percent of patients receiving standardized formulas
in both the adult (B4150, B4152) and pediatric (B4160) populations at 67%, is similar to that of the
Medicare population, as seen in the Medicare DMEPOS PUF database.15 The number of pediatric bene-
ficiaries is significant in this program, as can be seen in Table 22 in which 66% of patients use pediatric
formulas. The limitation to this data by age is that it was extrapolated from use of pediatric formulas and
not by actual age data.
TABLE 21 TABLE 22
Distribution of Formula Use Formula Use by

by Medi-Cal Recipientsa Intended Age of Formula
HCPCS Codes Use < 20 years > 21 to >65 years All
B4149 1.0% % use by age 65.5%a 34.5%b 100%
B4150 9.0%
a
Represents the percent of beneficiaries receiving formulas found in HCPCS B4160 and B4161
b
Represents the percent of beneficiaries receiving all other formula HCPCS reported
SOURCE: Medi-Cal data61
B4152 8.0%
B4153 2.0%
In order to better compare different data sets, the
B4154 5.0%
HCPCS codes were combined and identified with
B4155 7.0% more general formula types for both pediatric and
B4157/ B4162 2.0%
adult patients, as seen in Table 23. This allows for a
comparison between the big data presented above and
B4158 0.0%
the literature and survey data presented below.
B4159 0.0%
B4160 50.0%
B4161 16.0%
a
Represents the beneficiary percent for enteral nutrition claims (oral and tube), paid
July 1, 2015 thru June 30, 2016.
SOURCE: Medi-Cal data61
TABLE 23
Formula Types by HCPCS Codes

Formula Type HCPCS Codes HCPCS Codes for Pediatrics
Standard intact nutrient formulas B4149 (Blenderized), B4150, B4152 B4158, B4159, B4160
Hydrolyzed protein/amino acid formulas B4153 B4161
Disease specific formulas B4154
Formulas for inherited diseases of metabolism B4157 B4162
Modular B4155 B4155

Using the above Medi-Cal formula use by HCPCS codes and According to the ASPEN Survey data for acute care, 61%
combined according to formula type, Figure 15 shows the received standard intact nutrient formulas, 18% received
percentage of usage in all patients.61 This illustrates that in both hydrolyzed protein/amino acid formulas, 18% received disease
pediatric and adult patients, standard intact formulas are used specific formulas, and 3% received formulas for inherited
in about two-thirds of this population. diseases of metabolism. See Table 24 for the breakdown in
formula use by age population.
TABLE 24
FIGURE 15
Formula Types by Age Population
Medi-Cal Formula Usage by
in Acute Care Hospitals
Broad Type with HCPCS Codes Combined
Percent Used in Percent Used in Pediatric or
Formula Type
Adult Patients Infant/Neonatal Patients
2%
Inherited Disease 6.6% Standard intact nutrient 78% 22%
Modular
formulas
5.1%
Disease Specific
Hydrolyzed protein/amino 53% 47%
acid formulas
Disease specific formulas 62% 38%
Formulas for inherited 6% 94%

diseases of metabolism
Based on data collected in the ASPEN Survey for patients at

18.4%
Hydrolyzed Protein 67.7 % home, types of formulas used overall were 59% standard intact
Standard Intact nutrient formulas, 2% blenderized formulas, 23% hydrolyzed
protein/amino acid formulas, 12% disease specific formulas,
and 3% formulas for inherited diseases of metabolism. See
Table 25 for the breakdown in formula use by age population.
SOURCE: Medi-Cal61
TABLE 25
In terms of formula type in the home care setting, there were
2 studies in the literature that met the search criteria. Epp and Formula Type Use by Age in Home Care
colleagues described their home EN population at the Mayo
Percent Used in Percent Used in Pediatric or
Clinic.64 Using a patient survey, they found that blenderized Formula Type
Adult Patients Infant/Neonatal Patients
tube feeding formulas were being used in at least part of the
daily formula regimen by 89% of the pediatric patients and Standard intact nutrient 70% 30%
formulas
66% of the adult patients. In the study by Brettschneider et al.,
patients at age 5 or younger were prescribed formulas listed as Blenderized formulas 11% 89%
the “other category” 42% of the time.62 This category included Hydrolyzed protein/amino 31% 69%
metabolic formulas, modulars, and thickeners. Standard intact acid formulas
protein formulas were most commonly prescribed in the pop- Disease specific formulas 46% 54%
ulation of patients at age 6 or older. In the older adults, 68% of
patients received standard intact nutrient formulas. Formulas for inherited 1% 99%
diseases of metabolism
In the home care population, the use of standard intact nutri- Use of Modular Components
ent formulas can be compared across data sources. The Medi-
In HCPCS code B4155, modular additives are described as
care PUF data showed 68% of patients using standard intact
enteral formula, nutritionally incomplete/modular nutrients,
nutrient formulas. The Brettschneider study also reported 68%
includes specific nutrients, carbohydrates (e.g., Glucose poly-
in their data, and the ASPEN survey reported that 70% of this
mers), proteins/amino acids (e.g., Glutamine, arginine), fat
formula type is used in adult patients (not specifically older
(e.g., Medium chain triglycerides) or combination, administered
adults).15,62 This consistent reporting of use of standard intact
through and enteral feeding tube.26 Data from Medicare DME-
nutrient formulas adds validity to these data. Again, what is
POS and Medi-Cal on use of modular additives were available.
not easy to find is the number of infants at home receiving
There were 8011 (or 6.1% of all Medicare beneficiary claims) in
breast milk through a feeding tube. Tracking human breast
this data set who received modular additives.15 In the Medi-Cal
milk fortifiers, perhaps through HCPCS code B4155, may be
home EN patients, 1264 (7.0%) of the beneficiaries received
helpful for this purpose.
these products.61 No literature that reported use of modular
additives met the search criteria. The ASPEN Survey provided
There were no specific data that could be obtained on formula data for 2 care settings on this question. In acute care hospitals,
type used in nursing homes specifically or IRF facilities, how- 24% of patients receiving EN were also prescribed some type
ever, the ASPEN Survey respondents supplied formula type of modular nutrient such as carbohydrate, protein, fat, or a
used in LTCH facilities. Formula use was 69% standard intact combination. In the LTCH facilities, the number was higher, at
formula, 9.7% hydrolyzed protein formula, and 21.3% disease 29% of patients.
specific formula as seen in Figure 16.
Analysis of Formula Types

Overall, most adult patient populations, regardless of the
FIGURE 16
healthcare setting, use standard intact nutrient formulas. This
Formula Type in Long-term percentage seems to be about 70% of various populations.
Acute Care Hospital However, it is important when examining the data presented
above, that demographics of the population are noted. Medi-
care data will present an older population view with those
21.3%
Disease Specific patients using standard formulas, whereas Medicaid data (as
represented by Medi-Cal) has more pediatric patients who may
more often require non-standardized formulas. Modular com-
ponents to supplement formulas are used in less than one-third
of patients.

9.7%
Hydrolyzed 69% • About 70% of patients in all post-acute care settings
Protein Standard Intact used standard intact nutrient formulas.
• In acute care, this is true for adults but not for infants
and children.
• For acute care and LTCH settings, more than 25% of

patients received modular additives as well.

EN Delivery Methods The literature on EN delivery methods that met the search
criteria included a study of hospitalized patients by Pash and
EN can be delivered using several methods, including the bolus colleagues in which 89% received continuous feedings via
method using a syringe, by the gravity method using the barrel pump, and 11% received intermittent pump feedings.45 In the
of a syringe or feeding bag, or by the pump method which can Aloupis study that included ICU, non-ICU, and LTCH pa-
be administered using a feeding bag or syringe and given con- tients, all patients received EN via a pump.43 In an ICU study
tinuously, or less often, intermittently.75 The Medicare PUF data by Taylor, patients received formula by bolus and continuous
set provides some data on EN delivery methods by the number feeding methods,41 whereas Kozeniecki and colleagues reported
and percent of enteral administration kits provided.15 Table 26 using only continuous formula delivery in their ICU patients.36
illustrates that in this population, 35% of the patients deliver In terms of delivery methods, the acute care setting data from
their feeding via syringe, 58% deliver their feeding by pump, the ASPEN Survey was broken down by population and can be
and 7% deliver by gravity administration. seen in Table 27 and Figure 17.
TABLE 26 TABLE 27
Type of Administration Kit EN Delivery Methods in

Delivered to Medicare Beneficiaries Acute Care
HCPCS Description Number of Beneficiariesa Administration Method Adults Pediatrics Neonates
B4034 Enteral feeding supply kit; syringe 39,782 Continuous via a pump 79% 67.3% 31.7%
B4035 Enteral feeding supply kit; pump 66,199 Intermittent via a pump 11% 19.4% 32.3%
B4036 Enteral feeding supply kit; gravity 8,306 Bolus or intermittent via 10% 13.3% 40%
gravity or syringe
All Enteral Feeding Supply Kits 114,287
SOURCE: ASPEN Survey Data 2017
a
Total number of unique beneficiaries associated with DMEPOS claims submitted by suppliers and ordered by
the referring provider. Beneficiary counts fewer than 11 have been suppressed to protect the privacy of Medicare
beneficiaries.
SOURCE: Data from the 2013 Medicare Provider Utilization and Payment Data Public Utilization File for Referring
Durable Medical Equipment, Prosthetics, Orthotics and Supplies.15
FIGURE 17
Administration Methods in Acute Care by Age

80
70
60
Percent Method
50
40
30
20
10
0
Adult Patients Pediatric Patients Neonates or Infants
Age Group
Continuous via pump Intermittent via pump Bolus or intermittent via gravity or syringe
As for the home EN population, Brettschneider reported the majority of their patients under the age
of 65 were pump fed, while the majority of patients aged 65 or older were fed via the bolus (syringe)
method.62 The gravity feeding method constituted the smallest population of patients in each age group.
In terms of delivery methods data from the ASPEN Survey on home EN patients, 23% received a
continuous feeding via a pump, 17% received intermittent feedings via a pump, and 60% received bolus
or intermittent feedings via gravity or syringe. The LTCH patients, as reported in the ASPEN survey,
received 73.4% of feedings via continuous method, 18.4% via the intermittent method, and 8.2% via the
bolus method. The use of different delivery methods can be seen by care setting in Table 28 and Figure
18. These differences may be associated with type of tube, the acuity of the patients, the accessibility
of enteral pumps, and/or the reimbursement models across the various care settings. For instance, in
acute care, the critically ill patient may need a low dose rate delivered continuously via pump into the
stomach by NG tube, while a non-critically ill patient at home with a gastrostomy might receive syringe
feedings intermittently. Acute care hospitals and long-term acute care hospitals are very similar in feed-
ing delivery methods but differ widely from home practice.
TABLE 28
Administration Methods Across Healthcare Settings

Administration Method Adult Acute Care LTCH (primarily adult) Home Care (80% adult)
Continuous via a pump 79% 73.4% 23%
Intermittent via a pump 11% 18.4% 17%
Bolus or intermittent via gravity or syringe 10% 8.2% 60%

FIGURE 18
Use of Pumps to Administer EN Across Care Settings

100
80
60
Percent
40
20
0
Acute Care LTCH Home Care
Care Settings
Pump Gravity or Bolus

Open vs. Closed Delivery Systems TABLE 29
Enteral formulas are delivered via open system; by using cans,

Use of Open vs. Closed Enteral Systems
bottles, or powders that need reconstitution and then poured by Age in Acute Care Setting
into an administration set, or a closed system in which the
Open vs. Closed System Adults Pediatrics Neonates
container or bag is pre-filled with sterile, liquid formula by the
manufacturer and is ready to administer. This closed system Open system 25% 62% 76%
is also known as a ready-to-hang formula. The closed system
Closed system 75% 38% 24%
reduces opportunity for contamination and takes less nursing
time but generally requires a pump to deliver.76-83 SOURCE: ASPEN Survey 2017
No big data or literature could be found that met the search In the LTCH setting, a closed system is used 87% of the time
criteria on the use of open versus closed systems. In acute care, and the open system is used only 13% of the time. In the
the ASPEN Survey results showed a marked difference between home care setting, it is quite the opposite, with 89% of patients
use of these various systems based on age population, as seen receiving EN via an open delivery system versus 11% who used
in Table 29. This may be because not all pediatric or infant a closed system. Again, this may be due to the use of bolus
formulas are available as closed systems. Many of those formu- feedings, to limited reimbursement for pumps in the home, or
las are available only in powders that need to be reconstituted to the lack of need for a continuous feeding system, as seen in
prior to administration. This also correlates with the higher Figure 19 illustrates the differences in the use of these systems
bolus feeding rate in neonates as described above. across the care settings in adult patients.
FIGURE 19
Use of Open vs. Closed Systems Across Healthcare Settings

100
80
60
Percent
40
20
0
Acute Care LTCH Home Care
Care Settings
Open System Closed System
TABLE 30
Water Flushes Use of Water Flush Delivery Methods

Patients receiving EN need feeding tube water flushes to main- Across Healthcare Settings
tain tube patency, flush formula and medications into the GI
Flushing Method Acute Care Hospital LTCH
tract, and maintain hydration. A recent study by Drake demon-
strated that 37% of Medicare home EN patients are readmitted Manual syringe method 23% 11%
to the hospital with dehydration and/or malnutrition.63 Auto-
Automated pump method 36% 28%
mated flush pumps, which periodically deliver a water flush,
have been around for decades.84 Use of these pumps in big data Feeding bag manually 1% 0%
sets was not recorded, but recently, 2 studies have shown posi-
tive outcomes with the use of these pumps. In the study by Pash Combination of the manual syringe and 36% 56%
automated pump method
and colleagues, patients on the automated flush pump received
significantly higher amounts of prescribed water than did those Combination of the manual syringe and 4% 5%
on the manual flushing regimen.45 In the nursing home setting, manual feeding bag
Nadeau et al., found those patients with an automated flush SOURCE: ASPEN Survey 2017
pump had a 3.9% lower readmission rate than did those with
manual flushing.85 Analysis of Administration Methods
The findings in this report about EN administration methods
To assess the use of these pumps, the ASPEN Survey collected
clearly show differences between home care and institutional
data by asking respondents how enteral water is being admin-
care in terms of EN delivery. Patients in institutions more often
istered in their acute care hospital or LTCH facility for all age
have pump feedings over syringe or gravity methods. This is
populations. Respondents from the acute care hospitals report-
true across all populations, except less so in infants. This cor-
ed that 23% used the manual syringe method, 36% used the
relates with the use of ready-to-hang or closed feeding systems
automated pump method, 1% used the feeding bag manually
that are used in a majority of institutions and not as much in
to deliver water, 36% used a combination of the manual syringe
home care in adult and pediatric patients. This is not so much
and automated pump method, and 4% used a combination
the case with infants, likely due to the use of powdered infant
of the manual syringe and manual feeding bag. In the LTCH
formulas. Automated flush pumps have been shown to improve
setting, respondents reported similarly, with 11% having used
hydration in patients and are used in a majority of acute care
the manual syringe method, 28% used the automated pump
hospital and LTCH settings. More research is needed in this
method, 0% used the feeding bag manually to deliver water,
area to optimize delivery methods to meet patient needs.
56% used a combination of the manual syringe and automat-
ed pump method, and 5% used a combination of the manual
syringe and manual feeding bag. See Table 30 for comparison
between these 2 types of facilities. These data show, at least in
the inpatient settings, that more than two-thirds of the respon-
• Pediatric (67.3%) and infant (31.7%) patients receive
dents in the ASPEN Survey are using these automated flush continuous feedings via pump, much lower than adults
pumps, which should translate into better hydration for the (79% ) in the acute care setting.
patients. Although not studied, it could also potentially save
nursing time and decrease tube occlusions. • In hospitals and LTCHs, about 90% of feedings are
delivered via pump, whereas at home only 40% are
delivered via pump.
• A large majority of respondents from hospitals (75%)

and LTCHs (89%) use closed ready-to-hang feeding
systems, primarily in adult patients.
• In home care, only 11% use closed ready-to-hang

feeding systems, while most use open delivery systems.
• 72% of flushing occurs by automated flush pump or a

combination of automated flush pump and manual
syringe flush in hospitals.

Malnutrition and EN
Malnutrition in patients with acute and chronic medical conditions has been shown to have a significant
impact on outcomes. This has been demonstrated in studies dating back to 1936, particularly in hospital-
ized patients.86-92 In late 2016, 2 AHRQ statistical briefs outlined this association using the National Inpa-
tient Sample and the Readmissions database.93,94 Malnutrition in these patients is a condition for which
EN can be an important treatment. The purpose of this section of the report is to present the national
data on malnutrition in a variety of healthcare settings and the association to the use of EN.
Acute Care Hospitals

National inpatient survey data have been collected by the Healthcare Cost and Utilization Project of
AHRQ since 1993.1 There are several codes in ICD-9 for malnutrition that were included in this analysis.
See Figure 20 for the coded malnutrition in hospital discharges over time. For the diagnostic codes used
for this analysis, see Appendix Table F, ICD-9-CM Diagnosis Codes for Malnutrition Used in HCUP
Data Analysis.
FIGURE 20
Coded Malnutrition in Acute Care Over Time
3000000
2500000
2000000
# of Hospital Discharges
1500000
1000000
500000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
SOURCE: HCUP NIS1
These coded malnutrition data were then normalized per the number of total hospital discharges to
obtain a percentage of discharges over time that were coded for malnutrition. These data are shown in
Figure 21 for all age groups. The rate of malnutrition appears to be rising over time, but this is likely a
reflection of increased awareness and coding, as many clinical studies of selected hospitalized patients
have malnutrition rates at anywhere from 30 to 50%.95,96
FIGURE 21
Percent of Coded Malnutrition Normalized per Hospital Discharge Over Time
5
Percent
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Years
SOURCE: HCUP NIS1
Figure 22 illustrates the malnutrition rates in acute care hospitals in the United States and the use of EN
therapy. While malnutrition is being recognized, diagnosed, and coded for in an increasing fashion, the
use of EN is not rising to treat this condition. These data illustrate an opportunity to examine how and
when providers might prescribe this nutrition therapy, when appropriate, to hospitalized patients.

FIGURE 22
Coded Malnutrition and the Use of EN in Acute Care Hospitals Over Time
3000000
2500000
2000000
# of Hospital Discharges
1500000
1000000
500000
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Malnutrition EN per year
SOURCE: HCUP NIS1
This difference in coded malnutrition and the use of EN remains impressive even when normalized per
total hospital discharges, as seen in Figure 23.
FIGURE 23
EN Use and Malnutrition in Acute Care Hospitals per Total Discharges
5
% of Total Discharges
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
% Mal per Discharge % EN per Discharge
SOURCE: HCUP NIS1
Post-acute Care
Malnutrition data in post-acute care settings can be seen in 2 ways: first, by reviewing the readmissions
data from the 2016 AHRQ Statistical Brief #218 that compared those readmitted with an index stay
diagnosis of malnutrition to those without that malnutrition code;94 and second, by reviewing data from
the Nursing Home Data Compendium 2015 Edition.13 In 2013, the all-cause 30-day hospital readmission
rate for patients with malnutrition was 23.0 per 100 nonmaternal, nonneonatal index stays, compared to
14.9 per 100 index stays for patients without malnutrition. The average cost per readmission was $16,900
for patients with protein-calorie malnutrition during an index stay—26% higher than the readmission
cost for patients without malnutrition during an index stay ($13,400). Patients aged 65 to 84 year have
a readmission rate of 23.0 per 100 for patients with malnutrition, as compared with 15.5 per 100 for
patients without malnutrition.94 Malnourished patients’ readmission rate with Medicare as the primary
expected payer was 22.6 per 100 index stays, as compared to 16.8 per 100 stays in patients with Medicare
and no malnutrition, as seen in Table 31. These readmissions with malnutrition were found most often in
patients with digestive system disorders, sepsis, and respiratory system disorders. It was not noted in this
study if any of these patients were on EN therapy, but it is clear that in the post-acute care setting, these
patients may have benefited from nutritional assessment and some type of nutrition therapy.
TABLE 31
All Cause Readmissions Following Hospital Stays for Patients with Malnutrition, 2013
Coded Malnutrition in Index Stay No Malnutrition Diagnosis in Index Stay
Rate of 30-day All Cause Readmission 23.0 per 100 index stays 14.9 per 100 index stays
Cost of Readmission $16,200 $13,400
Pediatric Patient Readmission Rate 20.5 per 100 index stays 10.7 per 100 index stays
Older Adult Readmission Rate

Age 65-84 23.0 per 100 index stays 15.5 per 100 index stays
Age 85 and older 17.7 per 100 index stays 16.1 per 100 index stays
SOURCE: AHRQ Statistical Brief #218 94
For nursing homes, the Nursing Home Data Compendium 2015 Edition provides data on unintended
weight loss.13 This was defined in this report as a resident weight loss of 5% or more in the last month or
10% or more in the last 6 months that was not part of a physician-prescribed weight loss plan. Residents
were excluded if they were in end-stage disease or were receiving hospice care. A feeding tube was count-
ed when the resident had a nasogastric or abdominal feeding tube. The rate and number of residents with
unintended weight loss can be seen in Table 32. The feeding tube prevalence is very similar to both the
unintended weight loss and pressure prevalence over time. These 3 rates are also going down by single
digit percentages, and this trend will be interesting to follow.

TABLE 32
Nutrition Related Data from Nursing Home Data Compendium 2015 Edition
2011 2012 2013 2014
Number of NH Residents 1,431,730 1,409,749 1,404,949 1,406,220
Nutrition Related Clinical Measures
Feeding Tube Prevalence
Residents with Feeding Tubesa 84,472 80,356 78,677 75,936
Percent of Residents with Feeding Tubes 5.9% 5.7% 5.6% 5.4%
Trends in Prevalence:b 2011 to 2014 -9.0%
Unintended Weight Loss Prevalence
Residents with Unintended Wt. Lossa 84,472 81,765 77,272 75,936
Percentage Unintended Wt. Loss 5.9% 5.8% 5.5% 5.4%
Pressure Ulcer Prevalence
Residence with Pressure Ulcersa 84,472 76,126 73,057 71,717
Percentage Pressure Ulcers 5.9% 5.4% 5.2% 5.1%
a
Residents with feeding tubes: number of resident (opposed to number of beds or occupancy figures), was used to calculate number of residents for each clinical measure (feeding tube, unintended weight
loss, pressure ulcer),using the percentage reported for each clinical measure.
b
Trends in prevalence figures use a NH’s “bed size” (vs. occupancy or number of residents) to determine trend figure.
SOURCE: Nursing Home Data Compendium 2015 Edition, Centers for Medicare and Medicaid Services13
Market Drivers, Trends,
and Challenges
To better incorporate these data into the context of the current malnutrition-related stays, across malnutrition types, included
healthcare climate, market drivers, trends, and healthcare coding of EN or PN services. For that 1 exception, PN was
challenges were examined. These drivers and trends include coded during 28.7% of stays involving postsurgical non-ab-
growing awareness of the role of nutrition, the aging popula- sorption. Despite the efforts of the many clinicians to raise
tion, healthcare reform and reimbursement policies, greater awareness, the need for continued vigilance to assess patient
involvement of the consumer in self care, and changes in the nutrition status is required. Malnutrition must be avoided or
prescriber discipline, including registered dietitians with order treated to minimize associated poor outcomes, and EN is an
writing privileges. Each of these topics is addressed below in effective nutrition therapy when used appropriately.98
the context of EN therapy.
ASPEN and the Academy of Nutrition and Dietetics have
developed instruments for the assessment and documentation
Growing Awareness of the of the clinical characteristics of malnutrition in pediatric and
adult patients.99,100 These instruments have been adopted in
Role of Nutrition
many institutions and incorporated into their electronic health
The role of nutrition in the health of patients is being recog- record systems.101,102 The Academy of Nutrition and Dietetics
nized throughout the care continuum. Through the efforts is also serving as the steward of 4 nutrition electronic quality
of many clinical, industry, and community organizations, measures that have been reviewed by the National Quality
awareness of disease-related malnutrition, peri-operative nutri- Forum and are being considered by the Centers for Medicare
tion, and the optimization of nutritional health has grown. As and Medicaid Services.103 At a minimum, an e-measure for
addressed previously, malnutrition has a documented negative nutrition assessment would provide regulatory support for
impact on patient outcomes. Patients with malnutrition have addressing this condition.
more complications, poorer outcomes, longer lengths of stay,
utilize more healthcare resources, and have higher healthcare
costs.86-96 Examples of the efforts to raise awareness about this Patients with malnutrition have more
condition include ASPEN’s Malnutrition Awareness Week complications, poorer outcomes,
(www.nutritioncare.org/malnutrition), an annual event on the
National Healthcare Observances calendar, which provides
longer lengths of stay, utilize more
education and resources for both clinicians and consumers. healthcare resources, and have
DefeatMalnutritionToday is a coalition of over 60 organizations higher healthcare costs.86-96
and stakeholder groups working to defeat senior malnutrition.
Their goals are to achieve the recognition of malnutrition as a
key indicator and vital sign of older adult health and to achieve The Leapfrog Group is a national nonprofit organization that is
a greater focus on malnutrition screening and intervention driving a movement for giant leaps forward in the quality and
through regulatory and/or legislative change.97 Evidence safety of American health care. The flagship Leapfrog Hospital
suggests that early nutritional intervention may reduce com- Survey collects and transparently reports hospital performance
plication rates, mortality, and resource use associated with data to empower purchasers to find the highest-value care
malnutrition.95,96 Very few malnutrition-related stays included and to give consumers the information they need to make
EN or PN services according to HCUP Statistical Brief #210.93 informed decisions. In 2015, it began to survey hospitals for
With one malnutrition type exception, fewer than 7% of malnutrition, considering it a safety issue.104

The Enhanced Recovery After Surgery (ERAS) program has to quadruple from 2 million to 8 million by 2050 (see Figure
perioperative nutritional components, including preoperative 24). As the primary insurer for the elderly in the United States,
fluid and carbohydrate loading with no prolonged fasting, Medicare will face long-term financial pressures associated
avoidance of intraoperative fluid overload, and postoperative with an aging population and higher health care costs. 108
early oral nutrition resumption (http://erassociety.org/). This
program has been shown to decrease hospital length of stay The demographic shift towards a growing aging population,
and improve postoperative complication rates.105 This global coupled with changes in dietary and nutritional patterns in
effort has individual country organizations and the US based the elderly, will continue to be a challenge. Malnutrition,
group is called ERAS USA (http://erasusa.org/). which is frequently undetected, is the cumulative effect of
the often-compromised dietary habits of the elderly and the
In 2015, nutrition-related objectives were submitted to the physiological changes associated with aging and disease. It is
Healthy People 2020 program in the Office of Disease Preven- associated with a significant risk of morbidity and mortality in
tion and Health Promotion of the US Department of Health independently living older adults, as well as in nursing home
and Human Services. These two objectives were 1) to increase residents and hospitalized patients.98
recognition, diagnosis, documentation, and coding of dis-
ease-related malnutrition among hospitalized older adults and HCUP Statistical Brief #210 Characteristics of Hospital Stays
those presenting in emergency departments, and 2) to reduce Involving Malnutrition, 2013 provides national estimates on the
the rate of sarcopenia in community dwelling older adults. That characteristics of malnutrition reported during nonmaternal
year as well, ASPEN submitted the concept of preventing and and non-neonatal hospital inpatient stays in 2013.93 On aver-
treating malnutrition to the Joint Commission for consider- age, patients with cachexia, protein-calorie malnutrition, and
ation as a National Patient Safety Goal.95 Although neither of underweight were older (>65 years of age). The rate of malnu-
these efforts were adopted, raising awareness at the national trition was highest for patients aged 65 years and older across
level through submission briefs is a start. Multiple clinician and all 6 types of malnutrition (postsurgical nonabsorption, nutri-
consumer toolkits about recognizing, preventing, diagnosing, tional neglect, cachexia, protein-calorie malnutrition, weight
and treating malnutrition are available through a variety of loss or failure to thrive, and underweight). The mean patient
sources, including the recent publication National Blueprint: age among malnutrition-related hospital stays was highest for
Achieving Quality Malnutrition Care for Older Adults.103,106,107 stays involving cachexia (68.3 years), protein-calorie malnu-
trition (66.9 years), and underweight (65.0 years). The malnu-
With growing awareness of the role of nutrition, comes an op- trition rate for patients aged 85 years and older was 2.5 to 3.5
portunity to provide EN therapy as an intervention to prevent times higher than for patients aged 65 to 84 years for all types
or treat this condition in a variety of healthcare settings. Being of malnutrition except postsurgical non-absorption. For exam-
better able to track malnutrition and the use of EN will allow ple, among patients aged 85+ years, there were 3613 hospital
the field to predict the need for EN products and services. The stays per 100,000 population for protein-calorie malnutrition
ability to measure the effectiveness of this therapy in terms of compared with 1439 stays per 100,000 among those aged 65 to
value, complication prevention, and cost-effectiveness will be 84 years. A similar pattern was seen for weight loss and failure
critical. Challenges to these efforts include healthcare provider to thrive, reporting 1413 stays per 100,000 for those aged 85
education, standardized malnutrition definition and assess- years and older compared with 415 per 100,000 among 65 to
ment tools, and the obesity epidemic obscuring the recognition 84 year olds.93 Compared with the average cost of all nonma-
of malnutrition. ternal, non-neonatal hospital stays ($12,500), malnutrition-re-
lated stays for all types of malnutrition (except those coded
as underweight) were more costly, ranging from 13% more
Aging Population and costly for weight loss or failure to thrive diagnoses to twice as
costly for protein-calorie malnutrition. Average hospital costs
Malnutrition Risk
were higher for stays involving protein-calorie malnutrition
Between 2010 and 2050, the population aged 65 and older will ($25,200) and postsurgical non-absorption ($23,000) than
double, from approximately 40 million to 84 million people. for other malnutrition stays. 93 A recent publication entitled
The number of people aged 80 and older will nearly triple National Blueprint: Achieving Quality Malnutrition Care for
over these years from roughly 11 million to about 31 million, Older Adults, outlines the issue in the older adult population
while the number of people in their 90s and 100s is projected and provides potential actions to help improve outcomes.107
FIGURE 24
The Aging of the Population and Rising Health Care Costs

Are Contributing to the Growth in Medicare Spending Over Time
US population ages 65 and older, 2010 to 2050
100 Age 90+
Age 80-89
83.7 million
79.7 million Age 70-79
80
72.8 million 8.0
5.6 Age 60-69
3.3
22.1 22.9
60 56.0 million 16.1
2.8
10.4
40.3 million
40
1.9
9.4 33.2 34.0 32.7
24.8
20 16.6
18.1 20.1 18.1 20.1

12.4
0
2010 2020 2030 2040 2050
SOURCE: Kaiser Family Foundation analysis of 2010 population estimates from US Census Bureau. Population Division, Vintage2011: National Tables. Table 1. Annual Estimates of the Resident
Population by Sex and Five-Year Age Group for the United States: April 1, 2010 to July 1, 2011 (NC-EST2011-01), May 2012; and 2020 to 2050 population projections from US Census Bureau,
Population Division. 2012 National Population Projections Summary Tables. Projections of the Population by Age and Sex for the United States: 2015 to 2060 (NP2012-T12): December 2012.
Reprinted with permission from the Kaiser Family Foundation SOURCE: 10 Essential Facts About Medicare’s Financial Outlook Feb 02, 2017108
Healthcare Delivery and An important part of the health care reform law that is often
over shadowed by the mandatory health insurance policy are
Reimbursement Policies provisions that were intended to improve access to quality
While much of the attention on the 2010 Patient Protection health care. As a result of a national quality improvement strat-
and Affordable Care Act (PPACA) was focused on the individ- egy for improving the delivery of health care services, patient
ual mandate requiring US citizens and legal residents to have health outcomes, and population health, providers and institu-
qualifying health coverage, the health care reform law also tions are now required to find ways to improve the delivery of
expanded public programs such as Medicare, Medicaid and the care and to drive positive outcomes. As an example, Medicare
Children’s Health Insurance Program. It is unclear how many initiated pay-for-performance systems based on specified per-
more Americans have received EN therapy with expanded formance measures. Process measures are used to determine
health care coverage following the enactment of the PPACA. the extent to which providers consistently give patients specific
Based on the fact that the need for EN is relatively small in the services following evidence-based guidelines for care. These
general population, and the influx of the newly insured are measures are generally linked to procedures or treatments that
a younger, healthier population, it is hypothesized that there are known to improve health status or prevent future complica-
have been relatively few, new tube-fed beneficiaries added since tions. Outcome measures are used to evaluate patients’ health
the enactment of PPACA. as a result of the care they have received. These measures are
intended to monitor quality by using a representative list of
problems that are avoidable, high cost, high volume or both,
and could have reasonably been prevented through the applica-
tion of evidence-based guidelines.109

In a preliminary report, National Scorecard on Rates of Hos- rewards the quantity of services offered by providers rather
pital-Acquired Conditions 2010 to 2015: Interim Data From than the quality of care furnished. In 2017, CMS will continue
National Efforts To Make Health Care Safer, the Agency for to evaluate bundled payment models for hip and knee replace-
Healthcare Research and Quality reported a 21% decline in ments, heart attack treatment, bypass surgery, and surgical hip
hospital-acquired conditions (HACs) from 2010 to 2015.110 A and femur fracture treatment.112 Nutrition care for patients is
cumulative total of 3.1 million fewer HACs were experienced a prime example of a therapy that should be delivered across
by hospital patients over the 5 years (2011-2015) relative to the healthcare spectrum. For the cost of 1 dietitian visit and
the number of HACs that would have occurred if rates had nutrition assessment with follow-up in the community, adverse
remained steady at the 2010 level. The estimated healthcare events associated with malnutrition might be prevented.
cost savings totaled $28.2 billion. The specific reasons for the
decline are unknown, although improvement has likely been Similarly, Accountable Care Organizations (ACOs) are groups
stimulated by policies pertaining to Medicare and other payer’s of doctors, hospitals, and other health care providers that
payment incentive programs, public reporting of hospital-level coordinate care voluntarily for the patients they serve. Like
results, and the promotion of evidence-based practices. bundled payment, this coordinated care model seeks to create
incentives for providers to provide the right care at the right
While there are no national measures at this time that directly time, with the goal of avoiding unnecessary duplication of
monitor nutritional status or the provision of EN in the various services and preventing medical errors. The goal of an ACO is
pay-for-performance programs, there are measures related to to deliver high-quality care and spend health care dollars more
the incidence of postoperative infections, readmissions, pneu- wisely so that it can share in the savings it achieves.113
monia, and worsening pressure ulcers. These diagnoses and
conditions have been shown to be associated with nutritional As payers move away from traditional forms of payment to
status. Thus, the goal of nutrition healthcare professionals in bundled payment or ACO-type models, healthcare providers
this era of health care reform has been to implement evi- must look at all factors that influence outcomes and manage
dence-based protocols and policies to assess nutritional status, costs. An example of the value of nutrition support can be seen
appropriately feed the patient, and optimize transitions in care in using a peri-operative surgical nutrition protocol for certain
between healthcare settings. major elective surgery patients to reduce the risk for postop-
erative infectious complications.114 With the cost of a single
surgical site infection being more than $20,000, even 1 such
Setting up care systems across the healthcare infection could greatly affect a health system’s bottom line in an
era in which reimbursement may be fixed based on an admit-
continuum to monitor patients who are in
ting diagnosis alone.115 For data on payer mix of patients on
need of or who are receiving EN is essential. EN across healthcare settings, see Appendix Table D, EN Payer
Mix per Healthcare Setting.
A longer term initiative to improve outcomes while containing Frequent nutrition screening, assessment, care planning, and
costs is the Bundled Payment for Care Improvement initiative. intervention will be imperative in order to assure that each pa-
This initiative is composed of 4 broadly defined models of tient’s nutritional needs are met. Setting up care systems across
care, which link payments for multiple services beneficiaries the healthcare continuum to monitor patients who are in need
receive during an episode of care. Under the initiative, organi- of or who are receiving EN is essential.
zations enter into payment arrangements that include financial
and performance accountability for episodes of care. These
models may lead to higher quality and more coordinated care
at a lower cost to Medicare.111 Traditionally, Medicare makes
separate payments to each provider for the care they provide
a beneficiary for a single illness or course of treatment. CMS
believes that this approach has led to costly, fragmented care
with minimal coordination between providers and health
care settings. In other words, the current payment system
Coverage Policies for EN The first phase of Competitive Bidding was launched in 2011 in
9 Metropolitan Statistical Areas (MSAs), followed by the sec-
Competitive Bidding: Medicare ond phase in 2014 that included a significantly larger number
(91) of MSAs. In Phase 1 and 2, each MSA had its own unique
The DMEPOS Competitive Bidding Program was mandated by fee schedule based on the median of the winning bids in that
Congress through the Medicare Prescription Drug, Improve- MSA. In 2016 the program was expanded across the United
ment, and Modernization Act of 2003. The statute requires States by phasing in former Non-Competitive Bid Areas, in-
that Medicare Part B replace the current fee schedule payment cluding rural areas. By adjusting existing Competitive Bidding
methodology with a competitive bidding system for selected Areas’ Single Payment Amounts (SPAs) rates new rates were
DMEPOS items, including EN. Under the program, a compe- created for Rural and Non-Rural areas in each state.116 As can
tition among suppliers who operate in a particular competitive be seen from the Table 33, the average decrease in reimburse-
bidding area is conducted. Suppliers are required to submit ment rates for EN administration kits ranged from 43% to 59%
a bid for selected products. Contracts are awarded to Medi- from 2011 to 2017, depending on the type of administration
care suppliers who submit bids at or below the median price kit used and where the beneficiary resided. The reduction to
of the array of bids and meet applicable quality and financial reimbursement for EN formulas was even greater, ranging
standards. Contract suppliers must agree to accept assign- from 53% to 73% depending on the category of formula and
ment on all claims for bid items and will be paid the single the location.117
payment amount.116
TABLE 33
Medicare Part B Reimbursement by HCPCS Code (per 100 kcal Unit):

Before and After the Implementation of the Competitive Bidding Program
2017 Lowest 2017 Lowest Decrease in Decrease in
2011 National Rate by HCPCS Rate by HCPCS Rates Since Rates Since
HCPCS HCPCS Code Description Fee Schedule in the US in the US 2011a 2011b
Rural Non-Rural Rural Non-Rural
B4034 Enteral feed kit-syringe $5.92 $3.35 $2.99 57% 51%
B4036 Enteral feed kit-pump $11.29 $5.79 $4.85 51% 43%
B4036 Enteral feed kit -gravity $7.75 $4.58 $4.07 59% 53%
B4149 Blenderized foods $1.52 $1.11 $0.98 73% 64%
B4150 Complete intact nutrient $0.65 $0.41 $0.36 63% 55%
B4152 Complete, calorie dense>/= 1.5kcal $0.54 $0.34 $0.30 63% 56%
B4153 Hydrolyzed/amino acids $1.85 $1.31 $1.10 71% 59%
B4154 Special metabolic needs (non-inherited) $1.18 $0.72 $0.62 61% 53%
B4160b Ped complete intact nutrient
B4161b Ped hydrolyzed/amino acids
a
decrease % calculated by authors
b
Categories B4160 and B4161 are non-bid codes
SOURCE: https://med.noridianmedicare.com/web/jddme/fees-news/fee-schedules/lookup-tool 117

These regulatory and payer policies have had a tremendous opportunity existed for states to lower provider reimbursement
impact on health care in the United States, and EN is not an rates, resulting in approximately $30.1 million in potential
exception. Trade organizations and beneficiary advocates have cost savings for the states and the federal government. Spe-
unsuccessfully lobbied for the passage of legislation to change cifically, cost savings reported by product category using
or repeal the current competitive bidding program. Some trade Medicare’s Round 1 Competitive Bidding Program pricing
association proposals offer alternatives to the current pro- reported a total savings of $5,866,932 for enteral nutrients
gram while others advocate to simply repeal the competitive and supplies in 3 states (New York, Ohio, and Minnesota).
bidding process. Beneficiaries have been troubled by potential The OIG recommended that states enact legislation to limit
access issues related to the delivery and service of their needed state Medicaid DME reimbursement rates to match Medicare
products and supplies partially due to the smaller number of program rates and to encourage further reduction of Med-
suppliers able to participate in the program. icaid reimbursement rates through competitive bidding or
manufacturer rebates.120
In October 2016, the Government Accountability Office
(GAO) published the report, CMS’s Round 2 Durable Medical Some observers question whether DMEPOS suppliers could
Equipment and National Mail-order Diabetes Testing Supplies survive reduction to Medicaid reimbursement that would
Competitive Bidding Programs.118 The GAO found that the produce savings as large as the OIG report suggests. With the
number of beneficiaries receiving DME covered under the limitation that only winning bidders may participate in the
Competitive Bidding Program (CBP) generally decreased after Medicare Part B DMEPOS program, and with EN reimburse-
implementation of Round 2 and the National Mail-Order Pro- ment rates falling an average of 43 to 73% for those who win,
gram. There was a 20% decrease in the number of beneficiaries it will be interesting to see how many suppliers will be able to
accessing EN in the Round 2 MSAs and a 10% reduction in survive additional reductions to reimbursement and what the
Non-competitive Bid areas. The GAO believes that the de- business model will look like. As bundled payment models and
crease may have been due to reducing the level of unnecessary ACOs are vetted and eventually implemented, it is possible that
utilization prior to Competitive Bidding as well as a decrease homecare suppliers will become part of a larger system that
in fraud and abuse. Most Round 2 areas had at least 5 active will work together to provide more cost-efficient quality care.
contract suppliers. While some beneficiary groups and state
hospital associations reported access issues (locating a con- Private Insurance
tracted supplier, delivery delays), GAO indicated that there are
no widespread access issues.119 It has often been said that Medicare is the gold standard when
it comes to other payer policies in the United States. In evalu-
ating the enteral and oral nutrition coverage policies of eight
Medicaid
of the largest commercial health insurers in the United States,
Each state Medicaid program establishes its own criteria this is indeed true. Like Medicare Part B, nearly all insurers
regarding coverage of nutritional products in the outpatient (7 out of 8) cover EN when there is a medical necessity. While
or homecare setting. Most state Medicaid programs will cover Medicare Part B does not cover oral nutrition, 6 out of 8 insur-
nutritional products when fed through a feeding tube, and ers provide some coverage for oral nutrition. When enteral or
many states will cover products consumed orally when specific oral nutrition is covered, certain criteria must be met and the
criteria are met. Medicaid-managed care plans provides Medic- medical need documented. See Table 34 for private insurance
aid health benefits and additional services through contracted policies for outpatient enteral and oral nutrition.
arrangements between state Medicaid agencies and managed
care organizations.
In September 2015, the Office of the Inspector General (OIG)

of the Department of Health and Human Services, report-
ed that Medicaid provider reimbursement rates for selected
DME items varied significantly among the states and that an
TABLE 34
Private Insurance Policies for Outpatient Enteral and Oral Nutritiona

Regular Food Products (i.e.,
Insurer EN Oral self blenderized foods) Reference
United Health Group Yes Yes No http://bit.ly/2ukaWzo
Kaiser Foundation Group. No and Yes No Plan description does not address http://info.kaiserpermanente.org/info_assets/child_health_plan/
So CA Platinum 90 HMO specifically pdfs/membership_agreement_eoc.pdf
Anthem Inc. (Formerly Wellpoint Yes If >50% intake No https://www.anthem.com/medicalpolicies/guidelines/gl_pw_

Inc. Group) a053726.htm
Aetna Insurance Co. Yes No No http://www.aetna.com/cpb/medical/data/1_99/0061.html
Health Care Service Corporation Yes For limited No http://bit.ly/2tRtsgf

(HCSC) conditions
Cigna Health Group. Covers EN pump but Only for infants No http://bit.ly/2vipXPn
not formula on most <1 year or if state
plans mandates coverage
Molina Healthcare Yes If >50% intake No http://bit.ly/2tkGAZc
Highmark Insurance Co. Yes For limited No https://secure.highmark.com/ldap/medicalpolicy/wpa-

conditions highmark/O-6-020.html
a
Coverage for nutritional formula may be dependent upon medical benefit plan language for specific plans offered by the insurer. When enteral or oral nutrition is covered, certain criteria may need to be met and medical need documented.
Coverage may vary by state based on certain state mandates
There are 18 states (Arizona, Connecticut, Kentucky, Illi- amount of funding each year. In April 2014, the number of
nois, Maine, Maryland, Massachusetts, Minnesota, Missouri, participants enrolled in WIC was 9.3 million. For the full fiscal
Nebraska, New Hampshire, New Jersey, New York, Oregon, year 2014, appropriation for the program was $6.72 billion.123
Pennsylvania, Rhode Island, Texas, and Washington) with laws
mandating enteral formula coverage. However, some are writ- WIC Food Package III provides exempt infant formulas and
ten more broadly than others in that they may name specific WIC-eligible nutritionals to infants, children and women
medical conditions or have age limitations.121 who are participants and have a diagnosed medical condition
that precludes or restricts the use of conventional foods.124 An
Women, Infants, and Children exempt infant formula is one that is represented and labeled
for use by infants who have inborn errors of metabolism or
The Special Supplemental Nutrition Program for Women, low birth weight, or who otherwise have unusual medical or
Infants, and Children (WIC) is administered by the Food and dietary problems (Section 412(h), Federal Food, Drug, and
Nutrition Service of the US Department of Agriculture. WIC Cosmetic Act, 21 USC 360a(h)). Certain enteral products that
was established in 1974 to safeguard the health of low-income are specifically formulated to provide nutritional support for
women, infants, and children up to age 5 who are at nutritional individuals with a qualifying condition, when conventional
risk. This mission is carried out by providing nutritious foods foods are precluded, restricted, or inadequate, are considered
to supplement diets, nutrition education (including breastfeed- WIC-eligible medical foods. Such WIC-eligible medical foods
ing promotion and support), and referrals to health and other must serve the purpose of a food, meal, or diet and provide a
social services.122 source of calories and one or more nutrients; be designed for
enteral digestion via an oral or tube feeding; and may or may
WIC is not an entitlement program but rather a discretionary not be a conventional food, drug, flavoring or enzyme. WIC-el-
federal grant program for which Congress authorizes a specific igible foods include many, but not all, products that meet the

definition of medical foods by the FDA in Section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)
(3)). In the February 2016 report WIC Participant and Program Characteristics 2014 – Food Package
Report, the authors reported the number of infants, children and women who accessed WIC Food
Package III in 2014.125 At that time, 247,196, participants accessed the WIC Food Package III, which is a
small fraction of the 9.3 million WIC participants nationwide. This low number corresponds to the lim-
ited use of tube feeding or oral nutrition in the general, healthy population. In addition, state Medicaid
programs are the payer of the first resort for exempt infant formulas and medical foods issued to WIC
participants who are also Medicaid beneficiaries.126
The 2014 WIC Participant and Program Report indicated that more than two-thirds (68.8%) of WIC
clients received Medicaid benefits in 2014. The report goes on to say that this number may actually be
higher as WIC participants are frequently referred to other means tested programs at the time they are
enrolled in WIC.123 Another explanation for the small number of children who receive medical foods
through WIC may be due to the fact that WIC coverage for children ends at age 5. See Table 35 for the
number of WIC participants who receive medical foods as Food Package III.
TABLE 35
WIC-Eligible Medical Foods Prescribed for Recipients of Medical Packages (2014)

Children
Infants (age 1 to 4.9 years) Women Total
Number of Participants Accessing 179,539 66,286 1,371 247,196

Food Package III
SOURCE: WIC123
Greater Involvement in Self Care

Commercially blenderized and self-blenderized formulas have
become more popular in recent years for many reasons. These
reasons include reimbursement scrutiny, need to treat enteral
For caregivers, it may be an act of love and
feeding intolerance, desire to consume the same nutrition as increased sense of normalcy when feeding
the rest of the family, and concern about ingredients in com- their loved ones in a more natural way.128
mercial formulas.127 For caregivers, it may be an act of love and
increased sense of normalcy when feeding their loved ones in
a more natural way.128 While this started as a patient-driven
effort, it has gained acceptance by clinicians and manufactur- Initially, it was the only method of nourishing a patient who
ers as reports of success, both anecdotal and evidence based, could not sustain himself or herself on oral feeds. With the
appear in the literature.129-131 development of commercial formulas in the mid-20th century,
the usage of this feeding modality declined drastically due to
A blenderized tube feeding (BTF) is a mixture of food and the nutrition precision, ease, and sterility of commercial for-
liquid that is pureed and administered through a feeding tube. mulas. Recently, there has been a reemergence in blenderized
This method of providing nourishment has been used for mil- tube feeding, largely due to patient/family request.132 A recent
lennia. In fact, it could be viewed as the original form of nutri- cross-sectional study of adult patients receiving home EN indi-
tion support. However, over time, the role of BTF has changed. cated that 55.5% had used BTFs at some point.131 The modern
perception is that BTF is more natural because the nutrition The Oley Foundation, founded in 1983 by Dr. Lyn Howard
is coming from whole foods and is able to be varied, as would and her patient, Clarence “Oley” Oldenburg, is a national,
be the case in an oral diet. There are also reports of improved independent, non-profit 501(c)(3) organization that strives to
feeding tolerance, such as a reduction in constipation and gag- enrich the lives of patients dependent on home intravenous
ging/retching. However, potential concerns also exist, such as nutrition (parenteral) and tube feeding (enteral) through edu-
contamination of the blend with microorganisms, incomplete cation, advocacy, and networking. The Foundation also serves
nutrition, higher osmolality, and increased viscosity causing as a resource for consumers’ families, clinicians and industry
feeding tube occlusion.132 representatives, and other interested parties (www.oley.org).
A 2014 study by Chopy and colleagues showed that the Oley
There are a growing number commercially available BTF for- Foundation gives members the tools and confidence they need
mulas, many of which are being covered by most third-party to manage their complex therapy and enables them to achieve
payers. Examples of these are Real Food Blends®, Functional normalcy in their lives.134
Formularies® Liquid Hope, Kate Farms®, and Nestlé Compleat®.
Some of these formula manufacturers are partnering with large
home care companies, medical center home care agencies, EN Order Writing:
and medical supply distributors to offer these products to the
Changes in Prescribers
consumers.133 There are patients who are using hybrid formu-
la regimens, which entails use of homemade blenderized or With the concern over a potential physician shortage in the
commercially blenderized formulas and traditional commer- United States, there has been significant growth in numbers of
cial formulas. As EN consumers continue to be concerned with nurse practitioners and physician assistants. With the increase
feeding formula ingredients and payer policies, it is likely this in physician extender roles and the ability for these clinicians
trend will continue with EN in the homecare sector. to prescribe, the trends in non-physician ordering will likely
continue.135 Health Resources and Services Administration
Another way patients are expressing greater involvement in forecasts a 30% increase in the supply of primary care nurse
self-care is through involvement and utilization of EN focused practitioners from 2010 to 2020, and estimates that projected
patient and family support groups. Two large national organi- increases in both nurse practitioners and physician assistants
zations that support consumer use of EN are the Feeding Tube could potentially reduce the expected shortage of primary care
Awareness Foundation and the Oley Foundation. The Feeding providers in 2020. During the same time period, population
Tube Awareness Foundation was founded in 2010 to support growth and aging will account for 81% of the increased de-
parents of children who are tube-fed, while raising positive mand for primary care services.136 These primary care services
awareness of tube feeding as a lifesaving medical intervention. may include ordering and monitoring patients in a variety of
The organization is working to change the dialogue on tube care settings who are receiving EN therapy. In a gap analysis
feeding to focus on the positive benefits of receiving nutri- survey conducted in 2011, ASPEN found that nutrition sup-
tion support. The group’s annual Feeding Tube Awareness port team members (30.5%), pharmacists (28.3%), dietitians
Week® has gained the support of news media, online media, (20.9%), advanced practice nurses (14.7%), or physician as-
corporations, and organizations focused on tube feeding. The sistants (12.8%) were ordering PN, and it is likely that in 2017
week focuses on educating the broader public, promoting the more mid-level practitioners will be prescribing EN.137
positive benefits of tube feeding, and sharing personal experi-
ences. Feeding Tube Awareness Week® unifies and strengthens The 2014 Centers for Medicare and Medicaid Services (CMS)
the community. Increasingly, the Feeding Tube Awareness final rule permitting clinically qualified nutrition professionals,
Foundation is partnering with clinical organizations, prod- including registered dietitians, to be privileged to prescribe
uct manufacturers, and service providers to tackle issues patient diets under the hospital conditions of participation
that are important to the pediatric tube feeding community states, “patient diets, including therapeutic diets, must be
(http://www.feedingtubeawareness.org). ordered by a practitioner responsible for the care of the patient,

or by a qualified dietitian or qualified nutrition professional as
authorized by the medical staff and in accordance with state
law governing dietitians and nutrition professionals.”138 More
The opportunity to educate these
recently, CMS announced a final rule that applied this regu- practitioners, who may not be nutrition
lation to long-term care facilities.139 It is unclear how many support specialists, should be taken on by
registered dietitians have been granted prescribing privileges groups such as ASPEN in conjunction with
by their institutions since this regulatory rule was enacted,
other clinical and industry organizations
but the trend to have these clinicians prescribe EN therapy is
likely to grow as they follow these patients from a nutritional
so that patients receive optimal EN care.
perspective. The Academy of Nutrition and Dietetics has a
resource webpage with information and frequently asked
questions and answers along with information on a state-by-
state basis regarding relevant statutes and regulations related
to therapeutic diet ordering.140
The opportunity to educate these practitioners, who may

not be nutrition support specialists, should be taken on by
groups such as ASPEN in conjunction with other clinical and
industry organizations so that patients receive optimal EN
care. These data on EN use set the stage for such education
as large numbers of patients across the healthcare continuum
require this therapy.
Opportunity for
Future Research
One of the objectives of this report was to identify gaps in information and suggest future data collec-
tion and clinical research on the topic of EN. It would be important in future data collection to separate
EN from PN in the assessment data for these patients.
Overall in most care settings, all patients on EN need to be identified and tracked throughout the course
of their therapy. In particular, it is important to follow the types of tubes they have placed, along with
associated efficacy, adverse events, complications, and duration.
In terms of acute care, taking note of nasoenteric tube placement and use of these tubes for feeding is
important. Translation to coding in some way guarantees all patients on EN are accounted for. Rep-
resentative surveys of hospitalized patients on EN are needed to really understand who in acute care
needs this therapy.
In post-acute care, a change in assessment forms in IRFs and LTCHs can more specifically identify the
type of nutrition support rather than combining EN and PN. With very little observational research on
the LTCH population and with their long-term acute needs, there is an opportunity to place additional
investigative focus on EN in this population. Only a small percentage of the IRF populations appear to
require EN, but little research has been done to confirm these findings, and more information is needed.
Most importantly, with the seemingly large number of home EN patients, some type of national patient
registry would help quantify the true number of patients on EN, and what their current practice, com-
plications, outcomes, and costs are, across all payers.
Conclusion
This report captures the use and practice of EN in the United States across the healthcare continuum,
providing the best available collection of data in 1 document. This report offers stakeholders, including
clinicians, healthcare administrators, supply chain personnel, safety and regulatory organizations, pay-
ers, manufacturers, and policy makers, a comprehensive view of what has happened in the EN market
over the past few years. Some healthcare settings have sufficient data, while others are lacking even basic
data such as number of patients. Much research and quantification of practice needs to be done to deliv-
er optimal cost-effective care for all patients requiring EN.

Appendices
Glossary of Abbreviations and Terms
Accountable Care Organizations (ACOs) pharmacists, physicians, scientists, students, and other
ACOs are groups of doctors, hospitals, and other health health professionals from every facet of nutrition support:
care providers, who come together voluntarily to give coordi- clinical practice, research, and education.
nated high-quality care to the patients they serve.
Bolus Administration Method
Acute Care Hospital A method of feeding administration in which a set volume of
Acute care hospitals provide treatment for a severe injury feeding formula is given over a short period of time several
or episode of illness, an urgent medical condition, or during times per day, usually through a syringe.
recovery from surgery.
Closed Enteral System
Agency for Healthcare Research and Quality (AHRQ) A closed, ready-to-hang enteral container pre-filled with
The Agency for Healthcare Research and Quality’s (AHRQ) sterile, liquid formula by the manufacturer.
mission is to produce evidence to make health care safer,
higher quality, more accessible, equitable, and affordable, The Centers for Medicare & Medicaid Services
and to work within the US Department of Health and Hu- (CMS)
man Services and with other partners to make sure that the
evidence is understood and used. CMS, is part of the Department of Health and Human Ser-
vices (HHS) that administers programs including Medicare,
Medicaid, the Children’s Health Insurance Program (CHIP),
Academy of Nutrition and Dietetics and the Health Insurance Marketplace.
The Academy of Nutrition and Dietetics is the world’s
largest organization of food and nutrition professionals. Durable Medical Equipment, Prosthetics, Orthotics
The Academy is committed to improving health and and Supplies (DMEPOS)
advancing the profession of dietetics through research,
education, and advocacy. Section 302 of the Medicare Modernization Act (the Act)
required the Secretary to establish and implement quality
standards for suppliers of Durable Medical Equipment,
American Society for Parenteral and Prosthetics, Orthotics, and Supplies (DMEPOS). All sup-
Enteral Nutrition (ASPEN) pliers that furnish Durable Medical Equipment (DME),
ASPEN is dedicated to improving patient care by advancing prosthetic device, prosthetic, or orthotic items or services
the science and practice of clinical nutrition and metab- must comply with the quality standards in order to receive
olism. Founded in 1976, ASPEN is an interdisciplinary Medicare Part B payments and to retain a supplier billing
organization whose members are involved in the provision number. Covered items include: DME; medical supplies;
of clinical nutrition therapies, including parenteral and en- home dialysis supplies and equipment; therapeutic shoes;
teral nutrition. With more than 6,500 members from around parenteral and enteral nutrient, equipment and supplies;
the world, ASPEN is a community of dietitians, nurses, transfusion medicine; and prosthetic devices, prosthetics,
and orthotics.
Enteral Access Device Health and Human Services (HHS)
Tube placed directly into the gastrointestinal tract for the It is the mission of the US Department of Health & Human
delivery of nutrients and/or drugs. Services (HHS) to enhance and protect the health and
well-being of all Americans. We fulfill that mission by provid-
ing for effective health and human services and fostering
Enteral Nutrition (EN) advances in medicine, public health, and social services.
Feeding provided through the gastrointestinal tract via a
tube, catheter, or stoma that delivers nutrients distal to the
oral cavity. Also known as tube feeding. Healthcare Common Procedure Coding System
(HCPCS)
HCPCS is a standardized coding system that is used primar-
EN Use Process ily to identify products, supplies, and services not included
The EN Use Process is the system within which EN is used. in the CPT codes, such as ambulance services and durable
This involves a number of major steps: the initial patient medical equipment, prosthetics, orthotics, and supplies
assessment, the recommendations for an EN regimen, the (DMEPOS) when used outside a physician’s office.
selection of the EAD, the EN prescription, the review of the
EN order, the product selection or preparation, the product
labeling and dispensing, the administration of the EN to the Healthcare Cost and Utilization Project (HCUP)
patient, and the patient monitoring and reassessment, with AHRQ HCUP is the nation’s most comprehensive source of
documentation at each step as required. hospital care data, including information on in-patient stays,
ambulatory surgery and services visits, and emergency
department encounters.
Enhanced Recovery After Surgery (ERAS)
ERAS protocols are multimodal perioperative care pathways
designed to achieve early recovery after surgical procedures Home Care
by maintaining preoperative organ function and reducing Refers to the non-institutionalized setting where the individ-
the profound stress response following surgery. https:// ual resides in their own home, group home, board and care,
www.ncbi.nlm.nih.gov/pmc/articles/PMC3202008/ or assisted living facility.
Fee-for-service (FFS) Inpatient Rehabilitation Facilities (IRF)

FFS is a payment model in which services are unbundled Inpatient Rehabilitation Facilities (IRF) provide intensive
and paid for separately. In health care, it gives an incen- rehabilitation services (such as physical or occupational
tive for physicians to provide more treatments, because therapy, rehabilitative nursing, speech language pathology,
payment is dependent on the quantity of care, rather than and prosthetic or orthotic devices) after injury, illness, or
quality of care. https://en.wikipedia.org/wiki/Fee-for-service surgery. Medicare requires that the beneficiary actively par-
ticipates and benefits from therapy to qualify for this level of
care. (MedPAC REPORT)
Government Accounting Office (GAO)
The US Government Accountability Office (GAO) is an inde-
pendent, nonpartisan agency that works for Congress. Jejunostomy Tube
This is an enteral feeding tube where the tip is placed in
the jejunum portion of the small intestine. It can be placed
Gravity Administration Method through an endoscopic, surgical, or interventional radiologic
A method of feeding administration in which a set volume of procedure.
feeding formula is given over a short period of time several
times per day, generally using a feeding administration bag
as opposed to use of an enteral pump.

Length of Stay (LOS) Medicare Payment Advisory Commission (MedPAC)
LOS is a term to describe the duration of a single epi- MedPAC is an independent congressional agency estab-
sode of institutionalization such as at a hospital or other lished by the Balanced Budget Act of 1997 (P.L. 105-
healthcare facility. 33) to advise the US Congress on issues affecting the
Medicare program.
Long-term Acute Care Hospitals (LTCH)

Long-term acute care hospitals, also known as long-term Modular Enteral Feeding
care hospitals, provide long-term acute care to patients who Formulation created by combination of separate nutrient
continue to be medically complex and require an extended sources such as carbohydrate, fat and protein or by modifi-
stay in a hospital setting. LTCHs provide care to patients cation of existing formulations.
who need hospital level care for relatively long periods.
Nasoenteric/nasogastric tube
Malnutrition Short-term feeding tube placed via the nose with the tip of
An acute, subacute, or chronic state of nutrition, in which a the tube in the stomach or proximal small bowel.
combination of varying degrees of overnutrition or under-
nutrition with or without inflammatory activity have led to a
change in body composition and diminished function. Soet- National Center for Health Statistics (NCHS)
ers PB, et al. A rational approach to nutritional assessment. The National Center for Health Statistics is the nation’s
Clin Nutr 2008; 27:706–716.141 Defined in this report by a principal health statistics agency that produces statistical
variety of ICD-9 codes. information to guide actions and policies to improve the
health of the US people. It is an agency under the Centers
for Disease Control and Prevention (CDC).
Medicare
Medicare is the federal health insurance program for
people who are 65 or older, certain younger people with National Home Infusion Association (NHIA)
disabilities, and people with end-stage renal disease The mission of NHIA is to represent and advance the inter-
(permanent kidney failure requiring dialysis or a trans- ests of organizations that provide infusion and specialized
plant, sometimes called ESRD). pharmacy products and services to the entire spectrum of
home-based patients.
Medicaid
Medicaid provides health coverage to millions of Amer- National (Nationwide) Inpatient Sample (NIS)
icans, including eligible low-income adults, children, NIS is part of a family of databases and software tools
pregnant women, elderly adults, and people with disabil- developed for the Healthcare Cost and Utilization Project
ities. Medicaid is administered by states, according to (HCUP). The NIS is the largest publicly available all-payer
federal requirements. inpatient health care database in the United States, yielding
national estimates of hospital inpatient stays.
Medi-Cal
Medi-Cal is free or low-cost health coverage for children and Nursing Home
adults with limited income and resources as a Medicaid A nursing home is defined as a place for people who do not
program administered by the state of California. need to be in a hospital but cannot be cared for at home.
Most nursing homes have nursing aides and skilled nurses
on hand 24 hours a day.
Office of the Inspector General (OIG) Pump Administration Method
Office of Inspector General’s (OIG) mission is to protect the A method of EN administration in which feeding formula
integrity of Department of Health & Human Services (HHS) is given over a continuous period of time using a feeding
programs, as well as the health and welfare of program administration bag or syringe and an enteral pump.
beneficiaries.
Readmission
Open Enteral System A hospital readmission is an episode when a patient who
A feeding system in which the clinician/patient/caregiver is had been discharged from a hospital is admitted again with-
required to decant formula into the enteral container. in a specified time interval. Readmission rates have increas-
ingly been used as an outcome measure in health services
research and as a quality benchmark for health systems.
Percutaneous Endoscopic Gastrostomy (PEG) https://en.wikipedia.org/wiki/Hospital_readmission
A long-term feeding tube placed endoscopically with the tip
in the stomach.
Women, Infants, and Children (WIC)
The Special Supplemental Nutrition Program for Women,
Percutaneous Endoscopic Gastro-jejunostomy Infants, and Children (WIC) provides federal grants to states
(PEGJ) for supplemental foods, health care referrals, and nutrition
A long-term feeding tube placed endoscopically with a port education for low-income pregnant, breastfeeding, and
in the stomach, typically for drainage, and a second lumen non-breastfeeding postpartum women, and to infants and
with the tip in the jejunum for feeding. children up to age 5 who are found to be at nutritional risk.
Public Use Files (PUF)

For this report, these are CMS files of Medicare provider
data for EN beneficiaries.

References
1. Agency for Healthcare Research and Quality (AHRQ). HCUPnet 15. Centers for Medicare and Medicaid Services. 2013 Medicare
Healthcare Cost and Utilization Project. https://hcupnet.ahrq. Provider Utilization and Payment Data Public Utilization File for
gov/#setup Accessed June 26, 2017. Referring Durable Medical Equipment, Prosthetics, Orthotics and
Supplies. http://go.cms.gov/2195mem Accessed June 27, 2017.
2. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice
recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167. 16. Centers for Medicare & Medicaid Services. National Coverage
Determination (NCD) for Enteral and Parenteral Nutritional Therapy
3. Boullata JI, Long Carrera A, Harvey L, et al. ASPEN safe (180.2). 1984. http://go.cms.gov/2uf3e9V Accessed June 27, 2017.
practices for enteral nutrition therapy. JPEN J Parenter Enteral Nutr.
2017; 41(1):15-103. 17. National Home Infusion Association. 2010 NHIA Provider Survey:
Comprehensive Aggregate Analysis Report. 2011. NHIA. Alexandria,
4. Hudson LM, Boullata JI. A quality improvement case report: an VA. http://bit.ly/2sVqBBJ Accessed June 27, 2017.
institution’s experience in pursuing excellence in parenteral nutrition
safety. JPEN J Parenter Enteral Nutr. 2014; 38(3):378-384. 18. California Department of Healthcare Services, Research and
Analytic Studies Division. Medi-Cal Monthly Enrollment Fast Facts,
5. Agency for Healthcare Research and Quality (AHRQ). HCUPnet December 2015. April 2016. http://www.dhcs.ca.gov/dataandstats/
Healthcare Cost and Utilization Project. Definition of discharge to other statistics/Documents/Fast_Facts_December_2015_ADA.pdf Accessed
institution. https://hcupnet.ahrq.gov/#glossary Accessed June 27, 2017. June 27, 2017.
6. Manyika J, Chui M, Brown B, et al. Big data: The next frontier for 19. Centers for Medicare and Medicaid Services. Medicare Fee-For-
innovation, competition, and productivity. The McKinsey Global Service Provider Utilization & Payment Data Referring Durable
Institute (MGI). May 2011 https://bigdatawg.nist.gov/pdf/MGI_big_ Medical Equipment, Prosthetics, Orthotics and Supplies Public
data_full_report.pdf Accessed June 27, 2017. Use File: A Methodological Overview. Updated November 7, 2016.
http://go.cms.gov/2wBtexd Accessed June 27, 2017.
7. National Institutes of Health. What is big data? April 25, 2017.
https://datascience.nih.gov/bd2k/about/what Accessed June 28, 2017. 20. Howard L, Ament M, Fleming CR, Shike M, Steiger E. Current use
and clinical outcome of home parenteral and enteral nutrition therapies
in the United States. Gastroenterology. 1995;109(2):355-365.
8. American Hospital Association. Fast facts on hospitals. 2017 edition.
http://www.aha.org/research/rc/stat-studies/101207fastfacts.pdf
Accessed June 27, 2017. 21. The Henry J. Kaiser Family Foundation. Medicaid & CHIP.
2017. http://www.kff.org/state-category/medicaid-chip/ Accessed
June 27, 2017.
9. Medline Plus. US National Library of Medicine. Nursing
Homes. May 31, 2017. https://medlineplus.gov/nursinghomes.html
Accessed June 28, 2017. 22. Centers for Medicare & Medicaid Services. Medicare Payment
Advisory Commission (MEDPAC). Report to the Congress Medicare
Payment Policy. March 2016. http://go.cms.gov/2uf3e9V Accessed
10. AgingCare.com. What’s the difference between skilled nursing and a
June 27, 2017.
nursing home? https://www.agingcare.com/articles/difference-skilled-
nursing-and-nursing-home-153035.htm Accessed June 27, 2017.
23. Centers for Medicare and Medicaid Services. 2014 Admission
Long-Term Care Hospital (LTCH) Continuity Assessment Record
11. US Department of Health and Human Services, LongTerm
& Evaluation (CARE) Data Set. 2014. http://go.cms.gov/2d0aJGg
Care.Gov. Medicare, Medicaid & more. February 21, 2017. https://
Accessed June 27, 2017.
longtermcare.acl.gov/medicare-medicaid-more/ Accessed June 28, 2017.
24. Fleming Advanced Outcomes Design, Inc. Silver Spring, MD.

12. Centers for Medicare and Medicaid Services. Your Medicare
http://www.aod.cx/ Accessed June 27,2017.
coverage. enteral nutrition supplies & equipment (feeding pump).
http://bit.ly/2uXaO6F.Accessed June 27, 2017.
25. American Medical Rehabilitation Providers Association (AMPRA).
2014 American Medical Rehabilitation Providers Association (AMPRA)
13. Centers for Medicare and Medicaid Services. Nursing Home Data
Database of Inpatient Rehabilitation Facilities Patient Assessment
Compendium 2015 Edition. http://go.cms.gov/1VECZSm Accessed
Instrument. 2016. Accessed through Fleming Advanced Outcomes
June 27, 2017.
Design, Inc. Silver Spring, MD.
14. The Henry J. Kaiser Family Foundation. An overview of Medicare.

2016. http://www.kff.org/medicare/issue-brief/an-overview-of-
medicare/ Accessed June 27, 2017.
26. AAPC. What are HCPCS codes? https://www.aapc.com/resources/ 39. Roberts S, Brody R, Stankorb S. Delivery of the enteral nutrition
medical-coding/hcpcs.aspx Accessed June 27, 2017. prescription and incidence of feeding intolerance in critically ill patients
on volume-based enteral nutrition. ASPEN Clinical Nutrition Week
27. American Hospital Association. Fast facts on US hospitals. 2016 2015 poster. Long Beach, CA. http://journals.sagepub.com/page/pen/
edition. http://bit.ly/2ufcKds Accessed June 27, 2017. collections/abstracts/index Accessed June 27, 2017.
28. Mundi MS, Pattisson A, McMahon MT, Davidson J, Hurt RT. 40. Saran D, Brody RA, Stankorb SM, Parrott SJ, Heyland DK. Gastric
Prevalence of home parenteral and enteral nutrition in the United vs small bowel feeding in critically ill neurologically injured patients:
States. Nutr Clin Pract. 2017. doi:10.1177/0884533617718472 results of a multicenter observational study. JPEN J Parenter Enteral
Nutr. 2015; 39(8): 910-916.
29. Tian W. (AHRQ). An all-payer view of hospital discharge to
postacute care, 2013. HCUP Statistical Brief #205. May 2016. Agency for 41. Taylor B, Brody R, Denmark R, Southard R, Byham-Gray L.
Healthcare Research and Quality, Rockville, MD. http://bit.ly/2wBnvaL Improving enteral delivery through the adoption of the “feed early
Accessed June 27, 2017. enteral diet adequately for maximum effect (FEED ME)” protocol in a
surgical trauma ICU: a quality improvement review. Nutr Clin Pract.
2014;29(5):639-648.
30. Centers for Medicare & Medicaid Services. Chapter 2: Assessments
for the Resident Assessment Instrument (RAI). CMS’s RAI Version 3.0
Manual. 2013. http://bit.ly/2ujYlfs Accessed June 27, 2017. 42. Wood JD. Current postoperative enteral nutrition
support trends after cardiac surgery. ASPEN Clinical
Nutrition Week 2015 poster. Long Beach, CA.
31. Barrett ML, Wier LM, Jiang HJ, Steiner CA. All-cause readmissions
http://journals.sagepub.com/page/pen/collections/abstracts/index
by payer and age, 2009–2013. HCUP Statistical Brief #199. 2015. https://
www.hcup-us.ahrq.gov/reports/statbriefs/sb199-Readmissions-Payer-
Age.pdf Accessed June 27, 2017.
43. Aloupis M, Spencer C, Compher C, Nicolo M. Use of an adjusted
enteral nutrition feeding goal to improve enteral nutrition delivery.
32. Dijkink S, Fuentes E, Quraishi SA, Cropano C, Kaafarani H, Lee J.
ASPEN Clinical Nutrition Week Poster Long Beach, CA February 2015.
Nutrition in the surgical intensive care unit: the cost of starting low and
ramping up rates. Nutr Clin Pract. 2016;31(1):86-90.
33. Fuentes E, Yeh DD, Quraishi SA, Johnson EA, Kaafarani H, Lee J.
44. Chaudhry R, Kukreja N, Tse A, Pednekar G, Mouchli A, Young L, et
Hypophosphatemia in enterally fed patients in the surgical intensive
al. Trends and outcomes of early versus late percutaneous endoscopic
care unit common but unrelated to timing of initiation or aggressiveness
gastrostomy placement in patients with traumatic brain injury:
of nutrition delivery. Nutr Clin Pract. 2017;32(2): 252-257.
Nationwide population-based study. J Neurosurg Anesthesiol. 2017 Apr
28. doi:10.1097/ANA.0000000000000434 (epub ahead of print).
34. Gungabissoon U, Hacquoil K, Bains C, Irizarry M, Dukes G,
Williamson R. Prevalence, risk factors, clinical consequences, and
45. Pash, E, et al. M25—Attainment of enteral nutrition water flush
treatment of enteral feed intolerance during critical illness. JPEN J
orders using manual syringe versus automated pump delivery.
Parenter Enteral Nutr. 2015;39(4):441-448.
ASPEN Clinical Nutrition Week 2016 poster. Austin, TX. http://
journals.sagepub.com/page/pen/collections/abstracts/index Accessed
35. Haskins IN, Baginsky M, Gamsky N, Sedghi K, Yi S, Amdur RL.
June 27, 2017.
A volume-based enteral nutrition support regimen improves caloric
delivery but may not affect clinical outcomes in critically ill patients.
46. Lyman B, et al. Use of temporary enteral access devices in
JPEN J Parenter Enteral Nutr. 2017;41(4):607-611.
hospitalized neonatal and pediatric patients in the United States. JPEN J
36. Kozeniecki M, McAndrew N, Patel JJ. Process-related barriers to
optimizing enteral nutrition in a tertiary medical intensive care unit.
47. Savoie KB, Bachier-Rodriguez M, Jones TL, Jeffreys K, Papraniku
Nutr Clin Pract. 2016;31(1):80-85.
D, Sevilla W. Standardization of feeding advancement after neonatal
gastrointestinal surgery: does it improve outcomes? Nutr Clin Pract.
37. Metheny NA, Stewart BJ, McClave SA. Relationship between feeding
2016;31(6): 810-818.
tube site and respiratory outcomes. JPEN J Parenter Enteral Nutr.
2011;35(3):346-355.
48. Kuo S, Rhodes RL, Mitchell SL, Mor V, Teno JM. Natural history of
feeding‐tube use in nursing home residents with advanced dementia. J
38. Rice TW, Mogan S, Hays MA, Bernard GR, Jensen GL, Wheeler AP.
Am Med Dir Assoc. 2009;10(4):264‐270.
Randomized trial of initial trophic versus full-energy enteral nutrition
in mechanically ventilated patients with acute respiratory failure. Crit
Care Med. 2011;39(5):967-974

49. Burgermaster M, Slattery F, Islam N, Ippolito PR, Seres DS. Regional 62. Brettschneider AK, Reddick C, Emch VL. Apria Healthcare Inc.,
comparison of enteral nutrition–related admission policies in skilled Characteristics of Patients Receiving Home Enteral Nutrition. 2011
nursing facilities. Nutr Clin Pract. 2016;31(3):342-348. ASPEN Clinical Nutrition Week Poster. Vancouver, BC, CANADA
50. Mitchell SL, Mor V, Gozalo PL, Servadio JL, Teno JM. Tube feeding Accessed June 27, 2017.
in US nursing home residents with advanced dementia, 2000-2014.
JAMA. 2016;316(7):769-770. 63. Drake R, Ozols A, Nadeau WJ, Braid-Forbes MJ. Hospital inpatient
admissions with dehydration and/or malnutrition in Medicare
51. Finucane TE, Christmas C, Leff BA. Tube feeding in dementia: how beneficiaries receiving enteral nutrition: A cohort study. JPEN J Parenter
incentives undermine health care quality and patient safety. J Am Med Enteral Nutr. 2017 doi:10.1177/0148607117713479.
Dir Assoc. 2007;8(4):205-208.
64. Epp L, Lammert L, Vallumsetla N, Hurt RT, Mundi MS. Use of
52. Mitchell SL, Buchanan JL, Littlehale S, Hamel M. Tube-feeding blenderized tube feeding in adult and pediatric home enteral nutrition
versus hand-feeding nursing home residents with advanced dementia: a patients. Nutr Clin Pract. 2017; 32(2):201-205.
cost comparison. J Am Med Dir Assoc. 2003;4(1):27-33.
65. Hall BT, Englehart MS, Blaseg K, Wessel K, Stawicki SP, Evans DC.
53. Mitchell SL. Financial incentives to place feeding tubes in Implementation of a dietitian-led enteral nutrition support clinic results
nursing home residents with advanced dementia. J Am Geriatr Soc. in quality improvement, reduced readmissions, and cost savings. Nutr
2003;51(1):129-131. Clin Pract. 2014;29(5):649-655
54. Mitchell SL, Kiely DK, Gillick MR. Nursing home characteristics 66. Kranz E, Chaube V. Trends in enteral tube placement for utilization
associated with tube feeding in advanced cognitive impairment. J Am in the home setting. ASPEN Clinical Nutrition Week poster 2017
Geriatr Soc. 2003;51(1):75-79. Orlando, FL. http://journals.sagepub.com/page/pen/collections/
abstracts/index Accessed June 27, 2017.
55. Feeding Tube Awareness Foundation. Enteral formula coverage.
http://bit.ly/2uo1Nqh Accessed June 27, 2017. 67. Rosen D, Schneider R, Bao R, et al. Home nasogastric feeds: feeding
status and growth outcomes in a pediatric population. JPEN J Parenter
Enteral Nutr. 2016; 40(3): 350-354.
56. US Department of Agriculture Food and Nutrition Service.
Women, Infants and Children (WIC). WIC Eligibility Requirements.
2017. https://www.fns.usda.gov/wic/wic-eligibility-requirements 68. Vallumsetla N, Hurt R, Mundi M. Effect of home enteral nutrition
Accessed June 27, 2017. on diabetes and it management. ASPEN Clinical Nutrition Week 2016
poster Austin, TX. http://journals.sagepub.com/page/pen/collections/
abstracts/index Accessed June 27, 2017.
57. Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R,
Division of Health Care Statistics, Centers for Disease Control and
Prevention, National Center for Health Statistics. Home Health care and 69. Winkler MF, DiMaria-Ghalili RA, Guenter P, et al. Characteristics
discharged hospice care patients: United States, 2000 and 2007. April of a cohort of home parenteral nutrition patients at the time of
27, 2011. https://www.cdc.gov/nchs/data/nhsr/nhsr038.pdf Accessed enrollment in the Sustain registry. JPEN J Parenter Enteral Nutr.
June 27, 2017. 2016;40(8):1140-1149.
58. The Henry J. Kaiser Family Foundation. Medicaid enrollees by 70. Delegge MH. Home enteral nutrition. JPEN J Parenter Enteral Nutr.
enrollment group. FY2014. http://kaiserf.am/2uf1gGB Accessed 2002; 26 (5Suppl):S4-S7.
June 27, 2017.
71. Ireton-Jones C, DeLegge M. Home parenteral nutrition registry:
59. US Census Bureau. Quick Facts. 2016. https://www.census.gov/ a five-year retrospective evaluation of outcomes of patients receiving
quickfacts/table/PST045215/06 Accessed June 27, 2017. home parenteral nutrition support. Nutrition. 2005;21(2):156-160.
60. California Department of Healthcare Services, Medi-Cal. Provider 72. Horn SD, Corrigan JD, Beaulieu CL, Bogner J, Barrett RS, Giuffrida
Manuals, Part 2. Pharmacy. 2007. http://bit.ly/2sVXz4S Accessed CG. Enteral nutrition for TBI patients in the rehabilitation setting:
June 27, 2017. associations with patient pre-injury and injury characteristics and
outcomes. Arch Phys Med Rehabil. 2015; 96(8S): S245-S255.
61. National Freedom of Information Coalition. Medi-Cal Fee for
Service Program using the California Public Records Act (PRA) 73. Northington L, Lyman B, Guenter P, Irving SY, Duesing L. Current
process. 2016. http://www.nfoic.org/california-sample-foia-request practices in home management of nasogastric tube placement in
Accessed June 27, 2017. pediatric patients: a survey of parents and homecare providers. J Pediatr
Nurs. 2017 Mar-Apr;33:46-53.
74. Schpero WL, Morden NS, Sequist TD, Rosenthal MB, Gottlieb DJ, 88. Braunschweig C, Gomez S, Sheean PM. Impact of declines in
Colla CH. Blacks and Hispanics often receive more low-value care than nutritional status on outcomes in adult patients hospitalized for more
whites in Medicare. Health Affairs. 2017;36(6):1065-1069. than 7 days. J Am Diet Assoc. 2000;100(11):1316-1322; quiz 1323-1324.
75. Boullata J, Nieman Carney L, Guenter P. A.S.P.E.N. Enteral Nutrition 89. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence,
Handbook. Silver Spring, MD: ASPEN. 2010. identification and impact on patients and the healthcare system. Int J
Environ Res Public Health. 2011;8(2):514-527.
76. Marlon ND, Rupp ME. Infection control issues of enteral feeding
systems. Curr Opin Clin Nutr Metab Care. 2000;3(5):363-366. 90. Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining
readmission risk factors for general medicine patients. J Hosp Med.
77. Vanek V. Closed versus open enteral delivery systems: a quality 2011;6(2):54-60.
improvement study. Nutr Clin Pract. 2000;15(5):234-243.
91. Kassin MT, Owen RM, Perez SD, et al. Risk factors for 30-day
78. Moffitt SK, Gohman SM, Sass KM, Faucher KJ. Clinical and hospital readmission among general surgery patients. J Am Coll Surg.
laboratory evaluation of a closed enteral feeding system under 2012;215(3):322-330.
cyclic feeding conditions: a microbial and cost evaluation. Nutrition.
1997;13(7-8):622-628. 92. Snider JT, Linthicum MT, Wu Y, et al. Economic burden of
community-based disease-associated malnutrition in the United States.
79. Wagner DR, Elmore MF, Knoll DM. Evaluation of “closed” vs “open” JPEN J Parenter Enteral Nutr. 2014;38(S2):77S-85S.
systems for the delivery of peptide-based enteral diets. JPEN J Parenter
Enteral Nutr. 1994;18(5):453-457. 93. Weiss AJ (Truven Health Analytics), Fingar KR (Truven Health
Analytics), Barrett ML (M.L. Barrett, Inc.), Elixhauser A (AHRQ),
80. Fagerman KE. Limiting bacterial contamination of enteral nutrient Steiner CA (AHRQ), Guenter P (American Society for Parenteral
solutions:6-year history with reduction of contamination at two and Enteral Nutrition), Brown MH (Baxter International, Inc.).
institutions. Nutr Clin Pract. 1992;7(1):31-36. Characteristics of Hospital Stays Involving Malnutrition, 2013. HCUP
Statistical Brief #210. September 2016. Agency for Healthcare Research
and Quality, Rockville, MD. 2017. http://bit.ly/2vinhRL Accessed
81. Luther H, Barco K, Chima C, Yowler CJ. Comparative study of two
June 27, 2017.
systems of delivering supplemental protein with standardized tube
feedings. J Burn Care Rehabil. 2003;24(3):167-172.
94. Fingar KR (Truven Health Analytics), Weiss AJ (Truven Health
Analytics), Barrett ML (M.L. Barrett, Inc.), Elixhauser A (AHRQ),
82. Silkroski M, Allen F, Storm H. Tube feeding audit reveals hidden
Steiner CA (AHRQ), Guenter P (American Society for Parenteral and
costs and risks of current practice. Nutr Clin Pract. 1998;13(6):283-290.
Enteral Nutrition), Brown MH (Baxter International, Inc.). All-Cause
Readmissions Following Hospital Stays for Patients with Malnutrition,
83. Phillips W. Economic impact of switching from an open to a closed
2013. HCUP Statistical Brief #218. December 2016. Agency for
enteral nutrition feeding system in an acute care setting. Nutr Clin Pract.
Healthcare Research and Quality, Rockville, MD. http://bit.ly/2jVXtGK
2013;28(4):510-514.
84. Jones SA, Guenter P. Automatic flush feeding pumps: A move

95. Guenter P, Jensen GL, Patel V, et al. Addressing disease-related
forward in enteral nutrition. Nursing97. 1997;27(2):56-58.
malnutrition in hospitalized patients: a call for a national goal. Jt Comm
J Qual Patient Saf. 2015; 41(10):469-473.
85. Nadeau B, Tordella J The role automated flushing in decreased
30-day rehospitalization rates. ASPEN Clinical Nutrition Week. 2017
96. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang
poster. http://journals.sagepub.com/page/pen/collections/abstracts/
G, Ziegler TR. Critical role of nutrition in improving quality of care: An
index Accessed June 27, 2017.
interdisciplinary call to action to address adult hospital malnutrition.
JPEN J Parenter Enteral Nutr. 2013;37(4):482-497.
86. Studley HO. Percentage of weight loss: A basic indicator of surgical
risk in patients with chronic peptic ulcer. JAMA. 1936;106(6):458-460.
97. DefeatMalnutrition.Today. Home page.
http://defeatmalnutrition.today Accessed June 27, 2017.
87. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and
the occurrence of never events. Arch Surg. 2010;145(2):148-151.
98. National Alliance for Infusion Therapy and the American Society for
Parenteral and Enteral Nutrition Public Policy Committee and Board of
Directors. Disease-related malnutrition and enteral nutrition therapy:
a significant problem with a cost-effective solution. Nutr Clin Pract.
2010;25(5):548-554.

99. White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy 111. Centers for Medicare and Medicaid Services. Bundled
Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; payments for care improvement initiative (BPCI). August 13, 2015.
A.S.P.E.N. Board of Directors. Consensus statement: Academy of http://go.cms.gov/1VeqXP5 Accessed June 27, 2017.
Nutrition and Dietetics and American Society for Parenteral and Enteral
Nutrition: characteristics recommended for the identification and 112. Centers for Medicare and Medicaid Services. Notice of proposed
documentation of adult malnutrition (undernutrition). JPEN J Parenter rulemaking for bundled payment models for high-quality, coordinated
Enteral Nutr. 2012;36(3):275-283. cardiac and hip fracture care. July 25, 2016. http://go.cms.gov/2a5dGVo
100. Becker P, Carney LN, Corkins MR, et al. Consensus statement of
the Academy of Nutrition and Dietetics/American Society for Parenteral 113. Centers for Medicare and Medicaid Services. Accountable Care
and Enteral Nutrition: indicators recommended for the identification Organizations (ACOs): General Information. June 20,2017. https://
and documentation of pediatric malnutrition (undernutrition). Nutr innovation.cms.gov/initiatives/ACO/ Accessed June 27, 2017.
Clin Pract. 2015;30(1):147-161.
114. Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB,
101. Citty SW, Kamel A, Garvan C, Marlowe L, Westhoff L. Optimizing Heyland DK. Perioperative use of arginine-supplemented diets: a
the electronic health record to standardize administration and systematic review of the evidence. J Am Coll Surg. 2011;212(3): 385-399.
documentation of nutritional supplements. BMJ Qual Improv Rep. 2017
Feb 8;6(1). doi:10.1136/bmjquality.u212176.w4867.
115. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn
BB. Surgical site infection: incidence and impact on hospital utilization
102. Mosquera, C, MD, Koutlas NJ, Edwards KC, et al. Impact and treatment costs. Am J Infect Control 2009;37:387-397.
of malnutrition on gastrointestinal surgical patients. J Surg Res.
2016;205(1):95-101.
116. Centers for Medicare and Medicaid Services.
DMEPOS Competitive Bidding – Home. March 10, 2017.
103. Academy of Nutrition and Dietetics. Electronic clinical quality http://go.cms.gov/2tRNXJO Accessed June 27, 2017.
measures. http://bit.ly/2tkiWMJ Accessed June 27, 2017.
117. Noridian Healthcare Solutions. Fee schedule lookup tool. March
104. The Leapfrog Group. Leapfrog hospital survey hard copy: questions 31, 2017. http://bit.ly/2ukavFf Accessed June 27, 2017.
& reporting periods, endnotes, measure specifications, FAQs. April
2016. http://bit.ly/2vir4P6 Accessed June 27, 2017.
118. Government Accountability Office (GAO). CMS’s
round 2 durable medical equipment and national mail-order
105. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. diabetes testing supplies competitive bidding programs 2016.
Enhanced recovery program in colorectal surgery: a meta-analysis of http://www.gao.gov/products/GAO-16-570 Accessed June 27, 2017.
randomized controlled trials. World J Surg. 2014 Jun;38(6):1531-1541.
119. Centers for Medicare & Medicaid Services. Competitive bidding
106. ASPEN. Malnutrition Toolkit. 2017. http://bit.ly/1PaQxkC update—one year implementation update. 2012. Available from
Accessed June 27, 2017. http://go.cms.gov/2xpFI8e Accessed June 27, 2017.
107. The Malnutrition Quality Collaborative. National Blueprint: 120. Office of Inspector General (OIG), US Department of Health
Achieving Quality Malnutrition Care for Older Adults. Washington, and Human Services. State Medicaid agencies can significantly
DC: Avalere and Defeat Malnutrition Today. March 2017. reduce Medicaid costs for durable medical equipment and
http://defeatmalnutrition.today/blueprint Accessed June 27, 2017. supplies.2015. https://oig.hhs.gov/oas/reports/region5/51500025.pdf
108. Cubanski J, Neuman T. 10 Essential Facts about Medicare’s
Financial Outlook. The Henry J. Kaiser Family Foundation. 2017. 121. American Partnership for Eosinophilic Disorders (APFED). State
http://kaiserf.am/2o0g30W Accessed June 27, 2017. insurance mandates for elemental formula. 2017. http://bit.ly/2t8NuFI
109. The Henry J. Kaiser Family Foundation. Summary of the Affordable
Care Act. 2013. http://kaiserf.am/2sVI90v Accessed June 27, 2017. 122. US Department of Agriculture Food and Nutrition Service.
Women, Infants and Children (WIC). About WIC-WIC’s mission
110. Agency for Healthcare Research and Quality (AHRQ). National 2015. https://www.fns.usda.gov/wic/about-wic-wics-mission
scorecard on rates of hospital-acquired conditions 2010 to 2015: Accessed June 27, 2017.
interim data from national efforts to make health care safer. December
2016. Agency for Healthcare Research and Quality, Rockville, MD.
http://bit.ly/2iEXvlP Accessed June 27, 2017.
123. US Department of Agriculture Food and Nutrition Service Office 136. Health Resources and Services Administration (HRSA),
of Policy Support. WIC participant and program characteristics final National Center for Health Workforce Analysis, US Department of
report. 2015. https://fns-prod.azureedge.net/sites/default/files/ops/ Health and Human Services. Projecting the supply and demand for
WICPC2014.pdf Accessed June 27, 2017. primary care practitioners through 2020. 2013. http://bit.ly/2tRGN88
Women, Infants and Children (WIC). Final Rule: Revisions in the WIC 137. Boullata J, Mirtallo JM, Guenter P. A parenteral nutrition
Food Packages. 2016. http://bit.ly/2ukbVzn Accessed June 27, 2017. use survey with gap analysis. JPEN J Parenter Enteral Nutr.
2013;37(2):212-222.
125. Patlan, K. L. & Mendelson, M. (2016). WIC participant and
program characteristics 2014: food package report. Prepared by Insight 138. Centers for Medicare & Medicaid Services. 42 CFR Parts 413, 416,
Policy Research under Contract No. AG‐3198‐C‐11‐0010. Alexandria, 440, 442, 482, 483, 485, 486, 488, 491, and 493 [CMS–3267–F] RIN
VA: US Department of Agriculture, Food and Nutrition Service. 2016. 0938–AR49 Medicare and Medicaid Programs; Regulatory Provisions to
http://bit.ly/2uoBgcD Accessed July 5, 2017. Promote Program Efficiency, Transparency, and Burden Reduction; Part
II. Fed Regist. 2014;79(91):27106-27157.
WIC policy memorandum #2015-07 Medicaid primary payer for 139. Centers for Medicare & Medicaid Services. 42 CFR Parts 405,
exempt infant formulas and medical foods. 2015. http://bit.ly/2sVrSIS 431, 447, 482, 483, 485, 488, and 489 [CMS–3260–F] RIN 0938–AR61
Accessed June 28, 2017. Medicare and Medicaid programs; reform of requirements for long-
term care facilities. ACTION: Final rule. 10/04/2016 Fed Regist. 2016;81
127. Guenter P, Lyman B. ENFit enteral nutrition connectors. Nutr Clin (192):68688-68872. http://bit.ly/2ukbdSV Accessed June 27,2017.
Pract. 2016 Dec;31(6):769-772.
140. Academy of Nutrition and Dietetics. Consumer Protection and
128. Martin K, Gardner G. Home enteral nutrition: Updates, trends, Licensure. 2016. http://bit.ly/2uk3W5s Accessed June 27, 2017.
and challenges. Nutr Clin Pract. 2017 doi: 10.1177/0884533617701401
Published April 24, 2017. 141. Soeters PB, Reijven PL, van Bokhorst-de van der Schueren
MA, et al. A rational approach to nutritional assessment. Clin Nutr.
129. Johnson TW, Spurlock A, Pierce L. Survey study assessing attitudes 2008;27(5):706-716.
and experiences of pediatric registered dietitians regarding blended food
by gastrostomy tube feeding. Nutr Clin Pract. 2015;30(3):402-405 142. America Health Care Association (AHCA). 2013 Quality Report.
2013. http://bit.ly/2sVKRD0 Accessed June 27, 2017.
130. Pentiuk S, O’Flaherty T, Santoro K, Willging P, Kaul A. Pureed by
gastrostomy tube diet improves gagging and retching in children with
fundoplication. JPEN J Parenter Enteral Nutr. 2011;35(3):375-379. Acknowledgements
131. Hurt RT, Varayil JE, Epp LM, et al. Blenderized tube feeding use in ASPEN would like to thank Karen Allen, MD, from the
adult home enteral nutrition patients: a cross-sectional study. Nutr Clin University of Oklahoma Medical Center and member of the
Pract. 2015;30(6):824-829.
ASPEN Clinical Practice Committee for submission of the
survey protocol for review to the University of Oklahoma Insti-
132. Bobo E. Reemergence of blenderized tube feedings: exploring the
tutional Review Board, to the members of the ASPEN Clinical
evidence. Nutr Clin Pract. 2016;31(6):730-735.
Practice Committee for their assistance in the development of
133. McGowan D. Real Food Blends partners on national distribution. the ASPEN EN Survey, to the American Medical Rehabilita-
Inside Indiana Business. June 13, 2017. http://bit.ly/2t8MlhG tion Providers Association (AMPRA) as a contributor to this
Accessed June 27, 2017. data, to the Kaiser Family Foundation for their permission to
use Figure 24, and to the report reviewers for their thoughtful
134. Chopy K, Winkler M, Schwartz-Barcott D, Melanson K, Greene G. counsel on the content of this document.
A qualitative study of the perceived value of membership in The Oley
Foundation by home parenteral and enteral nutrition consumers. JPEN J
135. Salsberg, E. The nurse practitioner, physician assistant, and

pharmacist pipelines: continued growth. Health Affairs Blog May 26,
2015 http://bit.ly/2uX0tb7 Accessed June 27, 2017.

Tables
TABLE A
Discharge Status for Hospital Discharges 2014 National Statistics

Against
Total number of In-hospital Routine Another short- Another medical advice
Age group Home health care
discharges deaths discharge term hospital institutiona and missing
discharge
All discharges 35,358,818 (100%) 671,800 (1.90%) 24,652,748 703,140 (1.99%) 4,909,462 4,017,102 390,940 (1.11%)
(13.88%) (11.36%)
Less than 1 year 4,247,755 15,665 (0.37%) 4,051,750 76,245 7,885 (0.19%) 93,755 (2.21%) 1,870 (0.44%)
(12.01%) (95.39%)
1-17 years 1,347,359 (3.81%) 4,140 (0.31%) 1,253,729 19,190 29,930 (2.22%) 37,180 (2.76%) 2,865 (0.22%)
(93.05%)
18-44 years 8,714,895 35,435 (0.41%) 7,839,275 98,320 (1.13%) 246,205 (2.83%) 323,640 (3.71%) 170,660 (1.96%)
(24.65%)
45-64 years 8,709,298 156,820 (1.80%) 6,079,847 203,820 (2.34%) 950,675 (10.92%) 1,158,381 156,825 (1.80%)
(24.63%) (69.81%) (13.30%)
65-84 years 9,490,054 305,825 (3.22%) 4,641,467 249,385 2,408,266 1,828,736 51,340 (0.54%)
(26.84%) (48.91%) (25.38%) (19.27%)
85 years and older 2,837,716 (8.03%) 153,785 (5.42%) 775,860 (27.34%) 55,915 (1.97%) 1,266,221 575,190 (20.27%) 7,360 (0.25%)
(44.62%)
Missing age 11,740 (0.03%) 130 (1.11%) 10,820 (92.16%) 265 (2.26%) 280 (2.39%) 220 (1.87%) 35 (0.30%)
a
includes nursing homes, inpatient rehabilitation facilities, and long-term acute care hospitals Data from AHRQ HCUP NIS1
TABLE B
Prevalence of Clinical Measures in Nursing Home Residents by Age, by Percent, 2014

Age Group (Years) Total 0-21 22-30 31-64 65-74 75-84 85-94 95+
Total Number of Residents 1,406,203 2,758 4,509 210,655 232,077 371,295 475,050 109,859
by Age
Percent 100% 0.02% 0.30% 15.00% 16.50% 26.40% 33.80% 7.80%
CLINICAL MEASURE
Feeding Tube (5.4% – All Residents)
Number 76,089 2,005 1,560.11 22,540 15,781 18,193 14,252 1,758
Percent 72.7% 34.6% 10.7% 6.8% 4.9% 3.0% 1.6%
Unintended Weight Loss (5.4% – All Residents)
Number 75,747 88 189 9,269 12,068 20,793 27,078 6,262
Percent 3.2% 4.2% 4.4% 5.2% 5.6% 5.7% 5.7%
Pressure Ulcers (5.1% – All Residents)
Number 71,709 110 433 13,693 13,460 18,936 20,902 4,175
Percent 4% 9.6% 6.5% 5.8% 5.1% 4.4% 3.8%
Nursing Home Data Compendium 2015 Edition, Centers for Medicare and Medicaid Services13
TABLE C
Health Care Settings, Enteral Nutrition Coverage and Payer Policies

Setting Definition of Care Setting How Enteral Nutrition is Covered
Acute Care Provides treatment for a severe injury or episode of illness, an Medicare reimburses hospitals a lump sum based on the pa-
urgent medical condition, or during recovery from surgery. Care tient's Diagnostic Related Group or DRG. If the hospital provides
for acute health conditions is the opposite from chronic care, or more services or the patient's stay is longer than expected, the
longer term care. Hospital-based acute inpatient care typically hospital stands to lose money. If the patient’s stay is shorter
has the goal of discharging patients as soon as they are deemed than expected, the hospital receives the same amount of money
healthy and stable to their home or to a lower level of institution- and stands to come out ahead. Many payers mimic Medicare's
al care, such as LTCH, IRF, NH. model for payment. Some private payers may negotiate a rate
with the hospital. EN is not directly reimbursed but is covered
under the DRG or other negotiated payment arrangements.
Long Term Acute Hospital (LTCH) Transitional care hospitals provide long-term acute care to Stay is paid similar to Acute Care payment system. No explicit
patients who continue to be medically complex and require an payment for EN specifically.
extended stay in a hospital setting.
Inpatient Rehabilitation Facility (IRF) IRFs provide intensive rehabilitation services (such as physical Stay is paid similar to Acute Care payment system. No explicit
or occupational therapy, rehabilitative nursing, speech language payment for EN specifically.
pathology, prosthetic or orthotic devices) after injury, illness or
surgery. Medicare requires that beneficiary actively participates
and benefits from therapy in order to qualify for this level of care.
Nursing Home (Skilled Nursing and Custodial Care) Within the walls of a “Nursing Home” there may be patients Similar to Acute Care, Medicare Part A reimburses Skilled
who are considered skilled nursing residents and those who are Nursing Facilities a lump sum based on the acuity of the patient
there for custodial care. SNF residents are covered by Medicare for up to 100 days if the conditions of participation are met.11 If
(Part A) for a period of time if the stay is deemed medically there is a continued medical need for tube feeding beyond the
necessary to improve or to maintain the quality of health of first 100 days, the therapy may be covered by Medicare Part B
patients or to slow the deterioration of a patient’s condition. under the prosthetic device benefit to qualified beneficiaries.
Custodial care is the provision of services and supplies http://bit.ly/2uXaO6F State Medicaid programs cover nursing
for activities of daily living that can be provided safely and home services for all eligible beneficiaries and pay a monthly
reasonably by individuals who may not be skilled nor licensed lump sum.11
medical personnel.10
Home Care For the purpose of this report, the term “Home Care” refers to Medicare Part B covers EN supplies and equipment (feeding
the non-institutionalized setting in that the individual resides pump) under the prosthetic device benefit to qualified benefi-
in their own home, group home, board and care, assisted living ciaries in the home care setting as well as in NHs (see above).12
facility. These individuals may or may not be receiving “home Coverage by state Medicaid, WIC, and private insurance vary
health care services” since receiving EN does not necessarily by plan.55,56
justify the need for home health services. In most cases patients
who reside in this setting receive their formulas/supplies from a
Durable Medical Supply (DME) company or Infusion company.
They self administer, or with the assistance of a family member,
administer their own feedings.

TABLE D
EN Payer Mix per Healthcare Setting

HEALTHCARE SETTING
Insurance Type Acute Carea Nursing Homeb Home Carec LTCHd IRFe
Medicare 46.8% 14.2% 24% 54.6% 58.8%
Medicaid 24.2% 63.5% 31% 18.8% 8.4%
Private/Commercial 23.7% -- 40% 22.8% 12%

Insurance
Other/Self Pay 5.3% 22.3% contains private 5% 10.2% 18.4%

as well
DATA SOURCES:
a
HCUP NIS1
b
Payer mix for NH is all patients, not just those on EN142
c
NHIA data
d
Some had more than 1 type of coverage23, 24
e
Listed as top 10 types of coverage25
TABLE E
ASPEN Clinical Practice Committee Enteral Nutrition Survey January-February 2017

Q1. Do you care for patients who receive EN?
❑ Yes ❑ No
Q2. Do you primarily care for patients as? (select one)
❑ Inpatients in acute care hospitals ❑ Patients in home setting or clinic/ambulatory setting

❑ Inpatients in long-term acute care hospitals (LTCHs) ❑ Both acute care and home care/ambulatory
Inpatient, acute care hospital, or long-term acute care hospital settings
Q3. Bed size of your hospital?
❑ Less than 100 beds ❑ 251-500 beds

❑ 100-250 beds ❑ More than 500 beds
Q4. Current census as a percent of total
Q5. How many inpatients in your facility are currently receiving EN?
Q6. What percentage of EN patients are?
Adult patients %
Pediatric patients %
Neonatal patients %
Q7. What percentage of all EN patients have?
Short-term nasogastric tubes %
Short term nasoenteric (post-pyloric) tubes %
Gastrostomy tubes %
Jejunostomy tubes %
Q8. Insert the number of patients in your institution receiving each type of EN formula
Standard Intact Nutrient Formulas
Blenderized Tube Feeding
Hydrolyzed Protein/Amino Acid Formulas
Disease Specific Formulas
Metabolic Formulas for Inherited Disease of Metabolism
Q9. Of those patients receiving specific types of formulas, what percent are adult patients (with the remaining percent being
pediatric/neonatal)?
Standard Intact Nutrient Formulas %
Blenderized Tube Feeding %
Hydrolyzed Protein/Amino Acid Formulas %
Disease Specific Formulas %
Metabolic Formulas for Inherited Disease of Metabolism %
Q10. Percent of all enteral patients who are prescribed modular nutrients?
Q11. For adult patients, what is the use of open vs. closed feeding systems?
Open system %
Closed system %

Q12. For pediatric patients, what is the use of open vs. closed feeding systems?
Open system %
Closed system %
Q13. For neonatal patients, what is the use of open vs. closed feeding systems?
Open system %
Closed system %
Q14. For adult patients, how is enteral nutrition being administered in your facility?
Continuous feedings via a pump %
Intermittent feedings via a pump %
Bolus or intermittent feedings via gravity or syringe %
Q15. For pediatric patients, how is enteral nutrition being administered in your facility?
Q16. For neonatal patients, how is enteral nutrition being administered in your facility?
Q17. How is enteral water being administered in your facility? (select only one)
❑ Manual syringe method ❑ Combination of manual syringe/automatic pump

❑ Automatic pump method ❑ Combination of manual syringe/manually via a feeding bag
❑ Via the feeding bag (manually)
Q18. What percentage of these inhouse patients go home with EN?
Home patients/Ambulatory care or clinic
Q19. Are you reporting data based on?
❑ Branch level ❑ National level

❑ Regional level ❑ Hospital or medical center based home care system level
Q20. How many EN patients on your service?
❑ EN only ❑ EN and PN
Q21. What percentage of EN patients are?
Adult patients %
Pediatric patients %
Neonatal patients %
Q22. What percentage of all EN patients have?
Short-term nasogastric tubes %
Short term nasoenteric (post-pyloric) tubes %
Gastrostomy tubes %
Gastrojejunostomy tubes %
Jejunostomy tubes %
Q23. Please insert the number of patients on your service receiving each type of EN formula:
Standard Intact Nutrient Formulas
Blenderized Tube Feeding
Hydrolyzed Protein/Amino Acid Formulas
Disease Specific Formulas
Metabolic Formulas for Inherited Disease of Metabolism

Q24. Of those patients receiving specific types of formulas, what percent are adult patients (with the remaining percent being
pediatric/neonatal)?
Standard Intact Nutrient Formulas %
Blenderized Tube Feeding %
Hydrolyzed Protein/Amino Acid Formulas %
Disease Specific Formulas %
Metabolic Formulas for Inherited Disease of Metabolism %
Q25. What percentage the use of open vs. closed feeding systems?
Open system %
Closed system %
Q26. How is enteral nutrition being administered in your home patients?
TABLE F
ICD-9-CM Diagnosis Codes for Malnutrition Used in HCUP Data Analysis
ICD-9-CM
Description
Diagnosis Codes
Postsurgical nonabsorption
579.3 Other and unspecified postsurgical nonabsorption
Nutritional neglect
995.52 Child neglect (nutritional)
995.84 Adult neglect (nutritional)
Cachexia
799.4 Cachexia
Protein-calorie malnutrition
260 Kwashiorkor
261 Nutritional marasmus
262 Other severe protein-calorie malnutrition
263.0 Malnutrition of moderate degree
263.13 Malnutrition of mild degree
263.2 Arrested development following protein-calorie malnutrition
263.8 Other protein-calorie malnutrition
263.9 Unspecified protein-calorie malnutrition
Weight loss, failure to thrive
783.21 Loss of weight
783.3 Feeding difficulties and mismanagement
783.41 Failure to thrive (child)
783.7 Adult failure to thrive
Underweight
783.22 Underweight
V85.0 Body mass index less than 19, adult
V85.51 Body mass index, pediatric, less than 5th percentile for age

SOURCE: HCUP Statistical Brief #210 93

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ASPEN Enteral Nutrition by The Numbers EN Data Across The Health

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ASPEN Enteral Nutrition by The Numbers EN Data Across The Health

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ASPEN Enteral Nutrition

Peggi Guenter, PhD, RN, FAAN, FASPEN

American Society for Parenteral and Enteral Nutrition

All rights reserved. No part of this publication may be reproduced, stored in

Market Drivers, Trends, and Challenges ������������������������������������������������������ 50

Opportunity for Future Research �������������������������������������������������������������������������� 60

1. Healthcare setting: Incorporating information

2. Product type and delivery methods: Accounting

3. Malnutrition and EN: Providing information collected in

Enteral Nutrition Use Process

Prescribe an Review the

Monitor and Administer

2 © 2017 ASPEN www.nutritioncare.org

2. Discuss the data findings in the context of current nutrition

Discharge Status for Hospitalized Patients 2014

4 © 2017 ASPEN www.nutritioncare.org

Discharge Status for Pediatric Hospitalized Patients 2014

In-hospital Deaths 0.3%

Discharge Status for Hospitalized Older Adults 2014

In-hospital Deaths 3.7%

6 © 2017 ASPEN www.nutritioncare.org

8 © 2017 ASPEN www.nutritioncare.org

Description of HCPCS Codes for Formula Categories and Enteral Supplies

B4081 Nasogastric tubing with stylet

B4082 Nasogastric tubing without stylet

B4083 Stomach tube - levine type

B4087 Gastrostomy/jejunostomy tube, standard, any material, any type, each

B4088 Gastrostomy/jejunostomy tube, low-profile, any material, any type, each

B9000 Enteral nutrition infusion pump - without alarm

B9002 Enteral nutrition infusion pump - with alarm

10 © 2017 ASPEN www.nutritioncare.org

Segmentation by Healthcare Setting

Enteral Nutrition Data by Healthcare Setting for 2014

Number of Facilities/ 4,926a 15,640b Total Number Unknown 391d 1,180d

Number of Beds 786,874a 1,663,000b NA 27,000d NA

Percentage of Beds NA 82.4%b NA NA 64d

Patients/Discharges 255,140 e 75,936b 437,882g 72,360h 13,125i

Patients on EN in Acute Care Hospitals in 2014

SOURCE: HCUP National In-Patient Samples 20141

12 © 2017 ASPEN www.nutritioncare.org

Number of Hospital Discharges Where EN Was Coded 1993-2014

Use of EN as a Percentage of Total Hospital Discharges in the US from 1993-2014

Comparison of Discharges with EN with All Discharges by Age Group

Percent of hospital discharges Percent of EN patients

SOURCE: HCUP NIS1

EN Use as a Percent of Total Discharges in That Age Group Over Time

Peds % of total EN Older Ad % of total EN

SOURCE: HCUP NIS1

14 © 2017 ASPEN www.nutritioncare.org

EN Use as a Percent of Total Discharges in That Age Group Over Time

Peds-EN as % of discharges Older Ad-EN as % of discharges

SOURCE: HCUP NIS1

Infants on EN in Acute Care Hospitals Over Time

SOURCE: HCUP NIS1

Acute Care Hospital Data from the Literature

Summary of EN by Type of Patient in Acute Care Hospitals from the Literature

16 © 2017 ASPEN www.nutritioncare.org

Literature on Acute Care EN by Individual Studies

Adult Acutely Ill Patients

Studies Containing ICU and non-ICU Patients

18 © 2017 ASPEN www.nutritioncare.org

Pediatric and Neonatal Acute Care Hospitalized Patients

Neonatal ICU (NICU)

Market Drivers, Trends, and Challenges �� 50

Opportunity for Future Research �� 60