Instructions, contraindications, and rules for reimbursement of nutritional therapy costs

Nutritional support is a crucial aspect of therapy aimed at improving and maintaining the patient's nutritional status, enhancing prognosis, and accelerating recovery. It can be administered enterally (to the stomach or small intestine) and parenterally (intravenously), providing all necessary nutrients in quantities that meet the patient's current needs, who is unable to feed normally (orally) or whose nutritional intake is inadequate. It may be supplementary, addressing nutrient deficiencies due to insufficient natural feeding, or complete, covering 100% of the energy and nutritional requirements.

Clinical applications for nutritional therapy include: unintentional weight reduction exceeding 10 – 15% over the past 3 – 6 months, BMI below 17 kg/m², plasma albumin levels under 3.2 g/dl, prealbumin levels below 10.0 mg/dL, transferrin concentrations less than 150 mg/dl, CLL counts under 1000/mm³, and non-malnourished individuals facing a fasting period exceeding 7 days. The patient's clinical condition (the primary determinant) also justifies nutritional therapy. According to the ESPEN Guidelines on Enteral and Parenteral Nutrition (2006/2009), indications for nutritional therapy are based on two criteria: anticipated inability to initiate oral feeding within 7 days and existing or impending malnutrition. Inadequate oral intake for more than 14 days correlates with increased mortality, and nutritional therapy is also warranted for patients unable to sustain daily intake exceeding 60% of recommended levels for over 10 days. In such scenarios, nutritional support should commence promptly (enteral nutrition preferred when feasible). In intensive care settings, any patient unable to transition to full oral feeding within 3 days should receive early enteral nutrition.

There are specific circumstances under which nutritional therapy via the digestive tract is absolutely contraindicated. These include: mechanical or paralytic obstruction, shock, and patient refusal. The sole indication for extraintestinal treatment is the inability to administer appropriate nutritional therapy via the digestive tract that meets the patient's current needs. Contraindications for intraintestinal treatment include: diffuse peritonitis, mechanical and paralytic obstruction, severe diarrhea, unrelenting vomiting, gastrointestinal fistulas with significant fluid loss, disturbances in intestinal function, and shock.

Nutritional therapy reimbursement is available in various settings, including hospitals, homes, hospices, or outpatient treatment centers (ZOL). Exceptions include social care homes (no NFZ contract), rehabilitation units, and palliative care. In Poland, reimbursement is based on a uniform patient group system (PGP), where the NFZA covers costs for primary disease treatment and additional procedures (subject to the main procedure). Full reimbursement includes enteral nutrition therapy (up to 30 days via stoma) and parenteral nutrition (up to 15 days via central vein). To qualify for reimbursement, proper patient qualification (nutrition scale, qualification card), correct preparation of the mixture (qualification card + metabolic card), and regular monitoring (metabolic card) are required. Nutritional therapies are often vital, even life-saving, particularly for severely debilitated patients. Indications and contraindications should always be carefully considered in the context of the patient's condition. For patients discharged home but requiring ongoing nutritional therapy, NFZA reimbursement significantly reduces treatment costs.