BANS Report 2011 - Executive Summary

“The BANS committee wish to thank all Reporters for submitting their data for this year’s Annual Report. Although fewer centres have reported this year, we have more complete datasets from each of those centres which means that overall our reporting figures are up. I wish to add my own personal thanks to all members of the multi-disciplinary BANS Committee and to the lead authors and contributors to the various sections of the BANS Report. The BANS Report 2011 and the Executive Summary are freely available to download from the BAPEN website.”

Dr Trevor Smith
Chair of BANS, Standing Committee of BAPEN

Adult HETF (lead author Dr Rebecca Stratton)

  1. Since 2009 new registrations of adults receiving home enteral tube feeding (HETF) increased by 5% to 3430 in 2010. Point and period prevalence increased by 36% and 21% respectively. The number of new reporting centres decreased to 121 in 2010 (-18%).
  2. The number of new registrations per million of the population was 55 in the UK; it was remarkably higher in Northern Ireland (112) and the Isle of Man (167) than in the other UK constituent countries.
  3. The proportion of newly registered HETF patients with cancer (predominantly head and neck cancer) continues to gradually increase (from 25% in 2000 to 39% in 2010).
  4. Most (63%) HETF new registrations in 2010 were aged over 60 years, with 41% over 70 years (decreased by 11% from 2000).
  5. From 2000 to 2010, there was an increase in patients who were fully active (from 17% to 40%); independently living (from 21% to 40%); and living in their own home (from 56% to 69%).
  6. The two main reasons for patients registered with BANS starting HETF were ‘swallowing disorders’ (65%) and ‘to improve nutritional status’ (27%).
  7. Gastrostomy was the primary route of feeding (75%), as it has been over the last ten years.
  8. Home care companies supplied 86% of newly registered adult HETF patients in 2010, a decrease of 3% compared with 2009.
  9. At the end of the year, 71% of the patients continued on HETF, 6% returned to oral feeding and 12% of the patients died (predominantly due to the underlying disease).

Children’s HETF (lead author Amanda Hirst)

  1. In 2010, 448 new children were registered and 1336 were updated (period prevalence). Despite the shortfall of data this is a large cohort of representative patients.
  2. In 2007, 137 centres registered new children; by 2010 this had dropped by 60% to 55.
  3. The decline of reporting centres was seen across all UK constituent countries, showing a fall in new registrations over a 10 year period: England (-60%), Scotland (-86%), Northern Ireland (-50%), Wales (- 85%).
  4. In 2010, 69% of all newly registered children were less than 2 years old and 80% were 5 years or under. The overall trend over 10 years is that more children are receiving HETF at a younger age.
  5. Over the period 2000 to 2010, the proportion of new children with cancer requiring HETF fluctuated between 6.2% and 11%, whilst the number with CNS & mental health conditions (30%) and non-malignant GI disorders (~14%) were relatively stable.
  6. The ‘other conditions’ category, which includes congenital cardiac conditions, respiratory disease and faltering growth, (conditions that correspond with the higher percentage of younger children registered) increased to 49%.During 2010, 63% of new registrations were fed via a naso-gastric tube - this in stark contrast to just 17% of adults being fed this way.
  7. In 2010 only 2 out of 448 new children registered lived elsewhere other than their own home thus indicating that home is a viable discharge location for children receiving HETF.
  8. By 2010 the use of Home Care Companies to provide feeds and equipment to new children had grown to 88% from only 62% in 2000.
  9. Of the 1336 children reported on e- bans during 2010, 1148 (86%) continued on home enteral feeding, 74 (5.5%) returned to oral feeding, 23 (2%) died and 57 (5%) were lost to follow up or transferred to other centres.

Adult HPN (lead author Dr Trevor Smith)

  1. New adult HPN registrations increased during 2010 – 228 patients compared to 148 in 2009 and 157 in 2008. Point and period prevalence increased to 523 and 624 cases respectively. This represents a significant increase in reporting rates following the difficulties that were encountered with consent during 2008 and 2009 (described in 2009 and 2010 BANS reports).
  2. The number of centres registering new patients reduced from 27 in 2009 to 21 in 2010; the number of centres updating existing patients reduced from 35 in 2009 to 25 in 2010. These data suggest that fewer centres are managing larger number of HPN patients.
  3. The reported UK HPN point prevalence was 8.40 per million and period prevalence 10.02 per million. These are significant lower than data reported in 2007 (although higher than 2009) and are due to under-reporting rather than a true reduction in HPN prevalence. These data therefore need to be interpreted very cautiously.
  4. New registrations in England during 2010 increased to 196 patients (125 patients in 2009); new patient registrations grew by 69% compared to 2007 and 133% compared to 2006. Point and period prevalence increased to 413 and 506 patients respectively.
  5. New registrations in Scotland increased to 16 patients (6 patients in 2009). Point and period prevalence increased to 59 and 67 patients respectively.
  6. Welsh point and period prevalence was 23 patients; only 7 new HPN patients were reported to BANS. These low figures are due to significant under-reporting rather than an actual low prevalence of HPN in Wales.
  7. Reporting in Northern Ireland has improved considerably and should be considered complete. The point and period prevalence were both 15.56 per million population.
  8. The modal age for adult HPN is 51 – 60 years of age.
  9. Short bowel syndrome remains the main reason for HPN (54.4% new cases; 58.9% established cases).
  10. Crohns disease, small bowel ischaemia and pseudo-obstruction remain the major indications for new registrations (18.4%, 9.7% and 11% respectively) and established cases (29.3%, 15.3% and 15.1%). A substantial heterogeneous group including complex surgical problems accounts for 11.4% of new cases and 9.75% of point prevalence.
  11. The percentage of newly registered patients initially placed in a nursing home has remained very small (1.1% and 0.4% in 2000 and 2010 respectively) despite a rise to 10.1% in 2007. The vast majority of patients are discharged to their own home.
  12. Although a minority of new cases are described as house or bed bound (5.8%), 60.1% are described as fully independent, the remainder requiring assistance with their HPN.
  13. Venous access was via an external catheter in 98.7% and subcutaneous ports in 1.3%.
  14. Commercial homecare companies provided for all new patients in 2010; their contribution to point prevalence has been steadily rising from 70.6% in 2000 to 94% in 2010.
  15. 83.8% patients were still on HPN at the end of the year but only 7.5% had reverted to oral nutrition. 1.4% were in hospital, 3% were transferred to other centres (and no further outcome data were available) and the mortality rate was 6.6%.

Independently acquired data (lead author Dr Janet Baxter)

  1. The BANS objective to collect 100% of Home Artificial Nutrition patients has been tested once again by obtaining anonymous data from the commercial homecare companies. Using these data we have estimated the total number of cases whether receiving commercial homecare company support or not.
  2. For adult HPN, reporters returned 46.5% of the total estimated cases. This reflects the significant reduction in reporting since 2008, although there are encouraging signs of recovery since the re-launch of e-BANS in 2010.
  3. For paediatric HPN, BANS surveys only 10% of UK cases; the numbers were too small to formally publish in this year’s BANS report.
  4. Adult HETF returns were 18% of estimated cases.
  5. Paediatric HETF attracts only 7% of estimated cases.
  6. The significant reduction in reporting rates continues to pose a challenge for BANS; e-BANS was re-launched in July 2010 without the need for patients to provide consent. This has been approved by the National Information Governance Board (NIGB) and will help secure BANS’ future as the leading nutritional survey of its kind internationally.

Home enteral tube feeding for Head & Neck cancer patients: A national survey. (lead author Sarah Sharp, University Hospital Southampton)

  • Only 18 Cancer Centres (51.4%) had specific Dietetic funding for HNC patients.
  • Dietetic funding for HNC patients varies from 0.3 WTE – 5.0 WTE per cancer centre.
  • In total only 15 Cancer Centres (42.8%) report HNC patients to BANS.
  • Just over half (51.4%) of Cancer Centres have a local pathway for enteral tube feeding HNC radiotherapy patients.
  • There is currently no national pathway for enteral tube feeding HNC radiotherapy patients.
  • 77.1% of Cancer Centres place a feeding tube prophylactically in HNC patients (1 Centre (2.9%) uses NG tubes, 9 (25.7%) use RIG tubes and 17 (48.6%) use PEG tubes).
  • The most common factors used to determine if patients will automatically require tube feeding were cancer site (34.3%), radiotherapy treatment field (45.7%) and those who become malnourished during treatment (37.1%).
  • Only 25.9% of Cancer Centres use MUST to identify malnutrition pre-treatment, 17.9% during treatment and 15.4% after treatment.
  • Other tools and parameters used to identify malnutrition risk include BMI, percentage weight loss, ability to swallow, a local nutrition screening tool, weight, biochemistry, Dietetic assessment, diet history and clinical judgement.