National survey evaluating service provision for percutaneous endoscopic gastrostomy within the UK
ABSTRACT Percutaneous endoscopic gastrostomy (PEG) feeding has a significant morbidity and mortality associated with the procedure. Patient selection, procedural volume, timing of insertion and aftercare may have a direct bearing on mortality. We aimed to establish whether variation in PEG practice exists within the UK.
The British Society of Gastroenterology (BSG) approached all NHS hospitals providing an endoscopy service (n = 260). A custom designed web-based questionnaire was circulated.
The response rate was 83% (n = 215); 57% were Joint Advisory Group (JAG) accredited; 33% (70/215) of hospitals inserted more than 75 PEGs a year (4 hospitals inserting >150). Stroke and neurodegenerative conditions were the main indications for PEG insertion. However, 36% (77/215) of hospitals inserted PEGs for dementia. PEG insertion timings varied: 33% (72/215) had a strict policy of waiting more than 2 weeks from referral to insertion, 14% (30/215) performed immediately and 34% (74/215) determined the time delay depending on the underlying condition. Local guidelines for PEG insertion existed in 87% (186/215) of hospitals and 78% (168/215) had access to radiologically inserted gastrostomies. Prophylactic antibiotics were used in 93% (201/215) of hospitals. Only 64% (137/215) had a dedicated PEG aftercare service. This was significantly lower in non-JAG accredited units (p = 0.008).
This National BSG survey demonstrates variations in practice particularly with regards to PEG insertion in patients with dementia, the timing of PEG insertion and PEG aftercare. These variations in practice may be important factors accounting for the significant morbidity and mortality associated with this procedure.
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ABSTRACT: PEG is widely used; however, large-scale data for PEG have been lacking. To estimate the prevalence of placement of gastrostomy and jejunostomy tubes and to elucidate the patient background characteristics and their associations with in-hospital mortality. A retrospective analysis of the Japanese administrative claims database. Japanese acute-care hospitals. A total of 64,219 patients who underwent gastrostomy or jejunostomy tube insertion between July and December, 2007 to 2010, were identified among 11.6 million discharge records. Placement of gastrostomy and jejunostomy tubes. In-hospital mortality and the associated risk factors. The mean age was 77.4 years; >90% of patients were aged >60 years. Cerebrovascular disease and pneumonia were the most frequently recorded diagnoses, followed by neuromuscular disease and dementia. The estimated annual number of gastrostomy and jejunostomy placements in Japan ranged from 96,000 to 119,000. The in-hospital mortality was 11.9%, and the significantly associated risk factors were male sex, older age, placement of a jejunostomy tube, urgent admission, hospital with lower bed capacity, the presence of malignancy, miscellaneous diseases, pneumonia, heart failure, renal failure, chronic liver diseases, pressure sores and sepsis, and occurrence of peritonitis and/or GI perforation, GI hemorrhage, and intra-abdominal hemorrhage. Retrospective investigation of administrative database. Our large-scale data revealed the current status of gastrostomy tube placement in Japan. This can contribute to individual decision-making and the public consensus regarding artificial nutritional support in the elderly.Gastrointestinal endoscopy 01/2014; 80(1). DOI:10.1016/j.gie.2013.12.006 · 5.37 Impact Factor
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ABSTRACT: Background: The Japan Geriatrics Society published a guideline on the decision-making process for health care for the elderly in June 2012, noting that withholding or withdrawing feeding tubes are treatment options that should be discussed during the decision-making process. Arguments against the guideline posit that the insertion of a percutaneous endoscopic gastrostomy (PEG) tube feeding may improve quality of life (QOL) for elderly adults and their relatives. Objectives: The aim of the present study was to explore (a) expected outcomes with PEG tube placement and (b) outcomes from PEG tube feeding in long-term care settings among elderly adults with advanced dementia in Japan. Design: This study was conducted using a cross-sectional study design. Setting: A total of 381 hospitals and 985 long-term care facilities provided sets of completed questionnaires. Participants: There were 1 199 hospital patients and 2 160 long-term care patients aged 65 years or older with PEG tube placement included in the analysis. Measurements: The nurses or physicians at each hospital provided information on the level of dementia at the time of PEG tube placement and on the expected outcomes of PEG tube feeding for elderly hospital patients. The nurses or other direct care workers at each facility provided information on the level of dementia and outcomes from PEG tube feeding for the long-term care patients. Results: In the hospital patient group, 62.9% of patients had advanced dementia. PEG tube feeding was expected to prolong survival for 51.1% of hospital patients with advanced dementia. Improved QOL was expected for 39.1% of them. In the long-term care patient group, 61.7% of patients had advanced dementia. The rate of patients enjoying their own lives was lower in long-term care patients who had advanced dementia (4.2%) than in the other patients (16.4%). Approximately 60% of relatives reported satisfaction with the QOL of the patients, both in the long-term care patients with advanced dementia and the other patients. Conclusion: Our results question the assumption that PEG tube feeding may improve QOL among elderly adults with advanced dementia. The national health policy should explore an approach to help patients, relatives, and practitioners make decisions about feeding options.The Journal of Nutrition Health and Aging 05/2014; 18(5):503-509. DOI:10.1007/s12603-014-0011-9 · 3.00 Impact Factor
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ABSTRACT: This study aimed to evaluate the survival rate, pneumonia incidence, and hospital admissions among elderly patients with advanced dementia and to compare these outcomes between patients receiving enteral and oral nutrition. An observational, prospective, non-randomized, and unblinded study, with a minimum follow up of 6 months. Inpatient wards as well as ambulatory and emergency units run by a Brazilian university. Dysphagic elderly patients aged ≥60 years with advanced dementia (classified as at least 7A according to the Functional Assessment Staging [FAST]). Both patients with gastrostomies and nasogastric feeding tubes were included in the alternative feeding group. Following informed consent, a complete clinical examination was performed upon recruitment, and the primary caregiver was interviewed. Data concerning the major outcomes described above, as well as other demographic and clinical information, were recorded at admission and during follow-up phone calls. Survival analysis was performed using a Kaplan-Meier curve and a stepwise Cox regression analysis. Sixty-seven elderly patients were recruited: 36 (53,7%) for oral feeding and 31 for alternative feeding (n=28 nasogastric tube). Of these, 57 (85.1%) were classified as at least FAST 7C. They were, on average, 84.79 years old, mostly women (85.1%), and with a low level of education (2.9 years). Mortality at 3 months was 11.1% among the oral feeding group and 41.9% among the alternative feeding group (p=0.004). At 6 months, the mortality rate increased to 27.8% and 58.1%, respectively (p=0.012). The following variables persisted in the regression model at the end of the analysis: feeding route (p = .018; RR = 2.33; CI: 1.158-4.667), duration of dementia (p = .014; RR = .88; CI: .786-.974) and number of pressure ulcers (p = .007; RR = 1.250; CI: 1.063-1.470). A higher incidence of aspiration pneumonia was observed in the alternative feeding group (p=0.006), but no difference in the number of hospital admissions was detected between the groups (p=0.365). The use of alternative feeding, along with the number of pressure ulcers were associated with an increased risk of death in elderly patients with advanced dementia. A higher incidence of aspiration pneumonia was also observed in the alternative feeding group. The number of hospital admissions was not different between the feeding routes.The Journal of Nutrition Health and Aging 10/2014; 18(10):894-9. DOI:10.1007/s12603-014-0487-3 · 3.00 Impact Factor