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: Abstract Objective. Percutaneous endoscopic gastrostomy (PEG) is used for long-term enteral nutrition in neurological patients with dysphagia (NEUR), in head and neck cancer patients prior to chemoradiation therapy (head and neck malignancy group [HNM]), or in cases of oropharyngeal or esophageal tumor obstruction or stricture (OBSTR). Considerable morbidity and overall mortality is reported. Aim was to analyze the complication rates and mortality with PEG and to identify subgroups with poor outcomes. Material and methods. Patients underwent PEG (n = 401) in a single tertiary care center. Indications, characteristics, and causes of death were recorded. Results. Number of patients in groups: HNM 135 (34%), OBSTR 74 (18%), and NEUR 192 (48%); follow-up time median (interquartile range): 17 (39) months; the time PEG used for feeding: 4 (7) months. A total of 91 patients (23%) had 110 complications, 31 patients (8%) had early (≤30 days) complications, and 49 patients (12%) major complications. Two deaths (0.5%, 2 peritonitis) were related to PEG. The 30-day mortality was 11% (n = 47). According to multivariate analysis, an increased 30-day mortality was associated with ≥75 years of age, American Society of Anesthesiologists (ASA) class IV, a Charlson comorbidity index (CCI) ≥4, body mass index (BMI) <18.5, and ongoing antibiotic therapy. With this model, 95% specificity was obtained in the 30-day survival figures. Conclusion. The presented predictive model derived from our analysis may recognize patients with poor outcome when referred for PEG. The parameters in the present model (age, ASA class, CCI score, BMI, and data of ongoing antibiotic treatment) are easily measurable, and it is possible to integrate them into everyday work.Scandinavian Journal of Gastroenterology 12/2014; 50(2):1-8. · 2.33 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. · 2.39 Impact Factor
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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; · 4.90 Impact Factor