Healthcare costs associated with percutaneous endoscopic gastrostomy among older adults in a defined community.

OBJECTIVES: The effectiveness of percutaneous endoscopic gastrostomy (PEG) in older adults remains controversial. Although prior studies have examined the safety of PEG and its impact on nutrition, there are limited data on the economic costs. The purpose of this study is to describe the healthcare costs associated with PEG tube feeding over 1 year. DESIGN: Prospective cohort study. SETTING: Small community of approximately 60,000 residents served by two hospital systems. PARTICIPANTS: One hundred five (70%) of 150 patients age 60 and older receiving PEG over a 24-month period in the targeted community who permitted access to their medical records. MEASUREMENTS: Patients were interviewed at baseline and every 2 months for 1 year to obtain information on use of enteral formula, complication rates, and health services use. We obtained inpatient charge data for all hospitalizations and PEG procedures for 1 year. RESULTS: Censoring patients at death or 1 year post-PEG, the mean number of days of PEG tube feeding was 180 (range 5-365). The average cost for PEG tube feeding for this cohort of patients was $7,488 (median $3,691) in 1997 and 1998. The average daily cost of PEG tube feeding was $87.21 (median $33.50). The estimated cost of providing 1 year of feeding via PEG is $31,832 (median $12,227). The main components of this cost include the initial PEG procedure (29.4%), enteral formula (24.9%), and hospital charges for major complications (33.4%). CONCLUSIONS: Direct charges associated with PEG tube feeding over 1 year are conservatively estimated at $31,832; there was considerable variation in charges because of the cost of rare but costly major complications. Also, feeding patients via PEG resulted in cost shifts in terms of the primary payor. The economic cost of PEG tube feeding is another consideration in decision making for long-term enteral feeding among older adults.

Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) has become the preferred method to provide enteral tube feeding to older adults who have difficulty eating, but the impact of PEG on patient outcomes is poorly understood. The objective of this study was to describe changes in nutrition, functional status, and health-related quality of life among older adults receiving PEG. DESIGN: A prospective cohort study. SETTING: A small community of approximately 60,000 residents served by two hospital systems. PARTICIPANTS: One hundred fifty patients aged 60 and older receiving PEG from one of the four gastroenterologists practicing in the targeted community. MEASUREMENTS: Patients were assessed at baseline and every 2 months for 1 year to obtain clinical characteristics, process of care data, physical and cognitive function, subjective health status, nutritional status, complications, and mortality. RESULTS: Over a 14-month period, 150 patients received PEG tubes in the targeted community; the mean age was 78.9. The most frequent indications for the PEG were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%). All measures of functional status, cognitive status, severity of illness, comorbidity, and quality of life demonstrated profound and life-threatening impairment; 30-day mortality was 22% and 1-year mortality was 50%. Among patients surviving 60 days or more, at least 70% had no significant improvement in functional, nutritional, or subjective health status. Serious complications were rare, but most patients experienced symptomatic problems that they attributed to the enteral tube feeding. CONCLUSIONS: PEG tube feeding in severely and chronically ill older adults can be accomplished safely. However, there are important patient burdens associated with the PEG and there was limited evidence that the procedure improves functional, nutritional, or subjective health status in this cohort of older adults. The issues raised in this descriptive study provide impetus for a randomized trial of PEG tube feeding compared with alternative methods of patient care for older adults with difficulty eating.

Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting.

OBJECTIVE: To describe clinical decision-making for percutaneous endoscopic gastrostomy from the perspective of patients, caregivers, and physicians. DESIGN: A prospective cohort study. SETTING AND PATIENTS: All patients aged 60 and older receiving percutaneous endoscopic gastrostomies in a defined community over a 16-month period. MAIN OUTCOMES MEASURES: Either patients or their surrogate decision-makers completed a semistructured face-to-face interview to map out the information gathering process, expectations, and discussants involved in the decision to proceed with gastrostomy feeding. Physicians completed a written questionnaire to determine their likelihood of recommending percutaneous endoscopic gastrostomy, their involvement in the decision-making and recommendation process, and sources of perceived pressure in the decision-making. RESULTS: We identified 100 patients who received percutaneous endoscopic gastrostomy during the study window and 82 primary care physicians who provided care in the defined community. The most common reasons for the procedure were stroke, neurologic disease, and cancer. Patients or their surrogate decision-makers reported multiple discussants, incomplete information, and considerable distress in arriving at the decision to proceed with artificial feeding. This distress was usually in the context of an acute and debilitating illness that often overshadowed the decision about artificial feeding. The decision for gastrostomy often appeared to be a "non-decision" in the sense that decision-makers perceived few alternatives. Physicians also reported considerable distress in arriving at recommendations to proceed with percutaneous endoscopic gastrostomy, including perceived pressures from families or other healthcare professionals. Physicians have clear patterns of triage for percutaneous endoscopic gastrostomy, but the assumptions underlying these patterns are not well supported by the medical literature. CONCLUSIONS: Patients, caregivers, and physicians are often compelled to make decisions about long-term enteral feeding under tragic circumstances and with incomplete information. Decision-makers typically do not perceive any acceptable alternatives. Because data on these patients' long-term functional outcomes are lacking, decision-makers appear to focus primarily on the short-term safety of the procedure and the potential for improved nutrition.