Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan

Komiya, Kosaku; Usagawa, Yuko; Kadota, Jun Ichi; Ikegami, Noaki

doi:10.1111/jgs.15386

Cited by 18 publications

(22 citation statements)

References 15 publications

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“…The general rule is that enteral feeding should be considered in patients with normal digestive function, whereas TPN should be used if enteral nutrition is not feasible [32,33]. Contrastingly, artificial nutrition for older patients with dysphagia can be a life-prolonging treatment [34–36]; therefore, especially in Japan, the choice of enteral versus parenteral nutrition is not only based on the digestive function of the patients but also on their clinical condition and the preferences of the patients and their family members [10,15,30,31]. This may result in selection bias and differences in the baseline characteristics of the PEG feeding and TPN study groups; therefore, we performed propensity score matching to adjust baseline characteristics to compare the effect of PEG feeding and TPN more accurately [16,26–28,31].…”

Section: Discussionmentioning

confidence: 99%

“…As a result, the general population in Japan has come to view PEG as being representative of unnecessary life-prolonging treatment [15], despite the fact that both PEG and TPN can be life-prolonging treatments [10]. PEG is generally avoided in older patients; hence, a greater number of older patients with dysphagia choose TPN instead of PEG feeding for long-term artificial nutrition [15]. The long-term outcomes of PEG feeding versus TPN in older patients with dysphagia have previously been poorly documented.…”

Section: Introductionmentioning

confidence: 99%

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Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Masaki

Kimura

2019

PLoS ONE

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BackgroundThe long-term outcomes of artificial nutrition in older people with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is one of the major methods of artificial nutrition. Enteral feeding is indicated for patients with a functional gastrointestinal tract. However, total parenteral nutrition (TPN) is often inappropriately chosen for artificial nutrition in Japan, even in patients with a functional gastrointestinal tract, as PEG has recently been viewed as an unnecessary life-prolonging treatment in Japan. This study aimed to compare the long-term outcomes between PEG and TPN.MethodsThis single-center retrospective cohort study investigated long-term outcomes in older patients with dysphagia who received PEG or TPN between January 2014 and January 2017. The primary outcome was survival time. Secondary outcomes were oral intake recovery, discharge to home, and the incidence of severe pneumonia and sepsis. We performed 1-to-1 propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox regression analysis were used to compare the survival time between groups.ResultsWe identified 253 patients who received PEG (n = 180) or TPN (n = 73). Older patients, those with lower nutritional states, and severe dementia were more likely to receive TPN. Propensity score matching created 55 pairs. Survival time was significantly longer in the PEG group (median, 317 vs 195 days; P = 0.017). The hazard ratio for PEG relative to TPN was 0.60 (95% confidence interval: 0.39–0.92; P = 0.019). There were no significant differences between the groups in oral intake recovery and discharge to home. The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 25.5%, P = 0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 30.9%, P = 0.018).ConclusionsPEG was associated with a significantly longer survival time, a higher incidence of severe pneumonia, and a lower incidence of sepsis compared with TPN.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Masaki

Kimura

2019

PLoS ONE

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“…We have noted several reasons to explain this trend. Primarily, physicians lack ample amount of time to explain the risks and bene ts to family members (as proxy decision makers), and also the mortality rates, side-effects, and harms [14,24] .…”

Section: Discussionmentioning

confidence: 99%

Racial and Socioeconomic Disparities in Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement among elderly patients with dementia in the United States from the National inpatient sample

Kochar

Abugroun

Nayyar

et al. 2020

Preprint

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Background Placement of percutaneous endoscopic gastrostomy (PEG) tube in patients of advanced dementia has not been shown to improve nutritional status or mortality. The objective is to assess racial and socioeconomic disparities for PEG tube placement from National Inpatient Sample. Methods In a cross-sectional study, the National inpatient sample (NIS) registry was queried for all patients aged ≥ 70 who were diagnosed with dementia during the year 2016. Patients with dementia were identified using the Tenth revision (ICD-10) codes (F0150, F0151, F0280, F0281, F0390, F0391, G300, G301, G308, G309, G3109, G3183). Patients who received PEG tube were identified using ICD-10 diagnosis codes (Z431). Multivariable logistic regression models were utilized to determine the likelihood of PEG tube placement with adjustment for Patients demographics, socioeconomic factors, degree of frailty and comorbidities. Results Out of 1,745,028 patients with dementia, 35,075 patients had PEG tube placed. Majority of patients who received PEG tube were females (54.8%), of white race (45.5%) with a mean age of 82.3 years (SEM 0.02). Compared to controls, those who had PEG tube placement were more frail, had higher prevalence of chronic lung disease, diabetes, stroke, psychosis and nutritional deficiency anemias. On multivariable analysis, higher risk for PEG tube placement was seen in African Americans and Hispanics compared to Caucasians with a-OR 3.76 [95%CI: 3.47–4.07], p < 0.001 and 2.59 [95%CI:2.33–2.88], p < 0.001 respectively. A higher risk was also seen in patients with low income with a-OR 1.1(95%CI: 1.04–1.19), p = 0.002 and among those having Medicaid compared to Medicare insurance with a-OR 1.53 [95%CI: 1.30–1.80], p < 0.001. Compared to males, females were found to have low chances for PEG tube placement with a-OR: 0.78 [95%CO:0.74–0.82], p < 0.001. Hospital ownership, bed size and teaching status were found to have no impact on PEG tube utilization. Conclusion Despite the evidence against placement of PEG tubes in dementia patients, our findings confirm that PEG tubes are still being placed in frail and demented elderly. Apart from these, elderly patients with low income, African American origin and Medicaid enrollees have higher incidence of PEG tube placements. Efforts are needed to educate clinicians and community about worse outcomes of PEG tube placement in advanced dementia.

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“…The general rule is that enteral feeding should be considered in patients with normal digestive function whereas TPN should be used if enteral nutrition is not feasible [35]. Contrastingly, ANH for elderly patients with dysphagia can be a life-prolonging treatment [36]; therefore, the choice of enteral versus parenteral nutrition is not only based on the digestive function of the patients but also on their clinical condition and the preferences of the patients and their family members [14,36,37]. This may result in selection bias and differences in the baseline characteristics of the PEG feeding and TPN study groups; therefore, we performed propensity score matching to adjust baseline characteristics to compare the effect of PEG feeding and TPN more accurately [15–17,23].…”

Section: Discussionmentioning

confidence: 99%

“…Recently, the general population in Japan has come to view only PEG as representative of unnecessary life-prolonging treatment although both PEG and TPN can be a life-prolonging treatment. PEG is generally avoided in elderly patients; hence, a greater number of elderly patients with dysphagia choose TPN instead of PEG feeding for long-term ANH [14]. The long-term outcomes of PEG feeding versus TPN in elderly patients with dysphagia have previously been poorly documented.…”

Section: Introductionmentioning

confidence: 99%

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in the elderly with dysphagia: A propensity-matched cohort study

Masaki

Kimura

2019

Preprint

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21Background 22 The long-term outcomes of artificial nutrition and hydration (ANH) in the elderly with 23 dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy 24 (PEG) and total parenteral nutrition (TPN) are major methods of ANH. Although both 25 can be a life-prolonging treatments, Japan has recently come to view PEG as 26 representative of unnecessary life-prolonging treatment. Consequently, TPN is often 27 chosen for ANH instead. This study aimed to compare the long-term outcomes between 28 PEG and TPN in the elderly. 29 Methods 30This single-center retrospective cohort study identified 253 elderly patients with 31 dysphagia who received enteral nutrition via PEG (n=180) or TPN (n=73) between 32 January 2014 and January 2017. The primary outcome was survival time. Secondary 33 outcomes were oral intake recovery, discharge to home, and the incidence of severe 34 pneumonia and sepsis. We performed one-to-one propensity score matching using a 0.05 35 caliper. The Kaplan-Meier method, log-rank test, and Cox proportional hazards model 36 were used to analyze the survival time between groups. 37 Results 38Older patients with lower nutritional states, and severe dementia were more likely to 39 receive TPN. Propensity score matching created 55 pairs. Survival time was significantly 40 longer in the PEG group (median, 317 vs 195 days; P=0.017). The hazard ratio for PEG 41 relative to TPN was 0.60 (95% confidence interval: 0.39-0.92; P=0.019). There were no 42 significant differences between the groups in oral intake recovery and discharge to home. 43The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 44 25.5%, P=0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 45 30.9%, P=0.018). 46 Conclusions 47PEG was associated with a significantly longer survival time, a higher incidence of 48 severe pneumonia, and a lower incidence of sepsis compared with TPN. These results can 49 be used in the decision-making process before initiating ANH. 50 51 4 56 developed as an enteral feeding technique for pediatric patients with dysphagia [1,2]. 57Compared to feeding via a nasogastric tube, enteral feeding via PEG can relieve 58 laryngopharyngeal discomfort and prevent intervention failure; therefore, its use has 59 become widespread for long-term enteral feeding in multiple patient groups including 60 pediatric and geriatric populations [3]. However, studies have reported worse outcomes 61 following PEG feeding in patients with dementia [4,5]; therefore, the use of PEG in 62 elderly populations is controversial [6,7]. 63TPN is another common method of nutritional management [8,9]. Similar to tube 64 feeding, TPN is also occasionally used for ANH in elderly patients with dysphagia [10]. 65 Comparing the outcomes of enteral nutrition and parenteral nutrition are major concerns 66 among clinicians. Previous studies have demonstrated conflicting results among patients 67 who received enteral nutrition versus those who received parenteral nutr...

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Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan

Cited by 18 publications

References 15 publications

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Racial and Socioeconomic Disparities in Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement among elderly patients with dementia in the United States from the National inpatient sample

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in the elderly with dysphagia: A propensity-matched cohort study

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