1. Ryan Zitnay MD Journal Club December 14, 2012 Does Feeding Tube Insertion and Its Timing Improve Survival?

2. Patient Case 87 year old veteran male NH resident with multiple medical problems including advanced dementia (MMSE<10), systolic heart failure (EF 10%), Afib, CVA with residual deficits now with worsening eating problems Multiple episodes of aspiration pneumonia leading to transfers to acute care facilities

3. Patient Case Evaluated by speech: –Signs and symptoms consistent with ongoing aspiration with all consistencies Recurrent aspiration events likely –“All routes: prandial, secretions, reflux possible”

4. Patient Case On dysphagia mechanically altered and nectar thick liquids diet Requires full assist with feeds Strict aspiration precautions –HOB > 30 degrees –Thorough oral hygiene –Small amounts per mouthful

5. The Dilemma Resident no longer felt “safe” to take in food orally Continued aspiration episodes despite aggressive precautions by staff Generally declining health: dementia, CHF Family meeting with wife, daughter –Questioned possibility of tube feeding? –Main motivation to prolong survival

6. If you were the provider… Based on your knowledge of the current evidence, what would you recommend to this family?

7. Despite our common practice here at BUGS… PEG tubes are still being placed frequently in older adult patients nearing the end of their life Prevalence thought to be 18-34% nationally –Varies significantly state by state –56/1000 demented NH residents had PEGs placed

8. Feeding Tubes in Demented NH Residents Figure 1 Kuo et al 2009 Kuo S et al. Natural history of feeding-tube use in nursing home resident with advanced dementia. JAMDA. 2009; (10) 4: 264-270.

9. Why is this happening? Dementia is one of leading causes of death in US Eating problems develop in 90% of those with advanced dementia –Loved ones concerned will “starve to death” Many families & providers see as only option

10. Perceived Benefits of Tube Feeding By healthcare providers, patients, & surrogates: –Better nutritional status –Reduced risks of complications such as aspiration PNA, pressure ulcers, infection –Improved functional status and quality of life –Safe, effective, easily-obtained, inexpensive procedure –Prolonged survival But are these supported by the evidence? Kuo S et al. Natural history of feeding-tube use in nursing home resident with advanced dementia. JAMDA. 2009; (10) 4: 264-270.

11. Perceived Benefits of PEG Tubes Prolonged Survival –2 observational studies concluded against –BUT 6-mo survival varied tremendously among those with PEGs placed: 10-85% 5 studies performed at same institution 2 studies used MDS data solely: no differentiation between NGT & PEG = limited generalizability –Are patients being referred too late to receive benefits?

12. Background Editorial ’08 AJG questioned interpretation that feeding tubes do not effect survival –Most evidence retrospective –Called for prospective research to further examine Delegge MH. Percutaneous Endoscopic Gastrostomy in the Dementia Patient: Helpful or Hindering? Am J Gastroenter 2008; 103:1018-1020

14. Aims of Study Does feeding tube insertion affect survival in NH residents with advanced dementia? Is the timing of insertion after development of eating problems associated with different patterns of survival?

15. Methods Prospective cohort study 1999 – 2007 Nationwide data –All US nursing homes –Merged Medicare claims & Minimum Data Set (MDS) NH resident assessments NH residents with advanced cognitive impairment & new eating problems

16. Inclusion Criteria MDS assessment with –New Cognitive Performance Score (CPS) of 6 Indicates patient needs assist with eating Had to have increased from 4 or 5 previously –Diagnosis of Dementia

17. Exclusion Criteria Based on review of MDS & Medicare claims: –Comatose –Died within 2 weeks of MDS assessment –Any evidence of PEG feeding in prior 6 months Based on designated procedural codes identified in previous research

18. Methods Survival determined by: Potential confounding variables were chosen based on prior research Baseline MDS Assessment CPS score of 6 Death determined by Medicare Denominator File # of days

19. Statistical Analysis Descriptive analysis of baseline characteristics of pts +/- feeding tubes –Chi-square test for categorical variables –t-test for continuous variables 1 year survival after PEG insertion AND timing of insertion analyses –Multivariate survival models –Accounted for potential selection bias

20. Results n = 36,492 participants –1,956 patients in the cohort had feeding tubes inserted (5.4%) –34,536 without feeding tubes

23. Journal of the American Geriatrics Society Volume 60, Issue 10, pages 1918-1921, 24 SEP 2012 DOI: 10.1111/j.1532-5415.2012.04148.x http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2012.04148.x/full#jgs4148-fig-0001 Volume 60, Issue 10, http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2012.04148.x/full#jgs4148-fig-0001

24. Results: 1 Year Survival Median Survival 177 days No association found between insertion of PEG tube & survival time –From “baseline” = development of need for assistance in eating Adjusted Hazard Ratio 1.03

25. Journal of the American Geriatrics Society Volume 60, Issue 10, pages 1918-1921, 24 SEP 2012 DOI: 10.1111/j.1532-5415.2012.04148.x http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2012.04148.x/full#jgs4148-fig-0002 Volume 60, Issue 10, http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2012.04148.x/full#jgs4148-fig-0002

26. Results: Survival by Timing of Insertion from Baseline Adjusted Hazard Ratios comparing survival from PEG insertion in Months 1-3 with those 4+ months: –1 (n=569): 1.01 –2 (n=310): 1.12 –3 (n=205): 0.82 –4+ (n=872)

27. Discussion Study confirms lack of treatment effect on survival First to show earlier insertion of PEG tube not associated with improved survival –1 month with similar post-treatment survival as 4+ months

28. Strengths Prospective! National database Large cohort Distinguished between PEG & NGT Used statistical techniques to control for potential selection bias Focused on timing of insertion

29. Limitations Largely white, female population Did not incorporate: –Physiological measures of nutrition (other than BMI) –Pt or family member preferences for feeding tube placement Medical diagnoses were based on MDS Only focused on NH setting - Generalizable?

30. Conclusions Supports current literature that there is no survival benefit in PEG tube insertion in advanced dementia –? Prolonging dying process without meaningful gains in quality of life The early bird does not get the worm! Can use to strengthen argument against insertion in inappropriate patients

31. Back to the Patient NH team recommended against PEG tube placement Additional hospitalization for aspiration PNA –Pt intubated; wife pushed for PEG tube while in hospital –Communication between team & inpatient providers prevented placement Shifted goals to comfort care/hospice –Comfort feeding pursued Patient died a few months later in NH comfortably

32. Thank you!