Gastrostomy Tube Use in the Critically Ill, 1994-2014

Abstract

Rationale: Although gastrostomy tubes have shown to be of limited benefit in patients with advanced dementia, they continue to be used to deliver nutritional support in critically ill patients. The epidemiology and short-term outcomes are unclear. Objectives: To quantify national practice patterns and short-term outcomes of gastrostomy tube placement among the critically ill over the last two decades in the United States. Methods: Using the U.S. Agency for Healthcare and Research Quality's Healthcare Cost and Utilization Project's National Inpatient Sample, we evaluated trends in annual population-standardized rates of gastrostomy tube placement among critically ill adults from 1994 to 2014; we also quantified trends in length of stay, in-hospital mortality, and discharge location. We conducted sensitivity analyses among mechanically ventilated patients, survivors, and decedents of critical illness, and in a critically ill population excluding patients with dementia. Results: From 1994 to 2014, population-based rates of gastrostomy tube use in critically ill patients increased from 11.9 to 28.8 gastrostomies per 100,000 U.S. adults (peak in incidence in 2010), an increase of 142% (31,392-91,990 gastrostomy tubes in critically ill patients; P < 0.001). Patients receiving gastrostomy tubes during critical illness occupied a growing proportion of all gastrostomy tube placements, accounting for 19.6% of all gastrostomy tubes placed in 1994 and 50.8% in 2014. The rate of gastrostomies in critically ill patients remained roughly stable, from 2.5% of critically ill patients in 1994 to a peak of 3.7% in 2002 before declining again to 2.4% in 2014. Hospital length of stay and in-hospital mortality decreased among gastrostomy tube recipients (28.7 d to 20.5 d, P < 0.001; 25.9-11.3%, P < 0.001; respectively), whereas discharges to long-term facilities increased significantly (49.6-70.6%; P < 0.001). Sensitivity analyses among mechanically ventilated patients revealed similar increases in population-based estimates of gastrostomy tube placement. Conclusions: The incidence of gastrostomy tube placement among critically ill patients more than doubled between 1994 and 2014, with most patients being discharged to long-term care facilities. Critically ill patients are now the primary utilizer of gastrostomy tubes placed in the United States. Additional research is needed to better characterize the long-term risk and benefits of gastrostomy tube use in critically ill patients.

Keywords: critical illness; gastrostomy; patient care planning.

Figure 1.

Gastrostomy use rates in the critically ill in the United States, 1994–2014. (Left axis) Population-adjusted incidence of gastrostomy tubes among the critically ill (per 100,000 U.S. adults). (Right axis) Percent of hospitalized adults with critical illness (gray triangles), percent of adults with critical illness receiving a gastrostomy tube (orange squares).

Figure 2.

Proportion of gastrostomy tubes placed in critically ill and noncritically ill hospitalized patients, 1994–2014. Among all recipients of gastrostomy tube, the proportion of gastrostomy tubes placed in critically ill patients (orange squares) has steadily increased and ultimately superseded the proportion of gastrostomy tubes placed in noncritically ill (blue diamonds) over the last 20 years.

Figure 3.

Outcomes of critically ill patients receiving gastrostomies, 1994–2014. Over time, fewer patients died in the hospital (yellow x) or were discharged home (blue diamonds), but more patients were transferred to long-term facilities (orange squares). ICF = Intermediate Care Facility; SNF = Skilled Nursing Facility.