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Clinical selection criteria can predict futile intervention in patients referred for percutaneous endoscopic
D Q Holt1,2,3, J F McDonald2,4, M L Murray2,4
1Gastroenterology and Hepatology Unit, Monash Health, Melbourne, Australia.
Insights
Dietitian assessment of percutaneous endoscopic gastrostomy (PEG) appropriateness predicts mortality. Patients receiving PEG after dietitian-approved assessment had lower mortality, while those receiving PEG against advice showed no survival benefit.
Area of Science:
- Clinical Nutrition
- Gastroenterology
- Geriatrics
Background:
- Percutaneous endoscopic gastrostomy (PEG) placement is common in high-mortality patients.
- Current methods lack standardized tools to assess PEG appropriateness and predict outcomes.
- Many patients do not experience increased survival after PEG insertion.
Purpose of the Study:
- To evaluate if a dietitian's clinical assessment of PEG appropriateness predicts short- and medium-term mortality.
- To determine the prognostic value of dietitian-led PEG appropriateness evaluations.
Main Methods:
- Prospective audit of 198 PEG referrals at an Australian tertiary hospital (2005-2008).
- Dietitian assessed referral appropriateness; data collected on patient demographics, comorbidities, and referral reasons.
- Compared mortality at 30 and 150 days between patients receiving PEG after appropriate assessment versus all other patients.
Main Results:
- Of 198 referrals, 94 were deemed appropriate and 104 inappropriate.
- Patients receiving PEG after appropriate assessment showed significantly reduced 30-day (74.6% vs 96.4%) and 150-day (57.9% vs 82.1%) mortality.
- Patients receiving PEG despite inappropriate assessment had no significant survival advantage over non-recipients.
Conclusions:
- Trained assessors applying selection criteria improve patient selection for PEG insertion.
- This assessment predicts early and later mortality by identifying futile cases.
- PEG insertion without appropriate assessment offers no mortality benefit, suggesting potential futility.
Background:
Percutaneous endoscopic gastrostomy (PEG) placement is performed in a patient group with high mortality in the short and medium term. For a significant proportion of patients, the procedure provides no increase in survival. There are no standardised assessment tools available to determine the clinical appropriateness of PEG placement, nor any to predict clinical outcome.
Aim:
The study aims to determine whether clinical assessment, by a trained dietitian, of the appropriateness of PEG placement is predictive of mortality in the short and medium terms.
Methods:
A prospective audit was undertaken of all requests for PEG placement at a single large, publicly funded Australian tertiary hospital. The clinical appropriateness of each request was assessed by a trained dietitian, and data on age, sex, reason for referral, comorbidities and satisfaction of assessment criteria were collected, and patient outcome and survival were compared for all patients according to whether a PEG was inserted or not. Main outcome measures were mortality at 30 and 150 days after referral.
Results:
During the period 2005-2008, 198 patients were referred for PEG; 94 were assessed as appropriate referrals, 104 as inappropriate. Eighty-four patients who underwent gastrostomy, after being assessed as appropriate, had significantly reduced mortality at 30 days (96.4% vs 74.6%, P < 0.0001) and 150 days (82.1% vs 57.9%, P = 0.0001) compared with all other patients. Patients who received PEG despite contrary advice had no significant survival advantage, at 30 days or 150 days, over patients who did not receive PEG.
Conclusion:
The application of selection criteria by trained assessors improves patient selection for PEG insertion and predicts mortality at early and later time points, by identifying patients unlikely to benefit from PEG. The group of patients who received a gastrostomy despite an adverse assessment had no mortality benefit - in these patients, the procedure may have been futile.
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