Prospective implementation of algorithmic patient selection for gastrostomy tube placement consultations: a pre- and post-intervention analysis

Figures & data

Table 1 Patient selection algorithm

Category	Neurologic dysphagia	Mechanical obstruction	Advanced dementia	Pressure ulcers	Pulmonary aspiration risk	Vegetative state	HIV/AIDS wasting	Anorexia and cachexia syndrome	Geriatric population
Examples	Cerebral vascular accident (CVA), Multiple sclerosis, Parkinson’s disease, Myasthenia gravis, Amyotrophic lateral sclerosis (ALS)	Head, neck, or esophageal cancer	Nursing home patient, Alzheimer’s disease, Vascular dementia	Bed-bound patient	Debilitated patient	Anoxic brain injury	Untreated HIV with or without opportunistic infections	Advanced disease with a life expectancy of less than 1–2 months^Citation1	Age ≥65^Citation1 Failure to thrive
Additional testing	Evaluation by speech and neurology service^Citation1	Evaluation by oncologic services and appropriate cancer staging	Evaluation by neurology and palliative care services	Evaluation by wound care service	Evaluation by speech service	Evaluation by neurology service	Evaluation by infectious disease service	Evaluation by palliative care services	Evaluation by geriatric service
Gastrostomy tube (GT) recommendation	Offer GT if no short-term (<4 weeks) reversible etiology found^Citation1,Citation3	Offer GT for those with a reasonable expectation of response to treatment, or in whom the natural history of the untreated tumor is where survival is expected to be greater than 6 months^Citation1,Citation19 If inability to pass scope or tight esophageal stricture that is stented consider interventional radiology referral	Do not offer GT Careful hand feeds^Citation1,Citation15 Avoid anticholinergics, neuroleptics, benzodiazepines^Citation1	Do not offer GT	Do not offer GT Elevation of head of bed^Citation12 and careful hand feeds Percutaneous endoscopic gastrostomy (PEG)-J and PEJ may decrease risk of aspiration vs GT^Citation12	Do not offer GT^Citation1,Citation3	Offer GT Treatment of HIV and opportunistic infections	Do not offer GT^Citation1,Citation3	Do not offer GT Offer routine nutritional assessment and counseling^Citation17 If involuntary weight loss, evaluate for medical or social etiologies ^Citation17
Reason	In patients with dysphagic CVAs, studies have demonstrated improved nutrition and rehabilitative gains^Citation14 In patients with ALS, studies have shown improved nutritional indices and survival^Citation5,Citation13	Results in decreased hospitalization for dehydration, malnutrition, and less weight loss^Citation16 Can be used for “venting”^Citation1	No increased survival, quality of life (QOL), nutrition status^Citation1,Citation9,Citation15 Food avoidance is a poor prognostic indicator May increase risk of developing pressure ulcers^Citation11	No benefit with regard to development or healing of pressure ulcer^Citation1,Citation2,Citation11,Citation18 May increase risk in nursing home patients with dementia^Citation11	GTs do not prevent aspiration^Citation1,Citation2,Citation18 and can increase risk of aspiration in certain populations^Citation9	No improved QOL or clinical benefit^Citation3	Results in increased body weight and improved nutritional indices^Citation1	Unable to use nutrition and unlikely to improve QOL^Citation3	No long-term benefit in weight gain, markers of nutritional indices, or functional status

Table 2 Characteristics of the study cohort of 126 patients in whom gastrostomy tube (GT) consults were requested. Comparisons between groups based on GT placement and pre- and post-algorithm eras

	GT not placed	GT placed	P-value	Pre-algorithm	Post-algorithm	P-value
N	49	77		68	58
Age, Mean (SD)	74.6 (11.0)	68.4 (10.2)	0.002	70.9 (12.3)	70.6 (9.1)	0.88
Men	49 (100)	75 (97.4)	0.26	66 (97.1)	58 (100)	0.19
Race/Ethnicity			0.28			0.45
White	21 (42.9)	44 (57.1)		32 (47.1)	33 (56.9)
African American	23 (46.9)	28 (36.4)		31 (45.6)	20 (34.5)
Other	5 (10.2)	5 (6.5)		5 (7.3)	5 (8.6)
Consult for algorithm-approved indication	15 (30.6)	58 (75.3)	<0.001	36 (52.9)	37 (63.8)	0.22
GT placed	N/A	77 (100)	-	37 (54.4)	40 (69.0)	0.10
GT placed for approved indication	N/A	58 (75.3)	-	26 (38.2)	32 (55.2)	0.06
GT placed endoscopically	N/A	56 (72.7)	-	26 (38.2)	30 (51.7)	0.13
Albumin at consultation, mean (SD)	2.23 (0.64)	2.64 (0.68)	0.001	2.49 (0.71)	2.47 (0.67)	0.89
Albumin at 30 days post-GT or consultation if GT not placed (SD)	2.60 (0.74)	2.86 (0.71)	0.18	2.82 (0.75)	2.76 (0.69)	0.77
SGSS, mean (SD)	2.57 (0.65)	2.18 (0.84)	0.01	2.38 (0.81)	2.28 (0.77)	0.45
Died in same hospitalization	19 (38.8)	6 (7.8)	<0.001	15 (22.1)	10 (17.2)	0.50
30-day mortality	22 (44.9)	11 (14.3)	<0.001	20 (29.4)	13 (22.4)	0.37
Reason for consult			<0.001			0.03
CVA	5 (10.2)	21 (27.3)		11 (16.2)	14 (24.1)
Neurological disorder other than CVA	2 (4.1)	20 (26.0)		8 (11.8)	14 (24.1)
Dementia	10 (20.4)	3 (3.9)		6 (8.8)	6 (10.3)
Altered mental status	4 (8.2)	5 (6.5)		3 (4.4)	6 (10.3)
Cancer	6 (12.2)	12 (15.6)		10 (14.7)	7 (12.1)
Other	22 (44.9)	16 (20.8)		29 (42.6)	10 (17.2)

Abbreviations: SGSS, Sheffield Gastrostomy Scoring System; CVA, cerebral vascular accident.

Table 3 Comparison of outcomes among four groups based on the timing of gastrostomy tube (GT) consults (pre- and post-algorithm implementation) and their fulfillment of algorithm (- or +). Total of 126 patients in whom GT consults were requested

Timing with respect to intervention		- algorithm N=53	+ algorithm N=73	P-value
Pre-	N=68	32	36
	GT placed	11 (34.4)	26 (72.2)	0.002
	30-day mortality	12 (37.5)	8 (22.2)	0.17
	Died same hospitalization	9 (28.1)	6 (16.7)	0.26
	Change in serum albumin	0.37 (0.84)	0.17 (0.69)	0.33
Post-	N=58	21	37
	GT placed	8 (38.1)	32 (86.5)	<0.001
	30-day mortality	7 (33.3)	6 (16.2)	0.13
	Died same hospitalization	6 (28.6)	4 (10.8)	0.09
	Change in serum albumin	0.57 (0.89)	0.13 (0.71)	0.12

Note: P-value from chi-squared test comparing algorithm-inappropriate and algorithm-appropriate groups.

Table 4 Comparison of outcomes among four groups based on the timing of gastrostomy tube (GT) consults (pre- and post-algorithm implementation) and their fulfillment of algorithm (-or +). Total of 77 patients in whom GT was placed

		- algorithm N=19	+ algorithm N=58	P-value
Pre-	N=37	11	26
	30-day mortality	1 (9.1)	4 (15.4)	0.61
	Died same hospitalization	1 (9.1)	2 (7.7)	0.89
	Change in serum albumin	0.57 (0.73)	0.12 (0.68)	0.14
Post-	N=40	8	32
	30-day mortality	2 (25.0)	4 (12.5)	0.38
	Died same hospitalization	2 (25.0)	1 (3.1)	0.04
	Change in serum albumin	0.63 (0.98)	0.14 (0.74)	0.17

Note: P-value from chi-squared test comparing algorithm-inappropriate and algorithm-appropriate groups.

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