No one can point to a single culprit or clear explanation for why the medical profession continues the controversial and routine practice of surgically implanting feeding tubes in stomachs of dying, elderly patients.
But a lot of people in healthcare industry are reaping the benefit. Like hospitals. And nursing homes. And the global medical technology giants. A sector of that industry specializing in artificial feeding technology hauls in profits from a business worth more than half a billion dollars annually.
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Stomach Tubes to Feed Elderly Often Unnecessary, May Be Harmful
Feeding tubes surgically implanted into the stomach are coming under growing criticism in medical care for the elderly, even as their use among the frail, terminally ill and often demented patients has become commonplace.
Best Feed Tube Decisions Require Tough Choices
For physicians, this is routine and uncomplicated surgery. For the families of ailing seniors, it is yet another medical procedure fraught with uncertainty that arouses disturbing questions and fears about life and death, often accompanied by feelings of guilt and family turmoil.
PEG Tubes Used Appropriately Can Be Lifesaving
Little controversy surrounds the use of percutaneous endoscopic gastronomy (PEG) tubes in patients with long-term nutritional needs but good prospects for recovery from whatever condition has interfered with their ability to eat.
Surgeries for the implanting the tubes have risen annually for more than two decades. From 60,000 elderly patients in 1988, the number had jumped to 188,000 by the end of the first 10 months of 2010, a rate on pace to quadruple the earlier annual tally.
And a large proportion of the tubes go into patients suffering neurological disorders such as Alzheimer’s, despite the lack of solid medical evidence that these people will medically benefit from the devices, which are known as percutaneous endoscopic gastrostomy, or PEG, tubes.
Factors promoting use of these PEG tubes range from cultural customs and financial pressures to hospital policies aimed at discharging patients faster to free up beds for new patients, medical experts say. Other factors include the convenience of caregivers, the capabilities of care facilities, and the logistics of transferring patients from hospitals to nursing homes.
BIG BUSINESS PROFITS IN PEG MARKET
And the likelihood of stomach tube placement in elderly people with advanced cognitive impairment – dementia – may depend partly on where they go for treatment of acute illnesses. Large, for-profit hospitals, big hospitals in urban settings and academic medical centers have higher rates of stomach tube placements, according to a 2010 report in the Journal of the American Medical Association.
Read more about the elderly and PEG here.
Applied Medical Technology, Inc., an Ohio company specializing in artificial feeding technology and one of the first to manufacture PEGs, calls the device the “gold standard” for patients needing long-term nutritional support. Lisa Spzak, a spokeswoman, declined to disclose company sales data, but said the market for PEGs grows 15 to 20 percent annually.
Global giants such as Abbott Nutrition, Boston Scientific, Merck and Kimberly-Clark also produce feeding tubes, pumps for nutritional formulas, and related apparatus. Both U.S. and European markets for this sector “present opportunities for steady growth” through 2014, unaffected by economic downturn, according to a December 2009 report by the Millennium Research Group, a global information company. The combined worth of the sector in the U.S. and Europe should increase, the report says, from more than $500 million in 2009 to more than $700 million by 2014.
Clinicians at University of Iowa Hospitals and Clinics, who attest to growing use of stomach tubes offer diverse explanations, some related to the range of conditions handled at a large academic medical center.
Dr. Joseph Cullen, a gastrointestinal surgeon who said he places about 180 PEG tubes a year at the hospital, attributes the increase to an older population having more strokes and neurological problems, as well as more patients with head and neck cancer. The PEG is broadly accepted as the safest method for long-term feeding for those with head and neck cancer, especially if treatment involves extensive surgery.
PEG USE HIGH AMONG ELDERLY
Neurological disorders, however, remain the main conditions leading to PEG use; and a good proportion of these disorders correspond with aging, including stroke, Parkinson’s disease, and dementia from Alzheimer’s or other causes.
The doctor actually placing a feeding tube in a large hospital may not know the patient or family ahead of the procedure, nor have a role in follow-up care. Cullen said his interactions with patients getting the PEG tube are brief, occasioned when other departments call on his expertise.
The University of Iowa’s hospital is one of only a handful of stroke centers in the state, and its ear, nose and throat care services are recognized as among the best in the country. Referrals in these areas may have increased the use of PEG tubes over the past few years, said Dr. Dionne Skeete, a critical care surgeon.
Scott Wilson, a doctor of internal medicine at the university hospital, said standards of care have changed to make PEGs more acceptable. “I would say I have a lower threshold for placing this tube than 10 years ago,” he said.
And he noted that some elderly patients with a poor prognosis nevertheless want feeding tubes. Family members also may feel comforted by the procedure, and both patients and families may be inclined to go along with a physician who recommends it.
Wilson also pointed to ongoing administrative efforts to reduce the amount of time patients stay in the hospital, as well as the desire to get patients into nursing homes and other care facilities that might favor PEGs over other feeding methods, as factors promoting their use. “We’re under some pressure now to move people to different kinds of care,” he said.
FREEING UP BEDS
In regular presentations to Iowa’s Board of Regents, which oversees the state’s public universities, UI hospital officials have highlighted endeavors to reduce the length of patient stays. Ann Williamson, chief nursing officer, confirms that the hospital has begun “actively managing” length of stay to promote a better discharge process.
“We need to keep our patients moving,” she said. “We need to be efficient and effective. If a patient is here who doesn’t need to be here, we’re tying up a bed for a patient who does need it.
“We are also exposing them to risks,” she added, explaining how the chances of acquiring hospital infections and of suffering preventable medical mistakes increase with longer stays.
Williamson said the average stay at the university hospital – 6.24 days in fiscal year 2010-11, which is down from 6.29 days the prior year – is 20 percent above Medicare expectations. She attributes that partly to admissions of indigent patients, who are more likely to face social and behavioral problems that complicate their discharge.
The university hospital is one of only two in the state accepting patients under IowaCare, the Iowa’s indigent care program. Angela Carey, a social worker in the neurology unit, said IowaCare patients often have poor social support networks, which makes finding care outside the hospital difficult.
Money is also at stake. Discharging patients earlier frees up beds, facilitates turnover and allows for more admissions. More patients mean more revenue because Medicare pays hospitals a set amount for each patient case, regardless of how long the individual actually stays.
FINANCE SYSTEM PUSHES PEG USE
This provision is part of a system called Diagnosis Related Groups (DRG), which sorts patients into pay categories based upon diagnosis, the kind of procedures they receive and other factors. Hospitals get the same amount for patients in the same category no matter how long they take up bed space. The federal government began the grouping system in 1983 as a way of controlling runaway Medicare spending by procedure-intensive hospitals. Government analysts said per-case payments would discourage hospitals and physicians from extending treatment and encourage transfers to post-hospital settings.
The patterns of PEG use in the elderly suggest that, at least for this procedure, the analysts were correct.
Some studies and critics attribute the placement of PEG tubes in patients with dementia mainly to Medicare reimbursement incentives affecting nursing homes. Until recently, Iowa skilled nursing facilities got higher Medicare and Medicaid payments for residents who are tube fed versus those who are fed by hand, because the government considered tube feeding to be a higher level of skilled care.
Starting in October, federal guidelines have lowered reimbursement rates for feeding tubes. Still, the payment adjustments are unlikely to spur a corresponding rise in the sort of labor-intensive attention that hand feeding demands. As Dr. Gregory W. Rutecki of the Center for Bioethics and Human Dignity, a Christian bioethics research center at Trinity International University in Deerfield, Ill., has written: “Medical procedures are reimbursed, time spent caring is not.”
Others say tube feeding doesn’t necessarily provide a direct financial gain for nursing homes. Rachow explained that hand feeding is considered “nursing aide level,” whereas PEG tube feeding is “nursing level.” A nurses’ aide may have to spend one or two hours with three residents to handle a meal, whereas the nurse may spend one hour a day getting all three tube feedings set up and monitoring the patients. The nurse is paid more, but doesn’t work as many hours. “It roughly evens out,” Rachow said. “It’s almost too complicated a system to game.”
But nursing homes have additional reasons to favor surgically inserted PEG tubes over other kinds of feeding, even though less invasive alternatives exist.
PEG MAKING FEEDING EASIER
Feeding patients through a PEG tube is easier to manage than feeding them by hand or with a more temporary device.
“We have that down to a science,” said Nancy Upmeyer, director of nursing at Iowa City Rehabilitation and Health Care Center.
Two other common types of feeding tubes don’t entail surgical insertion. A nasogastric tube enters a patient’s nose and sits in the stomach. A Dobbhoff tube also goes through the nose but sits in a part of the small intestine. The American Gastroenterological Association recommends these options for patients needing feeding assistance for less than 30 days.
But tubes that go through the nose are more likely to fall out or get pulled out than PEG tubes. Caregivers know that patients who are upset or bewildered can tear out a nasal tube without much effort, but they must be cautious about tying a patient’s hands; both federal and state laws prohibit nursing homes from using restraints unless they are deemed medically necessary. Nursing homes lack the capacity to replace a tube that has come out, or to confirm by x-ray that a tube is properly placed, and must bear the costs of any replacement procedure as well as the expense of transporting the patient to and from the hospital.
NURSING HOMES DEMAND PEGS
Nursing home policies thus can be a main determinant of whether a patient being discharged gets a PEG tube versus a through-the-nose tube. Skilled nursing facilities in the Iowa City area generally refuse to take patients with PEG tubes, according to administrators, but some are beginning to offer more flexibility.
“Doctors and speech therapists are becoming a little bit more leery about automatically jumping to a PEG tube placement,” said Carey, the social worker at the University of Iowa hospital. And some care facilities will now accept patients fed through a nasogastric tube as long as they only need it for two weeks or less, she said.
Unlike some hospitals, the university hospital does not have an attached skilled care or acute rehabilitation facility. The resulting lack of “a progressive level of therapy” is another incentive for moving patients out of hospital beds, according to Carey. A patient transferred to an appropriate care facility often makes greater progress than at the hospital, she said.
Dr. Paul Mulhausen, a UI Hospital geriatrician, said he has not observed greater use of feeding tubes among his patients, but does see a “discontinuity of care” between hospital and nursing home.
The emphasis on shorter hospital stays and the pressure to transfer patients to other facilities mean that a doctor ordering stomach tube surgery often has less than 48 hours’ acquaintance with the patient, Mulhausen said.
“There is an incentive to use the nursing home as a step-down unit,” he said, and many nursing homes now take in much sicker patients than they’ve housed in the past. This is part of a move away from an earlier model of custodial care, according to Mulhausen.
“Nursing homes in Iowa are changing,” he said. “You used to think of a nursing home as a home full of old people. Now they are full of people who are really ill.”
(Gabe Gao is a December 2011 graduate of the University of Iowa’s Master of Arts in journalism program and is now a medical student at Northwestern University)
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