Elective home replacement of gastrostomy feeding tubes is safe and cost-effective. Has hospital referral become obsolete?

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for providing enteral nutrition in patients with functioning gastrointestinal tract. Available guidelines cover indications and procedural management for PEG placement, while there is no consensus about subsequent replacement with gastrostomy feeding tubes (GFT) and their management. We hypothesized that GFT replacement, according to a standardized protocol supervised by a trained gastroenterologist could be integrated into the home health care system. AIMS: To evaluate the safety and cost-efficacy of home GFT replacement. METHODS: All consecutive patients who underwent elective home GFT replacements from July 2016 to December 2019 were prospectively enrolled; all procedural details and outcomes have been recorded. RESULTS: Overall, 235 GFT replacements in 84 patients [40.5% male, 79.5 (74-94) years] were included. Among these, 230 (97.8%) were completed at patients' home while in five cases (2.2%) patients were referred to the hospital to confirm appropriate GFT placement. No adverse event occurred. An overall cost reduction of 46.8% was obtained, leading to €124 savings per procedure and up to €29,000 savings for the entire study period. CONCLUSIONS: When performed electively according to a standardized protocol, home GFT replacement is safe and effective, and leads to relevant cost reduction.

Gastrostomía por minilaparotomía / PERCUTANEOUS GASTROSTOMY WITHOUT LAPAROTOMY

Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares. Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares.

Introduction: Percutaneous surgery is undoubtedly the preferred technique to perform a gastrostomy for enteral feeding. Despite its advantages, it requires expensive sets and a complex procedure, which are not always available in our locations. All this led us to look for a safe alternative, easy to manage at home, and economically viable in all cases that occur in our locations. Material and Method: This is a retrospective study that includes 18 patients treated between 2005 and 2008 using the technique of minimal laparotomy (3 cm) for left median below the costal ridge, detection of the ascending portion of the stomach, placement of a Foley tube No. 18 and fixation of the stomach to the wall during the closure of the incision. Results: No serious complications were observed in the patients included in this study, except for some peri-tube reflux dermatitis and a mucous membrane prolapse. Easy home management and good patient tolerance were also observed. Discussion: Although this procedure is not the first-line treatment of choice, it is a safe and low-cost technique, which allows the placement of a safe, low-cost enteral feeding route with similar results in areas with scarce economic means like ours.

Healthcare provision in amyotrophic lateral sclerosis: procedures, queries and pitfalls in Germany and Poland.

There are a number of physical restrictions that develop in the course of amyotrophic lateral sclerosis (ALS). While loss of speech and motor control may be partially compensated by the support of assistive devices, swallowing difficulty and respiratory insufficiency require medical interventions (percutaneous endoscopic gastrostomy, noninvasive, and invasive ventilation). Based on the data collected within the NEEDSinALS study, we found major differences in personal satisfaction with the financing, healthcare provision, medical infrastructure, and regulations of German and Polish ALS patients, despite minor differences in economic burden caused by the disease. In order to explain this phenomenon, we thoroughly reviewed the legal basis, structure and organization of the healthcare systems in Germany and Poland to determine the range of obstacles in the everyday lives of patients and their caregivers that are attempting to attain an assistive device or care after the start of medical interventions.

Single-Step Method for Pull-Type Gastrostomy Tube Placement.

Single-step pull-type gastrostomy tube (PGT) placement is a method involving gastric puncture with a curved 18-gauge trocar needle allowing retrograde cannulation of the gastroesophageal junction without use of a sheath or snare. This retrospective review of 102 patients who underwent single-step PGT placement demonstrated 91% success in advancing the wire up the esophagus using only the curved trocar. Successful placement of a gastrostomy tube was 100%. Two major and 2 minor complications occurred within 30 days, all unrelated to the single-step technique. Mean fluoroscopy time for all patients was 5.1 min (range, 1.5-19.2 min). Single-step PGT placement is an effective, safe, fast, and equipment-sparing method for gastrostomy placement.

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties.

BACKGROUND: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty. METHODS: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model. RESULTS: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ±â€¯3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only. CONCLUSIONS: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care. STUDY AND LEVEL OF EVIDENCE: Cost-effectiveness study, Level II.

Race, Socioeconomic Status, and Gastrostomy after Spontaneous Intracerebral Hemorrhage.

INTRODUCTION: Spontaneous intracerebral hemorrhage is a disabling form of stroke, and some patients will require nutritional interventions for dysphagia. We sought to determine if socioeconomic status indicators mediate whether minorities undergo gastrostomy tube placement. MATERIALS AND METHODS: Patients with spontaneous intracerebral hemorrhage were enrolled in a single center, observational cohort study from 2010 to 2017. A socioeconomic index score was imputed using neighborhood characteristics by patients' ZIP code, according to an established method utilizing 6 indicators of wealth/income, education, and occupation. Multivariable logistic regression models were generated and stratified by racial/ethnic groups to determine the association of socioeconomic status with gastrostomy tube placement. RESULTS: Among 512 patients, 93 (18.2%) underwent gastrostomy tube placement. There were 245 Whites, 220 Blacks, and 47 Hispanic. Blacks underwent the highest percentage of gastrostomy placement (22.7%), and Whites had the lowest percentage (13.5%). Among patients with gastrostomy, Blacks and Hispanics had lowest median socioeconomic index (-2.1 [IQR: -3.0, .7]; .7 [IQR: -1.6, 2.9], respectively, P < .001). Increasing intracerebral hemorrhage score was correlated with higher odds of gastrostomy across all groups (P values ≤ .01) but only Hispanics had reduced adjusted odds of gastrostomy with increasing socioeconomic index (OR .56; 95% .33-.84; P = .01). DISCUSSION: Racial/ethnic minorities had lower socioeconomic index and underwent more gastrostomy placement. Socioeconomic index was independently associated with gastrostomy only in Hispanics, in whom the odds of gastrostomy decreased with increasing socioeconomic index. Summary & Conclusion: Differences in utilization of gastrostomy were evident among minorities, and socioeconomic status may mediate this relationship among Hispanics.

Clinical Features and Advantages of a Novel Percutaneous Endoscopic Gastrostomy Method.

BACKGROUND To study the clinical characteristics of novel percutaneous endoscopic gastrostomy. MATERIAL AND METHODS We retrospectively analyzed the hospital records of 173 patients undergoing various methods of gastrostomy (a novel PEG, traditional PEG, and surgical gastrostomy). Clinical characteristics were analyzed. For the novel PEG, the operation was as same as the traditional method for initial steps until the annular guide wire was inserted. The following steps were different: water was injected through an injection port to expand the capsule, then the water sac was confirmed to be close to the gastric wall under endoscope, and, finally, the incision was sutured and covered. RESULTS Patient ages ranged from 42 to 93 years (60.8±9.2 years, 91 males and 82 females). Among all patients, there were 27 cases of brain trauma, 42 cases of cerebral infarction, 74 cases of esophageal or cardiac carcinoma, 21 cases of laryngocarcinoma, and 9 cases of Alzheimer disease. Clinical features were significantly better for novel PEG compared to traditional PEG: duration of operation (19.75±3.14 min vs. 37.86±5.33 min and 54.12±9.48 min, P<0.001), intraoperative blood loss (27.14±3.63 ml vs. 43.53±6.24 ml and 75.78±12.41 ml, P<0.001), postoperative pain score (1.12±0.19 pts vs. 3.85±0.44 pts and 6.22±1.06 pts; P<0.001), infection rate (1.35% vs. 3.77% and 2.17%, P<0.001), length of hospital stay (3.16±0.42 d vs. 5.68±0.78 d and 8.29±1.31 d, P<0.001), and time to free activity (2.24±0.26h vs. 3.74±0.48 h and 14.85±2.38 d, P<0.001). The incidence of complications such as wound infection (1.35% vs. 3.77% and 4.76%), vomiting (1.35% vs. 5.66% and 6.52%), and nausea (2.70% vs. 1.88% and 6.52%) in the novel PEG group was lower than in the other groups (P<0.0001). Improved outcomes were obtained without increased medical costs in the novel PEG group. CONCLUSIONS For patients with difficult postoperative oral nutrition, the novel PEG treatment resulted in overall better clinical outcomes than traditional PEG.

Incremental Cost-Effectiveness of Aspiration Therapy vs Bariatric Surgery and No Treatment for Morbid Obesity.

INTRODUCTION: Despite its recent approval by the US Food and Drug Administration and Health Canada, aspiration therapy-one of the latest weight loss treatments-remains controversial. Critics have expressed concerns that the therapy could lead to bulimia and other binge eating disorders. Meanwhile, proponents argue that the therapy is less invasive, reversible, and cheaper than bariatric surgery. Cost-effectiveness of this therapy, however, is not yet established. METHODS: We developed a Markov model to estimate the incremental cost-effectiveness of aspiration therapy relative to 2 most common bariatric surgery procedures (gastric bypass and sleeve gastrectomy) and no treatment over a lifetime horizon. Costs were estimated from the health system's perspective using US data. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). RESULTS: Despite being a cheaper procedure than bariatric surgery, aspiration therapy costs more than bariatric surgery in the long term because of its high maintenance costs (i.e., periodic replacement of device parts). It also yields lower QALYs than bariatric surgery because of its smaller weight loss effects. Thus, the therapy is dominated by bariatric surgery. In particular, compared with gastric bypass, it costs US$5,318 more and yields 1.31 fewer QALYs. However, aspiration therapy is cost-effective relative to no treatment with an incremental cost-effectiveness ratio of US$17,532 per QALY gained. DISCUSSION: Given its high lifetime costs and its modest weight loss effects, aspiration therapy is not cost-effective relative to bariatric surgery. However, it is a cost-effective treatment option for patients who lack access to bariatric surgery.

To Pull or to Scope: A Prospective Safety and Cost-effectiveness of Percutaneous Endoscopic Gastrostomy Tube Replacement Methods.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common. GOALS: We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval. STUDY: A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs. RESULTS: Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively). CONCLUSION: Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.

Cost-Effectiveness Analysis of Intensity Modulated Radiation Therapy Versus Proton Therapy for Oropharyngeal Squamous Cell Carcinoma.

PURPOSE: To compared the cost-effectiveness of intensity modulated proton beam therapy (PBT) and intensity modulated radiation therapy (IMRT) in the management of stage III-IVB oropharynx cancer (OPC). METHODS AND MATERIALS: A Markov model was constructed to compare IMRT with PBT for a 65-year-old patient with stage IVA OPSCC. We assumed PBT led to a 25% reduction in long-term xerostomia, short-term dysgeusia, and the need for gastrostomy tube. Fewer dental complications were also expected with PBT. Incremental cost-effectiveness ratios (ICERs) were calculated, and value of information analyses were performed. The societal willingness-to-pay was defined as $100K per quality-adjusted life year (QALY). RESULTS: The ICERs for PBT for favorable human papillomavirus (HPV)-positive OPC were $288,000/QALY and $390,000/QALY in the payer perspective (PP) and societal perspective, respectively. Under nearly every scenario, PBT was not cost-effective, with ICERs above $150,000/QALY in the PP. The ICERs for HPV-negative OPC were typically greater than $250K/QALY in both perspectives. For HPV-positive patients, the ICER was less than $100,000/QALY in the PP only in younger patients who experienced a 50% reduction in both xerostomia and gastrostomy use. On probabilistic sensitivity analyses, there were 0% and 0.4% probabilities that PBT was cost-effective for 65- and 55-year old patients, respectively. The value of information was zero or negligible for all ages and perspectives at willingness-to-pay of $100,000/QALY and only meaningful in the PP for younger patients at a willingness-to-pay of $150,000/QALY. CONCLUSIONS: Intensity modulated proton beam therapy was only cost-effective in the PP if assumed to achieve profound reductions in long-term morbidity for younger patients; it was never cost-effective in the societal perspective. Prospective data are needed (and may be valuable) to better characterize the comparative toxicities of these treatments but are unlikely to change this calculation, except potentially in the most favorable cohort of patients.

Effects of gastrostomy fee schedule revision on artificial nutrition routes among older people with dementia in Japan: A time series observational study.

AIM: The present study aimed to investigate the effects of the 2014 Japanese fee schedule revision on trends in artificial nutrition routes, including gastrostomy, nasogastric tube and parenteral nutrition, among older people with dementia, using time series analysis. METHODS: The study used claim data in Japan submitted to Fukuoka Late Elders' Health Insurance from fiscal year 2010 to fiscal year 2016. We identified older people with dementia provided for the first time with artificial nutrition via gastrostomy, nasogastric tube or central venous line and aggregated their data by month. Interrupted time series analyses were used to examine trends in artificial nutrition routes over time. RESULTS: The numbers of older people with dementia receiving nutrition via gastrostomy, nasogastric tube and parenterally declined consistently. The slopes for pre-revision trends in gastrostomy, nasogastric tube and parenteral nutrition procedures were all significantly negative in the interrupted time series analyses. The post-revision trends in gastrostomy and parenteral nutrition continuously had significant negative slopes. In contrast, the significant negative trend in nasogastric tube procedures in the pre-revision period had disappeared during the post-revision period. CONCLUSIONS: The study showed that the fee schedule revision had limited impact on gastrostomy and parenteral nutrition. However the trend for nasogastric tube was ambiguous; hence, sustainable surveillance is required for evidence-based health policy. Geriatr Gerontol Int 2018; 18: 1405-1409.

Gastrostomy versus nasogastric tube feeding for chemoradiation patients with head and neck cancer: the TUBE pilot RCT.

BACKGROUND: Approximately 9000 new cases of head and neck squamous cell cancers (HNSCCs) are treated by the NHS each year. Chemoradiation therapy (CRT) is a commonly used treatment for advanced HNSCC. Approximately 90% of patients undergoing CRT require nutritional support via gastrostomy or nasogastric tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date (at the time of writing), not been compared. The aim of this pilot randomised controlled trial (RCT) was to compare these two options. METHODS: This was a mixed-methods multicentre study to establish the feasibility of a RCT comparing oral feeding plus pre-treatment gastrostomy with oral feeding plus as-required nasogastric tube feeding in patients with HNSCC. Patients were recruited from four tertiary centres treating cancer and randomised to the two arms of the study (using a 1 : 1 ratio). The eligibility criteria were patients with advanced-staged HNSCC who were suitable for primary CRT with curative intent and who presented with no swallowing problems. MAIN OUTCOME MEASURES: The primary outcome was the willingness to be randomised. A qualitative process evaluation was conducted alongside an economic modelling exercise. The criteria for progression to a Phase III trial were based on a hypothesised recruitment rate of at least 50%, collection of outcome measures in at least 80% of those recruited and an economic value-of-information analysis for cost-effectiveness. RESULTS: Of the 75 patients approached about the trial, only 17 consented to be randomised [0.23, 95% confidence interval (CI) 0.13 to 0.32]. Among those who were randomised, the compliance rate was high (0.94, 95% CI 0.83 to 1.05). Retention rates were high at completion of treatment (0.94, 95% CI 0.83 to 1.05), at the 3-month follow-up (0.88, 95% CI 0.73 to 1.04) and at the 6-month follow-up (0.88, 95% CI 0.73 to 1.04). No serious adverse events were recorded in relation to the trial. The qualitative substudy identified several factors that had an impact on recruitment, many of which are amenable to change. These included organisational factors, changing cancer treatments and patient and clinician preferences. A key reason for the differential recruitment between sites was the degree to which the multidisciplinary team gave a consistent demonstration of equipoise at all patient interactions at which supplementary feeding was discussed. An exploratory economic model generated from published evidence and expert opinion suggests that, over the 6-month model time horizon, pre-treatment gastrostomy tube feeding is not a cost-effective option, although this should be interpreted with caution and we recommend that this should not form the basis for policy. The economic value-of-information analysis indicates that additional research to eliminate uncertainty around model parameters is highly likely to be cost-effective. STUDY LIMITATIONS: The recruitment issues identified for this cohort may not be applicable to other populations undergoing CRT. There remains substantial uncertainty in the economic evaluation. CONCLUSIONS: The trial did not meet one of the three criteria for progression, as the recruitment rate was lower than hypothesised. Once patients were recruited to the trial, compliance and retention in the trial were both high. The implementation of organisational and operational measures can increase the numbers recruited. The economic analysis suggests that further research in this area is likely to be cost-effective. FUTURE WORK: The implementation of organisational and operational measures can increase recruitment. The appropriate research question and design of a future study needs to be identified. More work is needed to understand the experiences of nasogastric tube feeding in patients undergoing CRT. TRIAL REGISTRATION: Current Controlled Trials ISRCTN48569216. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 16. See the NIHR Journals Library website for further project information.

Safety, Efficacy, and Cost-Analysis of Percutaneous Endoscopic Gastrostomy and Ventriculoperitoneal Shunt Placement in a Simultaneous Surgery.

BACKGROUND: Limited historical data suggest that concomitant placement of both a ventriculoperitoneal (VP) shunt and percutaneous endoscopic gastrostomy (PEG) tube is associated with an increased risk of complications, including VP shunt infections. Here we compare the outcomes and cost difference between 2 groups of patients, one in which a VP shunt and PEG tube were placed in the same operation and the other in which separate operations were performed. METHODS: A total of 10 patients underwent simultaneous placement of a VP shunt and PEG tube. This group was compared with a group of 18 patients that underwent separate placements. Hospital billing charges were used to compare the total cost of the procedures in the 2 groups. RESULTS: Eight of the 10 patients presented with aneurysmal subarachnoid hemorrhage. The average length of stay was 25 ± 2 days for the simultaneous procedure group and 43 ± 7 days for the separate procedures group. The average duration of follow-up was 12 ± 3 months after simultaneous placement. No patient in the simultaneous surgery group had signs of infection or shunt malfunction at last follow-up. The overall complication rate was significantly lower in the simultaneous surgery group. A cost analysis demonstrated significant cost savings by completing both procedures in the same surgical procedure. CONCLUSIONS: Simultaneous placement of a PEG tube and VP shunt is safe, efficacious, and cost-effective. Thus, in patients requiring both a VP shunt and PEG tube, placement of both devices in a single surgical procedure should be considered.

Potential for health care cost savings with preoperative gastrostomy tube placement in the head and neck cancer population.

BACKGROUND: The purpose of this study was to examine the cost differences between preoperative and postoperative placement of gastrostomy tubes (G-tubes) in patients with head and neck cancer. METHODS: We conducted a retrospective chart review of patients with aerodigestive tract cancers from 2010 to 2015. Data included inpatient and postdischarge costs, demographics, tumor characteristics, surgical treatment, length of stay (LOS), time spent in the intensive care unit (ICU), and readmissions. RESULTS: Five hundred ninety patients were included in this study. There was a $7624 inpatient cost savings (P = .002) for those G-tubes placed preoperatively ($26 060) versus postoperatively ($33 754). Postdischarge costs did not differ significantly between groups (P = .60). There was a $9248 total costs savings (P = .009) for those patients with G-tubes placed preoperatively ($39 751) versus postoperatively ($48 999), despite patients with preoperative G-tubes having lower body mass index (BMI; P = .009), higher Association of Anesthesiologist (ASA) class (P = .02), more preoperative radiation (P < .001), and more free tissue transfer reconstruction (P = .007). CONCLUSION: There is potential for savings by placing G-tubes preoperatively, possibly driven by decreased LOS, despite data suggesting that patients with G-tubes placed preoperatively are higher risk.

Comparison of Emergency Department Visits for Complications of Gastrostomy Versus Gastrojejunostomy Tubes in Children.

OBJECTIVES: This study aims to evaluate frequency, type, and cost of gastrostomy tube (GT) versus gastrojejunostomy tube (GJT) complications in children presenting to the emergency department (ED). METHODS: Patients were selected by electronic health record search for International Classification of Diseases, Ninth Revision, and procedure codes for GTs and GJTs/jejunostomy tubes. All children aged less than 18 years with GTs or GJTs placed during a 5-year period (2007-2012) at the University of Minnesota Masonic Children's Hospital were identified for retrospective review. Comparisons were made on demographic data, number and type of complications, and interventions performed for ED visits, which were abstracted from the electronic health record. Cost data were abstracted from the financial data system. RESULTS: A total of 161 GT and GJT patients were identified; 31 children had 43 ED visits for complications. Ages ranged from 1 month to 17 years; median, 12 months; mean, 5.4 years; 25 (58%) were male, and 18 female (42%). Complications occurred in 15 GT (48.4%) and 16 GJT (51.6%) patients. The most common ED presenting complication was dislodgement, which occurred in 14 GTs (67%) and 18 GJTs (82%), followed by clogging 6 GTs (29%) and 1 GJTs (4.5%). Those presenting to the ED with GJT complications had higher mean overall charge (US $1987.00 vs US $913.10, P = 0.05). CONCLUSIONS: Although GTs and GJTs had similar rates of complications and ED visits, GJT complications were more likely to result in hospital admission and intervention by radiology, require specialist involvement, and have a higher cost charged to the patient.

Association of Transoral Robotic Surgery With Short-term and Long-term Outcomes and Costs of Care in Oropharyngeal Cancer Surgery.

Importance: The treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach. Objective: To investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC. Design, Setting, and Participants: Retrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database. Main Outcomes and Measures: The association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling. Results: Transoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724). Conclusions and Relevance: The use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.

Gastrostomy Placement Rates in Infants with Pierre Robin Sequence: A Comparison of Tongue-Lip Adhesion and Mandibular Distraction Osteogenesis.

BACKGROUND: This study was conducted to compare the gastrostomy rates in infants with Pierre Robin sequence treated with tongue-lip adhesion or mandibular distraction osteogenesis. METHODS: This was a retrospective study of symptomatic plastic and reconstructive surgery patients treated over an 8-year period. The primary predictor variable was surgical intervention (tongue-lip adhesion or distraction osteogenesis). Secondary predictor variables were categorized as demographic and clinical factors. The primary outcome was the need for gastrostomy tube placement. Secondary outcomes were complication rates, costs, and length of stay. RESULTS: Thirty-one tongue-lip adhesion and 30 distraction osteogenesis patients were included in the study. The groups were statistically comparable with regard to demographic and clinical factors (p > 0.18). Gastrostomy rates were higher in patients who underwent tongue-lip adhesion (48 percent) versus those who underwent distraction osteogenesis (16.7 percent; p = 0.008). In an adjusted model, subjects undergoing tongue-lip adhesion were more likely to require gastrostomy tube for nutritional support (OR, 6.5; 95 percent CI, 1.7 to 25.2; p = 0.007). There were two major complications in the tongue-lip adhesion group and none in the distraction osteogenesis group. There were three minor complications in the tongue-lip adhesion group and five in the distraction osteogenesis group. Total operating room costs were higher for distraction osteogenesis (p = 0.05), and total hospital costs and length of stay were higher for tongue-lip adhesion (p < 0.05). CONCLUSIONS: Among infants with symptomatic Pierre Robin sequence, treatment by distraction osteogenesis is associated with a lower risk for gastrostomy placement for nutritional support. Hospital costs are higher for tongue-lip adhesion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Infant gastrostomy outcomes: The cost of complications.

PURPOSE: Comparative outcomes of enhanced percutaneous endoscopic gastrostomy (PEG) and laparoscopic gastrostomy (LG) have not been elucidated in infants. We describe the outcomes and procedural episodic expenditures of PEG versus LG in this high-risk population. METHODS: One hundred eighty-three gastrostomies in children under 1year were reviewed from our institution spanning 1/2011-6/2015. Pertinent demographics and 3-month complications (mortality, gastrocolic fistula, reoperation, cellulitis, granulation, pneumonia, and tube dislodgement <6weeks) were collected. Facility and professional administrative data was used to conduct a charge and cost analysis of PEG and LG procedures as well as their statistically significant complications. RESULTS: Seventy-eight PEG and 105 LG infants were compared. LG infants were significantly younger, had higher ASA class, and increased frequency of cardiopulmonary disease. Significant major complications included a 3.8% incidence of gastrocolic fistula among PEGs (3.8% vs 0%, p=0.04) and 7.6% early tube dislodgements among LG infants (0 vs. 7.6%, p=0.01), resulting in $86,896 of additional charges with PEG complication. Incorporating complication frequency, average charges and variable cost per case were $8964 and $253 greater using PEG. CONCLUSIONS: Despite a healthier cohort, infants undergoing enhanced PEG have more morbid and costly complications. LG may be the less burdensome approach to gastrostomy in infants. LEVEL OF EVIDENCE: Case-Control Study/Retrospective Comparative Study - Level III.

Minimizing variance in pediatric gastrostomy: does standardized perioperative feeding plan decrease cost and improve outcomes?

BACKGROUND: A protocol for laparoscopic gastrostomy placement was implemented which specified perioperative antibiotics, feeding regimens, and discharge criteria. Our hypothesis was that hospital cost could be decreased, whereas at the same time improving or maintaining patient outcomes. METHODS: Data were collected on consecutive patients beginning 6 months after implementation of our protocol. We recorded surgeon compliance, patient outcomes (as defined by 30-day NSQIP complication rates), and cost of initial hospitalization, which was then compare to a 6-month historical control period. RESULTS: Our control group n = 26 and protocol group n = 39. Length of stay was shorter in the protocol group (P ≤ .05 by nonparametric analysis). The complication rate was similar in both groups (23% control vs 15% protocol, P = .43). Initial hospital costs were not different. Surgeon compliance to protocol was 82%. CONCLUSIONS: A standard protocol is achievable for gastrostomy tube management. After implementation of our protocol, we were able to show a significant decrease in length of stay, whereas maintaining quality.

Cost of ambulatory care for the pediatric intestinal failure patient: One-year follow-up after primary discharge.

BACKGROUND: Survival of children with intestinal failure has improved over the last decade, resulting in increased health care expenditures. Our objective was to determine outpatient costs for the first year after primary discharge. METHODS: A retrospective analysis was performed in pediatric intestinal failure (PIF) patients between 2010 and 2012. Patients were stratified into 3 groups (1=enteral support with no devices [7 patients], 2=enteral support with devices (gastrostomy and/or ostomy) [19 patients], 3=home parenteral nutrition (HPN) [22 patients]). Data abstraction included clinical characteristics and costs related to medication, enteral/parenteral nutrition, and supplies were calculated. Data were analyzed using one way ANOVA. RESULTS: Forty-eight patients (mean age 7.6months; 31 males [65%]) were studied. See attached table for results. HPN patients had significantly more ambulatory visits (p<0.0001), number of admitted days (p=0.01), and productive days lost (p<0.0001). Total cost of care was significantly higher for HPN patients (mean=$320,368.50, p<0.0001) when compared to other groups. Costs covered by the health care system were significantly higher for patients on HPN (mean=$316,101.56, p<0.0001). CONCLUSION: The outpatient expenditures to care for PIF patients in the first year post primary discharge are significant. Our single payer health care system supports the majority of costs, but families are also incurring expenses related to travel and lost productivity. Children on HPN have more visits to hospital, but have access to more funding options. Children solely on gastrostomy or stoma therapy, however, have a significantly greater personal financial burden.