The main focus of this study is on racial and socioeconomic differences in percutaneous endoscopic gastrostomy (PEG) tube placement among patients aged 70 and above who lived with dementia. Despite the strong evidence; against using enteral feeding in frail, elderly patients with dementia owing to unproven survival benefit, we found that 40.6% of the high-risk frail elderly patients hospitalized during the year 2016 in the united states received PEG tube .
Compared to Caucasians, the incidence of PEG tube placement is higher in African American and Hispanic populations, and highest among people who belong to low-income backgrounds who are insured through Medicaid. To date, the explanation for these medical choices is unclear but proposed to be due to availability of more advanced directives and end of life goals planning in Caucasians as compared to African Americans [15,16 ].
The racial and ethnic differences in end of life care for dementia patients have been reported for many years in the United States. Previous studies reported that Caucasian patients are more likely to have an insight about DNR (do not resuscitate) orders and have advanced care directives compared to their African American counterparts [17,18]. One of the reasons for this difference is thought to be mistrust amongst the African American population for physicians and healthcare personal or policy generally [19,20,21]. The major reason of this mistrust is proposed to be higher numbers of AA population being enrolled as subjects for research and investigation without being provided with accurate insight of the consequences. Particularly in older population, distrust is attributed to the complexity and ambiguity of US healthcare system specifically for physician-patient encounters. Furthermore, vulnerability of healthcare delivery adds to mistrust among these patients.
In terms of sex differences, previous epidemiological studies discovered a higher incidence of PEG tube insertions in men following an episode of stroke. In a study involving 36,109 patients who received PEG tube placement after a stroke, Faigle and colleagues found that the proportion of PEG tube placement was higher in men than in women (50.0% vs 39.2%, p < 0.001) . Our study is consistent with these findings, as males had significantly higher PEG tube placements than women.
Of note, insurance is an important component of healthcare delivery in the United States and has a significant impact on quality of life of a person carrying a diagnosis of dementia. It not only affects the patient but also has an impact on their families and treatment outcomes to a great extent. A study by Mitchell and colleagues in 2004 revealed that residents in long-term care homes having PEG tube generated a higher daily reimbursement from Medicaid and required less nursing home care. Alternatively, Medicare offered less reimbursement . Patients having low income (between 1-25th percentile and first quartile) had the highest incidence of PEG tube insertions as compared to patients who had higher incomes (Table 1-A, Fig. 4).
With respect to healthcare settings, we found out higher rate of PEG tube insertions in non-teaching hospitals, owing to time constraints, number of physicians, and patient volume. As expected, compared to rural hospitals, urban non-teaching hospitals had a higher incidence of PEG tube placements while no significant difference was noted on rate of PEG tube placement in teaching vs rural hospitals. In a survey conducted by Teno and colleagues on 486 family members of patients with dementia, the investigating team found out that in 71.6% of the cases, there was no reported decision about feeding tubes. Of respondents whose family members had feeding tubes, 13.7% stated that there was no discussion about insertion of a tube and 41.6% reported a discussion that was shorter than 15 minutes . This suggested that involving family members in the decision-making process and explaining the risks and benefits of PEG tube insertion clearly can help prevent unnecessary insertions of feeding tubes that can also lead to complications later on .
On a relevant note, studies have shown no appreciable difference in terms of patient recovery or mortality rates in teaching vs non-teaching hospitals . The capacity of the hospital in terms of size and beds, was not relevant to the number of patients receiving PEG tubes. Interestingly, the hospitals in the Northeast had a higher incidence of PEG tube insertions when compared with other regions (i.e., Mid-West or North-Central) . The reason for these regional differences is unknown, as there was no significant difference between government-run and private hospitals in terms of the number of PEG tube placements.
Despite the evidence against the use of PEG tube insertions among elderly frail patients with dementia, PEG tubes are still being placed in order to improve nutrition in this sub-stratum of the population. We have noted several reasons to explain this trend. Primarily, physicians lack ample amount of time to explain the risks and benefits to family members (as proxy decision makers), and also the mortality rates, side-effects, and harms [14, 24].
The advantage of this study is that it includes a large population sample representative of the general inpatient population of the United States. The main limitation of this study is that the type and stage of dementia is unknown. There is no stratification of dementia into early or late stages.