Implementation of a hospital-wide standardized feeding tube pathway is associated with a reduction in health care utilization

Abstract

Implementation of a hospital-wide standardized feeding tube pathway is associated with a reduction in health care utilization Richards MK, McAteer JP, Li C, Shaw DW, Wahbeh GT, Foti JL, Melzer L, BA, Goldin AB Background Relatively recent medical advances such as percutaneous endoscopic, image-guided, laparoscopic and even robotic gastrostomy tube (GT) placement have become common among pediatric patients. These minimally invasive approaches may be quick to perform and simple to complete, but they are not without subsequent complications such as infection, leakage, device malfunction, dislodgement, hemorrhage and intra-abdominal organ injury. In addition, many of the procedures require planned interventions such as tube exchanges or conversions from gastrostomy to gastrojejunostomy. We hypothesized that implementation of a hospital-wide clinical standardized work (CSW) feeding tube pathway would be associated with a reduction in hospital resource utilization. Methods We performed a retrospective cohort study comparing all children undergoing GT or gastrojejunostomy tube (GJ) placement following implementation of the hospital-wide clinical standardized work pathway (CSW) from June 1, 2013 - July 31, 2014 to those placed in a previous time period (January 1, 2010 - December 31, 2011). We limited follow up time to 365 days in both groups. Our primary outcome was the change in the rate of hospital resource utilization, defined as 1) GT/GJ-related emergency department visits, 2) planned events, or 3) unplanned events before and after implementation using adjusted Poisson regression. We also compared the time to first event between cohorts using adjusted Cox regression to understand the relative number of children requiring repeat utilization (p<0.05). Adjustment factors included age, ASA class, gender, insurance, race, comorbidities and GT/GJ at initial placement. Results Prior to CSW implementation, 145 (48.7%) devices were placed surgically, 113 (37.9%) endoscopically, and 40 (13.4%) with an image-guided technique. After implementation, 105 (73.4%) were placed surgically, 23 (16.1%) endoscopically, and 15 (10.5%) with an image-guided technique. Prior to implementation, 174/298 (58.4%) patients required additional hospital utilization compared to 58/143 (40.6%) after implementation. Poisson regression demonstrated that following implementation, the rate of resource utilization decreased by over 50% (Incidence Rate Ratio: 0.45; 95%CI 0.36-0.57; p<0.001). The risk of at least one additional feeding tube related intervention or emergency department visit was reduced by over 30% based on Cox regression (Hazard Ratio: 0.62; 95%CI 0.45-0.85; p=0.005). This demonstrated that fewer children required at least one repeat GT/GJ-related hospital utilization event after algorithm implementation. Conclusions Care of this complex and heterogeneous patient population is currently spread among multiple providers and specialties leading to variability in the pre-operative workup, intra-operative technique, and post operative care. Our study shows an association between a standardized approach to GT/GJ placement and decreased hospital resource utilization.