Does a Person Who Gets a Feeding Tube Ever Be Able to Eat Again?
J Gen Intern Med. 1997 February; 12(two): 88–94.
Survival Estimates for Patients with Aberrant Swallowing Studies
Marker E Cowen
1St. Joseph Mercy Hospital, Ann Arbor, Mich
2Department of Medicine, Academy of Michigan Medical School, Ann Arbor
Sherry Fifty Simpson
1St. Joseph Mercy Infirmary, Ann Arbor, Mich
Theresa Due east Vettese
1St. Joseph Mercy Infirmary, Ann Arbor, Mich
Abstract
Objective
To better empathize the life expectancy of patients who have an abnormal videofluoroscopic swallowing study.
Design
Retrospective accomplice study. The common starting point was the time of the severely abnormal swallowing written report. Infirmary charts were reviewed for clinical variables of potential prognostic significance by reviewers blinded to the outcome of interest, survival time.
Setting
A academy-affiliated, community education hospital.
Patients
1 hundred forty-nine hospitalized patients who were deemed nonoral feeders based on their swallowing study. Patients excluded were those with caput, neck, or esophageal cancer, or those undergoing a thoracotomy process.
Measurements And Chief Results
Clinical and demographic variables and fourth dimension until death or censoring were measured. Overall i-twelvemonth mortality was 62%. Multivariable Cox proportional hazards analyses identified four variables that independently predicted death: advanced age, reduced serum albumin concentration, disorientation to person, and higher Charlson comorbidity score. Fourscore patients (54%) subsequently underwent placement of a percutaneous endoscopic gastrostomy (PEG) tube after their swallowing study.
Conclusions
Mortality is loftier in patients with severely abnormal swallowing studies. Common clinical variables can be used to place groups of patients with particularly poor prognoses. This information may assist guide discussions regarding possible PEG placement.
Keywords: videofluoroscopic swallowing report, percutaneous endoscopic gastrostomy (PEG), nonoral feeding, survival
When patients cannot run across their nutritional needs past mouth or are at high risk of aspirating nutrient, tube feedings may be required.1 A videofluoroscopic swallowing study (VFSS) is frequently ordered to determine the run a risk of aspiration, and the underlying physiologic and anatomic reasons for the swallowing dysfunction.2 – 4 The prevalence of some swallowing difficulty in inpatients is at least 12%,5 and is in the twenty% to xl% range for patients with strokes,6 – 8 dementia,9 , ten or other neurologic conditions.xi , 12 Traditionally the about mutual method of tube feeding was via a nasogastric tube. Since 1980, the percutaneous endoscopic gastrostomy (PEG) method has become popular for long-term tube feedings considering it is reasonably safe and comfortable for the patient.xiii
The determination to place a PEG tube is not always straightforward. A recent survey of nursing dwelling residents found only 33% would cull tube feedings if they were no longer able to eat.xiv Some clinicians also feel PEG tube placement may be inappropriate for patients who are expected to dice soon.13 , 15 – 17 Many avant-garde directives or living wills have options for patients to refuse life-sustaining treatments if they have a terminal illness, or if the "burdens of the treatment outweigh the expected benefits."xviii , 19 Conversely, if a patient wanted to alive longer or allow time for the medical conditions to amend, then prolongation of life could be considered a do good,20 , 21 and tube feedings justifiable.
The beginning step in the decision-making procedure is to approximate the expected survival of a patient who has abnormal swallowing, then estimate the potential benefit of PEG placement. The medical literature currently provides simply office of the necessary data. Of stroke patients with swallowing difficulties, 45% to 68% are dead within 6 months.6 , 22 , 23 A contempo written report reported a survival advantage for stroke patients randomized to feedings past the PEG road versus nasogastric route.24 How such patients would fare without any form of tube feedings is non known. Still less is known for nonstroke weather condition. Most investigators report patients later on the PEG tube has been placed. As shown in Table 1, the mortality rate for these patients is high: 2% to 27% are dead within 30 days, and approximately 50% or more inside 1 year.16 , 25 – 40 Although informative, these studies cannot provide survival estimates for those who might non cull PEG feedings.
Published Studies on PEG Tubes with More Than l Patients*
Such information could be obtained from a randomized, controlled trial of patients having and not having PEG tubes, with a sample size sufficient to allow identification of prognostic factors. Yet, to conduct such a report would require the participants (and their families) to be sufficiently neutral toward tube feedings to allow randomization in the first place. At this point in fourth dimension, enrolling such patients in the U.s.a. would exist difficult. Yet, some insights might be achieved through a retrospective cohort analysis, starting at the time of an aberrant swallowing study, whether or not a PEG was subsequently placed. We therefore undertook the following study to examine life expectancy in these patients, and to begin identifying of import prognostic factors in those eligible to receive tube feedings.
Methods
Study Site
St. Joseph Mercy Hospital (Ann Arbor, Mich.) is a 560-bed, university-affiliated, community pedagogy infirmary. Because swallowing studies could be coded differently on billing data, nosotros obtained lists for all inpatients who had either a barium swallow study or VFSS during years 1990 –1992. This report focused on inpatients, to permit more than efficient data collection. Of ane,056 patient records requested, one,010 were able to be retrieved and reviewed.
Study Exclusion Criteria
Of the 1,010 charts reviewed, 122 of the patients had a barium swallow examination only and so were excluded, leaving 888 patients who had had a VFSS. Of these, 739 patients were non included in the report cohort for the following reasons: they were allowed to eat (unremarkably a modified diet) based on the VFSS results, and and then were not candidates for tube feedings (n = 577/888 or 65% of VFSS patients); or they already had a PEG tube placed at the fourth dimension of the VFSS (due north = 79, nine%). Patients were also excluded if they had a thoracotomy on the same hospital access (for example, coronary artery featherbed, n = 33, 4%), considering patient variables inverse oftentimes during the postoperative period and PEG placement could be considered function of the postoperative intendance. Other exclusions were patients for whom the decision to place a PEG tube seemed more than straightforward: those with oropharyngeal carcinoma, carcinoma of the thyroid, esophageal cancer, previous radiations therapy to the neck area, or resection of the epiglottis (n = 27, 3%); who had mechanical obstruction from cricopharyngeal spasm (due north = 6, 1%); who were intubated or had a cuffed tracheostomy (due north = 7, i%); were uncooperative (n = 8, 1%); or had an esophagectomy or gastrectomy (n = 2, 0.2%).
Inclusion Criteria
1 hundred twoscore-nine patients fulfilled the criteria of nonoral feeders despite compensatory strategies. These were patients who were able to participate in the VFSS evaluation for at least i bolus presentation, and had at least one of the post-obit: inability to sustain arousal for thirty minutes several times per day, combined with neurologic deficits or astringent deconditioning; inability to propel more than than 25% of the bolus to the pharynx; aspiration of more than 1 consistency, or frank, gross aspiration of 1 consistency, with suboptimal alertness; or moderate-to-severe (greater than 50% of the bolus) stasis in the pharynx that could not be cleared with dry out swallows or thin liquids.
Result
Charts were reviewed by ane of four reviewers (three physicians and a nurse) who were blinded to the master consequence of interest—survival time. All deaths were assumed to have occurred inside Michigan owing to the nature of the hospital admitting patterns. Indices compiled from death certificates from the Michigan Department of Public Health were reviewed for years 1990 –1993 to determine the appointment and reported master crusade of death. Patients not known to have died, either by expiry alphabetize or by infirmary chart, were causeless to be alive as of the last day of the 1993 index, December 31. 1 year of follow-upward was therefore available for all subjects.
Predictors
Data were collected on a number of variables every bit of the date of the VFSS: patient demographics, level of alacrity (normal/impaired), skin decubiti (yeah/no), urinary incontinence or catheterization (yes/no), and circumstantial comorbidities (counted if currently present or if there was a history of the status).41 Serum albumin concentration (thousand/dl) was likewise recorded on the mean solar day of the VFSS, if available. If a level was not available, then the level for the almost recent prestudy date was used, or if that was not available, so the commencement reported level later the study was used. If no serum albumin value could be found (for 18/149 patients), we imputed the mean value of the entire report group. The best level of orientation (person, place, and time) accomplished prestudy was also recorded, resulting in a binary variable for beingness at least oriented to person or not. For 19 of the 149 patients, the level of orientation was indeterminable or missing. In these cases, we chose to err on the side of biasing in favor of the zero hypothesis, meaning these patients were assumed to exist oriented to person.
The hospital course following the VFSS was reviewed to determine whether or not a PEG tube was placed before hospital discharge. If a PEG was non placed, the reason was listed. This resulted in three categories of patients post-VFSS: PEG tube placed (due north = 80), PEG tube non placed because of rapid clinical improvement prior to hospital discharge ("improved" group, n = 18), and PEG tube non placed due to comfort considerations (n = 51). This latter category included patients who refused (or whose families refused) whatever course of tube feedings (n = 28), patients discharged with some form of tube feeding by the nasogastric route (n = 10), patients who died before receiving a PEG (northward = 12), and one patient who was transferred to another infirmary.
Statistical Analysis
All analyses were performed using the SAS software packet (SAS Institute, Cary, NC). Overall group survival was estimated with a Kaplan-Meier curve. Univariate predictors of bloodshed risk were identified by the log-rank test for categorical variables, and by single-variable Cox proportional hazards regressions for continuous variables. Multivariable Cox proportional hazards models were synthetic from candidate variables related to survival with values of p = .20 or less on univariate analyses. The final multivariable model was determined using backwards elimination, with the benchmark for retention set p = .05. In order to detect overfitting that might occur from multiple significance testing with the backwards elimination process, the coefficients and standard errors were reevaluated using the bootstrap technique. This involved selecting 1,000 bootstrap samples, each containing 149 "subjects" selected with replacement from our data fix. A carve up proportional hazards model was developed from each sample, and the mean and standard deviations from the 1,000 sets of regression coefficients were calculated. As the mean regression coefficient and the respective standard difference provide a more valid (less prone to overfitting) reflection of the magnitude and the precision of the effect of each factor in the final model, a comparing of these values with the coefficients and standard errors of the final model provides a machinery for assessing the validity of that model. Finally, graphs displaying survival patterns for various combinations of the prognostic variables were constructed.
Results
The characteristics of the study population are presented in Tables two three. The mean age was 76.2 years, 41.6% were women, and 89.9% were white. Almost of the patients had serious comorbid conditions, with a mean Charlson score of 3.48. The most frequent conditions were cerebrovascular blow (56.4%), hemiplegia (41.6%), congestive heart failure (32.2%), and dementia (20.1%).
Characteristics of Report Population
Univariate Mortality Hazard Factors
Overall Grouping Analysis
The median survival of the study population was 159 days (95% confidence interval [CI] 72, 276 days), estimated xxx-24-hour interval mortality was 27%, 90-day bloodshed 42%, and 1-year mortality 62%. Causes of decease equally recorded on the expiry certificates were cardiac (29.viii%), cerebrovascular (18.three%), cancer (x.vi%), other neurologic weather (6.7%), diabetes (5.viii%), pneumonia (5.8%), chronic obstructive lung (5.eight%), and other (17.3%).
Table 3 summarizes the univariate analyses. The mortality charge per unit ratio (RR), or hazard of decease, was increased in those with advancing age, lower serum albumin concentration, higher Charlson comorbidity category, and in those who had had a myocardial infarction, congestive heart failure, cerebrovascular illness, or lymphoma. Patients disoriented to person were at deadline increased run a risk (RR 1.73; 95% CI 0.90 , three.33).
The multivariable proportional hazards model identified iv variables that were independently associated with an increased likelihood of death: advanced age category (RR 1.48 compared with the next younger category, 95% CI 1.x, 2.00), reduced serum albumin category (RR 1.29 compared with the adjacent higher category, 95% CI 1.04, one.59), disorientation to person (RR 2.29 over those who were oriented, 95% CI i.sixteen , iv.53), and higher Charlson comorbidity category (RR i.82 compared with the side by side lower category, 95% CI 1.39, 2.37). These remained significant predictors when reevaluated past the bootstrap technique. Figure i displays projected survival patterns based on various combinations of the explanatory variables in the multivariable model. Every bit shown, most combinations of the take a chance factors projected median survivals of less than half-dozen months.
Figure Projected survival estimates based on the multivariable model. For all panels, curves represent combinations of Charlson comorbidity scores and serum albumin levels (one thousand/dl): (A) age less than lxx, and oriented to person; (B) age greater than 80, and oriented to person; (C) age less than seventy, and disoriented to person; (D) age greater than eighty, and disoriented to person.
Subgroup Analysis
Survival curves for the three categories of patients based on subsequent PEG tube status (PEG, comfort care, and improved) are shown in Figure 2 (p = .0001). Unadjusted median survival was 33 days for the comfort group (95% CI 9 , 124 days), and 181 days for the PEG group (95% CI seventy, 318 days). Patients in the improved group had their clinical improvement, on the average, within 13.eight days after their VFSS. These patients were younger, more likely to exist men, and had higher serum albumin concentrations than the other subgroups. The survival advantage of the improved and the PEG groups compared with the comfort intendance group remained afterwards adjusting for the four survival determinants in the multivariable model (improved RR 0.09, 95% CI 0.03, 0.31; PEG RR 0.48, 95% CI 0.32, 0.74).
Figure Kaplan-Meier curves according to PEG status. Unadjusted survival curves according to PEG status. The top bend represents the clinically improved group; the middle curve, those who underwent PEG placement; the lower bend, those without PEG placement, comfort care status.
Discussion
The focus of this study was to derive survival estimates for patients with abnormal swallowing studies, in guild to assistance clinicians and patients with the tube feeding decision. Our study grouping was composed of 17% of all patients who had had a VFSS in our hospital. This is near the midpoint for the reported prevalence of 12% to 32% for severe dysfunction as demonstrated by VFSS.8 – 11 , 42 Nosotros establish these patients to be at high adventure of dying in the ensuing year. At particular take a chance were patients with avant-garde historic period, increasing comorbidity, low serum albumin concentration, and disorientation to person. Later adjusting for these predictors, patients with PEG tubes placed later their VFSS survived twice every bit long as those in the comfort care grouping. A subset of patients, comprising 12% of the report cohort, avoided a PEG tube considering of their rapid clinical improvement, occurring on average within 2 weeks of the swallowing study.
Bloodshed rates and previously identified predictors of decease in patients with PEG tubes are shown in Table 1. In our study, nosotros were able to confirm the increased take a chance associated with advancing age. We were unable to confirm the increased take a chance associated with male gender and diabetes. The differences in clinical predictors tin can all-time be explained by patient selection factors. The other studies began follow-up afterward patients had been selected for PEG placement for various reasons. Our report began at an before fourth dimension in the clinical class, at the time of an abnormal VFSS, and more closely approximated the point in time when the decision for or confronting a PEG is made. Other differences in results can be explained by patient inclusion criteria and written report settings. For example, we did not include patients with oropharyngeal or esophageal cancer in our report. Information technology is as well possible that our study lacked the necessary statistical power to ostend the findings from the other studies.
Despite these differences, the mortality rate is similarly high in these studies and in ours. The 62% one-year mortality of our patients was similar to the 59% rate in patients with Charlson points of three or greater.41 For stroke patients, the 56% six-month mortality in our series was almost identical to mortality rates found in ii other recent studies.6 , 16
The clinical predictors identified in our study are not novel. Age,43 Charlson score,41 , 43 serum albumin,44 – 46 and cognitive damage (our disorientation variable)47 , 48 have all been previously identified as mortality risk factors. In a sense, nosotros accept validated these every bit predictors for the population of patients with severely abnormal VFSS.
This study has a number of of import limitations. Information technology was not a randomized clinical trial comparing survival betwixt patients fed via the PEG route, versus no tube feedings. Our control group was a heterogeneous group that included patients who died in the infirmary (12/51), those who had tube feedings by a non-PEG route (10/51), and those who refused any course of tube feedings (28/51). It appears that patients who underwent PEG placement survived approximately twice as long as those who did not, after controlling for the four mortality run a risk factors. It is likely the survival advantage was due to other prognostic factors which were influencing the decision to place the PEG tube. All the same, these remain unidentified. We therefore cannot show the benefit of a PEG tube by this study design.
Another potential limitation is with the identification of the mortality chance factors. The selection of comorbidities was based on the prognostic factors identified by Charlson et al.41 However, nosotros did not distinguish between active versus historical problems for the patient, nor did nosotros identify levels of affliction severity inside the conditions. Equally currently defined, the number of comorbidities appears to have prognostic significance in the population of patients with abnormal swallowing. It is unknown if more precise prognostic data would be gained by further stratifying these based on current level of disease activeness. Similarly, the variable for cerebral dysfunction was rather crude—disorientation to person or not. If this could not exist determined by chart review, then patients were assigned to the default category, orientation to person. One tin can hypothesize that more precise information would have improved the explanatory ability of this variable. In this aforementioned line of reasoning, the serum albumin variable can be criticized because the exam was ordered at unlike times past different clinicians. Another problem is that missing values were assigned the hateful value for the group. These flaws would tend to weaken the changed relation between the serum albumin level and mortality risk. Because a number of factors may influence the serum albumin level,45 , 46 controlling for the acuity or chronicity of the underlying atmospheric condition might further refine this explanatory variable. Many of these discussed limitations are in part due to the retrospective cohort written report design. Nevertheless, such a written report has merit if information technology is viewed every bit an initial step in agreement the prognosis of these patients.
A final limitation is the absence of a "testing" set up, a second cohort of patients on which to test the validity of the explanatory variables. We began the validation attempt by submitting all of our multivariable regression models to bootstrap testing. This demonstrated that the selected multivariable parameters remained meaning through 1,000 replications, suggesting the stability of our findings. Yet, earlier the results could be applied with confidence to an individual patient, more definitive validation must be done.49
It is important non to enlarge the applicability of our study to individual decision making. At best, it provides a context for patient-physician dialogue. The reported survival estimates are a starting point for estimating the prognosis for patients with severely aberrant swallowing studies, rather than a formal clinical predictive rule. At this time, to extend these estimates for a group to an private as well volition require the clinician to consider other prognostic information such as the likelihood of reversibility of the medical conditions,20 , 21 , fifty disease-specific predictors found in the literature, individual patient characteristics, and clinical judgment.45 Quality of life, non addressed in our study, likewise must be considered.20 , 21 , 51 The decision for or against tube feedings must be based on all information at mitt, imprecise as information technology might be. Further studies are needed to provide clinicians, patients, and families with clearer guidelines for these difficult decisions.
Acknowledgments
This project was completed with the assistance of the post-obit: E. Francis Cook, ScD, Due east. John Orav, PhD, Glenn One thousand. Chertow, MD, Dorian D. Moore, MD, Mary Hawley, OTR, and Frances Gronczewski, Fine art.
References
1. Ott DJ, Pikna AL. Clinical and videofluoroscopic evaluation of swallowing disorders. AJR. 1993;161:507–thirteen. [PubMed] [Google Scholar]
ii. Martin BJW, Corlew MM, Wood H, et al. The association of swallowing dysfunction and aspiration pneumonia. Dysphagia. 1994;ix:ane–half-dozen. [PubMed] [Google Scholar]
3. Logemann JA. Treatment for aspiration related to dysphagia: an overview. Dysphagia. 1986;i:34–eight. [Google Scholar]
four. Feinberg MJ. Radiographic techniques and interpretation of abnormal swallowing in adult and elderly patients. Dysphagia. 1993;8:356–8. [PubMed] [Google Scholar]
5. Groher ME, Bukatman R. The prevalence of swallowing disorders in two teaching hospitals. Dysphagia. 1986;i:iii–6. [Google Scholar]
six. Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry. 1989;52:236–241. [PMC free article] [PubMed] [Google Scholar]
viii. Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN. Aspiration following stroke: clinical correlates and event. Neurology. 1988;38:1359–62. [PubMed] [Google Scholar]
9. Horner J, Alberts MJ, Dawson DV, Cook GM. Swallowing in Alzheimer'southward illness. Alzheimer Dis Assoc Disord. 1994;8:177–89. [PubMed] [Google Scholar]
10. Feinberg MJ, Ekberg O, Segall L, Tully J. Deglutition in elderly patients with dementia: findings of videofluorographic evaluation and bear upon on staging and management. Radiology. 1992;183:811–4. [PubMed] [Google Scholar]
xi. Chen MYM, Peele VN, Donati D, et al. Clinical and videofluoroscopic evaluation of swallowing in 41 patients with neurologic affliction. Gastrointest Radiol. 1992;17:95–8. [PubMed] [Google Scholar]
12. Bird MR, Woodward JC, Gibson EM, Phyland DJ, Fonda D. Asymptomatic swallowing disorders in elderly patients with Parkinson'south disease: a clarification of findings on clinical examination and videofluoroscopy in xvi patients. Age Ageing. 1994;23:251–iv. [PubMed] [Google Scholar]
13. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: indications, limitations, techniques, and results. World J Surg. 1989;13:165–70. [PubMed] [Google Scholar]
14. O'Brien LA, Grisso JA, Maislin Thou, et al. Nursing dwelling house residents' preferences for life-sustaining treatments. JAMA. 1995;274:1775–nine. [PubMed] [Google Scholar]
15. Stellato TA, Gauderer MWL. Percutaneous endoscopic gastrostomy in the cancer patient. Am Surg. 1988;54:419–22. [PubMed] [Google Scholar]
16. Taylor CA, Larson DE, Ballard DJ, et al. Predictors of outcome after percutaneous endoscopic gastrostomy: a customs-based study. Mayo Clin Proc. 1992;67:1042–9. [PubMed] [Google Scholar]
17. American Gastroenterological Association Medical Position Statement. Guidelines for the use of enteral diet. Gastroenterology. 1995;108:1280–301. [PubMed] [Google Scholar]
18. Emanuel LL, Emanuel EJ. The medical directive. JAMA. 1989;261:3288–93. [PubMed] [Google Scholar]
19. Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directives on medical treatments and costs. Ann Intern Med. 1992;117:599–606. [PubMed] [Google Scholar]
twenty. Quill TE. Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital. Arch Intern Med. 1989;149:1937–41. [PubMed] [Google Scholar]
21. Lo B, Dornbrand L. Agreement the benefits and burdens of tube feedings. Arch Intern Med. 1989;149:1925–6. [PubMed] [Google Scholar]
22. Schmidt J, Holas M, Halvorson K, Reding M. Videofluoroscopic evidence of aspiration predicts pneumonia and death merely not dehydration following stroke. Dysphagia. 1994;9:7–xi. [PubMed] [Google Scholar]
23. Wanklyn P, Cox N, Belfield P. Result in patients who require a gastrostomy after stroke. Historic period Ageing. 1995;24:510–4. [PubMed] [Google Scholar]
24. Norton B, Homer-Ward M, Donelly MT, Long RG, Holmes GKT. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996;312:13–half-dozen. [PMC costless article] [PubMed] [Google Scholar]
25. Rabeneck L, Wray NP, Petersen NJ. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. J Gen Intern Med. 1996;11:287–93. [PubMed] [Google Scholar]
26. Miller RE, Castlemain B, Lacqua FJ, Kotler DP. Percutaneous endoscopic gastrostomy. Surg Endosc. 1989;3:186–90. [PubMed] [Google Scholar]
27. Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous endoscopic gastrostomy. Gastroenterology. 1987;93:48–52. [PubMed] [Google Scholar]
28. Horton WL, Colwell DL, Burlon DT. Experience with percutaneous endoscopic gastrotomy in a community hospital. Am J Gastroenterol. 1991;86:168–ix. [PubMed] [Google Scholar]
29. Wolfsen HC, Kozarek RA, Brawl TJ, et al. Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy. Am J Gastroenterol. 1990;85:1120–2. [PubMed] [Google Scholar]
xxx. Raha SK, Woodhouse K. The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients. Age Ageing. 1994;23:162–3. [PubMed] [Google Scholar]
31. Stiegmann GV, Goff JS, Silas D. Endoscopic versus operative gastrostomy. Gastrointest Endosc. 1990;36:ane–5. [PubMed] [Google Scholar]
32. Stuart SP, Tiley EH, Boland JP. Feeding gastrostomy: a disquisitional review of its indications and bloodshed charge per unit. South Med J. 1993;86:169–72. [PubMed] [Google Scholar]
33. Zabel JS, Onstad GR, Cass OW. Long-term follow-up of patients with percutaneous endoscopic gastrostomy (PEG), jejunostomy (PEJ) and peg-jejunal tubes (PEGJ) Gastroenterology. 1989;96:A563. Abstract. [Google Scholar]
34. Fay DE, Poplausky 1000, Gruber M, Lance P. Long-term enteral feeding: a retrospective comparison of delivery via percutaneous endoscopic gastrostomy and nasoenteric tubes. Am J Gastroenterol. 1991;86:1604–9. [PubMed] [Google Scholar]
35. Llaneza PP, Menendez AM, Roberts R, Dunn GD. Percutaneous endoscopic gastrostomy. South Med J. 1988;81:321–4. [PubMed] [Google Scholar]
36. Slezak FA, Kofol WH. Combined tracheostomy and percutaneous endoscopic gastrostomy. Am J Surg. 1987;154:271–3. [PubMed] [Google Scholar]
37. Ciocon JO, Silverstone FA, Graver M, Foley CJ. Tube feedings in elderly patients. Arch Intern Med. 1988;148:429–33. [PubMed] [Google Scholar]
38. Jarnagin WR, Duh QY, Mulvihill SJ, Ridge JA, Schrock TR, Way LW. The efficacy and limitations of percutaneous endoscopic gastrostomy. Arch Surg. 1992;127:261–4. [PubMed] [Google Scholar]
39. Gay F, El Nawar A, Van Gossum A. Percutaneous endoscopic gastrostomy. Acta Gastroenterol Belg. 1992;55:285–94. [PubMed] [Google Scholar]
xl. Samii AM, Suguitan EA. Comparing of operative gastrostomy with percutaneous endoscopic gastrostomy. Mil Med. 1990;155:534–5. [PubMed] [Google Scholar]
41. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373–83. [PubMed] [Google Scholar]
42. Hodge RG, Pikna LA, Ott DJ, et al. Modified barium eat: clinical indication and radiographic results in determining feeding recommendations. Gastroenterology. 1992;103:1410. Abstruse. [Google Scholar]
43. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245–51. [PubMed] [Google Scholar]
44. Corti MC, Guralnik JM, Salive ME, Sorkin JD. Serum albumin level and concrete inability as predictors of mortality in older persons. JAMA. 1994;272:1036–42. [PubMed] [Google Scholar]
45. Knaus WA, Harrell Iron, Lynn J, et al. The Back up prognostic model. Ann Intern Med. 1995;122:191–203. [PubMed] [Google Scholar]
46. Klonoff-Cohen H, Barrett-Connor EL, Edelstein SL. Albumin levels every bit a predictor of mortality in the healthy elderly. J Clin Epidemiol. 1992;45:207–12. [PubMed] [Google Scholar]
47. Tatemichi TK, Paik M, Bagiella E, Desmond DW, Pirro M, Hanzawa LK. Dementia after stroke is a predictor of long-term survival. Stroke. 1994;25:1915–9. [PubMed] [Google Scholar]
48. Kelman HR, Thomas C, Kennedy GJ, Cheng J. Cognitive impairment and bloodshed in older community residents. Am J Public Health. 1994;84:1255–sixty. [PMC free article] [PubMed] [Google Scholar]
49. Braitman LE, Davidoff F. Predicting clinical states in individual patients. Ann Intern Med. 1996;125:406–12. [PubMed] [Google Scholar]
50. Hodges MO, Tolle SW, Stocking C, Cassel CK. Tube feedings. Curvation Intern Med. 1994;154:1013–20. [PubMed] [Google Scholar]
51. Meyers RM, Grodin MA. Determination making regarding the initiation of tube feedings in the severely demented elderly: a review. J Am Geriatr Soc. 1991;39:526–31. [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497065/
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