title: Predictors of emergent feeding tubes and tracheostomies in amyotrophic lateral sclerosis (ALS).
abstract: Predictable decline in ALS makes unplanned gastrostomy and tracheostomy avoidable. We determined whether gastrostomy or tracheostomy insertion during emergent hospitalization is associated with patient or hospital characteristics, changed Medicare policy in 2001, or proximity to specialized ALS care. We performed a retrospective analysis of hospitalizations and procedures for ALS/MND patients in Pennsylvania between 1996 and 2009. We identified predictors of gastrostomy/tracheostomy during emergent hospitalization and trends over time. Patients underwent 1748 gastrostomies and 373 tracheostomies. Thirty-two percent of gastrostomies and 67% of tracheostomies were placed emergently. Emergent hospitalizations involving gastrostomy were more expensive with fewer home discharges. Black patients and Medicaid patients had higher odds of emergent gastrostomy placement. Conversely, academic hospital affiliation decreased odds of emergent gastrostomy or tracheostomy placement (AOR 0.49, AOR 0.37, p < 0.001). After Medicare policy changes, gastrostomy use increased, while emergent gastrostomies decreased. Surprisingly, proximity to specialized care was associated with increased emergent gastrostomy placement. In conclusion, black patients and Medicaid patients were more likely to undergo emergent gastrostomy insertion. Patients receiving gastrostomy during emergent admissions had fewer home discharges and higher costs. Academic hospital affiliation decreased odds of emergent gastrostomy or tracheostomy. After Medicare changes broadening access, while gastrostomy use increased, the proportion of emergent procedures decreased.
authors.affiliation: Robert Wood Johnson Foundation Veterans Affairs Clinical Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA. amy.tsou@uphs.upenn.edu
authors.forename: Amy Y
authors.initials: AY
authors.lastname: Tsou
authors.forename: Jason
authors.initials: J
authors.lastname: Karlawish
authors.forename: Leo
authors.initials: L
authors.lastname: McCluskey
authors.forename: Sharon X
authors.initials: SX
authors.lastname: Xie
authors.forename: Judith A
authors.initials: JA
authors.lastname: Long
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000690:Amyotrophic Lateral Sclerosis / Q000191:economics / Q000628:therapy*; D004750:Enteral Nutrition; D005260:Female; D005774:Gastrostomy; D006291:Health Policy; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010414:Pennsylvania; D012189:Retrospective Studies; D014139:Tracheostomy / Q000191:economics; D014481:United States