PEDIATRIC ENTERAL ACCESS PROCEDURES IN THE U.S.: REGIONAL VARIATION AND CHANGING RATES

Purpose: Enteral access procedures may be a preference-sensitive decision, but practice variation has not been demonstrated in pediatrics.  Our purpose was to describe rates of pediatric gastrostomy tube and percutaneous endoscopic gastrostomy (PEG) tube insertion by age category and examine regional variation and incidence trends over time for these two procedures  

Method: We conducted a retrospective repeat cross-sectional study of admissions with a gastrostomy tube or PEG tube (ICD-9: 43.19 and 43.11) placement.  We combined data from the Kids’ Inpatient Database (1997, 2000, 2003, 2006, 2009) with U.S. census data to estimate national rates of hospitalizations that included one of these procedures. The population based rate was compared between the following age categories:  neonate, 30 days to 1 year, 1 to 4 years, 5-12 years, and 12 to 17 years.

Results: We examined a total of 64,411 admissions that had either a gastrostomy tube (62.3%) or PEG (37.7%) procedure.  We calculated a national rate of enteral access procedures of 17.7 per 100,000 children (100K) in the U.S. per year (gastrostomy 11.0 and PEG 6.7 per 100K children per year).  The West showed a 15% higher rate than the national average (Rate Ratio 1.15, p<0.01).  The individual procedures also showed variation by region with higher rates for PEG and gastrostomy tube placement in the Western region (Rate Ratio 1.10, p<0.01, and 1.18, p<0.01, respectively).  For the Northeast, the PEG rate ratio was 1.11 (p=0.05) and for gastrostomy procedures was .83 (p=0.05) compared to the national average.  For children < 5 years of age, the rate of enteral access admissions increased over time, with an increase of 16.2% from 1997 to 2009 (43.3 to 50.3 procedures per 100K children per year).  Gastrostomy procedures accounted for 68.0 percent of that increase.  Children over 5 years showed a decrease of 10.2% (6.5 to 5.8 procedures per 100,000 children) over the study period.   

Conclusions: Regional variation in the performance of enteral access procedures is supportive of the hypothesis that this decision is preference-sensitive and may benefit from a family decision aid designed specifically for pediatrics.  The increasing rate of enteral access procedures in the very young deserves further study to assess if this reflects changing preferences or a change in the population considered eligible for the procedures.