Practice variation in PEG tube placement: trends and predictors among providers in the United States

Abstract

Background: Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States.

Objective: To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States.

Design: Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010.

Setting: Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI).

Patients: Patients undergoing upper endoscopy.

Interventions: PEG tube placement.

Main outcome measurements: Number of PEG tubes placed.

Results: Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists.

Limitations: Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers.

Conclusion: Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings.