Background and purpose: Swallowing difficulties are common poststroke. National clinical guidelines recommend feeding by percutaneous endoscopic gastrostomy (PEG) when oral nutrition cannot be maintained although survival benefit might be short term. It is unknown whether a decade of general care improvements have impacted upon PEG provision and outcomes. This retrospective cohort study examined PEG placement and mortality poststroke in England.
Methods: National Health Service Hospital Episode Statistics and Office for National Statistics mortality data between April 2007 and March 2018 were linked to identify all admissions in England with stroke-related International Classification of Diseases codes (I61, I63, and I64)±PEG insertion and deaths at 3, 6, and 12 months. Linear and logistic regression examined trends over time and mortality.
Results: Patients (923 236) with stroke underwent 17 532 PEG procedures (mean rate 1.9%), with an average reduction of -27 procedures/year ([95% CI, -56 to 1.4]; P=0.06) despite an average increase of 1804 stroke admissions/year. Mortality decreased among cases without a PEG procedure: -190 deaths/year ([95% CI, -276 to -104]; P<0.001) at 3 months, -167 deaths/year ([95% CI, -235 to -98]; P<0.001) at 6 months and -103 deaths/year ([95% CI, -157 to -50]; P<0.01) at 12 months; and also reduced following PEG insertion: -28 deaths/year ([95% CI, -35 to -20]; P<0.001) at 3 months, -33 deaths/year ([95% CI, -46 to -20]; P<0.01) at 6 months and -30 deaths/year ([95% CI, -48 to -13]; P<0.01) at 12 months. With all years combined, PEG insertion was weakly associated with reduced mortality at 3 months (odds ratio, 0.94 [95% CI, 0.90-0.97]) but significantly higher mortality at 6 months (odds ratio, 1.69 [95% CI, 1.64-1.75]) and 12 months (odds ratio, 2.14 [95% CI, 2.08-2.20]).
Conclusions: PEG procedures and subsequent deaths have decreased in the context of general mortality reductions after hospitalization for stroke, but survival at 6 and 12 months remains significantly worse for patients with PEG placement.
Keywords: England; dysphagia; enteral nutrition; health services research; mortality; stroke.