Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Frail Patients: Exploring Postprocedural Outcomes and Readmissions Using the National Readmission Database, 2018–2020

Abstract

Objective

Percutaneous endoscopic gastrostomy (PEG) tube placement is a common gastrointestinal procedure that provides nutrition, fluids, and medications to patients with inadequate oral intake. A substantial proportion of patients undergoing PEG tube placement are frail. This study compares mortality, morbidity, and 30-day hospital readmission rates between frail and nonfrail patients undergoing PEG tube placement.

Materials and Methods

We conducted a retrospective analysis using data from the National Readmission Database for 2018 to 2020. The study included all patients aged ≥ 18 years who underwent PEG tube placement. Patients were stratified into two groups based on frailty, defined using the Johns Hopkins Adjusted Clinical Groups Frailty Indicator. Primary outcomes were mortality and all-cause 30-day readmission rates. Secondary outcomes included length of stay (LOS), total hospitalization charges, and inpatient complications such as sepsis and aspiration pneumonia.

Statistical Analysis

A multivariate regression model was used to estimate clinical outcomes between the two cohorts after adjusting for potential confounders.

Results

A total of 419,313 patients underwent PEG tube placement, among whom 278,564 (66.43%) were frail. Frail patients had higher mortality (p = 0.003), longer LOS, and higher all-cause readmission rates than nonfrail patients. Rates of gastric perforation and intraprocedural puncture/laceration were lower in frail patients. The most common causes of 30-day readmission were sepsis (53.14%), pneumonitis due to inhalation of food and vomit (15.55%), gastrostomy malfunction (6.13%), acute kidney failure (3.38%), and pneumonia, unspecified organism (3.97%). Independent predictors of all-cause readmission included frailty, age, Charlson Comorbidity Index, hospital bed size, and insurance, all statistically significant.

Conclusion

Frail patients undergoing PEG tube placement have higher mortality, morbidity, and readmission burden. These findings highlight the need for caution when performing PEG tube placement in frail patients. Further research is warranted to validate these findings.

Keywords

percutaneous endoscopic gastrostomy (PEG) tube - frailty - mortality - hospital readmission rate - morbidity - Johns Hopkins Adjusted Clinical Groups (ACG) Frailty Indicator

Introduction

Percutaneous endoscopic gastrostomy (PEG) tube placement is a minimally invasive procedure used to provide enteral nutrition to patients unable to maintain adequate oral intake. PEG placement was first described by Gauderer et al in 1980 and involves the insertion of a feeding tube directly into the stomach through the abdominal wall under endoscopic guidance.[1] [2] [3] This procedure is highly prevalent, with over 160,000 to 200,000 PEG placements performed annually in the United States due to advancements in medical care and an aging population.[4]

Significant practice variation exists in PEG tube placement regarding patient demographics, provider characteristics, and endoscopy settings.[5] PEG tubes are indicated for patients unable to meet nutritional requirements orally, such as those with dysphagia from neurological disorders, severe dementia, head and neck malignancies, or prolonged critical illness. Absolute contraindications include distal enteral obstruction, severe uncorrectable coagulopathy, and hemodynamic instability.[6]

In current practice, PEG tubes are frequently placed in frail patients with multiple comorbidities, and their prevalence has increased.[7] [8] We used the Johns Hopkins Adjusted Clinical Groups (ACG) Frailty Indicator, a population-based frailty assessment tool derived from the Johns Hopkins ACG System, which uses diagnostic and health care utilization data to identify frail individuals.[9] This tool categorizes patients based on comorbid conditions, including protein-energy malnutrition, dementia, blindness, decubitus ulcer, bladder discomfort, fecal incontinence, failure to thrive, housing problems, gait instability, and falls.[10] [11]

PEG tube placement is generally safe but carries risks of minor complications (e.g., wound infections, bleeding) and major complications (e.g., aspiration pneumonia, necrotizing fasciitis, tumor seeding at the stoma).[6] [12] This study evaluates in-hospital clinical outcomes, health care utilization, and resource burden between frail and nonfrail patients and determines frailty as a predictor of short-term prognosis.

Materials and Methods

Study Design and Database

We conducted a retrospective cohort study of adult patients who underwent PEG tube placement in the United States from 2018 to 2020 using the National Readmission Database (NRD), the largest publicly available readmission database in the United States, developed by the Healthcare Cost and Utilization Project (HCUP).[13] The NRD stores patient-level and hospital-level information. Hospitals are stratified by ownership, number of beds, teaching status, and metropolitan/nonmetropolitan location. Patient-level information includes demographics, diagnoses, procedures, discharge status, hospitalization charges, and length of stay (LOS). Hospital-level variable includes teaching status and number of beds. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes were used for diagnoses, and ICD-10 Procedure Coding System (ICD-10-PCS) codes for procedures.

Study Population

We identified 419,313 patients aged ≥ 18 years who underwent PEG tube placement using ICD-10-PCS codes 0DH64UZ and 0DH63UZ.[14] Patients were stratified into frail and nonfrail cohorts based on the Johns Hopkins ACG Frailty Indicator, a binary classification system that identifies patients at risk for adverse outcomes based on administrative claims data. This indicator has been validated against other frailty measures, including the Fried phenotype and Clinical Frailty Scale, and predicts mortality and readmissions in large population cohorts.[9] [15] Index hospitalizations in December were excluded to allow complete 30-day follow-up for readmission outcomes, as NRD follows a calendar-year structure.

Study Variables and Outcomes

Demographics, hospital characteristics, and Charlson Comorbidity Index (CCI) were collected. Information about age, sex, insurance provider, median income in patient's zip code, and hospital characteristics including hospital region, teaching status, and bed size were collected from NRD database directly. Patient comorbidities were categorized using the Deyo adaptation of CCI. Deyo adaption of CCI consists of a total of 19 categories of clinical comorbid conditions, which are assigned prespecified scores.[16] CCI predicts the 10-year mortality of the patient based on the CCI scores.

• Primary outcome: in-hospital mortality.

• Secondary outcomes: 30-day all-cause readmission, LOS, total hospitalization charges, sepsis, and aspiration pneumonia.

Mortality, LOS, and total charges were recorded in the NRD; secondary outcomes were coded using ICD-10-CM codes ([Supplementary File S1]). Confounders included age, sex, median income, CCI, hospital bed size, and teaching status. Variables included in multivariate regression were selected based on both clinical relevance and a univariate p-value threshold of < 0.2.

Statistical Analysis

Data analysis was conducted using Stata Version 18 (StataCorp, Texas, United States). Weighted samples were used for national estimates following HCUP regulations. HCUP rules and regulations were thoroughly followed in utilizing the NRD. NRD has complex sampling design that includes stratification, clustering, and weighting. Using a specialized set of commands in Stata, data was analyzed to produce nationally representative unbiased results, variance estimates, and p-values. Hospitalization characteristics such as mean age and distribution of variables like gender, hospital location, hospital teaching status, and hospital bed capacity were obtained from the database. Continuous variables were expressed as mean ± standard deviation and compared with Student's t-test; categorical variables were expressed as frequencies (%) and compared with Pearson's chi-square test. To identify all possible confounders, we performed thorough review of existing literature on PEG tube procedures, obtained expert opinion from the experts in the respective fields, and performed a univariate screening. Following the univariate screening, all the variables with p-value < 0.2 were included in the multivariate regression model to adjust for confounders while calculating the primary and secondary outcomes. Outcomes that were adjusted for included age, Charlson comorbidity groups, hospital location, hospital bed size, hospital teaching status, insurance status, and quartile of household income.

Multivariate linear regression was used for continuous outcomes; multivariate logistic regression for dichotomous outcomes. A p-value of < 0.05 was considered statistically significant.

Mortality was analyzed as an in-hospital binary outcome due to NRD constraints, precluding time-to-event analysis such as Kaplan–Meier or Cox regression.

Ethical Considerations

The NRD lacks patient- and hospital-specific identifiers. Therefore, this study was exempt from Institutional Review Board (IRB) approval as per guidelines put forth by our institutional IRB for analysis of the NRD database.

Results

A total of 419,313 adult patients (≥ 18 years) underwent PEG tube placement in the United States from 2018 to 2020, excluding December admissions to allow for complete 30-day follow-up. Of these, 278,564 (66.4%) were frail and 140,749 (33.6%) were nonfrail ([Fig. 1]).

Fig. 1 Flow diagram showing the selection process of the participants in the study.

The frail cohort were older, with a mean age of 68.8 years, and included a lower proportion of females (43.3%) compared with males (56.7%), relative to the nonfrail cohort (p = 0.02). Regarding comorbidity burden, the proportion of patients increased with higher CCI scores: 59.3% of frail patients had a CCI score ≥ 3, compared with 57.8% of nonfrail patients (p < 0.001). Most patients in both groups were admitted to metropolitan teaching hospitals and were covered by Medicare ([Table 1]).

Table 1 Comparison of demographic characteristics between frail and nonfrail patients, including p-values for statistical significance

Total PEG tube placement procedures (n = 419,313)
Variable	Frail (n = 278,564)	Nonfrail (n = 140,749)	p-Value
Age	68.77	63.65	< 0.001
Female (%)	43.27	42.72	0.02
Male (%)	56.73	57.28	0.02
Insurance (%)			< 0.001
Medicare	70.78	59.21
Medicaid	13.67	17.51
Private	13.99	20.83
Uninsured	1.55	2.45
Charlson Comorbidity Index (%)			< 0.001
0	8.95	13.01
1	13.90	13.74
2	17.85	15.47
3 or more	59.30	57.78
Median income in patients' zip code (%)			0.0002
$1–49,999	34.01	34.38
$50,000–64,999	27.10	27.81
$65,000–85,999	21.87	21.91
$86,000+	17.01	15.90
Hospital bed size (%)			< 0.001
Small	13.23	10.92
Medium	25.69	24.28
Large	61.08	64.80
Hospital teaching status (%)			< 0.001
Metropolitan nonteaching	15.92	13.30
Metropolitan teaching	78.68	82.61
Nonmetropolitan hospital	5.41	4.09

Abbreviation: PEG, percutaneous endoscopic gastrostomy.

Clinical Outcomes

Frailty was associated with higher odds of in-hospital mortality compared with nonfrail patients (p = 0.003). Frail patients also had higher odds of complications, including sepsis (p < 0.001) and aspiration pneumonia (p < 0.001) ([Fig. 2], [Table 2]).

Fig. 2 Comparison of rates of clinical outcomes between frail and nonfrail.

Table 2 Clinical outcomes and independent predictors of all-cause 30-day readmissions following PEG tube placement in frail and nonfrail patients, with corresponding p-values

Clinical outcomes
	Frail	Nonfrail	p-Value
In-hospital mortality (%)	8.17	7.29	< 0.001
Adjusted OR	1.06 (1.02–1.10)[a]		0.003
All-cause readmission (%)	15.37	12.98	< 0.001
Adjusted OR	1.16 (1.12–1.2)[a]		< 0.001
LOS (d)	23.86	22.50	< 0.001
Adjusted coefficient (d)	3.12 (2.83–3.42)[a]		< 0.001
Total charges ($)	300,961	326,836	< 0.001
Adjusted coefficient ($)	2,654 (–4130 to 9439)[a]		0.443
Sepsis (%)	6.44	5.02	< 0.001
Adjusted OR	1.31 (1.25–1.36)[a]		< 0.001
Aspiration pneumonia (%)	24.68	22.70	< 0.001
Adjusted OR	1.08 (1.05–1.11)[a]		< 0.001
Predictors of 30-day all-cause readmission for PEG tube placement
Variable	Adjusted OR		p -Value
Age	1.003 (1.0026–1.0050)		< 0.001
Frailty	1.16 (1.12–1.20)[a]		< 0.001
Charlson Comorbidity Index
0	Reference
1	1.20 (1.13–1.28)[a]		< 0.001
2	1.30 (1.23–1.38)[a]		< 0.001
3	1.58 (1.50–1.67)[a]		< 0.001
Insurance
Medicare	Reference
Medicaid	0.98 (0.94–1.02)[a]		0.434
Private	0.84 (0.81–0.88)[a]		< 0.001
Uninsured	0.76 (0.67–0.85)[a]		< 0.001
Hospital bed size
Small	Reference
Medium	0.93 (0.89–0.98)[a]		0.012
Large	0.91 (0.87–0.96)[a]		< 0.001

Abbreviations: LOS, length of stay; OR, odds ratio; PEG, percutaneous endoscopic gastrostomy.

^a 95% confidence interval.

Health Care Utilization

Hospital LOS, total hospitalization charges, and all-cause 30-day readmission rates were used as surrogate measures of health care utilization. Frailty was associated with a longer mean LOS compared with nonfrail patients (p < 0.001). There was no significant difference in total hospitalization charges between the groups (p = 0.443). Charges represent raw values and were not inflation-adjusted ([Table 2]).

Readmission Rates and Causes

Frailty was associated with significantly higher 30-day all-cause readmission rates compared with nonfrail patients (p < 0.001). The most common causes of readmission were sepsis (53.1%), pneumonitis (15.6%), gastrostomy malfunction (6.1%), acute kidney failure (5.7%), and pneumonia (4.0%) ([Table 2]).

Predictors of 30-Day Readmission

On multivariate regression, increasing age was associated with a small but statistically significant increase in 30-day readmission (p < 0.001). Frailty was an independent predictor of readmission (p < 0.001). A higher comorbidity burden (CCI ≥ 3) was also associated with increased readmission compared with CCI = 0 ([Fig. 3]).

Fig. 3 Graph showing predictors of 30-day all-cause readmission. CCI, Charlson Comorbidity Index.

Compared with Medicaid, uninsured patients had lower odds of readmission (p < 0.001). Medium-sized (p = 0.012) and large hospitals (p < 0.001) were associated with lower readmission rates compared with small hospitals ([Fig. 4]).

Fig. 4 Kaplan–Meier curve for 30-day all-cause readmission survival analysis. X axis: analysis time in days; Y axis: cumulative probability of readmission-free survival.

Outcomes Based on Type of Admission

Among frail patients, 29.3% (n = 256,984) underwent PEG tube placement during nonelective admissions, whereas 7.7% (n = 21,317) underwent elective placement. Compared with nonelective admissions, elective placement was associated with lower in-hospital mortality (p < 0.001) and reduced 30-day readmission rates (p = 0.001).

Elective placement was also associated with significantly fewer complications, including sepsis (p < 0.001) and aspiration pneumonia (p < 0.001). LOS was shorter with elective placement (p < 0.001). No significant difference in hospitalization charges was observed between elective and nonelective cases ([Table 3]).

Table 3 Clinical outcomes of frail patients undergoing PEG tube placement, stratified by type of hospital admission

Clinical outcomes of frail patients who underwent PEG tube placement based on type of admission
	Elective admission (7.65%)	Nonelective admission (92.34%)	p-Value
Mortality (%)	6.13	8.35	< 0.001
Adjusted OR	0.73 (0.67–0.80)[a]		< 0.001
All-cause readmission (%)	12.73	14.23	0.0001
Adjusted OR	0.89 (0.83–0.95)[a]		0.001
LOS (d)	21.28	24.08	< 0.001
Adjusted coefficient (d)	−3.72 (–4.3 to −3.1)[a]		< 0.001
Total charges ($)	306,633	300,498	0.311
Adjusted coefficient ($)	−7984 (−19707 to 3738)[a]		0.182
Sepsis (%)	2.99	6.73	< 0.001
Adjusted OR	0.42 (0.37–0.47)[a]		< 0.001
Aspiration pneumonia (%)	16.91	25.34	< 0.001
Adjusted OR	0.6 (0.56–0.64)[a]		< 0.001

Abbreviations: LOS, length of stay; OR, odds ratio; PEG, percutaneous endoscopic gastrostomy.

^a 95% confidence interval.

Discussion

Frailty is defined as a multidimensional state of increased vulnerability, resulting from age-associated decline in reserve and function across multiple physiologic systems that compromises the ability to cope with every day or acute stressors.[17] Fried et al described the clinical manifestations of frailty as a cycle of negative energy balance, sarcopenia, and diminished strength and tolerance for exertion.[18] These factors lead to inadequate oral intake and malnutrition, which may necessitate enteral nutrition through PEG tubes. Frailty is a critical factor in the management of elderly patients, particularly when considering invasive interventions.

Recent studies have highlighted an increase in the rates of PEG tube placement, particularly among individuals aged 75 and older, with a 38% rise in procedures observed in patients aged 65 and above.[7] [19] This was reflected in our study, where the mean age of the frail population was 68 years, as compared with the nonfrail group, with the mean age of 63. The decision to place a PEG tube is influenced by several factors, including the severity of dysphagia, nutritional requirements, reversibility of the underlying condition, patient preferences, and overall prognosis.[20] While PEG tubes provide crucial nutritional support, they do not significantly extend life expectancy, particularly in frail patients.[21] [22] This invasive procedure carries risks, such as aspiration and infection, that may complicate recovery. The patients' ability to tolerate the procedure, given their frailty and comorbidities, must also be carefully considered to ensure that the intervention aligns with their goals of care.

Frail individuals often exhibit diminished recovery capacity, which may reduce the effectiveness of PEG tube insertion in improving survival or functional status. Our results showed statistically significant differences between frail and nonfrail populations; however, the clinical significance of some differences, such as total hospital charges, was minimal. Frail patients had higher mortality (8.17% vs. 7.29%, p < 0.001) and increased all-cause readmissions (15.37% vs. 12.98%, p < 0.001). Frail individuals also had an average LOS that was 3.12 days longer than nonfrail patients (p < 0.001). In terms of costs, frail patients had lower total hospital charges, although this difference was not significant (p = 0.443). These findings emphasize that frailty, rather than the procedure itself, is likely driving worse outcomes.

A similar study by Mosquera et al on the impact of frailty on surgical outcomes revealed that frailty significantly increases the risk of surgical complications, 30-day mortality, and length of hospital stay.[22] Rockwood et al noted in their article that even mild frailty is associated with a 50% 5-year mortality.[23]

Frailty was also associated with a higher incidence of sepsis (6.44% vs. 5.02%, p < 0.001), though the NRD does not provide the source of sepsis, so it may be related to both frailty and procedural complications. This aligns with findings from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, which included 30,239 community-dwelling adult participants.[24] The REGARDS study also found frailty to be associated with increased odds of 28-day death after a sepsis hospitalization, supporting the notion that frailty itself is a major risk factor.

Frailty and sepsis are both strongly linked to advanced age, a decline in physical activity, immune system suppression, and the presence of chronic medical conditions.[25] [26] Additionally, biomarkers of cellular aging and inflammation, such as high-sensitivity C-reactive protein, interleukin-6, intercellular adhesion molecule-1, and E-selectin, have been shown to be elevated in both frailty and sepsis.[26] [27] These findings suggest biological mechanisms by which frailty predisposes patients to worse infectious outcomes.

In addition to sepsis, frail patients were also found to have a higher incidence of aspiration pneumonia (24.68% vs. 22.70%, p < 0.001). Recent studies, such as Niu et al, demonstrate that aspiration pneumonia in PEG patients is associated with increased mortality, longer hospitalizations, and higher health care utilization.[28] [29]

To our knowledge, this is among the first studies to examine differences in outcomes between elective and nonelective PEG tube placement in frail patients. Our findings indicate a significant disparity between the two cohorts, with nonelective PEG placement associated with higher rates of complications, including mortality, sepsis, and aspiration pneumonia. Elective placement appears to confer a protective effect, suggesting that careful timing of PEG placement could improve outcomes among frail patients.[30] Except in urgent scenarios such as burns, trauma, or emergent gastric decompression, elective PEG tube placement may help reduce overall mortality and complications in this population.[6]

Our study benefits from a large, nationally representative cohort derived from the NRD, enhancing generalizability of findings on PEG placement outcomes. However, several limitations exist. The NRD, as an administrative database, lacks detailed clinical information such as PEG indications, nutritional status, and disease severity, all of which may influence outcomes. Frailty was assessed using the Johns Hopkins ACG Frailty Indicator, which, though validated, may not fully capture clinical nuances. Coding errors and misclassification are possible despite using validated codes. To mitigate sampling bias, we adhered to the guidelines set by the HCUP and employed previously validated codes to define the patient population. December admissions were excluded to ensure complete 30-day follow-up, potentially introducing minor selection bias. Finally, time-to-event analyses for mortality were not feasible, limiting long-term survival assessment. Despite these limitations, the study provides valuable, nationally representative insights into outcomes and readmissions among frail versus nonfrail patients undergoing PEG placement.

A systematic review and meta-analysis conducted in 2021, which included 29 studies, found that frail individuals had significantly higher risks of adverse health outcomes—such as falls, bone fractures, disability, dementia, hospitalization, and death—compared with nonfrail groups.[31] These findings underline the greater risks and poorer outcomes frail patients face during hospitalization, emphasizing the need to consider these factors carefully during clinical decision-making. Clinicians should integrate frailty assessment into care planning, provide targeted interventions (e.g., nutritional optimization, early mobilization), and ensure informed consent discussions reflect the higher risk profile.

The end-of-life process for frail individuals, characterized by a gradual decline in function over the years leading up to death, presents significant challenges for both family members and clinicians in making decisions.[32] Future research should focus on strategies to mitigate procedural risks in frail patients, refine elective versus nonelective placement decision-making, and identify interventions to improve outcomes.

Conclusion

Overall, frailty appears to be associated with worse clinical outcomes across several parameters, including higher mortality, increased readmissions, longer hospital stays, and a higher incidence of sepsis and aspiration pneumonia. While elective placement of PEG tube among frail has found to be beneficiary among frail patients, further studies are required to explore and validate our study findings. The complex needs and substantial symptom burden of frail patients must be carefully weighed against the potential benefits and risks of any contemplated procedures.

Conflict of Interest

None declared.

Ethical Approval

This study was conducted using deidentified, publicly available data and was therefore exempt from institutional review board (IRB) approval. All data were handled in accordance with ethical standards for research involving human subjects.

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Publikationsverlauf

Artikel online veröffentlicht:
30. Oktober 2025