Title: Hospital admission of people receiving enteral tube feeding at home: prevalence, risk factors and exploration of interventions which promote management at home.
Funder: Health Education England

Abstract: Enteral tube feeding (ETF) is an essential therapy for people unable to meet their nutritional needs by oral intake. Recent estimates indicate over 31,770 UK adults receive ETF in primary care and this figure is growing1. People receiving ETF and their carers need support to enable them to manage at home. Poorly managed ETF increases risk of infection, malnutrition and inappropriate treatment, costs the NHS through hospital admissions, waste and transport2 and leads to dissatisfaction with care3. Hospital admissions avoidance, particularly when unplanned, is important because admission increases cost of care and can disrupt elective healthcare4. For people with ETF it can cause distress, discomfort and inconvenience caused by transportation and lengthy waits. The scale of hospital admission for ETF related issues and whether avoidable is not currently well defined. Existing evidence is limited but does suggest admission is not unusual, for example, Hospital Episode Statistics for England show 4,427 admissions for attention to gastrostomy (the main route for ETF) over one year5, and can be avoidable2.Despite the clear need for support to enable effective self-management and avoid admission there is little evidence to identify which systems of support deliver best quality care. Systems of support, also referred to as models of care6, are complex interventions because of their many components. Interventions have evolved in practice to enable people to manage ETF in primary care and the form they take varies between and sometimes within Trusts. Interventions include: acute Trust or community based specialist team case management, generic team case management and management by non-specialist community practitioners. The effectiveness of case management by a community specialist team has been investigated in a few studies2,7, but there is a lack of evidence for the effect of other interventions already embedded in practice on patient experience, avoidable treatment costs and hospital admissions. It is important to ascertain which admissions are potentially avoidable for ETF related issues and which interventions are likely to be effective in preventing admissions8. Further, identifying risk factors for hospital admission will enable targeting of those at risk to support them to manage. The research questions to be addressed are: Is hospital admission for ETF related issues avoidable; what are the risk factors and which complex interventions in primary care are associated with low hospital admission? The research aims to investigate frequency, reason and risk factors associated with admission for ETF related problems and describe which interventions in primary care are associated with areas of high and low hospital admission.Three studies are planned. Study 1 comprises of a retrospective review of patient records of people admitted to hospital for ETF related issues in order to identify frequency and reason for admission. This will enable identification of potentially avoidable admission for ETF related problems and risk factors for admission. Study 2 will use a qualitative approach to explore experiences of people with ETF and their carers of hospital admission and perception of how admissions could be avoided. Study 3 will identify low and high areas of admissions for ETF related issues in England and explore and describe existing interventions in place in these areas. Outcomes will be 1) quantification of avoidable hospital admissions 2) identification of risk factors for hospital admission 3) improved understanding of patient/carer views on reasons for admission and barriers to management at home 4) exploration of interventions associated with low admission. The outcomes will lead to recommendations for refinement of existing and development of new interventions and further research. The recommendations will inform care providers when identifying how the needs of this group are best met leading to improved patient experience and care.

Lay abstract: The number of people living at home receiving nutrition through a tube into their gut (enteral tube feeding or ETF) is increasing. Poorly managed ETF causes problems requiring hospital admission which may be avoidable, although it is not clear how frequently this occurs. This research aims to identify frequency, reason and risk factors for admission for ETF problems and investigate which interventions can support people to manage at home. Methods include review of patient records and admissions statistics and interviews. Expected outcomes include recommendations concerning interventions which improve peoples' experience and outcomes of ETF in the community.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: ORAL AND GASTROINTESTINAL