Clinical question

Should tube feeding versus oral diet be used for people at nutritional risk who are at risk of pressure injuries?

Context

Population:

Intervention:

Comparison:

Main Outcomes:

Setting:

Background:

Conflicts on Interest:

People at nutritional risk and at risk of pressure injuries

Tube feeding

Oral diet

Any clinical setting

Pressure Injury occurrence

None

Evidence to Decision Framework

(Click on the individual judgements for more information)

Summary of Judgements

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Yes

Trivial

Large

Very low

No important uncertainty or variability

Probably favors the comparison

Varies

No included studies

No included studies

Don’t know

Varies

Varies

1. Problem:
Is the problem (pressure injuries) a priority?

JUDGEMENT

  • No

  • Probably No

  • Probably Yes

  • Yes

  • Varies

  • Don’t Know

RESEARCH EVIDENCE

The problem of preventing pressure injuries is a significant priority to healthcare in most clinical settings.

In 2021, the Guideline Governance Group undertook a stakeholder survey on priority issues to address in the guideline. Receiving clinical guidance on nutritional interventions to prevent pressure injuries was rated as the highest priority by clinicians (median ranking 5/5) and rated as a high priority by researchers, industry representatives and people with or at risk of pressure injuries and their informal carers (median ranking for all these stakeholder groups 4/5).In an earlier survey conducted by the previous Guideline Governance Group in 2018,1 71.8% (275/383) of individuals with or at risk of PIs and 65.3% (555/850) of informal carers rated receiving information on diet and hydration as important or very important.

2. Desirable Effects:
How substantial are the desirable anticipated effects?

JUDGEMENT

  • Trivial

  • Small

  • Moderate

  • Large

  • Varies

  • Don’t Know

RESEARCH EVIDENCE

Outcome Tube feeding Oral diet Difference Relative effect
PI occurrence 463/1281 (36.1%) 471/2297 (20.5%) 103 more per 1,000
(from 4 more to 246 more)
RR 1.50
(1.02-2.20)

Outcome 1: PI Occurrence

The meta-analysis included one RCT6 and three non-randomised comparative studies7-9 that explored using any form of tube feeding compared to maintaining an oral diet to prevent PIs. The meta-analysis showed that using tube feeding is associated with an increase in the occurrence of PIs (relative risk [RR] 1.50, 95% confidence interval [CI] 1.02 to 2.20). It is very uncertain whether tube feeding has an impact on the risk of a new PI occurring in people at nutritional risk and at risk of a PI.

A systematic review5 noted that tube feeding is associated with some common PI risk factors, including urine and fecal incontinence and immobility related to increased use of restraints to prevent interference with feeding tubes. These risks might be one reason the meta-analysis results showed that tube feeding was not associated with a reduction in PIs.

** Regimens are described in the data extraction tables. Product names may have changed.

3. Undesirable Effects:
How substantial are the undesirable anticipated effects?

JUDGEMENT

  • Trivial

  • Small

  • Moderate

  • Large

  • Varies

  • Don’t Know

RESEARCH EVIDENCE

Outcome Tube
feeding
Oral diet Difference Relative effect
Mortality - - Favors oral diet OR 1.79
(1.04-3.07)
Pneumonia - - Favors oral diet OR 2.25
(0.81-6.24)

Mortality

A meta-analysis5 that included eight studies conducted in older people with advanced dementia showed that tube feeding was associated with an increase in risk of death (odds ratio [OR] 1.79, 95% CI 1.04 to 3.07), but the certainty of evidence is low. Death rates were higher in a group receiving tube feeding compared to oral diet (14.5% versus 0%) in a RCT6 that was conducted in people undergoing surgery for a hip fracture, although the researchers considered these results were not related to the intervention.

Pneumonia

A meta-analysis5 that included four studies conducted in older people with advanced dementia showed that tube feeding was associated with an increase in risk of experiencing pneumonia (OR 2.25, 95% CI 0.81 to 6.24), but the certainty of evidence is very low.

4. Overall certainty of evidence: What is the overall certainty of the evidence of effects?

JUDGEMENT

  • Very low

  • Low

  • Moderate

  • High

  • No included studies

RESEARCH EVIDENCE

Outcome Relative Importance Certainty of Evidence
PI occurrence CRITICAL VERY LOW

Outcome 1: PI occurrence

In a Delphi survey2 that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical importance (score of 7-9).

Certainty of the evidence was very low. The evidence was downgraded for risk of bias based on critical appraisal3-5 that indicated there was a high risk of bias across multiple domains. Certainty was also downgraded once for inconsistency and once for imprecision.

5. Values:
Is there important uncertainty about or variability in how much people value the main outcomes?

JUDGEMENT

  • Important uncertainty or variability

  • Possibly important uncertainty or variability

  • Probably no important uncertainty or variability

  • No important uncertainty or variability

RESEARCH EVIDENCE

In a Delphi survey2 that developed a core outcomes et for PI prevention trials, the outcome of PI occurrence was rated as being of critical important (score of 7-9) by all types of stakeholders (health professionals, people with or at risk of a PI and their informal carers, industry representatives and researchers). Greater than 90% of the 158 participants rated this outcome measure as critically important.2

6. Balance of Effects:
Does the balance between desirable and undesirable effects favour the intervention or the comparison?

JUDGEMENT

  • Favors the comparison

  • Probably favors the comparison

  • Does not favor either the intervention or the comparison

  • Probably favors the intervention

  • Favors the intervention

  • Varies

  • Don’t know

RESEARCH EVIDENCE

Both desirable and undesirable effects favor oral diet being used for people with nutritional risk and PI risk.

In the Guideline Governance Group’s opinion, the increase in adverse events associated with tube-feeding compared to oral diet, including an increase in PI occurrence, indicates that the balance of effects probably favors using an oral diet.

7. Resources Required:
How large are resource requirements (costs) of the intervention?

JUDGEMENT

  • Large costs

  • Moderate costs

  • Negligible costs and savings

  • Moderate savings

  • Large savings

  • Varies

  • Don’t know

RESEARCH EVIDENCE

In the Panel Group’s expert opinion nutritional supplements are usually funded within the costs of health care in acute care, intensive care and palliative care settings. Resources are required to implement the intervention, including equipment and nursing time.

In the Guideline Governance Group’s expert opinion, the resources required to implement tube feeding vary depending on the clinical and geographic context.

8. Certainty of evidence of required resources:
What is the certainty of evidence of resource requirements (costs) of the intervention?

JUDGEMENT

  • Very low

  • Low

  • Moderate

  • High

  • No included studies

RESEARCH EVIDENCE

No included studies

9. Cost Effectiveness: Does the cost-effectiveness of the intervention favour the intervention or the comparison?

JUDGEMENT

  • Favors the comparison

  • Probably favors the comparison

  • Does not favor either the intervention or the comparison

  • Probably favors the intervention

  • Varies

  • No included studies

RESEARCH EVIDENCE

There was no evidence on cost effectiveness.

10. Inequity:
What would be the impact of recommending the intervention on health inequity?

JUDGEMENT

  • Reduced

  • Probably reduced

  • Probably no impact

  • Probably increased

  • Increased

  • Varies

  • Don’t know

RESEARCH EVIDENCE

There was no evidence on inequity.

11. Acceptability:
Is the intervention acceptable to key stakeholders?

JUDGEMENT

  • No

  • Probably no

  • Probably yes

  • yes

  • Varies

  • Don’t know

RESEARCH EVIDENCE

In the Panel Group’s expert opinion, it is possible that there is low acceptance from some stakeholders regarding avoiding the use of tube feeding, particularly when the individual has inadequate oral intake. There may also be low acceptance from health professionals in geographic regions in which tube feeding is considered an imperative for preventing PIs in people with nutritional risk and high risk of PIs.

In the Guideline Governance Group’s expert opinion, there is likely to be variation in acceptability for avoiding the use of tube feeding. Some stakeholders are likely to accept that tube feeding is not beneficial for preventing PIs. However, other stakeholders are likely to consider provision of tube feeding is an ethical requirement in the absence of adequate oral intake.

12. Feasibility:
Is the intervention (limiting sitting time) feasible to implement?

JUDGEMENT

  • No

  • Probably no

  • Probably yes

  • yes

  • Varies

  • Don’t know

RESEARCH EVIDENCE

There was no evidence on feasibility.

In the Guideline Governance Group’s expert opinion, the feasibility of implementing tube feeding or otherwise vary according to the clinical and geographic context.