Clinical and Organizational Factors Associated with Feeding Tube Use among Nursing Home Residents with Advanced Cognitive Impairment

Susan L. Mitchell, Joan Teno, Jason Roy, Glen Kabumoto, Vincent Mor

Research output: Contribution to journalArticle

235 Citations (Scopus)

Abstract

Context: Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. Objective: To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. Design, Setting, and Participants: Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N=186835) and who resided in Medicare- or Medicaid-certified US nursing homes. Main Outcomes Measures: Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. Results Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N=63101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95% CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95% CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95% CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of non-white residents, and lacked a nurse practitioner or physician assistant on staff. Conclusions: More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.

Original languageEnglish (US)
Pages (from-to)73-80
Number of pages8
JournalJournal of the American Medical Association
Volume290
Issue number1
DOIs
StatePublished - Jul 2 2003
Externally publishedYes

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Enteral Nutrition
Nursing Homes
Odds Ratio
Confidence Intervals
Dementia
Resuscitation Orders
Advance Directives
Cognitive Dysfunction
Physician Assistants
Nurse Practitioners
Divorce
Medicaid
Certification
Marital Status
Expert Testimony
Medicare
Alzheimer Disease
Multivariate Analysis
Cross-Sectional Studies
Demography

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Clinical and Organizational Factors Associated with Feeding Tube Use among Nursing Home Residents with Advanced Cognitive Impairment. / Mitchell, Susan L.; Teno, Joan; Roy, Jason; Kabumoto, Glen; Mor, Vincent.

In: Journal of the American Medical Association, Vol. 290, No. 1, 02.07.2003, p. 73-80.

Research output: Contribution to journalArticle

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abstract = "Context: Empiric data and expert opinion suggest that use of feeding tubes is not beneficial for older persons with advanced dementia. Previous research has shown a 10-fold variation in this practice across the United States. Objective: To identify the facility and resident characteristics associated with feeding tube use among US nursing homes residents with severe cognitive impairment. Design, Setting, and Participants: Cross-sectional study of all residents with advanced cognitive impairment who had Minimum Data Set assessments within 60 days of April 1, 1999, (N=186835) and who resided in Medicare- or Medicaid-certified US nursing homes. Main Outcomes Measures: Facility and resident characteristics described in the 1999 On-line Survey Certification of Automated Records and the 1999 Minimum Data Set. Multivariate analysis using generalized estimating equations determined the facility and resident factors independently associated with feeding tube use. Results Thirty-four percent of residents with advanced cognitive impairment had feeding tubes (N=63101). Resident characteristics associated with a greater likelihood of feeding tube use included younger age, nonwhite race, male sex, divorced marital status, lack of advance directives, a recent decline in functional status, and no diagnosis of Alzheimer disease. Controlling for these patient factors, residents living in facilities that were for profit (adjusted odds ratio [OR], 1.09; 95{\%} confidence interval [CI], 1.06-1.12); located in an urban area (OR, 1.14; 95{\%} CI, 1.11-1.16); having more than 100 beds (OR, 1.04; 95{\%} CI, 1.01-1.07); and lacking a special dementia care unit (OR, 1.11; 95{\%} CI, 1.07-1.15) had a higher likelihood of having a feeding tube. Additionally, feeding tube use was more likely among residents living in facilities that had a smaller proportion of residents with do-not-resuscitate orders, had a higher prevalence of non-white residents, and lacked a nurse practitioner or physician assistant on staff. Conclusions: More than one third of severely cognitively impaired residents in US nursing homes have feeding tubes. Feeding tube use is independently associated with both the residents' clinical characteristics and the nursing homes' fiscal, organizational, and demographic features.",
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