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 =
186 835) and who resided in Medicare- or Medicaid-certified US nursing
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 = 63 101). 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 nonwhite 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.