title: Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison.
abstract: OBJECTIVE
  To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option.
  
  
  METHODS
  Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion.
  
  
  RESULTS
  Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding.
  
  
  CONCLUSIONS
  Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.
authors.affiliation: Hebrew Rehabilitation Center for Aged Research and Training Institute, the Department of Medicine of Beth Israel Deaconess Medical Center, and the Division on Aging, Harvard Medical School, Boston, MA 02131, USA. smitchell@mail.hrca.harvard.edu
authors.forename: Susan L
authors.initials: SL
authors.lastname: Mitchell
authors.forename: Joan L
authors.initials: JL
authors.lastname: Buchanan
authors.forename: Steven
authors.initials: S
authors.lastname: Littlehale
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Hamel
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston; D003365:Costs and Cost Analysis; D003704:Dementia / Q000145:classification*; D004750:Enteral Nutrition / Q000191:economics*; D005248:Feeding Methods / Q000191:economics; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid / Q000191:economics*; D009735:Nursing Homes / Q000191:economics*; D012189:Retrospective Studies; D012720:Severity of Illness Index