title: Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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 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 = 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.
authors.affiliation: Hebrew Rehabilitation Center for Aged Research and Training Institute, Department of Medicine, Beth Israel Deaconess Medical Center, and 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 M
authors.initials: JM
authors.lastname: Teno
authors.forename: Jason
authors.initials: J
authors.lastname: Roy
authors.forename: Glen
authors.initials: G
authors.lastname: Kabumoto
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
mesh_terms: D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000208:ethnology / Q000628:therapy*; D003430:Cross-Sectional Studies; D003704:Dementia / Q000628:therapy; D004750:Enteral Nutrition / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009735:Nursing Homes / Q000458:organization & administration; D015279:Organizational Culture; D014481:United States; D000078329:Workforce