title: Churning: the association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment.
abstract: BACKGROUND
  There is a tenfold variation across U.S. states in the prevalence of feeding tube use among elderly nursing home residents (NHR) with advanced cognitive impairment. The goal of this study was to examine whether regions with higher rates of health care transitions at the end of life are more likely to use feeding tubes in patients with severe cognitive impairment.
  
  
  METHODS
  A retrospective cohort study of U.S. nursing home residents with advanced cognitive impairment. The incidence of feeding tube insertion was determined by Medicare Part A and B billing data. A count of the number of health care transition in the last 6 months of life was determined for nursing home residents. A multivariate model examined the association of residing in a geographic region with a higher rates of health care transition and the insertion of a feeding tube in nusing home resident with advance cognitive impairment.
  
  
  RESULTS
  Hospital Referral Region (HRR) health care transitions varied from 192 (Salem, Oregon) to 509 per 100 decedents (Monroe, Louisiana) within the last 6 months of life. HRRs with higher transition rates had a higher incidence of feeding tube insertion (Spearman correlation = 0.58). Subjects residing in regions with the highest quintile of transitions rates were 2.5 times (95% confidence interval [CI] 1.9-3.2) more likely to have a feeding tube inserted compared to those that resided in the lowest quintile.
  
  
  CONCLUSIONS
  Regions with higher rates of care transitions among nursing home residents are also much more likely to have higher rates of feeding tube placement for patients with severe cognitive impairment, a population in whom benefit is unlikely.
authors.affiliation: Center for Gerontology and Health Care Research, Department of Community Health, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA. Joan_Teno@brown.edu
authors.forename: Joan M
authors.initials: JM
authors.lastname: Teno
authors.forename: Susan L
authors.initials: SL
authors.lastname: Mitchell
authors.forename: Jonathan
authors.initials: J
authors.lastname: Skinner
authors.forename: Sylvia
authors.initials: S
authors.lastname: Kuo
authors.forename: Elliott
authors.initials: E
authors.lastname: Fisher
authors.forename: Orna
authors.initials: O
authors.lastname: Intrator
authors.forename: Ramona
authors.initials: R
authors.lastname: Rhodes
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor