Sylvia Kuo

Natural history of feeding-tube use in nursing home residents with advanced dementia.

OBJECTIVES Despite the evidence that feeding-tube use in persons with advanced dementia is not associated with improved outcomes, there remains striking variation in their use. Yet, little is known about the national incidence of feeding-tube insertions, the circumstances of their insertion, and post-insertion health care use. DESIGN Secondary analysis of Minimum Data Set merged onto Medicare Claims Files. SETTING AND PARTICIPANTS Nursing home residents (NHR) without a feeding tube. MEASUREMENTS NHR were followed for up to 1 year to see whether a feeding tube was inserted and then followed for 1 year after insertion to examine health care use and survival. RESULTS The incidence of feeding-tube insertion was 53.6/1000 residents. Most (68.1%) feeding-tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within 1 year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over 1 year, tube feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission. CONCLUSION Most feeding tubes are inserted in an acute care hospital. Feeding-tube insertions are also associated with poor survival and significant rate of health care use after insertion.

Decision - Making and Outcomes of Feeding Tube Insertion: A Five - State Study

OBJECTIVES: To examine family members perceptions of decision‐making and outcomes of feeding tubes.

Does Feeding Tube Insertion and Its Timing Improve Survival

To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival.

Feeding Tubes and the Prevention or Healing of Pressure Ulcers

BACKGROUND The evidence regarding the use of feeding tubes in persons with advanced dementia to prevent or heal pressure ulcers is conflicting. Using national data, we set out to determine whether percutaneous endoscopic gastrostomy (PEG) tubes prevent or help heal pressure ulcers in nursing home (NH) residents with advanced cognitive impairment (ACI). METHODS A propensity-matched cohort study of NH residents with ACI and recent need for assistance in eating was conducted by matching each NH resident who had a feeding tube inserted during a hospitalization to 3 without a PEG tube inserted. Using the Minimum Data Set (MDS), we examined 2 outcomes: first, whether residents without a pressure ulcer developed a stage 2 or higher pressure ulcer (n = 1124 with PEG insertion); and second, whether NH residents with a pressure ulcer (n = 461) experienced improvement of the pressure ulcer by their first posthospitalization MDS assessment (mean [SD] time between evaluations, 24.6 [32.7] days). RESULTS Matched residents with and without a PEG insertion showed comparable sociodemographic characteristic, rates of feeding tube risk factors, and mortality. Adjusted for risk factors, hospitalized NH residents receiving a PEG tube were 2.27 times more likely to develop a new pressure ulcer (95% CI, 1.95-2.65). Conversely, those with a pressure ulcer were less likely to have the ulcer heal when they had a PEG tube inserted (OR 0.70 [95% CI, 0.55-0.89]). CONCLUSIONS Feeding tubes are not associated with prevention or improved healing of a pressure ulcer. Rather, our findings suggest that the use of PEG tube is associated with increased risk of pressure ulcers among NH residents with ACI.

Does Hospice Improve Quality of Care for Persons Dying from Dementia

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members.

Health care market trends and the evolution of hospitalist use and roles.

AbstractOBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists’ services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002–2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3–4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals’ and physicians’ responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians’ relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine’s 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians’ decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.

Churning: The association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment

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.

Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents

OBJECTIVES: To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents.

Skilled Nursing Facility Admissions of Nursing Home Residents with Advanced Dementia

To describe the extent to which hospitalized nursing home (NH) residents with advanced dementia were admitted to a skilled nursing facility (SNF) after a qualifying hospitalization and to identify resident and nursing home characteristics associated with a greater likelihood of SNF admissions.

Do Medicaid Wage Pass-through Payments Increase Nursing Home Staffing?

OBJECTIVE To assess the impact of state Medicaid wage pass-through policy on direct-care staffing levels in U.S. nursing homes. DATA SOURCES Online Survey Certification and Reporting (OSCAR) data, and state Medicaid nursing home reimbursement policies over the period 1996-2004. STUDY DESIGN A fixed-effects panel model with two-step feasible-generalized least squares estimates is used to examine the effect of pass-through adoption on direct-care staff hours per resident day (HPRD) in nursing homes. DATA COLLECTION/EXTRACTION METHODS A panel data file tracking annual OSCAR surveys per facility over the study period is linked with annual information on state Medicaid wage pass-through and related policies. PRINCIPAL FINDINGS Among the states introducing wage pass-through over the study period, the policy is associated with between 3.0 and 4.0 percent net increases in certified nurse aide (CNA) HPRD in the years following adoption. No discernable pass-through effect is observed on either registered nurse or licensed practical nurse HPRD. CONCLUSIONS State Medicaid wage pass-through programs offer a potentially effective policy tool to boost direct-care CNA staffing in nursing homes, at least in the short term.