Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, 121 S Main St, Providence, RI 02912, USA.
JAMA. 2010 Feb 10;303(6):544-50. doi: 10.1001/jama.2010.79.
Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization.
To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment.
DESIGN, SETTING, AND PATIENTS: The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital's care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered.
Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization.
In 2797 acute care hospitals with 280,869 admissions among 163,022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement.
Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.
对于患有晚期痴呆症的养老院居民，管饲的益处值得怀疑。在美国，大约三分之二接受管饲的养老院居民在急性护理住院期间插入了喂养管。
确定与高级认知障碍的养老院居民中更高的喂养管插入率相关的美国医院特征。
设计、地点和患者：该样本包括年龄在 66 岁或以上、患有高级认知障碍的养老院居民，他们在 2000 年至 2007 年期间入住急性护理医院。喂养管放置率基于所有医疗保险索赔文件的 20%样本，并在 8 年期间至少有 30 例此类入院的医院进行评估。多变量模型将分析单位作为医院入院，确定与喂养管插入率独立相关的医院水平因素，包括床位大小、所有权、城市位置和医学院附属关系。还评估了所有患有严重慢性疾病的患者的医院护理实践措施，包括在生命的最后 6 个月内使用重症监护病房（ICU）、使用临终关怀服务以及专科医生与初级保健医生的比例。还考虑了患者的特征。
在住院期间经内镜或手术插入胃造口管。
在 2797 家急性护理医院中，有 163022 名患有高级认知障碍的养老院居民中有 280869 名接受治疗，喂养管插入率在 0 到 38.9 之间每 100 次住院（平均值[SD]，6.5[5.3]；中位数[四分位距]，5.3[2.6-9.3]）。每 100 次入院的平均喂养管插入率在 2000 年为 7.9，到 2007 年降至 6.2。更高的插入率与以下医院特征相关：营利性所有权与政府所有（每 100 次住院 8.5 与 5.5 次插入；调整后的优势比 [AOR]，1.33；95%置信区间 [CI]，1.21-1.46）、更大的规模（>310 张床位与<101 张床位：每 100 次住院 8.0 与 4.3 次插入；AOR，1.48；95%CI，1.35-1.63）和生命最后 6 个月 ICU 使用量增加（最高与最低十分位数：每 100 次住院 10.1 与 2.9 次插入；AOR，2.60；95%CI，2.20-3.06）。在控制患者特征后，这些差异仍然存在。专科医生与初级保健医生的比例和临终关怀的使用与喂养管放置之间的关联较弱或没有关联。
在接受急性护理医院治疗的患有高级认知障碍的养老院居民中，营利性所有权、更大的医院规模和 ICU 使用量增加与喂养管插入率增加相关，即使在调整了患者水平特征后也是如此。
