Jennings Lee A, Liang Li-Jung, Wenger Neil S, Powell David, Parikh Punam, Escarce Jose J, Zingmond David
Reynolds Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
J Am Geriatr Soc. 2025 May 19. doi: 10.1111/jgs.19536.
The use of feeding tubes has shown no benefit in persons with advanced dementia and has declined over the last decade in this population. However, racial disparities in feeding tube placement have persisted. To better understand disparities in feeding tube use among nursing home residents, we examined artificial nutrition preferences over 6 years among all California nursing home residents, including differences by race, ethnicity, and cognition.
We used the CMS Long-term Care Minimum Data Set (MDS) and the California MDS Section S, which reports completion and contents of POLST (Physician Orders for Life Sustaining Treatment) for California nursing home residents, from 2011 to 2016. For each year, we created a cross-sectional cohort and examined racial and ethnic differences in artificial nutrition preferences stratified by resident length of stay, cardiopulmonary resuscitation preference, and degree of cognitive impairment using logistic mixed-effects regression, adjusted for resident and nursing home characteristics.
Of 762,659 unique individuals in California nursing homes from 2011 to 2016, 160,160 completed a POLST in 2011 and 233,868 in 2016. Resident preferences for artificial nutrition did not change substantively over time. Among long-stay residents, the preference for receipt of artificial nutrition was higher among residents with CPR orders, varied by race and ethnicity, and increased as cognitive impairment worsened. This was most pronounced among long-stay residents with severe cognitive impairment and DNR orders, where the preference for receipt of artificial nutrition was lowest among White, non-Hispanic residents (adjusted predicted probability 0.22, 95% 0.21, 0.24) and higher among Black (adjusted difference in probability: +0.22, 95% CI: 0.19-0.26), Hispanic (+0.19, 95% CI: 0.16-0.22), and Asian/Pacific Islander (+0.24, 95% CI: 0.21-0.27) residents.
Racial and ethnic differences in POLST orders for feeding tube use persist among long-term care nursing home residents with dementia and may reflect disparities in end-of-life care quality.
对于晚期痴呆患者，使用饲管并无益处，且在过去十年中，该人群使用饲管的情况有所减少。然而，饲管放置方面的种族差异依然存在。为了更好地了解疗养院居民在饲管使用上的差异，我们对加利福尼亚州所有疗养院居民在6年期间的人工营养偏好进行了研究，包括种族、族裔和认知方面的差异。
我们使用了医疗保险和医疗补助服务中心（CMS）的长期护理最小数据集（MDS）以及加利福尼亚州MDS的S部分，该部分报告了2011年至2016年加利福尼亚州疗养院居民的维持生命治疗医嘱（POLST）的完成情况和内容。每年，我们创建一个横断面队列，并使用逻辑混合效应回归分析按住院时间、心肺复苏偏好和认知障碍程度分层的人工营养偏好的种族和族裔差异，并对居民和疗养院特征进行了调整。
在2011年至2016年期间加利福尼亚州疗养院的762,659名个体中，160,160人在2011年完成了POLST，233,868人在2016年完成。居民对人工营养的偏好随时间没有实质性变化。在长期住院居民中，有心肺复苏医嘱的居民接受人工营养的偏好更高，因种族和族裔而异，并且随着认知障碍的加重而增加。这在患有严重认知障碍和“不要复苏”（DNR）医嘱的长期住院居民中最为明显，其中白人、非西班牙裔居民接受人工营养的偏好最低（调整后的预测概率为0.22，95%置信区间为0.21, 0.24），而黑人（概率调整差异：+0.22，95%置信区间：0.19 - 0.26）、西班牙裔（+0.19，95%置信区间：0.16 - 0.22）和亚裔/太平洋岛民（+0.24，95%置信区间：0.21 - 0.27）居民的偏好更高。
在患有痴呆症的长期护理疗养院居民中，饲管使用的维持生命治疗医嘱方面的种族和族裔差异依然存在，这可能反映了临终护理质量方面的差异。
