Specialist Docs Up Feeding Tube Use in Dementia Patients
When elderly patients with advanced dementia are hospitalized, the specialties of the doctors at their bedside have a lot to do with whether the patients will end up with a gastric feeding tube — a practice that some medical organizations recommend against for frail, terminal patients. That is the finding of a study done at Brown University and published in the April 2014 edition of the journal Health Affairs,
A release from the university notes that the team found that in tens of thousands of cases over the last decade, patients were much less likely to receive a feeding tube when their attending physicians were primary care generalists or hospitalists than when at least some of their attending doctors were subspecialists. Internal medicine subspecialties include geriatrics, cardiology, and endocrinology (for diabetes), among others. Patients with advanced dementia attended to only by hospitalists, for example, got gastric tubes only 1.6 percent of the time while patients with an attending mixture including subspecialists got them in 15.6 percent of cases.
Study leader Dr. Joan Teno said the results can help explain why the practice of feeding tube insertion continues in patients with advanced dementia, even though it's rarely consistent with the family's desire for end-of-life care focused on providing comfort. Both The American Academy of Hospice and Palliative Medicine and the American Geriatrics Society recommend feeding advanced dementia patients by hand instead of via tubes.
The release quotes Teno as saying, "What we've done in the past is establish an evidence base that feeding tubes in this population are not effective, and we have documented tremendous variation in hospitals' insertion rates of feeding tubes. Now we are trying to understand what's inside that black box of the hospital that explains why some people are more likely to have a feeding tube insertion."
To study the influence of physician specialty, Teno and her colleagues combined Medicare billing data with nursing home records to identify cases between 2001 and 2010 in which nursing home residents with dementia were hospitalized. From the records, the team could tell the specialty of the hospital attending physician each day of the hospital stay and whether the patients received a gastric feeding tube.
To minimize confounding medical complications in the data, Teno's team focused on hospital admissions stemming only from infections (such as pneumonia) or dehydration and excluded patients who visited the intensive care unit. Even so, more than 50,000 cases qualified for their analysis.
In their analysis, the researchers statistically controlled for the degree of patient dementia, their length of stay, and a variety of demographic, medical, and geographic factors.