Hospitals that insert feeding tubes into patients with advanced dementia and discharge them to skilled nursing homes may, in fact, cause harm by making these patients more susceptible to pressure ulcers, according to a review of Medicare claims.
"We know there is no survival difference whether you put in a feeding tube or you don't put in a feeding tube," says Joan M. Teno, MD the lead author of the research published in Monday's edition of the Archives of Internal Medicine, who has studied the issue for more than 10 years. Now, evidence of nine years of Medicare claims data indicates feeding tubes actually doubled the chance of a pressure ulcer in these patients.
It had been believed that in patients with dementia, who often have eating disorders, nutritional imbalances cause and exacerbate pressure ulcers and prevent their healing. Feeding tubes delivering protein supplements were presumed to have been helpful. But prior studies were inconclusive and Teno's study revealed exactly the opposite.
Of those nursing home patients with dementia who were hospitalized, 35.6% of those who received a feeding tube during their stay developed a stage 2 or higher pressure ulcer on return to the nursing home, compared with 19.8% of hospitalized patients who did not get a feeding tube. Risk adjusted, Teno says, pressure ulcer risk was 2.27 times higher with a feeding tube than without it.
Teno, a geriatrician who practices in Rhode Island, says that nursing homes and hospitals together have "a strong financial incentive" to deal with patients with dementia by inserting PEGs, or percutaneous gastrostomy tubes rather than hand feeding them, which takes more time and patience.
The majority of the people who get these feeding tubes have already been in a nursing home for a while, she explains. They've exhausted their wealth and now qualify for Medicaid, and then become "dual-eligibles," qualifying for both Medicare and Medicaid. If the patient gets an infection, even a minor one, rather than treating the infection in the nursing home, they send them to the hospital.
The patients then become eligible for skilled nursing facility services for up to 100 days, "which qualifies the nursing home to get paid roughly three to four times what would have been paid if the patient remains at the nursing home on Medicaid," she says.
Because of the setting change, these patients develop disruptive behaviors, which usually leads to physical or pharmacological restraint with neuroleptics. The nutritional supplements they're getting can produce diarrhea. "Now, with the immobility, the incontinence, and diarrhea, they end up with pressure ulcers."
Good nursing homes, she says, "know how to hand feed the patient and know what cues to use to keep the patient eating, but the hospital can't do that."
"It becomes a pathway. The nursing home wants to maximize its money so they send the patient to the hospital," Teno explains. "The hospital wants to get that person out of there quickly so they can have a short stay and be under the number of hospital days they're reimbursed for under that DRG. So the system is not focused on really doing a good job of talking with families about the risks and benefits of these feeding tubes. Instead, there's a rush to put these in, and send the patients back to the nursing home."
"After looking at and writing a number of papers on this for 10 years, I really think we have the wrong financial incentives, and those incentives are doing more harm than good," Teno says. "This is just another example of another intervention that needs to be carefully thought out, to weigh the risks and benefits."
In an invited commentary, Colleen Christmas, MD, and Thomas Finucane, MD, both of the Division of Geriatric Medicine and Gerontology at Johns Hopkins Bayview Medical Center in Baltimore, said Teno's findings "extend and confirm most earlier studies in this area and are now the most rigorous data we have on this subject."
They added, "Teno and colleagues provide sophisticated additional evidence that pressure sore outcomes are not improved, in fact are worsened, among patients with dementia who receive additional nutrition via feeding tubes."