Point of View
Will the New Medicare Rules Alter the Practice of Enteral Feeding in Patients With Advanced Dementia?
As internists working primarily in the inpatient setting of an acute care hospital with approximately 600 beds and providing care to a significant number of geriatric patients, it did not surprise us to read the results of a study published recently by Teno et al1 that identified the particular characteristics of the hospitals that are responsible for the majority of feeding tube placements in patients with advanced dementia. The study suggested that gastrostomy tubes were most likely to be placed in nursing home residents who were admitted to large hospitals, hospitals that were for-profit, or intensive care units in the 6 months preceding death.1 Under the newly adopted Federal Fiscal Year 2011 Inpatient Prospective Payment System (IPPS) Final Rule from the Centers for Medicare & Medicaid Services (CMS), the nation’s acute care hospitals are expected to see a significant change in their reimbursement rates for inpatient stays from the CMS.2 The rules will decrease overall operating payments to acute and long-term care hospitals paid under the IPPS Final Rule, by an estimated average of 0.4% in the year 2011. Those reductions include an initial market basket increase for inflation of 2.6%, reduced by 0.25% to 2.35% as mandated by the Patient Protection and Affordable Care Act for those facilities that submit data on quality. Hospitals not submitting these data will receive a 0.35% market basket increase only; however, there will be increased payments to hospitals in counties in the lowest quartile of per-capita Medicare spending.2 These new rules may impact the initial decision to place a gastrostomy tube in a patient with advanced dementia during an acute hospitalization, in an attempt to reduce Medicare spending.
It is important to examine, in general, the rationale behind the placement of gastrostomy tubes in hospitalized patients. It seems that in today’s medical practice, the purpose of the acute care hospital is to provide short-term patient care and to discharge the patient as soon as he or she is deemed “healthy” and “stable.” The nature of this practice raises a major dilemma. The World Health Organization (WHO) defines a state of health as “complete physical, mental and social well-being and not merely the absence of disease or infirmity.”3 So then, how do we discharge a patient with a terminal illness such as Alzheimer’s dementia in a state of “health” after a short and acute hospital visit? Does an attempt to promote “health” drive acute care hospitals to place more feeding tubes?
If the most common condition leading to death in community-dwelling older persons is frailty, as reported in a recent study by Gill and colleagues,4 then one might hypothesize that older people who reside in nursing homes, away from their home environment, family, friends, and social supports, and who additionally have a progressive illness such as advanced dementia, may be at a higher risk for frailty and death. It may then be only natural that families and physicians would opt to prevent this progression toward frailty and death by encouraging nutrition. This, perhaps, is the impetus behind the placement of a significant number of feeding tubes.
The long-term benefits of feeding tube placement remain debated. A well-known and commonly cited article published in the Journal of the American Medical Association that reviewed the medical literature from 1966 through 1999 pertaining to tube feeding in patients with advanced dementia showed that there were no data to support that tube feeding prevents aspiration pneumonia, lowers the risk of pressure sores or infections, improves function, provides palliation, or prolongs survival.5 These findings have been confirmed in multiple subsequent articles.6-8
Nursing homes with a homelike environment that promote the enjoyment of food and value hand-feeding tend to have a lower rate of tube feeding as compared with nursing homes with an institutional-like environment.9 The environment of an acute care hospital is an institutional one, and staffing limitations and the need to effectively address nutritional support in patients may promote more frequent placement of feeding tubes to prevent undernutrition and with the dubious goal of reducing aspiration.
Data from the Health and Retirement Study suggest that many elderly Americans require assistance with decision-making near the end of their life, at a time when they most likely lack the capacity to do so.10 Consequently, family members are often faced with making important decisions regarding nutritional routes before they have had time to adequately grasp the challenges surrounding their loved ones’ care. Ethics, clinical judgment, and the law may conflict at such times.11 What may be most important to families in regard to the patient’s care is how best to demonstrate that they care for their loved one,12 and physicians may be swayed by the uncertainty of the clinical outcome. Nursing home care providers are often reluctant to permit the withholding or withdrawing of artificial feeding, unless explicitly specified in advance directives, for fear of legal ramifications. 13 Ultimately, this may increase the placement of gastrostomy tubes as patients are transitioned from the acute hospital environment to long-term care facilities.
Of course, there may be a clear indication for the placement of feeding tubes in certain patients. The percutaneous endoscopic gastrostomy (PEG) tube was first described by Gauderer et al14 in the 1980s as an alternative to parenteral feeding in the pediatric and adult population with a normal-functioning gastrointestinal tract but the inability to take food by mouth. Since this study was published, PEG tubes have seen wider usage in both children and adults. Some patients in whom PEG tubes have been shown to be beneficial are those who are slowly recovering from a swallowing abnormality, such as after a stroke,15 during and after treatment of head and neck cancer,16,17 and after suffering a trauma.18 In many of these situations, PEG tubes serve as a bridge to the ultimate return of oral nutrition. A recent review concluded that PEG tube placement may be more effective and safe as compared with nasogastric tube feeding for adults with swallowing disorders.19 It may be safe to say that tube feeding may be most appropriate when there is a clear indication and anticipated time frame for its use, provided the benefits outweigh the risks, and when its use is consistent with the known values and preferences of the patient or his or her family.20
One last consideration is that acute care hospitals are influenced by financial incentives to reduce inpatient lengths of stay. Some investigators have examined the role of economic factors, such as reimbursement for PEG tube insertions and tube feeding, in the hopes of explaining the dramatic regional variability in the use of feeding tubes in patients with advanced dementia.21 Finucane and colleagues21 concluded that, in states whose Medicaid programs provide markedly greater reimbursement to nursing homes for the care of tube-fed residents than hand-fed residents, there are higher observed rates of tube feeding. It will be interesting to see if the recent reduction in reimbursement for hospitalized patients under the new CMS rules will alter the rates of PEG tube insertions for Medicare and Medicaid patients with advanced dementia during acute inpatient stays.
The decision regarding feeding tube placement still needs to be a medical decision rather than a financial decision. As with all aspects of patient care, this decision should be made after careful and thorough consideration. The risks and benefits must be weighed, and the expressed wishes of the patient or his or her surrogate decision-maker(s) must be kept in mind. This decision should not be overly influenced by policy and reimbursement. All in all, these various factors will need to be more closely examined if the overuse of feeding tubes in the elderly is to change for the better. Ultimately, evidence-based guidelines for the appropriate use of tube feeding may need to be developed and disseminated to acute care hospitals, along with the implementation of mandatory quality measures—that are tied to reimbursement—to affect meaningful change.
The authors report no relevant financial relationships.
From New Hanover Regional Medical Center, Wilmington, NC.
1. Teno JM, Mitchell SL, Gozalo PL, et al. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA 2010;303(6):544-550.
2. Centers for Medicare and Medicaid Services. FY 2011 IPPS Final Rule Home Page. https://www.cms.gov/AcuteInpatientPPS/IPPS2011/list.asp. Last updated December 28, 2010. Accessed January 26, 2011.
3. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
4. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med 2010;362(13):1173-1180.
5. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282(14):1365-1370.
6. Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia [published correction appears in Arch Intern Med 2003;163(19):2397]. Arch Intern Med 2003;163(11):1351-1353.
7. Meier DE, Ahronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with advanced dementia: Lack of benefit of tube feeding. Arch Intern Med 2001;161(4):594-599.
8. Dharmarajan TS, Unnikrishnan D, Pitchumoni CS. Percutaneous endoscopic gastrostomy and outcome in dementia. Am J Gastroenterol 2001;96(9):2556-2563.
9. Lopez RP, Amella EJ, Strumpf NE, Teno JM, Mitchell SL. The influence of nursing home culture on the use of feeding tubes. Arch Intern Med 2010;170(1):83-88.
10. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362(13):1211-1218.
11. When care becomes futile. In: Snyder JE, Gauthier CC. Evidence-Based Medical Ethics: Cases for Practice-Based Learning. Totowa, NJ: Humana Press; 2008:111-117.
12. Gillick MR, Volandes AE. The standard of caring: Why do we still use feeding tubes in patients with advanced dementia? J Am Med Dir Assoc 2008;9(5):364-367.
13. Meisel A, Snyder L, Quill T; American College of Physicians—American Society of Internal Medicine End-of-Life Care Consensus Panel. Seven legal barriers to end-of-life care: Myths, realities, and grains of truth. JAMA 2000;284(19):2495-2501.
14. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 1980;15(6):872-875.
15. Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GK. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ 1996;312(7022):13-16.
16. Baredes S, Behin D, Deitch E. Percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer. Ear Nose Throat J 2004;83(6):417-419.
17. Wiggenraad RG, Flierman L, Goossens A, et al. Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol 2007;32(5):384-390.
18. Dwyer KM, Watts DD, Thurber JS, Benoit RS, Fakhry SM. Percutaneous endoscopic gastrostomy: The preferred method of elective feeding tube placement in trauma patients. J Trauma 2002;52(1):26-32.
19. Gomes CA Jr, Lustosa SA, Matos D, Andriolo RB, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev 2010;11:CD008096.
20. American Medical Directors Association. Clinical Practice Guideline: Altered Nutritional Status in the Long Term Care Setting. Columbia, MD: American Medical Directors Association; 2010.
21. Finucane TE, Christmas C, Leff B. Tube feeding in dementia: How incentives undermine health care quality and patient safety. J Am Med Dir Assoc 2007;8(4):205-208.