"Tube Feeding in Dementia: How Incentives Undermine Health Care Quality and Patient Safety," in the current issue of the Journal of the American Medical Directors Association, says, "For nursing home residents with advanced dementia, very little evidence is available to show clinical benefit from enteral tube feeding." Physician authors Thomas E. Finucane, Colleen Christmas and Bruce A. Leff say, "No randomized clinical trials have been done," but "considerable evidence from studies of weaker design strongly suggest that tube feeding does not reduce the risks of death, aspiration pneumonia, pressure ulcers, other infections, or poor functional outcome."

Nevertheless, the practice is widespread nationally and is "highly variable." The authors write, "A basic misunderstanding about malnutrition and about aspiration pneumonia" supports this wide use. Patients with advanced dementia who eat little, are losing weight and sometimes coughing seem to be good candidates for feeding tubes. But, the article says, "Although advanced cachectic illness can closely mimic starvation, with decreased appetite, poor nutrient intake, weight loss, and increased morbidity and mortality, administering protein and calories does not prevent the adverse clinical outcomes imputed to malnutrition. The effort to distinguish wasting illness from inadequate nutrient intake is now under way."

The article asserts that "strong data" show that "tube feeding does not improve survival or reduce infection." Additionally, tube feeding "cannot protect the airway from either oral secretions or regurgitated gastric contents," both identified as prime causes of aspiration pneumonia. "In fact no published data suggest that tube feeding reduces the risk of aspiration pneumonia."

Other incentives, other than the "face validity" discussed above, also promote the use of feeding tubes.

• Studies which examine decisions made at the bedside to insert feeding tubes have found that advance planning for feeding tubes is uncommon, that substitute decision makers have reported being "inadequately informed about benefits and risks, were not advised of alternatives," or received little or conflicting information. Some were never informed before the insertion of the tube. Additionally, speech therapists and nutritionists may contribute to the increase in feeding tube use by their focus on problems with swallowing and nutrition. One article reports, "Nursing homes with speech therapists on staff have higher rates of tube feeding."

• Gastroenterologists and hospitals receive fees for placement of PEGs and hospitals trying to shorten their lengths of stay may believe that nursing homes will be more likely to take a severely demented patient if he has a feeding tube. Nursing home reimbursements are higher for patients with feeding tubes and their costs are higher for hand-fed patients. Additionally, "tube feeding offers nursing homes some protection against the deep-seated presumption that weight loss is a sign of negligence." Concerned families may also feel that "everything is being done" if the patient is receiving "adequate nutrition."

Changing the incentives that inspire feeding tube placement should begin with "education of family members and professionals alike," the authors say, citing one hospital that saw a two-thirds reduction in feeding tube use after an educational campaign and establishment of a palliative care team.

• Changes in reimbursement are more difficult and "administrative oversight is improbable." The article suggests lower reimbursement for gastroenterologists if the patient is diagnosed with dementia. They also note that reduction in length of stay for hospitalized patients will work against any effort to reduce placements of PEGs by hospitals. In nursing homes, one option is eliminating Medicare reimbursements for "skilled days" immediately after tube placements. Another option is equalizing payments for hand and tube feedings.

• The authors recommend revision of the federal nursing home regulations, saying, "They provide a strong incentive to deliver calories and protein, but they are based on discredited ideas about nutrition and nutritional markers." Additionally, "regulations should more explicitly acknowledge that weight loss and hypoalbuminemia often result from catabolic illness and that generous administration of protein and calories may not reverse them nor prevent subsequent morbidity and mortality. High rates of tube feeding among institutionalized patients with dementia should raise questions about the quality of care in a facility, particularly if associated with other evidence of suboptimal care."

• CMS should offer 'friendly' technical assistance, measurement and public reporting of feeding tube use, inclusion of tube feeding use rates as part of the payment formula for individual nursing homes, and, perhaps ultimately, explicit proscription of the practice as a condition of participation in Medicare."

• The authors make no specific recommendations about tort reform, saying, "Good solutions remain elusive." But research could distinguish disease from neglect and the authors say that this evidence is being developed. "Scrupulous scientific attention to the clinical value, if any, of swallowing studies, compensatory feeding techniques, dietary modifications, and local nursing home factors such as staffing levels would put nursing home practice onto surer footing. Finally, the effects of aligning economic and regulatory incentives with science should be studied."

The article is online, free, at www.jamda.com/current. (Journal of the American Medical Directors Association, 2007;8(4):205-208)

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