Demographic shifts will drive a doubling of stroke cases among older persons by 2050. For approximately 55% of ischemic stroke patients, dysphagia is a major barrier to recovery. Older stroke patients are at higher risk for severe and persistent dysphagia, prompting the surgical insertion of feeding tubes. Little is known about the clinical course of older patients with feeding tubes inserted during a hospitalization for stroke once they leave acute care. While it is generally assumed tube feeding is a temporary measure, the extent to which these patients ultimately regain the ability to eat by mouth remains largely unexamined. Similarly, while feeding tubes may be expected to contribute to functional improvements allowing patients to return home, their need for long- term care has never been well-explored. Most older stroke patients with feeding tubes are admitted to skilled nursing facilities (SNFs), which vary greatly in quality. No study has ever identified SNF features that influence whether these patients regain the ability to eat by mouth or return home. A more robust understanding of the clinical course of tube-fed older stroke patients will not only help inform realistic expectations for these patients and families, but also identify potentially modifiable factors that will promote positive long-term outcomes. The overriding objective of this proposal is to measure key long-term outcomes in the clinical course of older persons who had feeding tubes inserted post-stroke and identify patient and SNF-level factors associated with better outcomes. To conduct this research, we will leverage several linked nationwide databases from 2011- 2015, including: Medicare claims, the Minimum Data Set (MDS), and Certification and Survey Provider Enhanced Reporting (CASPER) data.
In Aim 1, the clinical course of patients over 65 admitted to SNFs for post-acute care after hospitalization for acute ischemic stroke with feeding tube insertion will be examined for the following primary outcomes: 1) 90 day disposition, 2) feeding tube use at 90 days, 3) time to death or hospice enrollment. Patient characteristics upon admission to SNF associated with these outcomes will be identified. Among long-stay nursing home residents, MDS data will be used to examine feeding tube use, functional and cognitive status at 180 and 365-days post-admission to sub-acute care.
Aim 2 will determine variation in outcomes across SNFs, and (after adjusting for patient and regional factors) identify SNF characteristics (e.g. stroke patient volume, speech pathologist staffing) associated with the primary outcomes. IMPACT: The proposed research will be the first rigorous, nationwide examination of the clinical course and determinants of outcomes among older patients with feeding tubes inserted post-stroke. As such, it has the potential to generate more realistic expectations of their future care needs and help identify addressable factors that could improve the outcomes of these patients (i.e., minimal volume and specialized staffing requirements for post-acute facilities). Finally, this research and professional development plan will help the PI evolve into one of the few independent investigators with expertise in aging, neurology and palliative care.
Stroke afflicts a rising proportion of older persons who are at greatest risk for needing a surgically placed feeding tube after stroke. There is very little known about the clinical course of older patients who have feeding tubes inserted after stroke once they enter nursing homes, and what features of nursing homes are important for recovery of swallowing in these patients. The proposed research will be the first rigorous, nationwide examination of the clinical course and determinants of outcomes among older patients with feeding tubes inserted post-stroke, and has the potential to generate more realistic expectations of their future care needs and help identify addressable factors that could improve the outcomes of these patients.
