The Clinical Course and Outcomes of Older Stroke Patients with Feeding Tubes

好了！ 项目摘要/摘要 到2050年，人口结构的变化将使老年人的中风病例翻一番。大约55% 对于缺血性中风患者，吞咽困难是康复的主要障碍。老年中风患者患中风的风险更高 严重且持续的吞咽困难，促使外科手术插入喂养管。人们对此知之甚少 老年卒中患者出院后住院期间插管的临床过程 急诊护理。虽然通常认为管喂是一种临时措施，但在一定程度上，这些 患者最终恢复了用口进食的能力，这在很大程度上仍未得到检查。同样，当喂管时 可能会对功能的改善做出贡献，允许患者回家，他们需要很长时间- 长期护理从来没有被很好地探索过。大多数有饲管的老年中风患者都是熟练入院的 护理设施(SNF)，质量差异很大。还没有研究确定SNF的特征会影响 这些患者是恢复了吃东西的能力，还是回家了。更深入地了解 管饲老年卒中患者的临床过程不仅有助于了解对这些患者的现实期望 但也要确定潜在的可改变的因素，以促进积极的长期结果。这个 这项建议的首要目标是衡量老年人临床病程中的关键长期结果 卒中后插入喂养管的人，并确定与以下因素相关的患者和SNF水平因素 更好的结果。为了进行这项研究，我们将利用2011年的几个相互关联的全国数据库- 2015年，包括：联邦医疗保险报销、最低数据集(MDS)以及认证和调查提供商 增强型报告(CASPER)数据。在目标1中，65岁以上的患者入院治疗的临床病程 将检查急性缺血性卒中患者入院后的急诊护理，并插入喂养管 主要结果如下：1)90天处置，2)90天使用导尿管，3)死亡时间或 临终关怀中心招生。入院时，与这些结果相关的患者特征将是 已确认身份。在长期入住养老院的居民中，MDS数据将被用于检查喂养管的使用情况， 亚急性护理入院后180天和365天的功能和认知状况。目标2将决定 不同SNF的结果差异，并(在调整患者和区域因素后)确定SNF 与主要结果相关的特征(例如，中风患者数量、言语病理学家人员配备)。 影响：拟议中的研究将是第一次严格的、全国性的临床病程和 卒中后插管的老年患者预后的决定因素。因此，它具有 有潜力对他们未来的护理需求产生更现实的期望，并帮助确定可解决的问题 可改善这些患者预后的因素(即最低限度的工作量和专门的人员配备 对急症后设施的要求)。最后，这项研究和职业发展计划将有助于PI 成为少数在衰老、神经学和姑息治疗方面拥有专业知识的独立调查人员之一。

! Project Summary/Abstract 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.