Artificial blood feeding for Culicidae colony maintenance in laboratories: does the blood source condition matter?

Culicidae colonization in laboratory is paramount to conduct studies aiming at a better understanding of mosquitoes' capacity to transmit pathogens that cause deadly diseases. Colonization requires female blood feeding, a necessary step for maturation of female's oocytes. Direct blood feeding on anesthetized mammals implies in a number of disadvantages when compared to artificial blood feeding. Consequently, laboratories worldwide have been trying to -feed female mosquitoes artificially in order to replace direct feeding. In this study, we compared the effects of direct blood feeding and artificial blood feeding on important life traits of three Culicidae species. Artificial feeding was performed using citrated or defibrinated sheep blood and citrated or defibrinated rabbit blood. Direct feeding was performed using anesthetized guinea pigs as the blood source and the experiment control. Results indicated that artificial feeding using sheep blood was not good enough to justify its use in the maintenance of laboratory colonies of Culicidae. However, artificial feeding using rabbit blood maintained a recovery rate always very close to the control, especially when blood was citrated. We concluded that artificial feeding using citrated rabbit blood can substitute direct feeding on mammals reducing the use of animals, eliminating the need to maintain a bioterium in the laboratory and reducing costs in scientific researches involving Culicidae vectors.

Rearing Ixodes scapularis, the Black-legged Tick: Feeding Immature Stages on Mice.

Ixodes scapularis, the vector of Lyme disease, is one of the most important disease vectors in the eastern and Midwestern United States. This species is a three host tick that requires a blood meal from a vertebrate host for each development stage, and the adult females require a blood meal for reproduction. Larval ticks attach to their host for 3 - 5 days for feeding and drop off the host when fully engorged. This dependency on several different hosts and the lengthy attachment time for engorgement complicates tick rearing in the laboratory setting. However, to understand tick biology and tick-pathogen interactions, the production of healthy, laboratory-reared ticks is essential. Here, we demonstrate a simple, cost-effective protocol for immature tick feeding on mice. We modified the existing protocols for decreased stress on mice and increased tick feeding success and survival by using disposable cages without mesh bottoms to avoid contact of ticks with water contaminated with mice urine and feces.

Meal box schemes a convenient way to avoid convenience food? Uses and understandings of meal box schemes among Danish consumers.

The term convenience food is subject to diversification, lack of clarity and moral ambiguity. In this paper we address these issues and critically discuss convenience food by using empirical findings from a Danish study that deals with practitioners' uses of meal box schemes. The methodological design consists of thirteen individual interviews, four focus groups and some observations of cooking practices. We combine the empirical findings with a particular definition of convenience food by Brunner et al. (2010) and selected practice theoretical concepts. This particular combination enables us to categorize meal box schemes as a new form of convenience food called convenient food. In addition, results suggest that meal box schemes reduce leftovers from dinner. Meal boxes also influence dinner related activities such as planning ahead in time and grocery shopping, which require less physical and mental effort.

Predictors of dietary diversity in children ages 6 to 23 mo in largely food-insecure area of South Wollo, Ethiopia.

OBJECTIVE: The aim of this study was to assess the level and predictors of dietary diversity (DD) in predominantly food-insecure area of South Wollo, Ethiopia among children ages 6 to 23 mo. METHODS: The study was conducted in October 2014. We selected 2080 children using a multistage sampling technique. DD in the preceding day of the survey was assessed with the standard seven-food group score. Predictors of DD were identified via Poisson regression model and the outputs are presented using adjusted incidence rate ratio (IRR) with 95% confidence interval (CI). RESULTS: Only 7% (95% CI, 5.9%-8.1%) of the children met the recommended minimum DD. Child age and maternal knowledge of infant and young child feeding (IYCF) were significant predictors of DD with IRR of 1.027 (95% CI, 1.022-1.032) and 1.026 (95% CI, 1.010-1.043). Households with moderate and severe food insecurity had 9% (95% CI, 3.8-13.9%) and 24.9% (95% CI, 14.6-44%) reduced chance of providing diversified food. Husbands' direct involvement in IYCF increased DD by 13.7% (95% CI, 7.4-20.4). Caregivers who discussed IYCF with health extension workers, participated in cooking demonstrations, and heard radio spots about IYCF in the preceding 3 mo had 11.7% (95% CI, 3.4-20.7%), 18.9% (95% CI, 0.3-40.9%), and 11.4% (95% CI, 4.8-18.4) higher chance of providing diversified food, respectively. Backyard gardening (IRR, 1.088; 95% CI, 1.031-1.148) and number of chickens owned (IRR, 1.011; 95% CI, 1.001-1.021) also were significant predictors. CONCLUSIONS: In predominately food-insecure areas, nutrition education, implementation of nutrition-sensitive agriculture, and husband involvement in IYCF can improve children's DD.

How do nurses feed a family?

Imposing student loans without consultation means nurses taking on a burden of debt that may never be repaid, with a negative effect on all with domestic or caring responsibilities. The student loan will take care of tuition fees, but what about feeding the family and keeping a roof over their heads?

Association between women's empowerment and infant and child feeding practices in sub-Saharan Africa: an analysis of Demographic and Health Surveys.

OBJECTIVE: To explore the relationship between women's empowerment and WHO recommended infant and young child feeding (IYCF) practices in sub-Saharan Africa. DESIGN: Analysis was conducted using data from ten Demographic and Health Surveys between 2010 and 2013. Women's empowerment was assessed by nine standard items covering three dimensions: economic, socio-familial and legal empowerment. Three core IYCF practices examined were minimum dietary diversity, minimum meal frequency and minimum acceptable diet. Separate multivariable logistic regression models were applied for the IYCF practices on dimensional and overall empowerment in each country. SETTING: Benin, Burkina Faso, Ethiopia, Mali, Niger, Nigeria, Rwanda, Sierra Leone, Uganda and Zimbabwe. SUBJECTS: Youngest singleton children aged 6-23 months and their mothers (n 15 153). RESULTS: Less than 35 %, 60 % and 18 % of children 6-23 months of age met the criterion of minimum dietary diversity, minimum meal frequency and minimum acceptable diet, respectively. In general, likelihood of meeting the recommended IYCF criteria was positively associated with the economic dimension of women's empowerment. Socio-familial empowerment was negatively associated with the three feeding criteria, except in Zimbabwe. The legal dimension of empowerment did not show any clear pattern in the associations. Greater overall empowerment of women was consistently and positively associated with multiple IYCF practices in Mali, Rwanda and Sierra Leone. However, consistent negative relationships were found in Benin and Niger. Null or mixed results were observed in the remaining countries. CONCLUSIONS: The importance of women's empowerment for IYCF practices needs to be discussed by context and by dimension of empowerment.

A short food-group-based dietary questionnaire is reliable and valid for assessing toddlers' dietary risk in relatively advantaged samples.

Identifying toddlers at dietary risk is crucial for determining who requires intervention to improve dietary patterns and reduce health consequences. The objectives of the present study were to develop a simple tool that assesses toddlers' dietary risk and investigate its reliability and validity. The nineteen-item Toddler Dietary Questionnaire (TDQ) is informed by dietary patterns observed in Australian children aged 14 (n 552) and 24 (n 493) months and the Australian dietary guidelines. It assesses the intake of 'core' food groups (e.g. fruit, vegetables and dairy products) and 'non-core' food groups (e.g. high-fat, high-sugar and/or high-salt foods and sweetened beverages) over the previous 7 d, which is then scored against a dietary risk criterion (0-100; higher score = higher risk). Parents of toddlers aged 12-36 months (Socio-Economic Index for Areas decile range 5-9) were asked to complete the TDQ for their child (n 111) on two occasions, 3·2 (SD 1·8) weeks apart, to assess test-retest reliability. They were also asked to complete a validated FFQ from which the risk score was calculated and compared with the TDQ-derived risk score (relative validity). Mean scores were highly correlated and not significantly different for reliability (intra-class correlation = 0·90, TDQ1 30·2 (SD 8·6) v. TDQ2 30·9 (SD 8·9); P= 0·14) and validity (r 0·83, average TDQ ((TDQ1+TDQ2)/2) 30·5 (SD 8·4) v. FFQ 31·4 (SD 8·1); P= 0·05). All the participants were classified into the same (reliability 75 %; validity 79 %) or adjacent (reliability 25 %; validity 21 %) risk category (low (0-24), moderate (25-49), high (50-74) and very high (75-100)). Overall, the TDQ is a valid and reliable screening tool for identifying at-risk toddlers in relatively advantaged samples.

Socio-demographic and lifestyle determinants of 'Western-like' and 'Health conscious' dietary patterns in toddlers.

Determinants of a child's diet shortly after weaning and lactation have been relatively understudied. The aim of the present study was hence to identify common dietary patterns in toddlers and to explore parental and child indicators of these dietary patterns. The study was a population-based, prospective birth-cohort study in Rotterdam, the Netherlands. Food consumption data of 2420 children aged 14 months were used. A 'Health conscious' dietary pattern characterised by pasta, fruits, vegetables, oils, legumes and fish, and a 'Western-like' dietary pattern characterised by snacks, animal fats, confectionery and sugar-containing beverages were extracted using principal component analysis. Low paternal education, low household income, parental smoking, multiparity, maternal BMI, maternal carbohydrate intake and television-watching of child were determinants of a 'Western-like' diet, whereas parental age, dietary fibre intake during pregnancy, introduction of solids after 6 months and female sex were inversely associated with a 'Western-like' diet of the child. Maternal co-morbidity, alcohol consumption during pregnancy and female sex were inversely associated with a 'Health conscious' dietary pattern of the child, while single parenthood, folic acid use and dietary fibre intake during pregnancy were positively associated. All aforementioned associations were statistically significant. In conclusion, both 'Western-like' and 'Health conscious' diets can already be identified in toddlers. Particularly, adherence to a 'Western-like' diet is associated with unfavourable lifestyle factors of the parents and child, and low socio-economic background. These findings can form a basis for future epidemiological studies regarding dietary patterns and health outcomes in young children.

Impact of personalized feeding program in 100 NICU infants: pathophysiology-based approach for better outcomes.

OBJECTIVES: In neonatal intensive care unit infants referred for home-tube feeding methods, we evaluated the effect of an innovative diagnostic and management approach on feeding outcomes at discharge and 1 year, by comparing data from historical controls; we hypothesized that clinical and aerodigestive motility characteristics at evaluation were predictive of feeding outcomes at discharge; we assessed the economic impact of feeding outcomes. PATIENTS AND METHODS: Patients (N = 100) who were referred for development of long-term feeding management strategy at 46.4 ±â€Š13.1 weeks' postmenstrual age were compared with 50 historical controls that received routine care. The focused approach included swallow-integrated pharyngoesophageal manometry, individualized feeding strategy, and prospective follow-up. Feeding success was defined as ability to achieve oral feedings at discharge and 1 year. Motility characteristics were evaluated in relation to feeding success or failure at discharge. RESULTS: Higher feeding success was achieved in the innovative feeding program (vs historical controls) at discharge (51% vs 10%, P < 0.0001) and at 1 year (84.3% vs 42.9%, P < 0.0001), at a reduced economic burden (P < 0.05). Contributing factors to the innovative program's feeding success (vs feeding failure) were earlier evaluation and discharge (both P < 0.05), greater peristaltic reflex-frequency to provocation (P < 0.05), normal pharyngeal manometry (P < 0.05), oral feeding challenge success (P < 0.05), and suck-swallow-breath-esophageal swallow sequence (P < 0.05). Probability of feeding success demonstrated a prediction rate of 79.6%. CONCLUSIONS: Short-term and long-term feeding outcomes in complex neonates can be significantly improved with innovative feeding strategies at a reduced cost. Clinical and aerodigestive motility characteristics were predictive of outcomes.

Substitution rate and milk yield response to corn silage supplementation of late-lactation dairy cows grazing low-mass pastures at 2 daily allowances in autumn.

Feed costs in dairy production systems may be decreased by extending the grazing season to periods such as autumn when grazing low-mass pastures is highly probable. The aim of this autumn study was to determine the effect of corn silage supplementation [0 vs. 8 kg of dry matter (DM) of a mixture 7:1 of corn silage and soybean meal] on pasture intake (PI), milk production, and grazing behavior of dairy cows grazing low-mass ryegrass pastures at 2 daily pasture allowances (PA; low PA=18 vs. high PA=30 kg of DM/cow above 2.5 cm). Twelve multiparous Holstein cows were used in a 4 × 4 Latin square design with 14-d periods. Pre-grazing pasture mass and pre-grazing plate meter pasture height averaged 1.8 t of DM/ha (above 2.5 cm) and 6.3 cm, respectively. The quality of the offered pasture (above 2.5 cm) was low because of dry conditions before and during the experiment (crude protein=11.5% of DM; net energy for lactation=5.15 MJ/kg of DM; organic matter digestibility=61.9%). The interaction between PA and supplementation level was significant for PI but not for milk production. Supplementation decreased PI from 11.6 to 7.6 kg of DM/d at low PA and from 13.1 to 7.3 kg of DM/d at high PA. The substitution rate was, therefore, lower at low than at high PA (0.51 vs. 0.75). Pasture intake increased with increasing PA in unsupplemented treatments, and was not affected by PA in supplemented treatments. Milk production averaged 13.5 kg/d and was greater at high than at low PA (+1.4 kg/d) and in supplemented than unsupplemented treatments (+5.2 kg/d). Milk fat concentration averaged 4.39% and was similar between treatments. Milk protein concentration increased from 3.37 to 3.51% from unsupplemented to supplemented treatments, and did not vary according to PA. Grazing behavior parameters were only affected by supplementation. On average, daily grazing time decreased (539 vs. 436 min) and daily ruminating time increased (388 vs. 486 min) from 0 to 8 kg of supplement DM. The PI rate was 6g of DM/min lower in supplemented than in unsupplemented treatments (17 vs. 23 g of DM/min). The high milk yield response to supplementation may be related to a cumulative effect of the low-mass pasture (low PI) and the low quality of the pasture, which strongly limited energy supply in unsupplemented cows.

Cost-effectiveness of nutrition interventions in nursing home residents: a pilot intervention.

OBJECTIVES: Unintentional weight loss is a prevalent and costly clinical problem among nursing home (NH) residents. One of the most common nutrition interventions for residents at risk for weight loss is oral liquid nutrition supplementation. The purpose of this study was to determine the cost effectiveness of supplements relative to offering residents' snack foods and fluids between meals to increase caloric intake. DESIGN: Randomized, controlled trial. SETTING: Three long-term care facilities. PARTICIPANTS: Sixty-three long-stay residents who had an order for nutrition supplementation. INTERVENTION: Participants were randomized into one of three groups: (1) usual NH care control; (2) supplement, or (3) between-meal snacks. For groups two and three, trained research staff provided supplements or snacks twice daily between meals, five days per week, for six weeks with assistance and encouragement to promote consumption. MEASUREMENTS: Research staff observed residents during and between meals for two days at baseline, weekly, and post six weeks to estimate total daily caloric intake. For both intervention groups, research staff documented residents' caloric intake between meals from supplements or snack items, refusal rates and the amount of staff time required to provide each intervention. RESULTS: Both interventions increased between meal caloric intake significantly relative to the control group and required more staff time than usual NH care. The snack intervention was slightly less expensive and more effective than the supplement intervention. CONCLUSIONS: Offering residents a choice among a variety of foods and fluids twice per day may be a more effective nutrition intervention than oral liquid nutrition supplementation.

Reproductive performance of heifers offered ad libitum or restricted access to feed for a one hundred forty-day period after weaning.

Reproductive performance was evaluated in composite heifers born over a 3-yr period that were randomly assigned to control (fed to appetite; n = 205) or restricted (fed at 80% of that consumed by controls adjusted to a common BW basis; n = 192) feeding for a 140-d period, beginning about 2 mo after weaning at 6 mo of age and ending at about 12.5 mo of age. Heifers were fed a diet of 67% corn silage, 18% alfalfa, and 9% of a protein-mineral supplement (DM basis). Restricted heifers consumed 27% less feed over the 140 d and had less ADG (0.53 +/- 0.01 vs. 0.65 +/- 0.01 kg/d; P < 0.001) than control heifers. After 140 d, all heifers were placed in common pens and subjected to an estrous synchronization protocol to facilitate AI at about 14 mo of age. Heifers were then exposed to bulls for the remainder of a 51-d breeding season. Average BW of heifers diverged within 28-d after initiation of feed restriction, and differences (P < 0.001) persisted through the prebreeding period (309 +/- 1 vs. 326 +/- 1 kg at approximately 13.5 mo of age) and subsequent grazing season (410 +/- 2 vs. 418 +/- 2 kg at about 19.5 mo of age). From the end of the 140-d restriction at about 12.5 to 19.5 mo of age, ADG was greater (P < 0.001) in restricted heifers than control heifers (0.51 +/- 0.01 vs. 0.47 +/- 0.01 kg/d). Proportion of heifers attaining puberty by 14 mo of age tended to be less (P = 0.1) in restricted (60 +/- 3%) than control-fed heifers (68 +/- 3%). Mean BW at puberty was less (P < 0.01) in restricted (309 kg) than control (327 kg) heifers. Pregnancy rate from AI tended to be less (P = 0.08) in restricted (48 +/- 4%) than control heifers (57 +/- 3%). Proportion of animals that were pubertal at breeding and pregnant from AI were positively associated (P < 0.1) with heifer age and ADG from birth to beginning of study. Final pregnancy rates were 87 and 91% for restricted and control heifers, respectively (P = 0.27). Day of breeding season that conception occurred was negatively associated with ADG from birth to weaning (P = 0.005), but was not associated with ADG within treatment (P = 0.60). Economic analysis revealed a $33 reduction in cost to produce a pregnant heifer under the restricted protocol when accounting for pregnancy rates and differences in BW and market prices between selection at weaning and marketing as open heifers at l.5 yr of age. A potential economic advantage exists for rearing replacement heifers on a restricted level of feeding during the postweaning period.

Winter grazing system and supplementation during late gestation influence performance of beef cows and steer progeny.

A 2 x 2 factorial study evaluated effects of cow wintering system and last trimester CP supplementation on performance of beef cows and steer progeny over a 3-yr period. Pregnant composite cows (Red Angus x Simmental) grazed winter range (WR; n = 4/yr) or corn residue (CR; n = 4/yr) during winter and within grazing treatment received 0.45 kg/d (DM) 28% CP cubes (PS; n = 4/yr) or no supplement (NS; n = 4/yr). Offspring steer calves entered the feedlot 14 d postweaning and were slaughtered 222 d later. Precalving BW was greater (P = 0.02) for PS than NS cows grazing WR, whereas precalving BCS was greater (P < 0.001) for cows grazing CR compared with WR. Calf birth BW was greater (P = 0.02) for CR than WR and tended to be greater (P = 0.11) for PS than NS cows. Prebreeding BW and BCS were greater (P 0.32) by PS. Calf weaning BW was less (P = 0.01) for calves from NS cows grazing WR compared with all other treatments. Pregnancy rate was unaffected by treatment (P > 0.39). Steer ADG, 12th-rib fat, yield grade, and LM area (P > 0.10) were similar among all treatments. However, final BW and HCW (P = 0.02) were greater for steers from PS-WR than NS-WR cows. Compared with steers from NS cows, steers from PS cows had greater marbling scores (P = 0.004) and a greater (P = 0.04) proportion graded USDA Choice or greater. Protein supplementation of dams increased the value of calves at weaning (P = 0.03) and of steers at slaughter regardless of winter grazing treatment (P = 0.005). Calf birth and weaning BW were increased by grazing CR during the winter. Calf weaning BW was increased by PS of the dam if the dam grazed WR. Compared with steers from NS cows, steer progeny from PS cows had a greater quality grade with no (P = 0.26) effect on yield grade. These data support a late gestation dam nutrition effect on calf production via fetal programming.

Economic and phosphorus-related effects of precision feeding and forage management at a farm scale.

Structural best management practices were implemented throughout the Cannonsville Reservoir Watershed (CRW) in an effort to reduce P losses to the reservoir. Yet long-term water quality control efforts within CRW are hindered by continuous P build-up in the soils resulting from dairy farm P imports exceeding exports. Addressing the P imbalance problems and maintaining economic viability of the farms requires a system-level redesign of farm management. One possible innovative strategy, precision feed management (PFM), reduces soil-P build-up by limiting feed and fertilizer purchases, and increasing high-quality homegrown forage production. This study applied the integrated farm system model (IFSM) to 2 CRW dairy farms to quantify the benefits of a PFM farm planning strategy in controlling P imbalance problems, and maintaining farm profit-ability and reducing off-farm P losses. The IFSM accurately simulated the 2 farms based on farm data supplied by farm planners; these scenarios were used as the baseline conditions. The IFSM simulations of more accurate feeding of P (based on P required in animal diets) integrated with increased productivity of grass-forage and increased proportion of forage in the diet reduced the P imbalance of 1 farm from 5.3 to 0.5 kg/ ha and from 9.6 to 0.0 kg/ha for the second farm. For both farms, soluble P lost to the environment was reduced by 18%. Feed supplement purchases declined by 7.5 kg/cow per year for dietary mineral P, and by 1.04 and 1.29 t/cow per year for protein concentrates through adoption of the PFM system. Moreover, when a land management practice of converting corn to grass was coupled with the precision feeding of P and improved forage management, IFSM predicted reductions of 5.8 and 9.3 kg/ha of converted land sediment-bound P in erosion loss each year. The model predicted slight purchase increases in corn grain to offset reductions in corn silage production and feeding rates, but no appreciable change in the farm P balance due to land conversion. The model-based studies conducted on a farm-by-farm basis complement farm planning efforts in exploring innovative farming systems. Moreover, the results set a benchmark for potential benefits of PFM strategies, economically and environmentally.

Economic comparison of divergent strains of Holstein-Friesian cows in various pasture-based production systems.

The objective of this paper was to compare the economic efficiency of 3 divergent strains of Holstein-Friesian cows--high-production North American (HP), high-durability North American (HD), and New Zealand (NZ)--across a variety of Irish pasture-based production systems: Moorepark (MP), high concentrate (HC), and high stocking rate (HS). Physical performance data were obtained from a 5-yr study conducted previously. The economic performance of each strain and feed system was derived for 3 production scenarios: European Union (EU) milk quota applied at the farm level using predicted future prices and costs (S1); EU milk quota applied at the industry level, thus permitting quota leasing at predicted future prices and costs (S2); and EU milk quota applied at the industry level with a limitation on land availability (S3). The economic results showed that in a fixed milk quota scenario, the NZ strain in the MP and HS feed systems returned the highest profitability. The HD strain in the MP and HS feed systems proved the next most profitable, whereas the HP animals were least profitable in all feed systems. Similar to S1, in S2 the NZ were most profitable; however, the difference between the MP and HS was much smaller. The HP strain proved least profitable in all feed systems. In S3, the NZ strain was again most profitable; however, within that scenario the HS feed system was optimal. These results show that exclusive genetic selection for increased milk production results in reduced farm profitability because the productivity gains achieved are outweighed by associated increases in reproductive wastage costs in a pasture-based system. These results reinforce the economic value of genetic improvement based on a selection index encompassing traits of economic significance pertinent to the production environment.

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison.

OBJECTIVE: To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN: Retrospective cohort study. SETTING: A 700-bed long-term care facility in Boston. PARTICIPANTS: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. MEASUREMENTS: Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS: Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS: Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison.

OBJECTIVE: To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN: Retrospective cohort study. SETTING: A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. MEASUREMENTS: Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS: Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS: Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.