High Resource Utilization Does Not Affect Mortality in Acute Respiratory Failure Patients Managed With Tracheostomy

Abstract

BACKGROUND:

Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly among institutions. This variability has the potential to be reflected in the resources expended providing care. In various healthcare environments, increased resource expenditure has been associated with a favorable effect on outcome.

OBJECTIVE:

To examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy.

METHODS:

We developed analytic models employing the University Health Systems Consortium (Oakbrook, Illinois) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, post-discharge destination, and survival. Mean resource intensity of participating academic medical centers was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach that incorporated patient-level demographic and clinical variables and institution-level resource intensity.

RESULTS:

We analyzed data from 44,124 ARF subjects, 4,776 (10.8%) of whom underwent tracheostomy. Compared to low-resource-intensity settings, treatment in high-resource-intensity academic medical centers was associated with increased risk of mortality (odds ratio 1.11, 95% CI 1.05–1.76), including those managed with tracheostomy (odds ratio high-resource-intensity academic medical center with tracheostomy 1.10, 95% CI 1.04–1.17). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (P > .05 for both), mortality for tracheostomy patients experiencing complications was greater in high-resource-intensity (95/313, 30.3%) versus low-resource-intensity (552/2,587, 21.3%) academic medical centers (P < .001).

CONCLUSIONS:

We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy.

Keywords

tracheostomy acute respiratory failure mechanical ventilation critical illness practice variation quality assurance

Get full access to this article

View all access options for this article.

References

Dewar

, Kurek

, Lambrinos

, Cohen

, Zhong

. Patterns in costs and outcomes for patients with prolonged mechanical ventilation undergoing tracheostomy: an analysis of discharges under diagnosis-related group 483 in New York State from 1992 to 1996. Crit Care Med, 2003; 27(12):2640-2647.

Heffner

. The role of tracheotomy in weaning. Chest, 2001; 120(6):477S–481S.

Frutos-Vival

, Esteban

, Apezteguía

, Anzueto

, Nightingale

, Gonzalez

, et al. Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med, 2005; 33(2):290-298.

Cox

, Carson

, Holmes

, Howard

, Carey

. Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002. Crit Care Med, 2004; 32(11):2219-2226.

Freeman

, Borecki

, Coopersmith

, Buchman

. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med, 2005; 33(11):2513-2520.

Cox

, Martinu

, Sathy

, Clay

, Chia

, Gray

, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med, 2009; 37(11):2888-2894.

Kurek

, Cohen

, Lambrinos

, Minatoya

, Booth

, Chalfin

. Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York State during 1993: analysis of 6,353 cases under diagnosis-related group 483. Crit Care Med, 1997; 25(6):983-988.

Merrill

, Elixhauser

; US Department of Health & Human Services; Agency for Healthcare Research and Quality. HCUP Fact Book #7: Procedures in US Hospitals, 2003. AHRQ Publication no. 06-0039. http://archive.ahrq.gov/data/hcup/factbk7. Accessed August 23, 2013.

Freeman

, Morris

. Concise Definitive Review: Tracheostomy practice in adults with acute respiratory failure. Crit Care Med, 2012; 40(10):2890-2896.

10.

Mirski

, Pandian

, Bhatti

, Haut

. Safety, efficacy, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Crit Care Med, 2012; 40(6):1827-1834.

11.

Freeman

. Implementation of a specialized tracheostomy team as a strategy for quality improvement. Crit Care Med, 2012; 40(6):1980-1981.

12.

Rodriguez

, Steinberg

, Luchetti

, Gibbons

, Taheri

, Flint

. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery, 1990; 108(4):655-659.

13.

Rumbak

, Newton

, Truncale

, Schwartz

, Adams

, Hazard

. A prospective randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med, 2004; 32(1):1689-1694.

14.

Brook

, Sherman

, Malen

, Kollef

. A comparison of early- vs late-tracheostomy in patients requiring prolonged mechanical ventilation. Am J Crit Care, 2000; 9(5):352-359.

15.

Blot

, Guiguet

, Antoun

, Leclercq

, Nitenberg

, Escudier

. Early tracheotomy in neutropenic, mechanically ventilated patients: rationale and results of a pilot study. Support Care Can, 1995; 3(5):291-296.

16.

Boynton

, Hawkins

, Eastridge

, O'Keefe

. Tracheostomy timing and the duration of weaning in patients with acute respiratory failure. Crit Care, 2004; 8:R261-R267.

17.

Barquist

, Amortegui

, Hallal

, Giannotti

, Whinney

, Alzamel

, MaCleod

. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma, 2006; 60(1):91-97.

18.

Terragni

, Antonelli

, Fumagalli

, Faggiano

, Berardino

, Pallavicini

, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. JAMA, 2010; 303(15):1483-89.

19.

Young

. Early tracheostomy reduces sedative use but does not affect mortality. Brussels: 29th International Symposium on Intensive Care and Emergency Medicine; March 26, 2009.

20.

Trouillet

, Luyt

, Guiguet

, Ouattara

, Valsser

, Makri

, et al. Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery. Ann Int Med, 2011; 154(6):373-383.

21.

Nathens

, Rivara

, Mack

, Rubenfeld

, Wang

, Jurkovich

, et al. Variations in the rates of tracheostomy in the critically ill trauma patient. Crit Care Med, 2006; 34(12):2919-2924.

22.

Freeman

, Kennedy

, Coopersmith

, Buchman

. Examination of non-clinical factors affecting tracheostomy practice in an academic surgical intensive care unit. Crit Care Med, 2009; 37(12):3070-3078.

23.

Garland

, Shamon

, Baron

, Conners

. Physician-attributable differences in intensive care unit costs. Am J Respir Crit Care Med, 2006; 174(11):1206-1210.

24.

Stukel

, Fisher

, Alter

, Guttmann

, Ko

, Fung

, et al. Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA, 2012; 307(10):1037-1045.

25.

Chen

, Jha

, Guterman

, Ridgway

, Orav

, Epstein

. Hospital cost of care, quality of care, and readmission rates: penny wise and pound foolish?. Arch Int Med, 2012; 170(4):340-346.

26.

Barnato

, Chang

, Farrell

, Lave

, Roberts

, Angus

. Is survival better at hospitals with higher ‘end of life’ treatment intensity?. Med Care, 2010; 48(2):125-132.

27.

Romley

, Jena

, Goldman

. Hospital spending and inpatient mortality: evidence from California. An observational study. Ann Int Med, 2011; 154(3):160-167.

28.

Iezzoni

, editor. Risk adjustment for measuring healthcare outcomes, 3rd edition. Chicago: ACHE/Health Administration Press; 2003.

29.

Kim

, Daskalakis

, Lee

, Adams

, Hohmann

, Silvestry

, et al. Racial disparity in the relationship between hospital volume and mortality among patients undergoing coronary artery bypass grafting. Ann Surg, 2009; 248(5):886-892.

30.

Bankowitz

, Neikirk

, Juris

. A UHC clinical database analyst reference manual. Oak Brook, IL: University Healthsystems Consortium; 2000.

31.

Elixhauser

, Steiner

, Harris

, Coffey

. Comorbidity measures for use of administrative data. Med Care, 1998; 36(1):3-5.

32.

Esteban

, Frutos

, Tobin

, Alía

, Solsona

, Valverdú

, et al. A comparison of four methods of weaning patients from mechanical ventilation. N Engl J Med, 1995; 332(6):345-350.

33.

Esteban

, Alía

, Tobin

, Gil

, Gordo

, Vallverdú

, et al. Effect of spontaneous breathing trial duration on outcomes of attempts to discontinue mechanical ventilation. Am J Respir Crit Care Med, 1999; 159(2):512-519.

34.

Kress

, Pohlman

, O'Connor

, Hall

. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med, 2000; 342(20):1471-1477.