Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

doi:10.1016/j.jcrc.2017.11.037

Journal of Critical Care

Volume 44, April 2018, Pages 285-288

https://doi.org/10.1016/j.jcrc.2017.11.037 Get rights and content

Highlights

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Early tracheostomy reduces ICU & hospital costs.
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Early tracheostomy reduces ICU length of stay.
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Findings are consistent after sensitivity analysis.

Abstract

Introduction

Up to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown.

Objectives

To conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients.

Methods

We extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations.

Results

The average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (< 4 days) cost on average $3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (< 10 days but > 4) cost on average $6385 USD less than late tracheostomies (95% CI: –4396–17,165).

Conclusion

This study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.

Introduction

Given an aging population increasingly laden with medical comorbidities, hospital admissions are becoming more frequent with longer lengths of stay (LOS) and increased intensive care unit (ICU) admission rates leading to increased healthcare expenditures [1], [2]. Intensive care costs account for 13.2% of hospital expenditures, or $108 billion United States Dollars (USD) in 2010. This has more than doubled from a previous cost of 56 billion in 2000. This can be represented as 0.72% of the gross domestic product of the United States of America, a 32% rise from 2000 [1], [2]. It is estimated that a single day in the intensive care unit (ICU) costs $2500–4300 USD per patient, representing a 61.1% increase in costs over the same time period, largely owing to new medications, technologies, and labor costs [1], [2], [3], [4]. In order to maintain financial viability, strategies which reduce ICU costs while maintaining standard of care are necessary. Indeed, new interventions will be evaluated not only by clinical outcomes but also by the resources required to implement them [5].

In the United States alone, approximately 800,000 patients undergo mechanical ventilation each year [6]. Of these patients, up to 34% of those who require mechanical ventilation over 48 h receive a tracheostomy [7]. As a result, over 100,000 tracheostomies are performed in the United States annually [8]. In prolonged mechanically ventilated patients, tracheostomy can improve lung mechanics, improve oral hygiene, decrease pain, decrease need for sedatives and improve communication [6], [9]. It is also associated with a number of adverse side effects, including procedural risks and cosmetic concerns [10], [11], [12]. Changes in technology have allowed for a more liberal use of tracheostomies [6]. However, there have been conflicting results regarding the benefits of early tracheostomy and it remains unknown how much the early tracheostomy costs to the healthcare system compared to usual care.

A recent systematic review conducted by Hosokawa et al. [13] examined 12 randomized controlled trials (RCTs) that compared very early tracheotomy (within 4 days of initiation of mechanical ventilation) to relatively early tracheotomy within 10 days of initiation of mechanical ventilation) to late tracheotomy (after 10 days). This accounted for a total of 2689 patients, and showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. Given this, we perform a cost analysis of early tracheotomies from a hospital perspective.

Section snippets

Data collection

We identified RCTs included in the systematic review from Hosokawa et al. [13] and collected individual length of hospital stay and length of ICU stay data from those studies. We also searched for any recent randomized control trials on the topic that were published after this review. Two authors (KK and DC) searched PubMed and Google Scholar for any new RCTs published on the topic. They also reviewed bibliographies of the identified articles, used the PubMed-related articles search feature and

Study selection

Out of the 12 studies reported by Hosokawa et al. [13], only 8 reported data on ICU length of stay and 3 reported data on hospital length of stay. Additional searches, through PubMed and Google Scholar, as well as reviewed bibliographies, did not identify any additional RCTs examining the same topic.

Primary outcomes

Table 1 denotes average LOS obtained for the three subgroups: very early, early and late tracheotomy respectively. One study [19] further sub-divided patients as “survivors” and “non-survivors”, so

Discussion

This cost analysis demonstrates that across multiple centers, early tracheostomy, defined as tracheostomy performed within 10 days of tracheal intubation, consistently significantly reduces hospital costs based on LOS alone. The cost of the intervention itself has a negligible role to play in overall costs as both early and late groups had it performed. The cost of the procedure is about $1700 USD per patient [23]. While the majority of costs in the ICU are fixed, such as equipment and hospital

Conclusion

This study shows that early tracheostomy can significantly reduce direct variable and likely total costs in the intensive care unit based on length of stay alone. This difference can potentially represent hundreds of thousands of dollars in savings. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication [13]. Further prospective studies on this topic are needed to prove

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Cited by (48)

Impact of Early Tracheostomy After Lung Transplantation: A National Analysis
2024, Annals of Thoracic Surgery
Prolonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes.
All adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization.
Of an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (β-coefficient, −16.5 days; 95% CI, −25.3 to −7.6 days) and index hospitalization costs (β-coefficient, −$97,600; 95% CI, −$153,000 to −$42,100).
The present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.
Early tracheostomy after cardiac surgery improves intermediate- and long-term survival
2023, Medicina Intensiva
Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study’s second aim was to assess the incidence of both superficial and deep sternal wound infections.
Retrospective study of prospectively collected data.
Tertiary hospital.
Patients were divided into 3 groups, according to the timing of tracheostomy; early (4−10 days); intermediate (11−20 days) and late (≥21 days).
None.
The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection.
During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014–1.036)] and timing of tracheostomy [0.315 (0.159−0.757)] had significant impacts on mortality.
This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4−10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.
La evolución complicada de un postoperatorio de сirugía cardiaca puede dar lugar tanto a una estancia prolongada en UCI como a ventilación mecánica prolongada y puede requerir de una traqueotomía. Este estudio presenta la experiencia acumulada sobre traqueostomía en el postoperatorio de cirugía cardiaca en un único hospital.El objetivo era evaluar el momento de la realización de la traqueotomía como factor de riesgo de mortalidad temprana, intermedia y tardía.
Estudio retrospectivo.
Hospital terciario.
Pacientes fueron divididos en 3 grupos según el momento de la traqueotomía; temprano (4−10 días); intermedio (11−20 días); tardío (≥21 días).
No.
Los resultados primarios fueron la mortalidad en cada grupo.
Durante los 17 años de duración del estudio, de los 12.782 pacientes sometidos a cirugía cardíaca, 407 (3,18%) requirieron traqueotomía postoperatoria. Se practicaron 147 (36,1%) traqueotomías tempranas, 195 (47,9%) intermedias y 65 (16%) tardías. La mortalidad temprana, a los 30 días dentro del marco hospitalario, fue similar en todos los grupos. Sin embargo, las traqueotomía temprana e intermedia demostraron una mortalidad inferior estadísticamente significativa a 1 y 5 años (42,8%; 57,4%; 64,6%; y 55,8%; 68,7%; 75,4%, respectivamente; P < ,001). El modelo de Cox demostró que la edad [1,025 (1,014–1,036)] y el momento [0,315 (0,159–0,757)] impacta significativamente la mortalidad.
La traqueotomía temprana (dentro de los 4−10 días de ventilación mecánica) en el postoperatorio de cirugía cardíaca se asoció con una mejor supervivencia a medio/largo plazo.
Effect of tracheostomy timing in pediatric patients with traumatic brain injury
2023, International Journal of Pediatric Otorhinolaryngology
Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established.
This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes.
The Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days).
Of the 68,793 patients (mean age = 14, IQR 4–18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence.
Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.
Risk factors for 90-day mortality in critically ill ICU patients who undergo a tracheostomy. Frailty: A matter of great concern
2022, Acta Colombiana de Cuidado Intensivo
Tracheostomy (TR) remains one of the most performed procedures in the Intensive Care Unit (ICU). The literature normally focusses on technical issues and its timing; however, it is important to identify modifiable factors that increase the risk of mortality.
Prospective cohort study between October 2013 and April 2019.
ICU in a University Hospital in Spain.
Admitted to the ICU who underwent a TR during their ICU stay.
None.
Main comorbidities, baseline frailty status, severity scores, and variables related to mechanical ventilation (MV), TR weaning, decannulation, and mortality.
A total of 3010 admissions were identified; 212 (7%) underwent TR during their ICU stay. The final cohort comprised 135 patients. Median age was 69.6 (61.5–77.4) years; prevalence of frailty was 17.8%. Median time of MV before TR was 8.3 (5.3–11.1) days. All-cause 90-day mortality was 49.6%. Age, severity of illness, the impossibility of attempting a spontaneous breathing (SB) trial, SB time less than 50% of the time with TR, and TR in place at ICU discharge were independent predictors of 90-day mortality. The 90-day mortality rate was 2.2-fold higher in frail (Clinical Frailty Scale, CFS ≥ 5), tracheostomized patients.
Frailty (CFS ≥ 5), the inability of maintaining SB for more than 50% of the time with TR and discharge from ICU with TR in place were independent predictors of 90-day mortality. The creation of a surveillance team focusing on frail and non-decannulated patients to decrease 90-day mortality warrants further investigation.
La traqueotomía (TR) es uno de los procedimientos más empleados en las Unidades de Cuidados Intensivos (UCI). La literatura se centra en aspectos técnicos y en el momento de realización; sin embargo, es importante identificar factores modificables que aumenten el riesgo de mortalidad.
Estudio de cohortes prospectivo llevado a cabo entre 2013-2019.
UCI en un Hospital Universitario en España.
Ingresados en UCI que precisaron TR.
Ninguna.
Comorbilidades, fragilidad basal, scores de gravedad, relacionadas con ventilación mecánica (VM), TR, decanulación y mortalidad.
De 3.010 ingresados, 212 (7%) precisaron TR. La cohorte final fue de 135 pacientes. Mediana de edad 69,6 (61,5-77,4) años, mediana de tiempo en ventilación mecánica (VM) antes de TR 8,3 (5,3-11,1) días. Mortalidad global 49,6% a 90 días. Los factores predictores de mortalidad a 90 días fueron la edad, gravedad, imposibilidad de realizar un intento de respiración espontánea (RE), un tiempo en RE inferior al 50% del tiempo con TR y ser dado de alta a planta sin decanular. La mortalidad fue 2,2 veces mayor en los pacientes frágiles (Clinical Frailty Scale ≥ 5).
Los factores predictores de mortalidad a 90 días fueron fragilidad (CFS ≥ 5), imposibilidad de realizar un intento de RE o mantenerlo menos del 50% del tiempo con TR y ser dado de alta a planta con TR. Para disminuir la mortalidad, deberían realizarse nuevos estudios enfocados a evaluar la utilidad de equipos entrenados en el manejo de pacientes frágiles y/o dados de alta de UCI sin decanular.
Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient
2022, Surgical Clinics of North America
Citation Excerpt :
In multivariate analysis in the Nationwide Insurance claims study adjusting for demographics, comorbidities, insurance, and patient income, ET significantly reduced length of stay (effect ratio: 0.77, 95% CI 0.76–0.79) and hospital costs (effect ratio: 0.78, 95% CI 0.77–0.79).100 A cost analysis modeling study estimated that ET reduces hospital costs by $4316 (95% CI: 403–8229), mostly due to reductions in ICU length of stay.102 Increasing awareness is mounting surrounding disparities in the type and quality of tracheostomy care received among minority populations.
Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis
2021, Annals of Thoracic Surgery
Citation Excerpt :
Given the aforementioned benefits of early tracheostomy, as well as our findings demonstrating the safety of early tracheostomy, surgeons should feel reassured to consider an early tracheostomy in their patients. From the available evidence it is generally accepted that early tracheostomy improves health care utilization and costs, with shortened intensive care unit and hospital lengths of stay.26-29 Similarly, in the cardiac literature, Devarajan and colleagues12 reported improved outcomes, including reduced intensive care unit length of stay, among a propensity-matched analysis of 114 cardiac patients who underwent tracheostomy before 10 days.12
Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes.
We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes.
An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40).
In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

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Clinical PotpourriEarly vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

Highlights

Abstract

Introduction

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Data collection

Study selection

Primary outcomes

Discussion

Conclusion

Chest

Mayo Clin Proc

Am J Med

Egypt J Chest Dis Tuberc

Lancet

Arch Phys Med Rehabil

Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: 2000–2010

Crit Care Med

Critical care medicine in the United States 2000–2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

Crit Care Med

Growth of intensive care unit resource use and its estimated cost in Medicare

Crit Care Med

Reducing the cost of critical care: new challenges, new solutions

Am J Respir Crit Care Med

A clinician's guide to cost-effectiveness analysis

Ann Intern Med

Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes. Respir Care

2-month mortality and functional status of critically ill adult patients receiving prolonged mechanical ventilation

Chest

Tracheostomy patients on the ward: multiple benefits from a multidisciplinary team?

Crit Care

Late complications of tracheostomy

Respir Care

Clinical Potpourri
Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs