By Betty Tran, MD, MSc, Editor
SYNOPSIS: Tracheostomy use rose over the last two decades until 2008 in the United States and was associated with an increase in discharge to long-term care facilities with a concomitant decrease in hospital length of stay and hospital mortality.
SOURCE: Mehta AB, et al. Trends in tracheostomy for mechanically ventilated patients in the United States, 1993–2012. Am J Respir Crit Care Med 2015;192:445-454.
Using the National Inpatient Sample (NIS) from the U.S. Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, Mehta et al had the primary aim of examining yearly rates of tracheostomy among mechanical ventilation (MV) patients from 1993 to 2012. Secondary outcomes included hospital length of stay (LOS), hospital mortality, discharge location, and factors associated with receipt of tracheostomy. As the NIS is a 20% probability sample of all nonfederal acute care inpatients, the hope was that it would be representative of ICU care provided across the United States. Adults receiving mechanical ventilation (> 18 years), tracheostomies, and the presence of surgical procedures were identified using ICD-9 codes. Sensitivity analyses were performed excluding patients with diagnosis-related groups for tracheostomies related to face, head, or neck conditions and for patients with time to tracheostomy ≤ 0 days, as the focus was on patients with anticipated prolonged MV as opposed to those receiving emergent or prophylactic tracheostomies.
Between 1993 and 2012, 9.1% of patients on MV received a tracheostomy, with rates increasing from 6.9% in 1993 to a peak of 9.8% in 2008 and subsequently declining to 8.6% in 2012 (P < 0.0001). Age-adjusted, population-based rates of tracheostomy increased 106% over the study period, which was disproportionate to the growth in MV. This was mainly driven by an increase in tracheostomies for surgical MV patients, whereas tracheostomy rates in nonsurgical MV patients kept pace with the rise in MV during the same time.
During the study period, patients receiving tracheostomy tended to be younger, more likely to be male, more likely to be in a racial/ethnic minority group, and more likely to have Medicaid insurance; these trends were noted to outpace smaller changes in the overall MV population. Additionally, there was an increase in the number of comorbidities over time in patients undergoing tracheostomies. Median time to tracheostomy decreased from 11 days in 1998 to 10 days in 2012 (P < 0.0001).
Hospital mortality for patients receiving tracheostomies decreased from 38.1% in 1993 to 14.7% in 2012 (P < 0.0001) with similar findings for both surgical and nonsurgical patients. Hospital LOS decreased from a median of 39 days to 26 days (P < 0.0001). In conjunction with theses findings, there was a significant increase in discharges to long-term acute care hospitals (LTACHs) and skilled nursing facilities (SNFs) (40.1% in 1993 vs 71.9% in 2012) and fewer discharges to home (21.4% in 1993 vs 13.1% in 2012; P < 0.0001). Similar trends in factors associated with tracheostomy placement were observed in the sensitivity analyses.
The study by Mehta et al provides an insightful glimpse into the practice patterns surrounding not just tracheostomy use but also ICU care in the United States over the past two decades. Tracheostomy has become a more readily available procedure; it can be performed at bedside and by a variety of specialists, including otolaryngologists, general surgeons, cardiothoracic surgeons, and critical care physicians. Coupled with observations that patients on MV with tracheostomies tend to require less sedation and may be more comfortable, as well as some early studies that suggested early tracheostomies were associated with decreased days on MV and hospital LOS, it is no surprise that tracheostomy rates have increased over the past two decades. Although rates peaked in 2008, they remain higher overall, despite more recent, randomized studies showing no differences in mortality, antibiotic-free days, or ICU LOS.1
At first glance, the ramifications of this trend are deceivingly optimistic. The authors found that hospital mortality and LOS decreased over the same time period. I agree, however, with their discussion that this may represent merely a shift from dying in an acute care hospital to dying in an LTACH. Rates of discharges to LTACHs increased during the study, which is consistent with the rapid increase in number of LTACHs and LTACH beds observed over the past two decades.2 Additionally, studies have shown that 1-year outcomes for patients with prolonged MV are grim: Only 56% are alive, only 27% report a good quality of life, and a mere 9% are at home and independently functioning.3 Tracheostomy placement, in addition to advances in critical care medicine, have resulted in a growing population of patients with chronic critical illness who receive their care settings outside the acute care hospital. Although some patients do recover, discussions about tracheostomy in the acute care setting should inform patients and/or surrogates about prognosis and expectations surrounding long-term hospitalization at LTACHs/SNFs and explore whether these outcomes are in line with the patients’ values, preferences, and goals.
Young D, et al. Effect of early vs. late tracheostomy placement on survival in patients receiving mechanical ventilation: The TracMan randomized trial. JAMA 2013;309:2121-2129.
Kahn JM, et al. Long-term acute care hospital utilization after critical illness. JAMA 2010;303:2253-2259.
Unroe M, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: A cohort study. Ann Intern Med 2010;153:167-175.