Cost-Effectiveness of Percutaneous Tracheostomy
Abstract & Commentary
Synopsis: In 80 selected adult ICU patients who needed long-term airway access for ventilatory support and were randomized to tracheostomy technique, percutaneous dilational tracheostomy was performed more quickly and at significantly lower patient charges than surgical tracheostomy. There were no differences in the complications or other outcomes examined in the 2 patient groups.
Source: Freeman BD, et al. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 2001;29:926-930.
This randomized clinical trial was carried out at Barnes Jewish Hospital in St. Louis by investigators in the surgery, anesthesiology, and medicine departments at Washington University. Its purpose was to determine the cost-effectiveness of percutaneous dilational tracheostomy (PDT) in comparison with surgical tracheostomy (ST) in critically ill patients who required elective placement of a long-term airway. Patients were excluded if they had been ventilated for less than 1 week, were hemodynamically unstable, required more than 40% oxygen and/or 5 cm H2O of positive end-expiratory pressure (PEEP), were coagulopathic, or had difficult neck anatomy. PDT was performed at the patient’s bedside in the ICU; ST was done in the operating room.
Eighty patients were enrolled. The PDT and ST groups were similar in terms of age (about 65), gender, duration of intubation and ventilatory support prior to the procedure (13 vs 16 days, respectively), APACHE II scores (17 vs 18), and primary diagnosis leading to prolonged respiratory failure. There were no significant differences in ICU length of stay (24 vs 28 days) or hospital length of stay (50 vs 44 days). Four patients who underwent PDT required conversion to ST. Overall mortality was 22% in the PDT patients vs. 45% in the ST patients, although this difference was not statistically significant (P = 0.06).
In terms of cost-effectiveness, the primary focus of the study, PDT was performed more quickly than ST (means, 20 vs 42 min, respectively), P < 0.001. Mean hospital charges were $1569 for PDT and $3172 for ST; equipment and supply charges were $688 vs. $1526, and professional charges were $880 vs. $1647, all differences significant at P < 0.001. Freeman and colleagues conclude that they consider PDT to be the procedure of choice for establishing elective tracheostomy in the appropriately selected patient requiring long-term mechanical ventilation.
Comment by David J. Pierson, MD, FACP, FCCP
This study found no differences in complications or other outcomes in PDT vs. ST, and it documented statistically significantly lower patient charges in the PDT group. Although it is the largest randomized clinical trial of PDT yet reported, its size is still modest in terms of conclusions about complications. Illustrating this is the fact that the 22% vs. 45% mortality rates in the 2 patient groups were not different at the P < 0.05 level. It is also important to emphasize that only relatively stable patients requiring relatively modest support were included. Although the patients are referred to throughout the paper as being critically ill, I doubt that they would have been listed as "critically ill" in most hospitals. Only patients requiring 40% oxygen and 5 cm H2O PEEP or less, with no signs of active infection, were studied. Patients whose need for long-term airway access was in the context of being "chronically critically ill" with ongoing sepsis or acute respiratory distress syndrome would not have qualified. Patients with difficult neck anatomy were also excluded. Thus, this study covered long-term ventilation patients, such as those typically sent to long-term acute care facilities or regional weaning units, and the reported results might not apply to the "chronically critically ill" patient needing a tracheostomy.
It should be pointed out that charges, not costs, were compared in this study, and that the observed differences were due primarily to having to go to the operating room for ST. As Freeman et al acknowledge, if both procedures were performed in the OR the cost differences would likely disappear. Also not dealt with in this multidisciplinary study in which surgeons performed all procedures was the issue of turf, an important consideration in some institutions. PDT has been widely touted as an intensivist’s procedure, and who should be performing tracheostomy—by any technique—remains controversial.
Although PDT has been associated with some complications that are unlikely to occur with ST, such as paratracheal insertion, tracheal laceration, pneumothorax, and loss of airway, a recent meta-analysis by Freeman et al concluded that PDT is associated with fewer complications overall than ST.1 Although the cost/charge issue can be debated, the weight of evidence seems undeniable at this point in favor of PDT as relatively easy, quick to perform, no more dangerous, and cheaper than ST, at least for the kinds of patients included in this study. Whether PDT would be cheaper than and as safe as ST in chronically critically ill patients has not yet been determined.
1. Freeman BD, et al. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000; 118:1412-1418.