Abstract
Background: Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly amongst 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. We undertook the current investigation to examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy.
Methods: We developed analytic models employing the University Healthsystems Consortium (Oakbrook, IL) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, postdischarge destination and survival. Mean resource-intensity (RI) of participating academic medical centers (AMCs) was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach which incorporated patient-level demographic and clinical variables and institution-level RI (SAS 9.2, SAS Institute, Cary NC).
Results: We analyzed data from 44,124 ARF patients; 4,776 (10.8%) of whom underwent tracheostomy. Compared to low RI settings, treatment in high RI AMCs was associated with increased risk of mortality (OR (95% CI) 1.114 ((1.049- 1.763)) including those managed with tracheostomy (high RI AMC*tracheostomy: 1.104 (1.040-1.168)). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (p>0.05 for both), mortality for tracheostomy patients experiencing complications was greater in high (95/313 (30.3%)) vs. low RI (552/2587 (21.3%)) AMCs (p <0.001).
Conclusions: We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy. Future investigations in this area should focus on identifying clinically beneficial strategies, and assessing the cost-effectiveness of these strategies when applied in diverse clinical environments.
- Tracheostomy
- acute respiratory failure
- mechanical ventilation
- critical illness
- practice variation
- quality assurance
Footnotes
- Corresponding Author: Bradley D. Freeman, MD, FACS, Washington University School of Medicine Department of Surgery, 660 South Euclid Ave., Box 8109, St. Louis, MO 63110. freemanb{at}wustl.edu, (314) 362-1064, (314) 362-5743
Conflict of Interest Statement: As noted, two authors (SM, SFM) are employed by University Healthsystems Consortium, Oakbrook, IL. There are no additional potential conflicts of interest to disclose.
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