Trends in the quality and cost of inpatient surgical procedures in the United States, 2002-2015.

OBJECTIVES: This study documents trends in risk-adjusted quality and cost for a variety of inpatient surgical procedures among Medicare beneficiaries from 2002 through 2015, which can provide valuable insight on future strategies to improve public health and health care. METHODS: We focused on 11 classes of inpatient surgery, defined by the Agency for Health Research and Quality's (AHRQ's) Clinical Classification System. The surgical classes studied included a wide range of surgeries, including tracheostomy, heart valve procedures, colorectal resection, and wound debridement, among others. For each surgical class, we assessed trends in treatment costs and quality outcomes, as defined by 30-day survival without unplanned readmissions, among Medicare beneficiaries receiving these procedures during hospital stays. Quality and costs were adjusted for patient severity based on demographics, comorbidities, and community context. We also explored surgical innovations of these 11 classes of inpatient surgery from 2002-2015. RESULTS: We found significant improvements in quality for 7 surgical classes, ranging from 0.08% (percutaneous transluminal coronary angioplasty) to 0.74% (heart valve procedures) per year. Changes in cost varied by surgery, the significant decrease in cost ranged from -2.59% (tracheostomy) to -0.34% (colorectal resection) per year. Treatment innovation occurred with respect to surgical procedures utilized for heart valve procedures and colorectal resection, which may be associated with the decrease in surgical cost. CONCLUSIONS: Our results suggest that there was significant quality improvement for 7 surgery categories over the 14-year study period. Costs decreased significantly for 6 surgery categories, and increased significantly for 3 other categories.

Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients.

OBJECTIVES/HYPOTHESIS: To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN: Retrospective case series. METHODS: All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS: A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS: Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2469-E2474, 2021.

A Minority of Patients on Mechanical Ventilation Consume Disproportionate Resources: A Retrospective Cohort Study.

BACKGROUND: The Pareto principle states that the majority of any effect comes from a minority of the causes. This property is widely used in quality improvement science. RESEARCH QUESTION: Among patients requiring mechanical ventilation (MV), are there subgroups according to MV duration that may serve as potential nodes for high-value interventions aimed at reducing costs without compromising quality? STUDY DESIGN AND METHODS: This multicenter retrospective cohort study included approximately 780 hospitals in the Premier Research Database (2014-2018). Patients receiving MV were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, codes. They were then divided into quintiles according to MV duration; their hospital costs, post-MV onset length of stay (LOS), ICU LOS, and cumulative post-MV onset hospital days per quintile were compared. RESULTS: A total of 691,961 patients were included in the analysis. Median [interquartile range] duration of MV in days by quintile was as follows: quintile 1 (Q1), 1 [1, 1]; Q2, 2 [2, 2]; Q3, 3 [3, 3]; Q4, 6 [6, 7]; and Q5, 13 [10, 19]. Median [interquartile range] post-MV onset LOS (Q1, 2 [0, 5]; Q5, 17 [12, 26]) and hospital costs (Q1, $15,671 [$9,180, $27,901]; Q5, $70,133 [$47,136, $108,032]) rose from Q1 through Q5. Patients in Q5 consumed 47.7% of all post-MV initiation hospital days among all patients requiring MV, and the mean per-patient hospital costs in Q5 exceeded the sum of costs incurred by Q1 to Q3. Adjusted marginal mean (95% CI) hospital costs rose exponentially from Q1 through Q5: Q2 vs Q1, $3,976 ($3,354, $4,598); Q3 vs Q2, $5,532 ($5,103, $5,961); Q4 vs Q3, $11,705 ($11,071, $12,339); and Q5 vs Q4, $26,416 ($25,215, $27,616). INTERPRETATION: Patients undergoing MV in the highest quintiles according to duration of MV consume a disproportionate amount of resources, as evidenced by MV duration, hospital LOS, and costs, making them a potential target for streamlining MV care.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Design and Evaluation of a Low-Cost Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Simulator.

INTRODUCTION: Bronchoscopy-guided percutaneous dilatational tracheostomy (BG-PDT) is an invasive procedure regularly performed in the intensive care unit. Risk of serious complications have been estimated in up to 5%, focused during the learning phase. We have not found any published formal training protocols, and commercial simulators are costly and not widely available in some countries. The objective of this study was to present the design and simulator performance of a low-cost BG-PDT simulator. METHODS: A simulator was designed with materials available in a hardware store, synthetic skin pads, ex vivo bovine tracheas, and a pipe inspection camera. The simulator was tested in 8 experts and 9 novices. Sessions were video recorded, and participants were equipped with the Imperial College Surgical Device, a hand motion-tracking device. Performance was evaluated with a multimodal approach, including first attempt success rate, global success rate, total procedural time, Imperial College Surgical Device-derived proficiency parameters, and global rating scale applied blindly by 2 expert observers. A satisfaction survey was applied after the procedure. RESULTS: A simulator was successfully constructed, allowing multiple iterations per assembly, with a fixed cost of US $30 and $4 per use. Experts had greater global and first attempt success rate, performed the procedure faster, and with greater proficiency. It presented high user satisfaction and fidelity. CONCLUSIONS: A low-cost BG-PDT simulator was successfully constructed, with the ability to discriminate between experts and novices, and with high fidelity. Considering its ease of construction and cost, it can be replicated in almost any intensive care unit.

One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure.

OBJECTIVES: Tracheostomy utilization has dramatically increased recently. Large gaps exist between expected and actual outcomes resulting in significant decisional conflict and regret. We determined 1-year patient outcomes and healthcare utilization following tracheostomy to aid in decision-making and resource allocation. DESIGN: Retrospective cohort study. SETTING: All California hospital discharges from 2012 to 2013 with follow-up through 2014. PATIENTS: Nonsurgical patients who received a tracheostomy for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our primary outcome was 30-day, 90-day, and 1-year mortality. We also determined hospitals readmissions rates and healthcare utilization in the first year following tracheostomy. We identified 8,343 tracheostomies during the study period. One-year mortality following tracheostomy was high, 46.5%. Older adults (≥ 65 yr) had significantly higher mortality compared with younger patients (< 65 yr) (54.7% vs 36.5%; p < 0.0001). Median survival for older adults was 175 days (95% CI, 150-202 d) compared with greater than 1 year for younger adults (adjusted hazard ratio, 1.25; 95% CI, 1.14-1.36). Within 1 year of tracheostomy, 60.3% of patients required hospital readmission. Older adults were more likely to be readmitted in the first year after tracheostomy compared with younger adults (66.1% vs 55.2%; adjusted hazard ratio, 1.19; 95% CI, 1.09-1.29). Total short-term acute care hospital costs (index and readmissions) in the first year after tracheostomy were high (mean, $215,369; SD, $160,874). CONCLUSIONS: Long-term outcomes following tracheostomy are extremely poor with high mortality, morbidity, and healthcare resource utilization especially among older patients. Some subsets of younger patients may have better outcomes compared with the general tracheostomy population. Short-term acute care costs were extremely high in the first year following tracheostomy. If extended to the entire U.S. population, total short-term acute care hospital costs approach $11 billion dollars per year for tracheostomy-related to acute respiratory failure. These findings may aid families and surrogates in the decision-making process.

Association of Transoral Robotic Surgery With Short-term and Long-term Outcomes and Costs of Care in Oropharyngeal Cancer Surgery.

Importance: The treatment of oropharyngeal cancer has undergone a paradigm shift in the past 2 decades, with an increase in the use of nonoperative treatment owing to poor functional outcomes associated with traditional surgical approaches. Transoral robotic surgery (TORS) allows surgical resection of oropharyngeal cancer (OPC) with less morbidity through a minimally invasive approach. Objective: To investigate the relationship among TORS and short- and long-term outcomes and costs in surgically treated patients with OPC. Design, Setting, and Participants: Retrospective cross-sectional analysis of 3573 patients who underwent an ablative procedure for OPC in 2010 to 2012 using the MarketScan Commercial Claim and Encounters database. Main Outcomes and Measures: The association between TORS and short- and long-term outcomes, length of hospitalization, and treatment-related costs was analyzed using descriptive statistics and multivariate regression modeling. Results: Transoral robotic surgery was performed in 304 surgical cases (8.5%); 94.7% of patients were 40 to 64 years old, and 70.7% were male. The use of TORS increased from 4.1% of surgical cases in 2010 to 13.2% of surgical cases in 2012. Patients who underwent TORS had a lower rate of tracheotomy during treatment (3.9% vs 11.4%), and posttreatment gastrostomy tube use (21.9% vs 34.2%), compared with patients undergoing non-TORS procedures. On multivariate analysis, TORS was not associated with significant differences in postoperative complications or length of hospitalization. There was no significant difference in the odds of receiving postoperative radiation therapy between patients who underwent TORS and those who did not; however, among patients receiving radiation therapy, chemoradiation was significantly less likely following TORS (odds ratio [OR], 0.52; 95% CI, 0.29-0.90). TORS was associated with significantly decreased odds of posttreatment gastrostomy (OR, 0.54; 95% CI. 0.30-0.95) and tracheostomy during treatment (OR, 0.17; 95% CI, 0.06-0.55) at 1 year, and was associated with significantly decreased overall treatment-related costs of care (mean incremental cost, -$22 724). Conclusions and Relevance: The use of TORS for surgical resection of OPC is increasing in the United States and is associated with significantly lower use of adjuvant chemoradiation, late gastrostomy and tracheostomy dependence, and lower overall treatment-related costs of care. These data have implications for discussions of value in OPC care at a time of health care reform.

Surgical management of bilateral vocal fold paralysis: A cost-effectiveness comparison of two treatments.

OBJECTIVES/HYPOTHESIS: Endoscopic management of bilateral vocal fold paralysis (BVFP) includes cordotomy and arytenoidectomy, and has become a well-accepted alternative to tracheostomy. However, the costs and quality-of-life benefits of endoscopic management have not been examined with formal economic analysis. This study undertakes a cost-effectiveness analysis of tracheostomy versus endoscopic management of BVFP. STUDY DESIGN: Cost-effectiveness analysis. METHODS: A literature review identified a range of costs and outcomes associated with surgical options for BVFP. Additional costs were derived from Medicare reimbursement data; all were adjusted to 2014 dollars. Cost-effectiveness analysis evaluated both therapeutic strategies in short-term and long-term scenarios. Probabilistic sensitivity analysis was used to assess confidence levels regarding the economic evaluation. RESULTS: The incremental cost effectiveness ratio for endoscopic management versus tracheostomy is $31,600.06 per quality-adjusted life year (QALY), indicating that endoscopic management is the cost-effective short-term strategy at a willingness-to-pay (WTP) threshold of $50,000/QALY. The probability that endoscopic management is more cost-effective than tracheostomy at this WTP is 65.1%. Threshold analysis demonstrated that the model is sensitive to both utilities and cost in the short-term scenario. When costs of long-term care are included, tracheostomy is dominated by endoscopic management, indicating the cost-effectiveness of endoscopic management at any WTP. CONCLUSIONS: Endoscopic management of BVFP appears to be more cost-effective than tracheostomy. Though endoscopic cordotomy and arytenoidectomy require expertise and specialized equipment, this model demonstrates utility gains and long-term cost advantages to an endoscopic strategy. These findings are limited by the relative paucity of robust utility data and emphasize the need for further economic analysis in otolaryngology. LEVEL OF EVIDENCE: NA Laryngoscope, 127:691-697, 2017.

A Cost-effectiveness Analysis of Early vs Late Tracheostomy.

Importance: The timing of tracheostomy in critically ill patients requiring mechanical ventilation is controversial. An important consideration that is currently missing in the literature is an evaluation of the economic impact of an early tracheostomy strategy vs a late tracheostomy strategy. Objective: To evaluate the cost-effectiveness of the early tracheostomy strategy vs the late tracheostomy strategy. Evidence Acquisition: This economic analysis was performed using a decision tree model with a 90-day time horizon. The economic perspective was that of the US health care third-party payer. The primary outcome was the incremental cost per tracheostomy avoided. Probabilities were obtained from meta-analyses of randomized clinical trials. Costs were obtained from the published literature and the Healthcare Cost and Utilization Project database. A multivariate probabilistic sensitivity analysis was performed to account for uncertainty surrounding mean values used in the reference case. Results: The reference case demonstrated that the cost of the late tracheostomy strategy was $45 943.81 for 0.36 of effectiveness. The cost of the early tracheostomy strategy was $31 979.12 for 0.19 of effectiveness. The incremental cost-effectiveness ratio for the late tracheostomy strategy compared with the early tracheostomy strategy was $82 145.24 per tracheostomy avoided. With a willingness-to-pay threshold of $50 000, the early tracheostomy strategy is cost-effective with 56% certainty. Conclusions and Relevance: The adaptation of an early vs a late tracheostomy strategy depends on the priorities of the decision-maker. Up to a willingness-to-pay threshold of $80 000 per tracheostomy avoided, the early tracheostomy strategy has a higher probability of being the more cost-effective intervention.

Economic analysis of routine neuromonitoring of recurrent laryngeal nerve in total thyroidectomy / Análisis económico de la monitorización neurológica rutinaria del nervio laríngeo recurrente en la tiroidectomía total

Introduction: Thyroidectomy is a common surgery. Routine searching of the recurrent laryngeal nerve is the most important strategy to avoid palsy. Neuromonitoring has been recommended to decrease recurrent laryngeal nerve palsy. Objective: To assess if neuromonitoring of recurrent laryngeal nerve during thyroidectomy is cost-effective in a developing country. Materials and methods: We designed a decision analysis to assess the cost-effectiveness of recurrent laryngeal nerve neuromonitoring. For probabilities, we used data from a meta-analysis. Utility was measured using preference values. We considered direct costs. We conducted a deterministic and a probabilistic analysis. Results: We did not find differences in utility between arms. The frequency of recurrent laryngeal nerve injury was 1% in the neuromonitor group and 1.6% for the standard group. Thyroidectomy without monitoring was the less expensive alternative. The incremental cost-effectiveness ratio was COP$ 9,112,065. Conclusion: Routine neuromonitoring in total thyroidectomy with low risk of recurrent laryngeal nerve injury is neither cost-useful nor cost-effective in the Colombian health system.

Introducción. La tiroidectomía es una cirugía común. La búsqueda rutinaria del nervio laríngeo inferior es la estrategia más importante para evitar la parálisis. Objetivo. Evaluar el costo-efectividad en un país en desarrollo de la monitorización neurológica del nervio laríngeo inferior durante la tiroidectomía. Materiales y métodos. Se diseñó un análisis de decisiones para evaluar el costo-efectividad de la monitorización neurológica del nervio laríngeo inferior. Para las probabilidades se usaron datos de un meta-análisis. La utilidad se determinó con medidas de preferencia. Se incluyeron los costos directos. Se hizo un análisis determinístico y probabilístico. Resultados. No se encontraron diferencias en la utilidad entre las estrategias. La frecuencia de la lesión de este nervio fue de 1 % en el grupo bajo monitorización neurológica y de 1,6 % en el grupo de control. La tiroidectomía sin monitorización fue la alternativa menos costosa. La razón de costo-efectividad incremental fue de COP$ 9.112.065 Conclusión. La monitorización neurológica rutinaria en la tiroidectomía total con bajo riesgo de lesión del nervio laríngeo inferior, no es útil con relación a su costo ni costo-efectiva en el sistema de salud colombiano.

Economic analysis of routine neuromonitoring of recurrent laryngeal nerve in total thyroidectomy.

INTRODUCTION: Thyroidectomy is a common surgery. Routine searching of the recurrent laryngeal nerve is the most important strategy to avoid palsy. Neuromonitoring has been recommended to decrease recurrent laryngeal nerve palsy. OBJECTIVE: To assess if neuromonitoring of recurrent laryngeal nerve during thyroidectomy is cost-effective in a developing country. MATERIALS AND METHODS: We designed a decision analysis to assess the cost-effectiveness of recurrent laryngeal nerve neuromonitoring. For probabilities, we used data from a meta-analysis. Utility was measured using preference values. We considered direct costs. We conducted a deterministic and a probabilistic analysis. RESULTS: We did not find differences in utility between arms. The frequency of recurrent laryngeal nerve injury was 1% in the neuromonitor group and 1.6% for the standard group. Thyroidectomy without monitoring was the less expensive alternative. The incremental cost-effectiveness ratio was COP$ 9,112,065. CONCLUSION: Routine neuromonitoring in total thyroidectomy with low risk of recurrent laryngeal nerve injury is neither cost-useful nor cost-effective in the Colombian health system.

Cost analysis of mandibular distraction versus tracheostomy in neonates with Pierre Robin sequence.

OBJECTIVE: To evaluate costs associated with surgical treatment for neonates with Pierre Robin sequence (PRS). STUDY DESIGN: Retrospective cohort study. SETTING: Cincinnati Children's Hospital Medical Center. SUBJECTS AND METHODS: With Institutional Review Board approval, we retrospectively studied neonates with PRS treated from 2001 to 2009 with either tracheostomy (Trach), mandibular distraction (MD), or Trach with subsequent MD (Trach+MD). Actual charges over a 3-year period associated with operative costs, hospital stay, imaging and sleep studies, clinic visits, and related emergency room visits were collected. Home tracheostomy care charges were estimated individually for each patient. Charges were compared using regression and appropriate statistical analyses. RESULTS: Forty-seven neonates were included in the study (MD, n = 26; Trach, n = 12; Trach+MD, n = 9). Trach group patients had 2.6-fold higher charges than the MD group despite no difference in length of hospital stay. This difference increased to 7.3-fold when including home trach care-related costs. Trach+MD group patients had longer hospital lengths of stay and higher operation room (OR) fees, but no increased total charges compared with the Trach only group. CONCLUSIONS: For patients with severe PRS, mandibular distraction provides significant cost savings over tracheostomy ($300,000 per patient over 3 years). Increased costs with tracheostomy come from greater hospital-related charges, more frequent airway procedures, a higher incidence of gastrostomy tube feeds, and home trach care costs. A careful examination of long-term outcomes will be critical as mandibular distraction continues to gain acceptance for treatment of PRS.

Tracheostomy versus mandibular distraction osteogenesis in infants with Robin sequence: a comparative cost analysis.

Many treatments have been described for infants with Robin sequence and severe respiratory distress, but there have not been many comparative studies of outcome and cost-effectiveness. The aim of this study was to compare the cost and complications of two common interventions - mandibular distraction osteogenesis and tracheostomy. Nine patients with isolated Robin sequence (mandibular distraction osteogenesis, n=5, and tracheostomy, n=4) were included in the analyses. Predetermined costs and complications were obtained retrospectively from medical records and by questionnaires to the parents over a 12-month period. Overall direct costs (admission to hospital, diagnostics, surgery, and homecare) were 3 times higher for tracheostomy (€105.523 compared with €33.482, p=0.02). Overall indirect costs (absence from work) were almost 5 times higher (€2.543 compared with €543, p=0.02). There was a threefold increase in overall total cost/patient (both direct and indirect) for tracheostomy (€108.057 compared with 34.016, p=0.02) and 4 times more complications were encountered. This study shows that mandibular distraction osteogenesis in infants diagnosed with Robin sequence costs significantly less and results in fewer complications than tracheostomy, and this contributes to our current knowledge about the ideal approach for infants with Robin sequence and might provide a basis for institutional protocols in the future.

[The role of routine chest radiography after percutaneous dilatational tracheostomy. A prospective randomized study]. / Bedeutung der routinemäßigen Röntgenkontrolle nach perkutaner Dilatationstracheotomie. Eine prospektive randomisierte Studie.

BACKGROUND: Routine chest radiography (X-ray) after percutaneous dilatational tracheostomy has been considered standard procedure in the past. However, recent observations show this to be unnecessary and cost ineffective. Prospective randomised trials have been lacking. PATIENT AND METHODS: Critically ill patients admitted to an ICU with an indication for a percutaneous tracheostomy were consecutively randomized into group 1 (routine postprocedural chest X-ray) and group 2 (chest X-ray only when considered clinically indicated). Tracheostomy was performed under bronchoscopic guidance. RESULTS: A total of 100 patients (50 per group) were included. Three major complications were observed in group 1 and one presumed complication in group 2. There were 11 minor complications in group 1 and 16 in group 2. Routine chest X-ray in group 1 did not reveal any abnormality related to the tracheostomy. A control chest X-ray was considered necessary in only one patient in group 2, but with no pathological change observed. CONCLUSION: Routine chest radiography after a percutaneous dilatational tracheostomy conducted under fibre optic bronchoscopic guidance is probably not useful.

Parental perception of functional status following tracheostomy in infancy: a single center study.

OBJECTIVE: To examine the functional outcomes of children who underwent a tracheostomy in the initial hospitalization after birth and to determine their correlates. STUDY DESIGN: We administered the validated 43-item Functional Status-II (FS-II) questionnaire by Stein and Jessop over the telephone to caregivers of surviving children. The FS-II items generated a total score, age-specific: (1) total; (2) general health (GH); and (3) responsiveness, activity, or interpersonal functioning (IPF) scores in specific age group categories. RESULTS: FS-II was administered to 51/62 (82.2%) survivors at a median (range) age of 5 (1-10) years; 27% children were on the ventilator and 43% required devices. About 40% of children had a median of 1 (1-4) hospitalization in the previous 6 months. Scores were >2 SD below means in 55%, 24%, and 55% cases for age-specific T, GH, and R/A/IPF scores respectively. The T and R/A/IPF scales were significantly higher in those with private, rather than public, maternal insurance, as were T and R/A/IPF scores for children ≥ 4 years, compared with younger children. On regression analysis, FS-II T, GH, and R/A/IPF scores were independently associated with maternal private insurance (P = .02). R/A/IPF scores were also significantly associated with corrected age at FS-II administration. CONCLUSIONS: One-third of surviving children who underwent tracheostomy during their initial hospitalization remained technology-dependent. The parental FS-II questionnaires revealed low R/A/IPF scores, especially at younger ages and in those with maternal public insurance. Further research on family-level interventions to improve functional outcomes in this population is warranted.

Evolution of percutaneous dilatational tracheostomy--a review of current techniques and their pitfalls.

Tracheostomy is the most commonly performed surgical procedure in critically ill patients with acute respiratory failure. While few absolute indications exist, this procedure is widely used in patients with upper respiratory obstruction and those requiring long-term mechanical ventilation. The traditional approach to tracheostomy has been an open procedure performed in the operating room. This method is associated with an increased rate of complications and costs. Accordingly, percutaneous bedside tracheostomy procedures have largely replaced the traditional operative approach at many institutions. Numerous methods for percutaneous tracheostomy have thus emerged. However, the benefits of one technique versus another have not been well demonstrated. In this article, we review the evidence supporting the use of percutaneous tracheostomy procedures over the traditional operative approach. Furthermore, we review the currently available and emerging methods by which percutaneous tracheostomy can be performed. In addition, we highlight the available evidence concerning the safety and complication rates of each technique.

Tracheostomy versus mandibular distraction osteogenesis in Canadian children with Pierre Robin sequence: a comparative cost analysis.

INTRODUCTION: Upper airway obstruction in newborns with Pierre Robin sequence (PRS) may be severe enough to require a surgical intervention. Tracheostomy has been the traditional gold standard, but mandibular distraction osteogenesis (MDO) has been proven to be an effective alternative procedure. OBJECTIVE: The objective of the present study was to conduct the first comparative cost analysis between tracheostomy and MDO in Canada. METHODS: All patients with PRS who underwent tracheostomy or MDO between January 2005 and December 2010 were included. Tracheostomy and MDO procedures were broken down into individual components, and the associated costs for these components were totaled. The average per-patient cost for each modality was then compared. RESULTS: During the study period, 52 children underwent either a tracheostomy (n  =  31) or MDO (n  =  21). The average age at surgery, gender, and presence of associated syndromes were similar in both groups. Taking into account the cost of the surgeries, health care professional fees, and hospital stay, the total per-patient treatment cost was determined to be $57,648.55 for MDO and $92,164.45 for tracheostomy. The majority of the cost for the tracheostomy group was associated with prolonged hospital stay after the operation ($72,827.85). Overall, the average per-patient cost was 1.6 times greater in the tracheostomy group compared to the MDO group (p  =  .039). CONCLUSION: The initial cost of MDO was less than the tracheostomy cost for newborns with PRS and severe upper airway obstruction at our health care centre. Further prospective analysis considering the long-term costs is required to possibly reduce long-term health care costs.

Multidisciplinary team approach in the management of tracheostomy patients.

OBJECTIVE: To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. STUDY DESIGN: Case series with planned data collection. SETTING: Urban, academic, tertiary care medical center. SUBJECTS AND METHODS: Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. RESULTS: Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center. CONCLUSIONS: Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

OBJECTIVE: The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN: A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING: Single-center, major university hospital. PATIENTS: The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS: The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS: An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

When is surgical tracheostomy indicated? Surgical "U-shaped" versus percutaneous tracheostomy.

OBJECTIVE: Tracheostomy is one of the most frequent interventions for ICU patients. The current trend in performing a tracheostomy is a percutaneous approach because of its popularity and significant advantages. In this study, certain indications of surgical tracheostomy (ST) are suggested and furthermore, ST is compared with percutaneous tracheostomy (PT). PATIENT AND METHODS: We performed a U-shaped ST in 121 patients and PT in 85 patients between March 2003 and December 2006. All of the STs were opened U-shaped in the operating room. In this technique; instead of removing the tracheal ring, it was used to create a flap. The tracheal flap was hung with a suture from middle of the 2nd or the 3rd cartilage rings, as a guide. Also, the PT procedure "Griggs dilatation technique" was performed in the ICU. RESULTS: PT and ST had similar complication rates: 4.1% for ST [bleeding in 2 patients, stenosis in 2, and stomal infection in 1] versus 3.6% for PT [bleeding in 2 patients, and pneomothorax in 1] (p = 0.08). No significant difference was found regarding mean operation time between ST [12 min (9-18)] and PT [8 min (6-16)] (p = 0.09) CONCLUSIONS: Staff utilization and cost seem like the major advantages of PT. However, our surgical technique has similar complication rates with PT and moreover, using ST still remains favorable for select patients with thyroid hyperplasia, short neck, tracheaomalacia, obesity, neck operation history and for children.