Dataset Information

Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study.

ABSTRACT: Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.2012 National Inpatient Sample.A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.None.Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.

SUBMITTER: Mehta AB

PROVIDER: S-EPMC4949074 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study.

Mehta Anuj B AB Cooke Colin R CR Wiener Renda Soylemez RS Walkey Allan J AJ

Critical care medicine 20160801 8

<h4>Objective</h4>Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.<h4>Design</h4>In a retrospective cohort study, we identified mechanically ventilated patients with the most co ...[more]

PMID: 27031382

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Project description:BackgroundLittle is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke.ObjectiveThe objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke.DesignThis was a retrospective, cohort design.MethodsThe sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes.ResultsAmong 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes.LimitationThe findings are limited to patients with ischemic stroke.ConclusionOnly 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Project description:OBJECTIVES:Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown. DESIGN:Retrospective cohort study. SETTING:Nationwide Inpatient Sample in 2011. PATIENTS:Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011. INTERVENTIONS:We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics. MEASUREMENTS AND MAIN RESULTS:We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03). CONCLUSIONS:Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

Project description:Describe the longitudinal national epidemiology of tracheostomies performed in acute care hospitals and describe the annual rate of tracheostomy performed for patients with respiratory failure with invasive mechanical ventilation.DesignSerial cross-sectional study.SettingThe 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets.PatientsDischarges greater than or equal to 18 years old, excluding those with head and neck cancer or transferred from another hospital. We used diagnostic and procedure codes from the International Classification of Diseases, 9th and 10th revisions to define cases of respiratory failure, invasive mechanical ventilation, and tracheostomy.InterventionsNone.Measurements and main resultsThere were an estimated 80,612 tracheostomies performed in 2002, a peak of 89,545 tracheostomies in 2008, and a nadir of 58,840 tracheostomies in 2017. The annual occurrence rate was 37.5 (95% CI, 34.7-40.4) tracheostomies per 100,000 U.S. adults in 2002, with a peak of 39.7 (95% CI, 36.5-42.9) in 2003, and with a nadir of 28.4 (95% CI, 27.2-29.6) in 2017. Specifically, among the subgroup of hospital discharges with respiratory failure with invasive mechanical ventilation, an annual average of 9.6% received tracheostomy in the hospital. This changed over the study period from 10.4% in 2002, with a peak of 10.9% in 2004, and with a nadir of 7.4% in 2017. Among respiratory failure with invasive mechanical ventilation discharges with tracheostomy, the annual proportion of patients 50-59 and 60-69 years old increased, whereas patients from 70 to 79 and greater than or equal to 80 years old decreased. The mean hospital length of stay decreased, and in-hospital mortality decreased, whereas discharge to intermediate care facilities increased.ConclusionsOver the study period, there were decreases in the annual total case volume and adult occurrence rate of tracheostomy as well as decreases in the rate of tracheostomy among the subgroup with respiratory failure with invasive mechanical ventilation. There is some evidence of changing patterns of patient selection for in-hospital tracheostomy among those with respiratory failure with invasive mechanical ventilation with decreasing proportions of patients with advanced age.

Dataset Information

Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study.

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Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study.

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