By Samuel Nadler, MD, PhD
Critical Care, Pulmonary Medicine, The Polyclinic Madison Center, Seattle; Clinical Instructor, University of Washington, Seattle
SYNOPSIS: Medicare beneficiaries who underwent tracheostomy and gastrostomy tube placement often remained institutionalized beyond three months, with three-, six-, and 12-month mortality greater than 40%, 50%, and 60%, respectively.
SOURCE: Law AC, Stevens JP, Choi E, et al. Days out of institution after tracheostomy and gastrostomy placement in critically ill older adults. Ann Am Thorac Soc 2022;19:424-432.
In patients with chronic critical illness, tracheostomy and gastrostomy tube placement can facilitate continued medical care. Patients and families considering these interventions must understand the risks, benefits, and long-term outcomes to choose if this is appropriate. The current retrospective cohort study evaluated patients in the U.S. Center for Medicare and Medicaid Provider Analysis and Review database ages 66 years and older who underwent tracheostomy and/or gastrostomy tube placement during critical illness between Jan. 1, 2013, and Sept. 30, 2014. A total of 13,614 patients were included, with 3,365 undergoing tracheostomy alone, 6,709 with gastrostomy alone, and 3,540 receiving both. Co-primary outcomes were days alive outside institutions (DAOIs) during the first 90 days and one-year mortality. The mean age of the total cohort was 77.6 years. The study participants were 48.5% female, 74.6% white, 17.3% Black, and 8.1% other race/ethnicity. Prior to their hospitalization, 13.1% had chronic organ failure, 7.4% were identified as frail, and 38.6% were frail with chronic organ failure.
This study showed significant morbidity and mortality in older intensive care unit (ICU) patients undergoing tracheostomy, gastrostomy, or both, with overall mortality at one year reported as 62%, 60%, and 64%, respectively. In the 90 days after tracheostomy or gastrostomy, DAOIs were 3, 12, and 0, respectively. Most patients undergoing tracheostomy who survived to hospital discharge went to long-term acute care hospitals (LTACHs) (57%), followed by skilled nursing facilities (SNFs) (28%), then home (6%). Those undergoing gastrostomy were discharged mostly to an SNF (70%), followed by home (11%), then a LTACH (9.3%). For those undergoing both procedures, only 2% were discharged to home, with 58% ending up in LTACHs and 33% in SNFs. When stratified by pre-ICU state, the most common category was “chronic organ failure and frail” (n = 5,252, 39%). These patients had only six DAOIs in 90 days, 90-day mortality of 43.2%, 180-day mortality of 55.4%, and one-year mortality of 65.9%. In contrast, patients identified as being “robust” prior to their hospitalization had 27 DAOIs in 90 days, 90-day mortality of 25.8%, 180-day mortality of 31.5%, and one-year mortality of 37.7%.
Commentary
As critical care medicine has improved, more patients are chronically critically ill, requiring long-term interventions such as tracheostomy and gastrostomy. Adding to a previous meta-analysis, the current study sheds light on both patient-centered outcomes and long-term survival of these patients.1 These studies both report similar one-year mortality rates between 59% and 64%. To many patients, getting home or DAOIs is a more relevant outcome. This study nicely demonstrated in patients with tracheostomy, gastrostomy, or both, the DAOIs in the 90 days after hospitalization were 6, 12, and 0 days, respectively. Even more telling data in the study’s supplemental figure 1 showed the histogram of DAOIs in every group, with the most common group, by far, including 0 days. Among patients who died within 180 days of their procedure, the DAOI was 0 in every group. Only a few days at home were gained by select patients with these interventions. Despite these data, every family hopes their family member will be the one with the less common, more favorable outcome, which makes counseling patients challenging.
This paper rigorously documented patient disposition immediately after the index hospitalization. In patients with tracheostomy or tracheostomy and gastrostomy tubes, the most common discharge plan was LTACHs. In patients with gastrostomy tubes only, the most common disposition was SNFs. Notable in these groups with mortality exceeding 60% was the low level of hospice referrals (3.2% to 5.7%). While this group may be selected for patients wishing to receive active treatment, there may be an opportunity for more palliative care involvement.
Several subgroup analyses in this paper deserve attention. Patients defined as robust (i.e., no diagnoses of chronic organ failure, frailty, or cancer and no SNF claims in the prior year) prior to hospitalization had the best outcomes, with 90-day DAOI of 27 days and one-year mortality of 37.7%. In contrast, the most common group had chronic organ failure and frailty (39% of the cohort), with 90-day DAOI of six days and one-year mortality of 65.9%. The next most common group, patients with cancer, chronic organ failure, and frailty (22%) had 90-day DAOI of four days and one-year mortality of 69.9%. Thus, pre-hospitalization health state had a significant effect on outcomes.
This study adds to the growing data regarding outcomes of patients with tracheostomy, gastrostomy, or both. Using these data as a framework for discussions with patients and families can help guide shared decision-making and best align patient goals with likely outcomes.
REFERENCE
- Damuth E, Mitchell JA, Bartock JL, et al. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: A systematic review and meta-analysis. Lancet Respir Med 2015;3:544-553.
Medicare beneficiaries who underwent tracheostomy and gastrostomy tube placement often remained institutionalized beyond three months, with three-, six-, and 12-month mortality greater than 40%, 50%, and 60%, respectively.
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