Abstract
This cohort study uses Hospital Episode Statistics admission data to evaluate hospital resource use and associated costs for pediatric tracheostomy.
Pediatric tracheostomy is often performed to facilitate long-term ventilation.1 It is frequently associated with ongoing problems requiring medical attention.1,2 Little is known about current health care resource use (HRU) after pediatric tracheostomy. We used a comprehensive database to report hospital HRU and costs associated with caring for children after a tracheostomy at a national level.
Methods
This cohort study used the Hospital Episode Statistics (HES) Admitted Patient Care data set, which includes all National Health Service (NHS) admissions (including day case procedures) conducted in hospitals across England.3 The data set was interrogated for all pediatric tracheostomies (patients aged ≤16 years) between April 1, 2013, and March 31, 2018. Patients were followed up longitudinally until March 31, 2020. Episodes of care extracted from the data set were aggregated into admissions.4 Complications were derived from additional diagnosis codes.5 No patient-identifiable information was used; therefore, no patient consent or institutional review board approval was sought. This study followed the STROBE reporting guideline.
The Kaplan-Meier method was used to analyze survival. Analyses were performed using R, version 3.6.1 (R Foundation). Details are given in the eMethods in the Supplement.
Results
The initial search of HES identified 1709 episodes of care that included a tracheostomy insertion procedure in 1607 patients. We excluded 6 patients with missing, duplicate, or invalid admission identifiers; 114 admissions with incomplete or inconsistent information; 69 nonindex procedures; and 91 patients with a history of tracheostomy, leaving 1389 index tracheostomy admissions in 1389 patients for analysis.
The majority of the children in the cohort (953 [69%]) were younger than 1 year (1-5 years, 180 [13%]; 6-10 years, 67 [5%]; 11-16 years, 189 [14%]); 60% were boys. Race and ethnicity data were not collected. The median length of stay during the index tracheostomy admission was 39 nights (IQR, 11-97 nights). There were 634 in-hospital complications experienced during the tracheostomy admission in 393 patients (28%), of whom 64%, 25%, 8%, and 3% experienced 1, 2, 3, and 4 complications, respectively. The most common complication was tracheostomy malfunction (18%; code includes various complications and problems related to tracheostomy). Coding information was complete and translated to relevant costs in 1312 tracheostomy admissions (94%), with a median cost of £17 527 (IQR, £4566-£49 315 [median, $23 975; IQR, $6246-$67 457]).
The cohort (including 100 children who died during tracheostomy admission) accrued a total recorded follow-up of 2 201 889 days (median, 1670 days; IQR, 1123-2264 days). A total of 17 032 readmissions in 1186 patients (median, 7 readmissions per patient; IQR, 2-7 readmissions per patient) were recorded during follow-up (Table). Coded diagnoses within subsequent readmissions included acute lower respiratory tract infection (2683 admissions in 688 patients), acute upper respiratory tract infection (972 admissions in 445 patients), and tracheostomy malfunction (889 readmissions in 443 patients); 1378 admissions in 826 patients occurred within 30 days of discharge.
Table. Hospital Readmissions and Costs After Pediatric Tracheostomya.
| Year | Total admissions | LRTI admissions with tracheostomy in placeb | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. patients | Cost | Cost per patient, median (IQR) | Cost | Cost per patient, median (IQR) | |||||||
| GBP | USD | No. admissions | GBP | USD | GBP | USD | No. admissions | GBP | USD | ||
| 1 | 1122 | 36 176 809 | 49 491 656 | 6511 | 15 908 (6576-39 198) | 21 762 (8996-53 622) | 8 446 138 | 11 554 072 | 1213 | 6637 (2760-19 339) | 9080 (3776-26 457) |
| 2 | 824 | 14 275 934 | 19 530 528 | 3764 | 7428 (2744-18 090) | 10 161 (3795-24 747) | 3 203 246 | 4 381 715 | 620 | 4848 (1836-11 451) | 6632 (2512-15 665) |
| 3 | 673 | 7 934 059 | 10 854 028 | 2552 | 5610 (2075-14 834) | 7675 (2839-20 293) | 1 736 318 | 2 375 106 | 385 | 5094 (2369-12 652) | 6969 (3241-17 308) |
| 4 | 504 | 5 073 596 | 6 940 946 | 1677 | 5200 (1751-11 772) | 7113 (2396-16 104) | 1 037 895 | 1 419 895 | 226 | 5331 (1443-10 084) | 7292 (1974-13 794) |
| 5 | 322 | 2 993 132 | 4 094 762 | 1017 | 3402 (1446-10 677) | 4654 (1978-14 605) | 472 394 | 646 260 | 109 | 4518 (1350-9306) | 6181 (1847-12 730) |
| 6 | 183 | 1 560 704 | 2 135 116 | 524 | 3548 (1430-9652) | 4854 (1956-13 204) | 359 127 | 491 305 | 59 | 8434 (2890-21 515) | 11 538 (3953-29 430) |
| 7 | 63 | 474 868 | 474 868 | 165 | 2985 (1164-9455) | 4084 (1592-12 933) | 75 079 | 102 706 | 18 | 5331 (1922-8854) | 7292 (2629-12 111) |
Abbreviations: GBP, British pound sterling; LRTI, lower respiratory tract infection; USD, US dollars.
The data present the number of admissions with attributed costs that could be used in the costing analysis. n = 1186. GBP converted to USD on January 17, 2022.
Defined by International Classification of Diseases, Tenth Revision codes J20-J22 (n = 1182).
A total of 16 218 readmissions in 1182 patients (92% of the follow-up cohort) had attributed costs (Table). Costs attributed to admissions for lower respiratory infection accounted for £8 446 138 ($11 55 072; 23% of total costs) in year 1 and £3 203 246 ($4 381 715; 22% of total costs) in year 2.
During follow-up, an additional 145 patients died, including 34 within 30 days of tracheostomy discharge. Mean survival was 86.0% (95% CI, 84.2%-87.8%; 1194 patients) at 1 year and 84.3% (95% CI, 82.4%-86.2%; 1171 patients) at 2 years.
Discussion
Here, we present hospital HRU after pediatric tracheostomy covering NHS hospitals in England with a minimum 2-year follow-up, including 1389 children and 94 hospitals. Two US studies have investigated HRU after pediatric tracheostomy (including 917 children1 and 502 children6), but both drew from data collection periods of more than a decade ago. Readmissions for respiratory tract infection represent considerable HRU in children with tracheostomies and should be a target for clinical intervention and research. These data do not include community services, which may also incur considerable HRU. We advocate for national and international prospective data collection in this patient group to capture all clinical features and outcomes.
eMethods. Supplementary Methods
References
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Associated Data
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Supplementary Materials
eMethods. Supplementary Methods