Days out of Institution after Tracheostomy and Gastrostomy Placement in Critically Ill Older Adults

Abstract

Abstract Rationale Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life support, with most placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives To determine the number of days alive and out of institution (DAOIs) and mortality after tracheostomy and gastrostomy placement during critical illness and to evaluate associations between health states before critical illness and outcomes. Methods In this retrospective cohort study of Medicare beneficiaries admitted to an intensive care unit (ICU) who received a tracheostomy, gastrostomy, or both, we determined the number of DAOIs after procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year before admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of cancer, chronic organ failure, frail, and robust) and assessed their association with DAOIs in 90 days and 1-year mortality. Results Among 3,365 patients who received a tracheostomy, 6,709 patients who received a gastrostomy tube, and 3,540 patients who received both procedures, the median number of DAOIs in the first 90 days after placement was 3 (interquartile range, 0–46), 12 (0–61), and 0 (0–37), respectively. Over half died within 180 days. One-year mortality was 62%, 60%, and 64%, respectively. When compared with the robust state, all other pre-ICU health states were associated with loss of DAOIs and increased 1-year mortality; however, between the seven non-robust pre-ICU health states, there were no differences in outcomes. Conclusions Medicare beneficiaries with prior comorbidity who received tracheostomy, gastrostomy tube, or both during critical illness spent few DAOIs and had high short- and long-term mortality.

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