title: High resource utilization does not affect mortality in acute respiratory failure patients managed with tracheostomy.
abstract: BACKGROUND
  Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly among institutions. This variability has the potential to be reflected in the resources expended providing care. In various healthcare environments, increased resource expenditure has been associated with a favorable effect on outcome.
  
  
  OBJECTIVE
  To examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy.
  
  
  METHODS
  We developed analytic models employing the University Health Systems Consortium (Oakbrook, Illinois) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, post-discharge destination, and survival. Mean resource intensity of participating academic medical centers was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach that incorporated patient-level demographic and clinical variables and institution-level resource intensity.
  
  
  RESULTS
  We analyzed data from 44,124 ARF subjects, 4,776 (10.8%) of whom underwent tracheostomy. Compared to low-resource-intensity settings, treatment in high-resource-intensity academic medical centers was associated with increased risk of mortality (odds ratio 1.11, 95% CI 1.05-1.76), including those managed with tracheostomy (odds ratio high-resource-intensity academic medical center with tracheostomy 1.10, 95% CI 1.04-1.17). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (P > .05 for both), mortality for tracheostomy patients experiencing complications was greater in high-resource-intensity (95/313, 30.3%) versus low-resource-intensity (552/2,587, 21.3%) academic medical centers (P < .001).
  
  
  CONCLUSIONS
  We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy.
authors: Department of Surgery.
authors: Bradley D
authors: BD
authors: Freeman
authors: Dustin
authors: D
authors: Stwalley
authors: Dennis
authors: D
authors: Lambert
authors: Joshua
authors: J
authors: Edler
authors: Peter E
authors: PE
authors: Morris
authors: Sofia
authors: S
authors: Medvedev
authors: Samuel F
authors: SF
authors: Hohmann
authors: Steven M
authors: SM
authors: Kymes
mesh_terms: D000208:Acute Disease; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000191:economics*; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000639:trends; D011785:Quality Assurance, Health Care; D012121:Respiration, Artificial / Q000191:economics; D012131:Respiratory Insufficiency / Q000191:economics / Q000401:mortality* / Q000628:therapy; D014139:Tracheostomy / Q000191:economics* / Q000379:methods; D014481:United States / Q000453:epidemiology
keywords: acute respiratory failure; critical illness; mechanical ventilation; practice variation; quality assurance; tracheostomy
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