The Epidemiology of Adult Tracheostomy in the United States 2002-2017: A Serial Cross-Sectional Study

Abstract

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.

Design: Serial cross-sectional study.

Setting: The 2002-2014 and 2016-2017 Healthcare Utilization Project's National Inpatient Sample datasets.

Patients: Discharges 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.

Interventions: None.

Measurements and main results: There 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.

Conclusions: Over 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.

Keywords: epidemiology; health services research; respiratory failure; tracheostomy.

Figure 1.

Annual case volume of adult tracheostomies in acute care hospitals. Figure includes annual point estimates with shaded area representing 95% CIs of the estimates. We excluded patients with head and neck cancer. Over the study period: 1) the number of participating states in sample increased from 35 to 48, including the District of Columbia; 2) in 2012, there was a change in sample design; and 3) in 2015, diagnosis and procedure reporting changed from International Classification of Diseases (ICD), 9th revision, Clinical Modification coding to the ICD, 10th revision, Clinical Modification (8). The 2015 year was not included, given that the ICD coding changed during the year, preventing the use of standard methods for making annual estimates with either coding system for that year.

Figure 2.

Annual occurrence rate of adult tracheostomies in acute care hospitals. Figure includes annual point estimates with shaded area representing 95% CIs of the estimates. We excluded patients with head and neck cancer. Over the study period: 1) the number of participating states in sample increased from 35 to 48, including the District of Columbia; 2) in 2012, there was a change in sample design; and 3) in 2015, diagnosis and procedure reporting changed from International Classification of Diseases (ICD), 9th revision, Clinical Modification coding to the ICD, 10th revision, Clinical Modification (8). The 2015 year was not included, given that the ICD coding changed during the year, preventing the use of standard methods for making annual estimates with either coding system for that year.

Figure 3.

Annual rate of tracheostomy among U.S. adults hospitalized with respiratory failure with invasive mechanical ventilation. Figure includes annual point estimates with shaded area representing 95% CIs of the estimates. We excluded patients with head and neck cancer. Over the study period: 1) the number of participating states in sample increased from 35 to 48, including the District of Columbia; 2) in 2012, there was a change in sample design; and 3) in 2015, diagnosis and procedure reporting changed from International Classification of Diseases (ICD), 9th revision, Clinical Modification coding to the ICD, 10th revision, Clinical Modification (8). The 2015 year was not included, given that the ICD coding changed during the year, preventing the use of standard methods for making annual estimates with either coding system for that year. Annual U.S. Census Bureau annual population estimates for those greater than or equal to 18 yr old comprise the denominators in the calculation of annual occurrence rates (10, 11).