Date of Award

Spring 5-2019

Degree Name

Doctor of Public Health (DrPH)

Advisor(s)

J. MICHAEL SWINT, PHD

Second Advisor

LINCY S. LAL, PHARMD, PHD

Third Advisor

XIANGLIN L. DU, MD, PHD

Abstract

Heart failure is one of the leading causes of high morbidity and mortality. Acute exacerbation of heart failure may result in acute respiratory failure, which requires mechanical ventilator support. Despite supportive management, patients can fail extubation of the endotracheal tube and need a tracheostomy to continue mechanical ventilator support. However, optimal timing of tracheostomy has been controversial. Systemic study to assess the clinical and economic outcome of early tracheostomy among patients with acute heart failure exacerbation is lacking. The purpose of the study was to assess the national trend of tracheostomy among those who are admitted for acute respiratory failure with acute congestive heart failure exacerbation and to compare clinical and economic outcomes between the two groups (early and late tracheostomy) using national discharge data between from 2005 to 2014. We also conducted an economic evaluation comparing early and late tracheostomy among them using average cost and incremental costs with an outcome of length of stay. Among those who are admitted with acute heart failure exacerbation, 0.30% patients underwent the tracheostomy, and among them, 9.69% received early tracheostomy. There was no trend in the percentage of early tracheostomy. The length of stay in the hospital has decreased over time in late tracheostomy group, but it was stable in early tracheostomy group. Median total hospital length of stay (19 days) and total hospital cost ($52,158.23) in early tracheostomy group were significantly lower than late tracheostomy group (25 days and $68,037.40). Patients with coronary artery disease, pneumonia, and liver disease are less likely to receive early tracheostomy (OR 0.79, 0.63 and 0.64 respectively). After propensity score matching, it showed that the two groups did not show a significant difference in inhospital mortality (OR 0.91, p-value 0.676), or decannulation rate (OR 2.01, p-value 0.571). However, early tracheostomy was associated with higher likelihood of having a complication from tracheostomy with OR 2.08 (p-value 0.044) but was also associated with lower total hospital length of stay with coefficient factor -6.50 (p-value 0.000) from the linear regression model. From the economic evaluation, the early tracheostomy dominates the late tracheostomy with the outcome of total hospital length of stay and post-procedural length of stay with lower cost and higher effectiveness. The incremental cost-effectiveness ratio (ICER) is negative, meaning it costs $3,492.65 for each additional day in the hospital for late tracheostomy compared to early tracheostomy. ICER with the outcome of post-procedural length of stay was again negative, showing $2,032.67 per extra day in the hospital after the procedure among late tracheostomy group. Early tracheostomy among patients with acute heart failure exacerbation had no significant difference in mortality but had significant economic benefit with lower cost and less total hospital length of stay.

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