Economic Analysis
A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients.
This review may be edited
Posted By: Gord Doig
Posted Date: 9Nov2001
Title: A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients.
Authors: Freeman BD, Isabella K, Cobb P et al
Reference: Crit Care Med 2001;29:926-930
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
OBJECTIVE: To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients. DESIGN: Prospective randomized study.
SETTING: Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.
PATIENTS: Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.
INTERVENTIONS: Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.
MEASUREMENTS AND MAIN RESULTS: Treatment groups were well matched with respect to age (PDT, 65.44 +/- 2.82 [mean +/- se] years; ST, 61.4 +/- 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 +/- 0.84; ST, 17.88 +/- 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 +/- 2.0 mins; ST, 41.7 +/- 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, 1,569 dollars +/- 157 dollars vs. ST, 3,172 dollars +/- 114 dollars; equipment/supply charges: PDT, 688 dollars +/- 103 dollars vs. ST, 1,526 dollars +/- 87 dollars; professional charges: PDT, 880 dollars +/- 54 dollars vs. ST, 1,647 dollars +/- 50 dollars; p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 +/- 1.1 days; ST, 15.6 +/- 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 +/- 2.5 days; ST, 28.5 +/- 3.1 days, p = .33), or hospital length of stay (PDT 49.7 +/- 4.2 days; ST, 43.7 +/- 3.5 days, p = .28) when we compared these two techniques.
CONCLUSIONS: PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.
Are the Results Valid?
1. Did the analysis provide a full economic comparison of health care strategies?
1a. Was a broad enough viewpoint adopted?
A full economic analysis must, by definition, undertake a comparison of the full costs of care. Since patients, hospitals, third-party payers (insurance companies) and even departments within hospitals all experience different 'costs' for the same episode of care, it is important to realize that care can be 'costed' from each of these different perspectives. Although the authors state that they wish to undertake a cost-effectiveness analysis, they do not state which perspective they will cost their study from. Indeed, it would appear that the only 'costs' that are presented were direct charges (billing) of performing the actual trach itself (the perspective of the surgeon????). Since the authors recognize that ST and PDT may have different complication rates, a fully costed study should have costed ALL aspects of care (especially complications) that were delivered AFTER the performance of the trach. These authors chose an extremely limited perspective which drastically limits the usefulness of their reported findings.
1b. Were all the relevant clinical strategies compared?
Yes. The authors undertook a comparison PDT vs. ST, which are reasonable alternatives.
2. Were the Costs and Outcomes Properly Measured and Valued?
2a. Was clinical effectiveness established?
No. It is unclear as to what the authors decided to use as their measure of 'effectiveness'.
2b. Were costs measured accurately?
No. Although the investigators realize that they are reporting 'charges' (which is the total $$$ billed by the hospital for the services provided), they do not undertake any additional investigation to determine the true costs behind these charges.
2c. Were data on costs and outcomes appropriately integrated?
No. The investigators do not present a true index (Ex. $$$ per life saved or $$$ per infection prevented) of 'cost-effectiveness'.
3. Was appropriate allowance made for uncertainties in the analysis?
No. A sensitivity analysis of the assumptions made during costing was not undertaken.
4. Are estimates of costs and outcomes related to the baseline risk in the treatment population?
The comparison groups appear equal with respect to age, gender, APACHEII and principle diagnosis.
What are the Results?
1. What are the Results?
Unable to determine due to the limited perspective undertaken with the ascertainment of costs, however it is extremely important to realize that there was a very strong trend (p=0.06) towards excess mortality in the ST group. This extremely important finding must be investigated in future trials.
2. How much does allowance for uncertainty change the results?
Unable to determine.
3. Do incremental costs and effects differ between sub-goups?
Unable to determine.
Will the Results Help Me In Caring For My Patients?
1. Are the treatment benefits worth the harms and costs?
Unable to determine.
2. Could I expect similar health outcomes?
If your ICU can provide a similar level of care to similar patients, then it is reasonable to expect similar outcomes.
3. Could I expect similar costs?
Unable to determine.

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A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients.

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