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

Rationale Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life-support, with the majority placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives To determine days alive and out of institution and mortality after tracheostomy and gastrostomy placement during critical illness; to evaluate associations between health states prior to 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 number of days alive and out of institution (DAOI) following procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year prior to admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of: Cancer, Chronic Organ Failure, Frail, Robust) and assessed their association with DAOI 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 DAOI in the first 90 days after placement was 3 (IQR 0-46), 12 (0-61), and 0 (0-37), respectively. Over half died within 180 days. 1-year mortality was 62%, 60%, and 64%, respectively. When compared to the Robust state, all other pre-ICU health states were associated with loss of DAOI 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 days alive and out of institution and had high short- and long-term mortality.