Cost Effectiveness of Immediate Tracheostomy versus Early Tracheostomy in Decompressive Craniectomy Patients: A Retrospective Study
Cost Effectiveness of Immediate Tracheostomy versus Early Tracheostomy in Decompressive Craniectomy Patients: A Retrospective Study Dr. Hezry bin Abu Hasan ’, Dr. Sofan bin Zenian ’, Dr. Regunath Kandasamy 2, Prof. Dato’ Dr. Syed Mohamed Aljunid Syed Junid 3'4. 1. Neurosurgical Unit, Hospit...
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| Format: | Thesis |
| Language: | English |
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2021
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| Online Access: | http://eprints.usm.my/62508/ http://eprints.usm.my/62508/1/DR%20HEZRY%20BIN%20ABU%20HASAN%20-%20e.pdf |
| Summary: | Cost Effectiveness of Immediate Tracheostomy versus Early Tracheostomy in
Decompressive Craniectomy Patients: A Retrospective Study
Dr. Hezry bin Abu Hasan ’, Dr. Sofan bin Zenian ’, Dr. Regunath Kandasamy 2, Prof. Dato’ Dr.
Syed Mohamed Aljunid Syed Junid 3'4.
1. Neurosurgical Unit, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia.
2. Department of Neurosurgery, Hospital Universiti Sains Malaysia (HUSM), Kubang
Kerian, Kelantan, Malaysia.
3. Health Policy and Management Department, Faculty of Public Heal±, Kuwait University,
Kuwait City, Kuwait.
4. International Center for Casemix and Clinical Coding (ITCC), National University of
Malaysia, Kuala Lumpur, Malaysia. Traumatic Brain Injury (TBI) patients often present with refractory intracranial
hypertension, necessitating a supratentorial decompressive craniectomy to relieve malignant
intracranial pressure and prevent further neurological insult. However, due to the poor
neurological condition of these patients, many are electively intubated and put on mechanical
ventilation to protect tire airway and facilitate cerebral protective measures. Unfortunately, as a
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result of poor and prolonged neurological recovery, many patients have to be put on tracheostomy in view of prolonged intubation. Prolonged mechanical ventilation also
inefficiently utilizes the already limited mechanical ventilators and Intensive Care Unit (ICU)
beds. In an attempt to maximize our limited hospital resources, we innovate a new method of
tracheostomy timing strategy by performing the tracheostomy in the same setting as the
supratentorial decompressive craniectomy (Immediate Tracheostomy) in patients who are
anticipated to require prolonged mechanical ventilation. We attempt to answer ‘How early
should Early Tracheostomy be done?’ by comparing the clinical and cost-saving benefit of the
Immediate Tracheostomy strategy. A retrospective study on patients requiring a supratentorial decompressive craniectomy
and tracheostomy done within 7 days of the cranial surgery from January 2013 to December 2019
in Hospital Queen Elizabeth was done. Patients receiving a tracheostomy in the same setting of
their supratentorial decompressive craniectomy were assigned to the Immediate Tracheostomy
(IT) group, whereas those who received a tracheostomy within 7 days of their cranial surgery was assigned to the Early Tracheostomy (ET) group. Normally distributed quantitative data was analyzed using the independent T-test, while non-normally distributed data was analyzed using the
Mann-Whitney U-test. Qualitative variables were analyzed with a Chi-square test. Cost of
treatment of each patient was obtained based on Malaysian costing database provided by Casemix
System MY-DRG. Of 411 patients reviewed, a total of 63 patients were included in the study. 21
patients (33.3%) were allocated to the Immediate Tracheostomy (IT) group and 42 patients
(66.7%) in the other. Patients in the Immediate Tracheostomy (IT) group had significantly lower total GCS
scores (Median (IQR): 6 (3) versus 9 (4), p = 0.011), reduced duration of mechanical ventilation
(Median (IQR): 72 hours (48) versus 120 hours (72), p = 0.001) and sedation (Median (IQR):
48 hours (24) versus 72 hours (54),/? = 0.001), and shorter ICU length of stay (Median (IQR):
72 hours (48) versus 144 hours (96), p = 0.001). Cost reduction with the Immediate
Tracheostomy (IT) strategy was estimated to be RM 18,463.14 — RM 39,223 per patient. The
diagnosis of severe TBI, total GCS score <6 on presentation, and the presence of
Intraventricular Hemorrhage (IVH) on CT brain imaging were identified as possible indicators
for patients who will benefit from the Immediate Tracheostomy (IT) strategy. The Immediate Tracheostomy strategy has shown evidence of increasing ICU bed
turnover and reducing the cost of treatment. Patients presenting with a total GCS of < 6 and
presence of IVH on CT Brain were seen to benefit from Immediate Tracheostomy. With the
clinical and treatment cost benefits seen, the Immediate Tracheostomy (IT) strategy should be
considered a viable option for the management of Traumatic Brain Injury patients undergoing
supratentorial decompressive craniectomy. |
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