This study examined long-term tracheostomy decanulation rates at facilities in Japan using a large health insurance claims database, which included data after discharge from acute care hospitals. Cancellation rates were 40.8% at 3 months, 63.9% at 12 months, and 65.0% at 24 months. Factors associated with prolonged tracheotomy included advanced age, female gender, cerebrovascular disease, head injury, and other forms of heart disease.
The rate of decanulation increased rapidly up to 3 months after tracheotomy, reaching a plateau after 12 months. Decancellation is performed in acute care hospitals and rarely in long-term care hospitals or after discharge home. A previous study conducted in an acute care hospital in Japan reported a 31% decanulation rate at 3 months22; another study reported a rate of 59% in a rehabilitation hospital20. Our results are consistent with these reports. The average hospital stay in Japan is 30.6 days25which is the longest among OECD countries26. Although the length of hospital stay in acute care is set at 90 days, critically ill patients tend to remain hospitalized for a much longer period. Many of these patients are transferred to a rehabilitation hospital or a long-term care hospital. In the present study, one-third of the patients were transferred to a rehabilitation hospital or a long-term care hospital. The problem is that once patients are discharged from acute care hospitals, they may lose the opportunity to have their decanulation readiness assessed due to lack of access to specialists and equipment. Rehabilitation/long-term care hospitals offer rehabilitation or daily care services, but not specialized medical care, such as decanulation. In other words, the last opportunity for patients to have their condition and readiness for decannulation assessed, and then to undergo decannulation, is while they are still hospitalized in an acute care hospital.
The decanulation time in Japan is relatively longer than in other countries. Previous studies from Canada, the United States, Italy, Spain, and Australia have reported shorter decanulation times and higher decanulation rates, with few adverse effects16,17,18,19,27,28. These studies have shown that the time required for decanulation is shortened by having patients followed up by specialized teams and by developing decanulation protocols. Patients who survive the initial acute state but still require further intensive care are said to be chronically critically ill (CCI)29; the recent increase in the number of patients with CHF has become a serious problem29,30,31,32. CCI patients are those in devastating circumstances and include those with poor long-term survival, severe physical and cognitive disabilities, and significant medical costs29,30,31,32,33. A previous CHF study found that tracheostomy, one of the clinical conditions of CHF, accounts for more than 20% of all CHF patients in Japan.32. Intensivists need to be aware of long-term outcomes such as CHF burden32. Assessing patients’ readiness for decanulation before discharge from acute care hospitals could reduce the number of patients with CHF and thereby reduce clinical and economic burden, improve patient quality of life, and contribute establishment of a decanulation protocol.
Older age and female gender have been identified as factors associated with prolonged tracheostomy. Population-based studies conducted in the United States have reported that older people undergo tracheostomy more often than younger people.3.4. According to a Japanese national database, people aged ≥ 65 years account for more than 70% of all tracheostomies performed each year in Japan6 (see Supplementary Figure S2). Older people tend to have multiple illnesses and are likely to get worse. It is therefore more likely that the tracheostomy tubes will be kept in place longer. Although the present study did not include patients aged ≥75 years, if such patients were included, we would expect a much lower rate of decanulation in Japan. Although the reason why more women have an extended tracheostomy compared to men is unclear, there may be gender disparities in treatment decisions. However, more information will be needed to verify this. Tracheostomy can reduce the quality of life of patients and their families. When making decisions about tracheostomy, it is important for doctors to understand the factors associated with a prolonged tracheostomy. Further investigation of decannulation procedures is warranted to establish appropriate protocols34.
Cerebrovascular disease and head injury were also factors associated with prolonged tracheotomy. Tracheotomy is performed in patients with a wide range of diseases, with cerebrovascular disease accounting for more than 20% in the present study. Other illnesses accounted for less than 10%. Previous studies have reported that surgical patients are more likely to undergo early tracheostomy4.11, and that patients with severe brain injury may be more likely to undergo tracheostomy, with a tendency for prolonged tracheostomy. Rehabilitation is important for these patients in terms of improving mobility. Readiness for decanulation should be assessed in the acute care hospital prior to transfer to a rehabilitation hospital.
Many patients with other forms of heart disease had cardiac arrest, and the rate of decanulation in these patients was extremely low due to high mortality. This finding highlights the importance of end-of-life care in critical care settings. While advances in intensive care have saved the lives of critically ill patients, they have also created large numbers of CHF patients.30. Critical care health care providers often face difficult ethical decisions about whether to save lives or provide end-of-life care35,36,37. In the United States, discontinuation of therapy is common in patients with severe brain damage due to stroke, trauma, or cardiac arrest, and these patients do not undergo tracheostomy.36. Japan’s intensive care end-of-life guidelines recommend discontinuation of life-sustaining treatment for terminally ill patients. However, it is difficult to immediately predict patient outcomes. Currently, life-sustaining treatment can be provided without the need to consider these ethically difficult decisions in Japan. Treatment decisions for critically ill patients should be based on patient-centered thinking and an understanding of their values and preferences, while avoiding overuse or underuse of services29,35,36,37. To achieve optimal end-of-life care in critical care settings, it will be important to have a system in place that provides opportunities for communication with patients’ families.35,36,37. Particularly in Japan, where the super-aging society is progressing, the consideration of end-of-life care in intensive care facilities is all the more important.
There are several limitations to this study. First, the claims database did not include important factors known to affect decanulation, such as the patient’s socioeconomic status, family information, hospital characteristics, and location of the facility. hospital. Second, we were unable to obtain certain clinical information, such as the physical condition of the patients and the severity of their disease. Although we have identified illnesses from claims data related to the “tracheotomy” procedure, this method has not been validated and the illnesses identified may differ from the actual illnesses that led to the tracheostomy. We have, however, identified diseases and medical procedures in consultation with researchers experienced in analyzing claims databases, as well as an infectious disease physician Third, some data has been censored due to of a patient’s death or transfer to a rehabilitation/long-term care hospital, from which he was not discharged until after the study period. This may have resulted in an overestimate of decannulation rates. Finally, the database is limited to company employees and their families, and people aged ≥ 75 years were not included. Therefore, our results may not be widely generalizable.