P0774 - Trends in Tracheostomy Placement and Resource Use in Preterm Infants with Bronchopulmonary Dysplasia in the United States, 2008 - 2017

Purpose
Although advances in perinatal care have led to a dramatic increase in the survival of extremely preterm infants, the incidence of bronchopulmonary dysplasia (BPD) has not changed over the decades. Infants with severe BPD sometimes require tracheostomy placement but data on recent trends and resource use are lacking. The objective of the study was to determine the contemporary trends and predictors of tracheostomy placement in preterm infants ≤30 weeks gestational age (GA) with BPD in the United States (US) from 2008-2017.

Methods
We performed a retrospective, serial cross-sectional study using data from the National Inpatient Sample, the largest healthcare database in the US. Inclusion criteria were: GA ≤30 weeks, hospitalization at ≤28 days of age, assignment of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM), or ICD10-CM code for BPD (770.7 or P27.1) and tracheostomy (31.1, 31.2, 31.29, and 0B110F4). Transfers between facilities were excluded to avoid double counting. Trends in tracheostomy placement and associated resource utilization were assessed Cochran-Armitage trend test for categorical variables and Jonckheere-Terpstra test for continuous variables. P-value <0.05 was considered significant.

Results
Overall, 987 out of 68,953 (1.4%) hospitalizations with BPD had tracheostomy. Characteristics of the study population: 60.8% were male, 68.4% ≤26 weeks GA, 43.8% White, 60.5% with Medicaid or self-pay, 65.2% in the Midwest and South census regions of the US, and 45.7% had gastrostomy tube placement. The proportion of preterm hospitalizations with BPD who had tracheostomy decreased from 1.8% in 2008 to 0.9% in 2011 (P = 0.054). The proportion with tracheostomy increased significantly from 0.9% in 2011 to 2.1% in 2017 (P = 0.026) [Figure 1]. The incidence rate of tracheotomy placement (expressed as per 100,000 live births) increased from 2.14 in 2008 to 3.50 in 2017 (figure 2). Pulmonary hypertension (odds ratio (OR) 4.61, 95% confidence interval (CI), 3.27-6.50, P<0.001) and GA ≤24 weeks (OR 2.63, 95% CI 1.29-5.38, P=0.008), were associated with increased odds of tracheostomy placement. Gastrostomy tube placement did not significantly change during the study period. For those who survived to discharge, median length of stay increased from 170 to 231 days (β = 5.8 days, CI = 1.6-10.1 days, P=0.008) while median inflation-adjusted hospital cost increased from $323,091 to $687,14 (β = $60,017; CI = $29,451 – 90,583; P <0.001) between 2008 and 2017.

Conclusion
Although tracheostomy placement among preterm hospitalizations with BPD remained low, there was a significant upward trend in tracheostomy placement and resource utilization during the study period. Further studies are needed to devise strategies to minimize tracheostomy placement in preterm hospitalizations with BPD.