Research

Original Investigation

A Cost-effectiveness Analysis of Early vs Late Tracheostomy

C. Carrie Liu, MD, MPH; Luke Rudmik, MD, MSc

IMPORTANCE The timing of tracheostomy in critically ill patients requiring mechanical

ventilation is controversial. An important consideration that is currently missing in the

literature is an evaluation of the economic impact of an early tracheostomy strategy
vs a late tracheostomy strategy.
OBJECTIVE To evaluate the cost-effectiveness of the early tracheostomy strategy vs the late
tracheostomy strategy.
EVIDENCE ACQUISITION This economic analysis was performed using a decision tree model
with a 90-day time horizon. The economic perspective was that of the US health care
third-party payer. The primary outcome was the incremental cost per tracheostomy avoided.
Probabilities were obtained from meta-analyses of randomized clinical trials. Costs were
obtained from the published literature and the Healthcare Cost and Utilization Project
database. A multivariate probabilistic sensitivity analysis was performed to account for
uncertainty surrounding mean values used in the reference case.
RESULTS The reference case demonstrated that the cost of the late tracheostomy strategy
was $45 943.81 for 0.36 of effectiveness. The cost of the early tracheostomy strategy was
$31 979.12 for 0.19 of effectiveness. The incremental cost-effectiveness ratio for the late
tracheostomy strategy compared with the early tracheostomy strategy was $82 145.24 per
tracheostomy avoided. With a willingness-to-pay threshold of $50 000, the early
tracheostomy strategy is cost-effective with 56% certainty.
CONCLUSIONS AND RELEVANCE The adaptation of an early vs a late tracheostomy strategy
depends on the priorities of the decision-maker. Up to a willingness-to-pay threshold of
$80 000 per tracheostomy avoided, the early tracheostomy strategy has a higher probability
of being the more cost-effective intervention.
JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2016.1829
Published online July 28, 2016.

he ideal timing of performing a tracheostomy in critically ill patients requiring mechanical ventilation has
been the subject of much contention. Numerous trials
have taken place to investigate the differential outcomes associated with early and late tracheostomies1-11; however, the
results have been inconsistent. Meta-analyses have been
performed to synthesize the existing data.12-14 Outcomes have
suggested that early tracheostomy is associated with a decreased intensive care unit (ICU) length of stay,12 decreased
short-term mortality,13 and decreased rates of pneumonia.14
However, adopting an early tracheostomy strategy increases
the risk of performing unnecessary surgery in patients who,
when given more time, would have been successfully weaned
and extubated.
A late tracheostomy strategy would theoretically result in
fewer inappropriate tracheostomies being performed; however, it may result in prolonged ICU stays and worse clinical
outcomes. Given the lack of current validated instruments to
jamaotolaryngology.com

Author Affiliations: Division of

OtolaryngologyHead and Neck
Surgery, Department of Surgery,
University of Calgary, Calgary,
Alberta, Canada.
Corresponding Author: Luke
Rudmik, MD, MSc, Division of
OtolaryngologyHead and Neck
Surgery, Department of Surgery,
University of Calgary, Foothills
Medical Centre, 1403 29th St NW,
South Tower, Ste 602,
Calgary T2N 2T9, AB, Canada
(Lukerudmik@gmail.com).

predict the duration of mechanical ventilation, physicians are

faced with a difficult decision on when to perform a tracheostomy in a critically ill patient, where they need to balance
the clinical benefits of an early tracheostomy while trying to
minimize the risks of unnecessary surgery.
Currently, there is great emphasis in the health care system to limit spending. In line with this goal, decision makers
are increasingly turning to economic evaluations in choosing
between 2 or more competing medical interventions. As such,
the cost of an intervention relative to its effectiveness has become important in assisting the decision-making process of
whether or not an intervention will be adopted.
The objective of this economic evaluation was to evaluate the cost-effectiveness of the early tracheostomy strategy
compared with the late tracheostomy strategy. Specifically, we
examined the additional cost associated with the late tracheostomy strategy relative to its benefit of reducing unnecessary tracheostomies.

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E1

Research Original Investigation

Early vs Late TracheostomyA Cost-effectiveness Analysis

Methods

Key Points

This modeling-based economic evaluation developed a decision

tree with a time horizon of 90 days (Figure 1). The model simulated the treatment of a critically ill patient admitted to the
ICU requiring mechanical ventilation. The comparative interventions were (1) early tracheostomy strategy and (2) late tracheostomy strategy. Early tracheostomy strategy was defined as the
performance of tracheostomy during the first 7 days of ICU admission. This temporal definition was chosen based on the protocols of published randomized clinical trials on early vs late
tracheostomy.1-11,15-18 A time horizon of 90 days was chosen to
be inclusive of a range of lengths of ICU stays.12,19,20 All costs and
effects are presented in aggregated and disaggregated form.
Discounting was not applied because the time horizon was less
than 1 year. The 2013 Consolidated Health Economic Evaluation
Reporting Standards (CHEERS) guidelines were followed.21
The primary outcome was the cost per tracheostomy
avoided, presented as the incremental cost-effectiveness ratio (ICER) between the late and early tracheostomy strategies. The ICER is the ratio of the difference in costs to the difference in the effectiveness between 2 strategies: (Cost Strategy
A Cost Strategy B)/(Effectiveness Strategy A Effectiveness
Strategy B).22 In other words, the ICER provides the additional cost associated with the additional benefit of the intervention being evaluated. The advantage of using the ICER to
report the primary outcome is that it offers decision-makers
with comparative information such that the additional cost
associated with a strategy (in this case, late tracheostomy) is
put in context of its added benefit (the avoidance of a tracheostomy). The assumptions of our model were (1) the goal of
the decision maker is to avoid tracheostomies; (2) both open
and percutaneous tracheostomies are performed, the distribution of each follows that described in the literature; and
(3) patients discharged with tracheostomies will require homecare for 1 year. TreeAge Pro 2015 software (TreeAge Pro Inc)
was used to program the model.
This study contains only data from the published literature, and no patient data were used; therefore, institutional
review board and ethics committee approval from the University of Calgary was not required.

Patient Population
The population of critically ill patients requiring prolonged mechanical ventilation is heterogeneous. Similarly, randomized
clinical trials investigating early vs late tracheostomy have
involved varied patient populations, including those who require mechanical ventilation secondary to trauma, burn injuries, neurological insult, and medical illnesses such as pneumonia. Subgroup analysis from a recent meta-analysis did not
find a statistically significant difference in outcomes based on
the illness population12; therefore, our model was based on an
unselected group of critically ill patients.

Effectiveness and Probabilities

Effectiveness was defined as the avoidance of one tracheostomy. We assigned the avoidance of one tracheostomy an
E2

Question Is an early tracheostomy strategy more cost-effective

compared with a late tracheostomy strategy?
Findings This economic analysis was performed using a decision
tree model from the perspective of a US health care third-party
payer. The incremental cost-effectiveness ratio for the late
tracheostomy strategy compared with the early tracheostomy
strategy was $82 145.24 per tracheostomy avoided.
Meaning Up to a willingness-to-pay threshold of $80 000 per
tracheostomy avoided, the early tracheostomy strategy has a
higher probability of being the more cost-effective intervention.

effectiveness value of 1 (eNoTrach). The performance of a tracheostomy was assigned an effectiveness value of 0 (eTrach)
(Table). The probabilities and clinical outcomes used for our
model were extracted from meta-analyses of randomized and
quasi-randomized clinical trials of early vs late tracheostomies (Table).12-14 The probabilities of decannulation in the early
and late tracheostomy groups were taken from a randomized
clinical trial by Koch et al.8 The probability of short-term complication occurrence associated with a tracheostomy was taken
from a multi-institutional retrospective study by Halum et al.23
Long-term complication rates (eg, the rates of tracheal stenosis) were not included in our model because studies have not
found a significant difference in this parameter between tracheostomized patients and those who receive prolonged
endotracheal intubation.5,32

Costs
The analysis was performed from the perspective of the US
health care third-party payer. All costs are expressed in US
dollars as of August 2015. The mean cost per ICU day of $2119
(SE, $773) was obtained from a prospective microcosting study
by Lefrant et al.26 This daily ICU cost included staff time for
patient care, medications, consumables (eg, dressing material), interventions (eg, hemodialysis machines), laboratory
tests, and administrative expenses. The length of ICU stays in
the early and late tracheostomy groups are 13.5 and 22.6 days,
respectively.12 There is a paucity of data for the exact timeline of short-term mortality in the ICU; however, it has been
found that most deaths occur within the first 7 days.25 Therefore, in our model, the length of stay in those patients who die
in the ICU is 7 days.
The tracheostomy cost was estimated from a metaanalysis of percutaneous vs open tracheotomy outcomes performed by Oliver et al24 combined with data from a retrospective analysis by Halum et al,23 which demonstrated that 82.2%
of tracheostomies were performed in an open fashion and 17.8%
were performed percutaneously. Using the open:percutaneous
ratio of 4:1 and the cost data from the study by Oliver et al,24
we calculated the weighted mean cost of 1 tracheostomy to be
$3178.01 (SE, $215.73) (Table).
A recent meta-analysis27 showed that the most common
short-term complications following either percutaneous or open
tracheostomy were major postoperative bleeding and infection of the stoma. Major postoperative bleeding was defined

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Early vs Late TracheostomyA Cost-effectiveness Analysis

Original Investigation Research

Figure 1. Decision Tree Model of Early Tracheostomy Strategy vs Late Tracheostomy Strategy
Short-term mortality

[cTrach + cDeath + (cICU*DaysICUMortality)]\eTrach

pEarlyMortality

Decannulation
Pneumonia

Short-term complication
(bleeding, stomal
infection)

Early trach
pEarlyTrach

pEarlyPneumonia

#
Survive

pEarlyTrachDecan

Pneumonia
pEarlyPneumonia

No trach
complication
#

Short-term mortality

pEarlyTrachDecan

[cTrach + (cICU*DaysICUEarly) +
cPneumonia]\eTrach

Discharge with trach [cTrach + (cICU*DaysICUEarly) +

cPneumonia + cHomeCare]\eTrach
#
Decannulation

No pneumonia

[cTrach + (cICU*DaysICUEarly) +
cTrachComp]\eTrach

Discharge with trach [cTrach + (cICU*DaysICUEarly) +

cTrachComp+ cHomeCare]\eTrach
#
Decannulation

#
Early
tracheostomy
strategy

[cTrach + (cICU*DaysICUEarly) +
cTrachComp + cPneumonia]\eTrach

Discharge with trach [cTrach + (cICU*DaysICUEarly) +

cTrachComp + cPneumonia +
#
cHomeCare]\eTrach
Decannulation

pTrachComp
No pneumonia

pEarlyTrachDecan

[cTrach + (cICU*DaysICUEarly)]
\eTrach

Discharge with trach [cTrach + (cICU*DaysICUEarly) +

cHomeCare]\eTrach
#

[cDeath + (cICU*DaysICUMortality)]\eNoTrach

pEarlyMortality

No trach

Pneumonia

[(cICU*DaysICUEarly) + cPneumonia]\eNoTrach

pEarlyPneumonia

Survive
#

No pneumonia

ICU admission
cDeath = dist_cDeath
cHomeCare = dist_
cHomeCare
cICU = dist_cICU
cPneumonia =
dist_cPneumonia
cTrach = dist_cTrach
cTrachComp =
dist_cTrachComp
DaysICUEarly =
dist_daysICUEarly
DaysICULate =
dist_daysICULate
DaysICUMortality =
dist_DaysICUMortality
eNoTrach = 1
eTrach = 0
pEarlyMortality = dist_
pEarlyMortality
pEarlyPneumonia =
dist_pEarlyPneumonia
pEarlyTrach =
dist_pEarlyTrach
pEarlyTrachDecan =
dist_pEarlyTrachDecan
pLateMortality =
dist_pLateMortality
pLatePneumonia =
dist_pLatePneumonia
pLateTrach =
dist_pLateTrach
pLateTrachDecan =
dist_pLateTrachDecan
pTrachComp =
dist_pTrachComp

pEarlyTrachDecan

[(cICU*DaysICUEarly)]\eNoTrach

Short-term mortality

[cTrach + CDeath + (cICU*DaysICUMortality)]\eTrach

pLateMortality

Decannulation
Pneumonia

Short-term complication
(bleeding, stomal
infection)

Late trach
pLateTrach

pLatePneumonia

#
Survive

Pneumonia
pLatePneumonia

No trach
complication
#

Short-term mortality

[cTrach + (cICU*DaysICULate) +
cTrachComp]\eTrach

Discharge with trach [cTrach + (cICU*DaysICULate) +

cTrachComp+ cHomeCare]\eTrach
#
pLateTrachDecan

[cTrach + (cICU*DaysICULate) +
cPneumonia]\eTrach

Discharge with trach [cTrach + (cICU*DaysICULate) +

cPneumonia + cHomeCare]\eTrach
#
Decannulation

No pneumonia

pLateTrachDecan

Decannulation

#
Late
tracheostomy
strategy

[cTrach + (cICU*DaysICULate) +
cTrachComp + cPneumonia]\eTrach

Discharge with trach [cTrach + (cICU*DaysICULate) +

cTrachComp + cPneumonia +
#
cHomeCare]\eTrach
Decannulation

pTrachComp
No pneumonia

No trach

pLateTrachDecan

pLateTrachDecan

[cTrach + (cICU*DaysICULate)]
\eTrach

Discharge with trach [cTrach + (cICU*DaysICULate) +

cHomeCare]\eTrach
#

[cDeath + (cICU*DaysICUMortality)]\eNoTrach

pLateMortality
Pneumonia

[(cICU*DaysICULate) + cPneumonia]\eNoTrach

pLatePneumonia

Survive
#

No pneumonia

[(cICU*DaysICULate)]\eNoTrach

A decision tree model with a 90-day time horizon. c Indicates cost; comp, complication; decan, decannulation; dist, distribution; e, effect; ICU, intensive care unit;
p, probability; trach, tracheotomy; #, 1 (the probability of the event of the complement branch) (eg, the probability of receiving an early tracheostomy
(pEarlyTrach) = 0.81. In this case, # represents the probability of not receiving a tracheostomy. Therefore, # for no trach is 0.19 (ie, 1 0.81).

as bleeding requiring surgical exploration or transfusion of

packed red blood cells.27 The treatment of major postoperative bleeding was taken from 5 prospective studies33-37 of percutaneous and conventional tracheostomies. Of those with major postoperative bleeding requiring an intervention, 57.1%
returned to the operating room, 28.6% received a blood transjamaotolaryngology.com

fusion, and 14.3% required both surgical hemostasis and a blood

transfusion. The overall probability of experiencing a major
bleeding event or stomal infection were 2.7% and 6.6%,
respectively.27 Therefore, the weighted mean cost of a shortterm tracheostomy complication was $7642.47 (SE $262.39)
(Table).

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Research Original Investigation

Early vs Late TracheostomyA Cost-effectiveness Analysis

Table. Reference Case Model Data With Sensitivity Ranges

Variable
Probabilities

Description

Early
mortality
Early
pneumonia
Early
tracheostomy
Early
decannulation
Late
mortality
Late
pneumonia
Late
tracheostomy
Tracheostomy
complication
Late
decannulation
Length of
ICU stay, d
Early

Probability of short-term mortality in patients

randomized to the early tracheostomy group
Probability of developing pneumonia in patients
randomized to the early tracheostomy group
Probability of receiving a tracheostomy
if assigned to the early tracheostomy strategy
Probability of decannulation if assigned to the
early tracheostomy strategy
Probability of short-term mortality in patients
randomized to the late tracheostomy group
Probability of developing pneumonia in patients
randomized to the late tracheostomy group
Probability of receiving a tracheostomy
if assigned to the late tracheostomy strategy
Probability of experiencing a short-term
complication related to tracheostomy
Probability of decannulation if assigned to the
late tracheostomy strategy

Late
Mortality

Value (SE)

The average length of ICU stay of the early

tracheostomy strategy
The average length of ICU stay of the late
tracheostomy strategy
The length of stay of patients who die in the ICU

Source

0.20 (0.093)

Liu et al13

0.42 (0.300)

Siempos et al14

0.81 (0.145)

Liu et al12

0.72 (0.35)

Koch et al8

0.25 (0.137)

Liu et al13

0.51 (0.239)

Siempos et al14

0.64 (0.233)

Liu et al12

0.057 (0.01)

Halum et al23
Putensen et al27
Koch et al8

0.40 (0.20)

13.46 (6.44)

Liu et al12

22.59 (10.65)

Liu et al12

7 (3)

Potgieter et al25

Costs, $
ICU

Daily cost of ICU stay

2119.15 (773.13)

Lefrant et al26

Pneumonia

Cost of pneumonia treatment

9386.33 (212.05)

HCUP DRG 17928

Tracheostomy

Cost of tracheostomy

3178.01 (215.73)

Oliver et al25

Tracheostomy
complication
Home care

Cost of short-term tracheostomy complication

(ie, bleeding and stomal infections)
Cost of home care for 1 y following discharge
with a tracheostomy
Cost associated with in-hospital death

7642.47 (262.39)

HCUP DRG 133, 60328;

Shander et al29
Unroe et al30

Death

14 842.26 (7400)
1826.43 (600.00)

Nemetz et al31

Effects
Tracheostomy

Effect of receiving a tracheostomy

0 (NA)

Present study

No
tracheostomy

Effect of not receiving a tracheostomy

1 (NA)

Present study

The mean treatment cost for pneumonia of $9386.33 (SE

$212.05) was taken from the Healthcare Cost and Utilization
Project (HCUP) database, DRG 179.28 The cost of inpatient death
was taken from a survey study by Nemetz et al,31 which reported the mean cost per autopsy to be $1826.43 (SE $600)
(Table). Finally, the cost of home care for patients who were
discharged with a tracheostomy was taken from a prospective cohort study by Unroe et al.30

Sensitivity Analysis
To account for the inherent uncertainty surrounding mean values inputted into the model, we performed a multivariate
probabilistic sensitivity analysis (PSA) using a Monte Carlo
simulation with 15 000 scenarios. Following guideline recommendations, SEs were used as the measure of variance for
model inputs. 38 The SEs were obtained from the metaanalyses or calculated using the data extracted from the
individual trials. Results are presented in both a costeffectiveness acceptability curve (CEAC) and ICER scatterplot.
The CEAC provides a quantitative value of certainty that the
intervention is cost-effective at different willingness-to-pay
(WTP) thresholds.39 It provides the probability that the intervenE4

Abbreviations: HCUP, health care cost

and utilization project; ICU, intensive
care unit; NA, not applicable;
SE, standard error.

tion is cost-effective based on the specified WTP threshold. The

ICER scatterplot is another method to illustrate the certainty in
the cost-effectiveness of the intervention being evaluated. The
scatterplot is divided into 4 quadrants based on if the intervention is more or less costly and more or less effective in relation
to the comparator intervention.40 Each of the ICER values generated from the 15 000 iterations of the PSA are then plotted on
the graph. Visualizing the distribution of the ICER scatterplot
helps to provide information regarding the overall uncertainty
in the cost-effectiveness of the intervention. For example, scatterplot with a wide distribution in ICERs over the 4 quadrants
demonstrates large uncertainty for the mean ICER value as opposed to a scatterplot with a narrow distribution of ICERs, which
demonstrates higher certainty around the mean ICER.

Results
Reference Case
The reference case demonstrated that the cost of the late tracheostomy strategy was $45 943.81 for 0.36 of effectiveness.
The cost of the early tracheostomy strategy was $31 979.12 for

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Early vs Late TracheostomyA Cost-effectiveness Analysis

Original Investigation Research

0.19 of effectiveness. The ICER of the late tracheostomy strategy compared with the early tracheostomy strategy is
$82 145.24 per tracheostomy avoided.

tracheostomy strategy becomes cost-effective with 51% certainty. The ICER scatterplot is shown in Figure 3 and demonstrates that 56% of the ICERs of early vs late tracheostomy lie
below the $50 000 WTP line in quadrants I and III.

Sensitivity Analysis
The multivariate probabilistic sensitivity analysis demonstrated that the probability that the early tracheostomy strategy is cost-effective at a maximum WTP threshold of $50 000
per quality-adjusted life-year (QALY) is 56% (Figure 2). When
the WTP threshold is increased to $80 000, the 2 strategies
have approximately equal probabilities of being the more costeffective intervention. At a WTP threshold of $85 000, the late

Figure 2. Cost-effectiveness Acceptability Curve

for the Early vs Late Tracheostomy Strategies

Iterations Cost-effective, %

100
Strategy
Early tracheostomy
Late tracheostomy

80

60

40

20

0
0

20 000

40 000

60 000

80 000

100 000

Willingness-to-Pay, $

At a willingness-to-pay (WTP) threshold of $50 000, the early tracheostomy

strategy is cost-effective with 56% certainty. Up to a WTP threshold of
$80 000, the early tracheostomy strategy has a higher probability of being the
cost-effective decision compared to the late tracheostomy strategy.

Discussion
Tracheostomies are among the most commonly performed procedures in the critically ill population.41,42 Currently, the indications and timing for tracheostomy in this population are
poorly defined, and the decision to perform surgery can be
challenging. With the goal to assist in clinical-decision making, the objective of this economic evaluation was to examine the cost-effectiveness of an early tracheostomy strategy vs
a late tracheostomy strategy in the critically ill population requiring prolonged mechanical ventilation. Outcomes from this
model suggested that an early tracheostomy strategy might be
more cost-effective; however, the decision to adopt a strategy depends on the hospital and payers threshold to pay for
the avoidance of a tracheostomy.
Based on the literature, the possible benefits of an early
tracheostomy are decreased rates of pneumonia, decreased
short-term mortality, and decreased ICU length of stay.12-14
However, more tracheostomies are performed with an early
tracheostomy strategy, thus increasing the risk that some patients are receiving a tracheostomy unnecessarily. Adopting a
late tracheostomy strategy would circumvent the issue of
unnecessary tracheostomy because patients receive more
time to be weaned from mechanical ventilation; however, a late
strategy may increase rates of pneumonia, short-term
mortality, and ICU stay.
The outcome from this economic models reference case
demonstrated that adopting a more conservative late

Figure 3. Incremental Cost-effectiveness Ratio (ICER) Scatterplot of the Early vs Late Tracheostomy Strategies
160 000
140 000

IV: More costly and less effective

(dominated)

I: More costly but more effective

120 000
100 000
80 000

Incremental Cost, $

60 000
40 000
20 000
0
20 000
40 000
60 000
80 000

95% Confidence
ellipse

100 000
120 000
140 000
160 000
1.0

III: Less costly

but less effective

0.80

0.60

II: Less costly and more effective

(dominant)
0.40

0.20

0.20

0.40

0.60

0.80

1.0

Incremental Effectiveness

jamaotolaryngology.com

The model was run 15 000 times

using a range of values for each
model input. The resulting ICER from
each simulation is plotted around the
$50 000 willingness to pay (WTP)
threshold (dashed line). Values falling
to the right of the dashed line in
quadrants I and III, as well as all ICERs
in quadrant II, are considered
cost-effective.

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Research Original Investigation

Early vs Late TracheostomyA Cost-effectiveness Analysis

tracheostomy strategy is more effective at avoiding a tracheostomy but it was also more expensive. The incremental cost
of avoiding a single tracheostomy was $82 145.24. When a payer
is willing to pay $50 000 per tracheostomy avoided (ie, WTP
threshold), the early tracheostomy strategy is the costeffective strategy with 56% certainty. If the WTP increases to
$85 000, then the late tracheostomy strategy becomes costeffective with 51% certainty (Figure 2). The adaptation of either
the early or late tracheostomy strategy depends on the ultimate goal of the decision-makers. If the goal is to minimize
costs, then an early tracheostomy strategy would be an appropriate decision. On the contrary, if the priority were to minimize the risk of performing unnecessary tracheostomies,
regardless of the cost, then a late tracheostomy strategy would
be preferable.
The strengths of this economic evaluation include the use
of high-quality data derived from multiple meta-analyses, use
of true health care costs as opposed to hospital charges, and
the inclusion of a robust multivariate sensitivity analysis to account for inherent uncertainty surrounding mean values used
in the reference case. Despite these strengths, there are limitations that should be considered when interpreting the results from this study. The primary outcome of cost per tracheostomy avoided is not generalizable compared with using
the cost per QALY. However, there is a lack of data evaluating the long-term utilities for various health states in critically ill patients with tracheostomies, making the QALY an unreliable outcome at present time. We hope that future research
will shed light on tracheostomy-associated quality of life, which
can be used to refine the economic evaluation of this important clinical topic.
A second limitation of our study relates to the absence of
data regarding certain model parameters, thereby necessitat-

Conclusions
Tracheostomy is a commonly performed procedure in critically ill patients requiring mechanical ventilation. The results
from this decision tree economic evaluation suggests that up
to a WTP threshold of $80 000, an early tracheostomy strategy would have a higher probability of being the cost-effective
decision compared with a late tracheostomy strategy. Whether
the early tracheostomy strategy becomes adopted by a health
care system depends on the value that is placed on avoiding tracheostomies. To improve the accuracy of this model, future research is needed to elucidate tracheostomy-associated quality
of life as well as long-term sequelae associated with tracheostomy and prolonged endotracheal intubation.

for primary airway management in the surgical

critical care setting. Surgery. 1990;108(4):655-659.

ARTICLE INFORMATION
Accepted for Publication: May 22, 2016.
Published Online: July 28, 2016.
doi:10.1001/jamaoto.2016.1829.
Author Contributions: Both authors had full access
to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both
authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important
intellectual content: Both authors.
Statistical analysis: Both authors.
Study supervision: Rudmik.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and
none were reported.

3. Sugerman HJ, Wolfe L, Pasquale MD, et al.

Multicenter, randomized, prospective trial of early
tracheostomy. J Trauma. 1997;43(5):741-747.
4. Saffle JR, Morris SE, Edelman L. Early
tracheostomy does not improve outcome in burn
patients. J Burn Care Rehabil. 2002;23(6):431-438.
5. Rumbak MJ, Newton M, Truncale T, Schwartz
SW, Adams JW, Hazard PB. A prospective,
randomized, study comparing early percutaneous
dilational tracheotomy to prolonged translaryngeal
intubation (delayed tracheotomy) in critically ill
medical patients. Crit Care Med. 2004;32(8):16891694.
6. Barquist ES, Amortegui J, Hallal A, et al.
Tracheostomy in ventilator dependent trauma
patients: a prospective, randomized
intention-to-treat study. J Trauma. 2006;60(1):
91-97.

1. Dunham CM, LaMonica C. Prolonged tracheal

intubation in the trauma patient. J Trauma. 1984;24
(2):120-124.

7. Terragni PP, Antonelli M, Fumagalli R, et al. Early

vs late tracheotomy for prevention of pneumonia in
mechanically ventilated adult ICU patients:
a randomized controlled trial. JAMA. 2010;303(15):
1483-1489.

2. Rodriguez JL, Steinberg SM, Luchetti FA,

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ing the making of assumptions. Specifically, our model assumed that all patients discharged with tracheostomies will
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