Risk factors associated with unplanned readmissions and frequent emergency department visits after pediatric tracheostomy: a nation-wide inpatient database study in Japan

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Revealing the risk factors of medical resource use may help improve health outcomes. This study aimed to describe the clinical features of children who underwent tracheostomy and to determine the risk factors associated with unplanned readmission and frequent out-of-hour ED visits. Methods Data of children aged between 0 and 18 years who underwent tracheostomy and were discharged between April 2016 and March 2019 were retrieved from the Japanese National Inpatient Database and retrospectively analyzed. Risk factors for readmission and frequent out-of-hour ED visits within 180 days of tracheostomy were estimated using multiple logistic regression analysis. Results A total of 1112 patients underwent tracheostomy during the study period. A total of 483 (43%) patients were readmitted and 220 (20%) visited the ED frequently. The multiple logistic regression analysis showed that less than 1 years-of-age (Odds ratio [OR]:1.77; 95% confidence interval [CI]:1.26–2.47; p < .05), tube feeding (OR:1.36; 95% CI:1.03–1.80; p < .05), neuro-impairment (OR:1.52; 95% CI:1.02–2.25; p < 05), and mechanical ventilation (OR:1.94; 95% CI:1.29–2.92; p < .05) were risk factors for readmissions. Moreover, less than 1 years-of-age (OR:1.53; 95% CI:1.03–2.27; p < .05), home oxygen therapy (OR:1.94; 95% CI: 1.29–2.92; p < .05), and unplanned tracheostomy (OR:2.38; 95% CI: 1.05–5.40; p < .05) were risk factors for ED visits. Conclusions This study describes the clinical features and risk factors for readmission and frequent out-of-hour ED visits after tracheostomy. This study may help improve health outcomes, healthcare plans, and evidence-based policymaking. tracheostomy readmission emergency department visits complications health outcomes Figures Figure 1 Figure 2 Figure 3 What is Known The use of tracheostomy in children with medical complexity has increased, and these children are known to be frequent users of medical resources. Multicenter studies dealing with the long-term outcomes of pediatric tracheostomy and risk factors associated with high medical resource use are still limited. What is New: Using the nationwide database in Japan, this study identified several risk factors associated with unplanned readmissions and out-of-hours emergency department visits (less than 1 years of ages, dependent on medical technologies, etc.). This study contributes for coordinating appropriate home care plans and reducing preventable medical resource use. 1. Introduction Tracheostomy is performed in patients with upper airway obstruction or respiratory failure requiring long-term ventilator support [1; 2]. In particular, the use of tracheostomy for children with medical complexity (CMC), such as children with neuro-impairments (NIs) who require home ventilator support, has increased [ 3 – 5 ]. A previous study reported that hospitalized CMCs accounted for less than 1% of the population; however, they required one-third of the medical costs of pediatric hospitalizations [ 6 ]. The American Academy of Pediatrics recommends the importance of evaluating unplanned hospitalizations and emergency department visits for quality-improvement of the health care system around CMCs. [ 7 ]. In recent years, the understanding of these high medical utilizers and improvement of care coordination has grown because of their potential to improve outcomes and reduce unnecessary medical healthcare utilization [ 8 ]. Among CMCs who have severe and complex conditions or require ventilators, many visit the emergency department (ED) and are readmitted in the short term after tracheostomies [9; 10]. These reports indicate that children who undergo tracheostomy require the frequent use of medical resources. They were hospitalized for various reasons, including aspiration pneumonia and complications related to tracheostomy. The American Academy of Otolaryngology-Head and Neck Surgery Foundation recognizes the need to investigate risk factors for readmission and ED visits after tracheostomy [ 8 ]; however, the evidence is limited. A few multicenter studies deal with the outcomes of tracheostomy [9; 10] and a few reports investigate the risk factors for readmissions and frequent long-term ED visits after tracheostomy [4; 9; 10]. Hence, there is limited information on a large cohort of multicenter epidemiological data and the long-term outcomes of children who underwent tracheostomy in Japan [ 11 ]. Revealing the clinical features and risk factors of medical resource use in children is beneficial for improving health outcomes and healthcare plans [12; 13]. Therefore, this study aimed to describe the clinical features of children who underwent tracheostomy in Japan and to determine the risk factors for unplanned readmission and frequent out-of-hour ED visits after index hospitalization when tracheostomies were performed using the Japanese administrative database. 2. Material and methods The cohort for this retrospective study was identified using the Japanese Administrative Database, Diagnosis Procedure Combination/per-diem payment system (DPC/PDPS). This database is a case-mix patient classification system linked to payments at acute care hospitals in Japan since 2003. Details of this database have been described previously [14; 15]. The DPC/PDPS covered 1730 hospitals and 488563 beds in 2018, and almost all acute inpatients were included, accounting for more than half of the 894,000 hospital beds in Japan [14; 16]. Patient clinical and administrative claims data were collected annually from hospitals. This database included information on: age; sex; diagnostic information using the International Statistical Classification of Diseases, Tenth Revision (ICD-10) code; all procedures; medical device use; medications; purpose of admission; duration of admission; outcome at discharge; and discharge destination. This database also included hospital information regarding the number of beds for pediatric patients. This study was approved by the Institutional Review Board of the Tokyo Medical and Dental University (M2024-075). The board determined that informed consent was not required because the data were anonymized. We recruited children aged between 0 and 18 years who underwent tracheostomy (Japanese operative code: K386-00) and were discharged from Japanese hospitals between April 2016 and March 2019 to avoid the effect of the COVID-19 pandemic. Hospitalizations in which the patient underwent tracheostomy for the first time were defined as index hospitalizations. Patients who died during the index hospitalization, underwent tracheostomy closure (K396-00) during the index hospitalization, were transferred to other hospitals and post-acute care facilities, or were scheduled to visit other hospitals were excluded. The primary outcome was unplanned readmission for treatment within the same hospital during the first 180 days after the index hospitalization in patients who had undergone a tracheostomy. We only dealt with readmissions for treatment because CMCs sometimes use respite admissions after significant changes, such as starting mechanical ventilation in Japan. In general, complex cases are associated with background diseases and various conditions, leading to longer hospital stays and more visits and readmissions. As a large number of CMCs were expected in our cohort, we followed up for a longer period. We set the follow-up period at 180 days because the characteristics of DPC may not have been successfully followed up for a follow-up period of approximately 1 year. Our database included 30 days of unplanned readmissions data. We did not include details of the unplanned readmissions data between 31 and 180 days because there was no need to record whether readmissions during this period were planned or not in this database. Unplanned readmissions from 31 to 180 days after the index hospitalization were defined as flags of unplanned readmissions or emergent readmissions to treat at readmission because we had to rule out readmissions for respite as much as possible. Readmission was categorized using the ICD-10. The secondary outcome was the frequency of ED visits within the same hospital during the first 180 days after index hospitalization. Frequent out-of-hour ED visits were defined as two or more night/holiday ED visits according to previous reports [10; 17; 18]. Individual- and hospital-level data were collected from the DPC and PDPS. Individual data included: age, sex, ICD-10 diagnosis, procedures, medical device use at discharge, length of hospital stay, admission status (planned or unplanned), purpose of admission, outcome at discharge, discharge destination, and the distance between the hospital and patient. Comorbidities were categorized into five groups according to previous studies: upper airway anomaly, neurological impairment, prematurity, trauma, and others [9; 19–21] (Supplemental table 1). Respiratory support was categorized according to the degree of support, as follows: non-respiratory support, only home oxygen therapy (HOT) use, or home respirator use (with or without HOT). Tube-nutrition use included children who used all types of tube feeding, with or without gastrostomy. The diagnosis at readmission was categorized into five groups according to previous studies: respiratory, digestive, nervous system, infectious, and other [9; 10]. Tracheostomy complications were defined as ‘Tracheostomy complications’ (J950) and ‘Hemorrhage from other sites in the respiratory passages’ (R048), based on ICD-10 codes. We used the Manhattan distance as the scale of the distance between the hospital and the patient’s home. Because some samples had no Manhattan distance data, we recruited straight-distance data. The indicator of bed size of the Pediatric ward was divided into lowest quartile (< 1652 pediatric patients/year), interquartile (1652–3137 pediatric patients/year), and highest quartile (≥ 3137 pediatric patients/year). The clinical course classification was separated into three categories: planned tracheostomy (planned admission and receiving tracheostomy within 3 days after admission), tracheostomy during hospitalization after birth (admission within 0–7 days-of-age), and unplanned tracheostomy (patients not eligible for the other two categories). Continuous variables are presented as medians and interquartile ranges (IQRs) or means ± standard deviations (SDs), depending on their distribution. Group comparisons between the readmission and non-readmission groups and between groups with and without frequent after-hour visits were analyzed using Pearson's chi-square test and the Kruskal-Wallis’s test. Multivariate logistic regression was used to estimate predictors associated with 180-day unscheduled hospital readmissions and after-hour ED visits. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). All analyses were two-tailed, and p-values less than .05 were considered statistically significant. Multicollinearity between covariates was determined using the variance inflation factor and tolerance values. All analyses were performed using EZR version 1.54.33. 3. Results 3.1 Participant characteristics A total of 2308 patients underwent tracheostomy during their index hospitalization in Japan between April 2016 and March 2019 (Figure 1). After excluding patients who met the exclusion criteria, 1112 patients were discharged to their homes and scheduled to visit the same hospital. There were no significant differences in characteristics between the study cohort and the excluded patients. Table1 shows the characteristics of the study cohort. The median age at index hospitalization was 0 years (IQR:0-6 years), and 601 patients (54%) were under 1 year old. The most common comorbidity associated with tracheostomy was NI (69%), followed by upper airway anomalies (21%), and prematurity (18%). More than 60% of patients depended on respiratory support, and 45% used feeding tubes at discharge from their index discharge. Tracheostomy-related complications occurred in eight patients. The most common clinical course was an unplanned tracheostomy (63%). 3.2 Unplanned readmissions within 180 days of tracheostomy Among the 1112 patients, 374 (34%) were readmitted within 180 days of tracheostomy (Table 2). Children readmitted within 30 days were the most common group (172/374 patients). Fifteen percent were readmitted within 30 days, 25% within 90 days, and 32% within 150 days of tracheostomy. The readmission group was younger than the non-readmission group (p<.05) and less than 1 years of age was more common in the readmission group than the non-readmission group (62% vs. 50%, respectively; p<.05). Tube nutrition at discharge was more common in the readmission group than in the non-readmission group (p<.05). Among the comorbidities, trauma was less common in the readmission group than in the non-readmission group (1% vs. 5%,respectively; p<.05). The most common reason for readmission was a respiratory disorder (54%), followed by a nervous system disorder (20%). The incidence of tracheostomy-related complications during readmission was only 12 cases (2%) (Table 3). Figure 2 shows the multiple logistic regression analysis of the odds of readmission within 180 days after tracheostomy. We found that age less than 1 year (OR:1.77; 95% CI:1.26-2.47; p<.05), tube feeding (OR:1.36; 95% CI:1.03-1.80; p<.05 ), NI (OR:1.52; 95% CI:1.02-2.25; p<.05), and ventilation support (OR: 1.94; 95% CI: 1.29-2.92; p<.05)) were risk factors associated with readmission within 180 days after tracheostomy. 3.3 Frequent out-of-hours ED visits within 180 days of tracheostomy Among the 1112 patients, 220 (20%) frequently visited the ED within 180 days of tracheostomy (Table 2). This group was younger than the group with no frequent ED visits (p<.05) and being less than 1 years old was also more common in this group than the group with no frequent ED visits (64% vs. 52%, respectively; p<.05). Using multiple logistic regression analysis (Figure 3), we found that age less than 1 year (OR:1.53; 95% CI:1.03-2.27; p<.05), HOT (OR:1.94; 95% CI: 1.29-2.92; p<.05), a hospital distance of 20.7 km or less (OR:0.41; 95% CI:0.25-0.66) , and unplanned tracheostomy (OR:2.38; 95% CI: 1.05-5.40; p<.05) were associated with out-of-hours ED visits 180 days of tracheostomy. 4. Discussion To the best of our knowledge, this is the first nationwide study on unplanned readmission and out-of-hour ED visits among children who underwent tracheostomy in Japan. This study adds to previous studies by analyzing risk factors for readmissions and out-of-hour ED visits, considering not only factors related to patient characteristics but also other factors that may affect medical resource use, such as differences between hospitals based on bed size, distance to hospitals, and type of clinical course. We found that 20% of patients were readmitted within 90 days after tracheostomy, and more than 40% of patients were readmitted within 180 days after index hospitalization. While most previous studies were conducted over a short period, our results highlight the importance of long-term follow-up for children who undergo tracheostomy. The characteristics of our study cohort were similar to those in previous reports, with half of the cases being less than 1 years old, approximately 40% on mechanical ventilators and tube feeding, and almost 70% having NIs. Surprisingly, more than 60% of the tracheostomies were unplanned, which has not been reported previously. Appropriate assessment of tracheostomy and daily care in cases of deteriorating health conditions is important. Guidelines on the indications for pediatric tracheostomy in chronic conditions are required. The most common cause of readmission was respiratory-related diseases, and the frequency of tracheostomy-related complications was low in our cohort. This is similar to the low frequency of tracheostomy complications in previous reports, and readmissions for respiratory-related diseases, such as respiratory failure and airway infection, being the most common causes of readmissions [4; 9; 10]. This indicates the importance of expectoration, education of care, and prevention of respiratory infection among CMCs. Compared with previous studies, the readmission rates were lower than those in other developed countries: 30 days (17% vs. 18–45%, respectively) [1; 9; 22], 90 days (25% vs. 44%, respectively) [ 4 ], and 180 days (34% vs. 63–66%, respectively) [10; 23] after tracheostomy. This is partly because this study was limited to readmissions to the same hospital and readmissions for treatment, which may have underestimated hospitalization rates. Moreover, differences in the indications for tracheostomy, discharge criteria, and healthcare systems may have influenced this disparity. Furthermore, most studies did not consider avoidable or unavoidable readmissions. Owing to the internationally high readmission rates from long-term assessments, further studies on unavoidable readmissions and long-term outcomes are required. Less than 1 years of age, NI, tube feeding, and ventilation support were identified as risk factors associated with readmission within 180 days after tracheostomy. Infants and mechanical ventilators have been reported to be risk factors for readmission and frequent resource use in previous reports [10; 19; 24]. In the case of infants, because they are known to be immunologically vulnerable and their caregivers have just started to raise their child and are often unfamiliar with care, even if they have no medical technologies, they are potentially at risk of using hospital resources. Complex cases, such as those with NIs and children depending on medical technology, are known to use a large proportion of medical resources [6; 9]. For these children, it is advisable to prepare sufficient care training and dense care plans, such as home-visiting nurses or doctor plans, before initial discharge [25; 26]. In our cohort, 220 (20%) patients visited the ED within 180 days of tracheostomy. Frequent ED visits are reportedly associated with readmission [ 18 ]. The risk factors tended to be similar to those for readmission, although children using only HOT had a higher risk of ED visits compared with those on mechanical ventilation, and patients living far from the hospital had a lower risk of ED visits. Since it has been reported that patients with long distances to hospitals often visited multiple hospitals [ 17 ], it is possible that the frequency of visits was underestimated in this study. Additionally, because severely complex cases, such as children depending on home ventilators, are often supported by home-visiting doctors and nurses in Japan, home ventilators may not be a risk factor for ED visits. We also found that unplanned tracheostomy was associated with a higher risk of frequent out-of-hour ED visits than planned cases. While guidelines for the management of pediatric patients undergoing tracheostomy in the acute care setting exist [ 27 ], there has been no evidence of an association between the clinical course before tracheostomy and hospital resource use. Further research is needed to identify why unplanned tracheostomy are performed and why ED visits are frequent, which may reveal important factors in addressing this issue. In children with unstable airways, tracheostomy after appropriate evaluation during non-emergency conditions reduces the risk of frequent out-of-hour ED visits. Less than 1 years of age was a common risk factor, and children depending on medical technologies have some risk of medical resource use. Emergency visits and subsequent hospital admissions have been reported to increase the length of hospital stay and lead to increased costs [ 28 ]. It is important to provide close care planning and patient education for children with these risk factors to minimize the use of medical resources, not only to improve patients’ health outcomes and quality of life but also to address the issue of social costs. Furthermore, the care of children with medical technology, such as tracheostomy independence, places a heavy burden on families [ 29 ]. Further research into the needs of the family is required as it is necessary to secure personnel and improve the uneven distribution of home medical care in order to expand the welfare system and services so that the burden is not placed solely on the family to provide care. This study had a few limitations. First, due to the characteristics of this database, we were only able to track readmissions and visits to the same hospital. However, CMCs are generally less likely to be transferred to other hospitals; hence, we focused on patients who planned on attending outpatient clinics at the same hospital as the discharge destination. Second, disease classification was based on previous reports as there is no validated classification of diseases. Third, we were unable to obtain detailed information on the characteristics of the home ventilator, and we did not have data on the family background environment (structure, income, and educational standards of their parents). Fourth, regional differences in the density of support by home-visiting doctors and nurses may have been associated with readmissions; however, we could not account for this because we did not have detailed data on home care medicine. Fifth, we selected unplanned admissions among readmissions within 30 days after tracheostomy; however, between 31 and 90 days after the index discharge, we used admissions for treatments in the absence of the same information, which may have included a small number of admissions for respite. Finally, our database system did not capture daytime ED visits, and there were no data on the reasons for these visits; therefore, we were unable to investigate them. 5. Conclusion We found that 43% of children required unplanned readmission after tracheostomy, and 20% experienced frequent out-of-hour ED visits 180 days of tracheostomy. We identified age less than 1 year, tube feeding, neuro impairment and ventilation support as risk factors associated with readmission, and we also revealed that age less than 1 year, HOT, and a hospital distance of 20.7 km or less, unplanned tracheostomy as risk factors associated with ED visits. Estimating these risk factors before the index discharge would be helpful in coordinating appropriate home care plans and reducing preventable medical resource use. This study may help improve health outcomes, healthcare plans, and evidence-based policymaking. Further research accounting for additionally factors may be required to validate our findings. Abbreviations CMC; children with medical complexity, Cis; confidence intervals, ED; emergency department, HOT; home oxygen therapy, IQRs; medians and interquartile ranges, NI; neuro-impairments, ORs; odds ratios, SDs; standard deviations Declarations Statements and Declarations The authors have no relevant financial or non-financial interests to disclose. Data availability statements Data cannot be disclosed to the public due to a license agreement and ethical issues in each participating facility. To request the dataset generated during this study, please contact the Office of Life Science and Bioethics Research Center via: Email: [email protected] Telephone: +81-3-3813-6111. The corresponding author is also available for data requests. Acknowledgements We would like to thank everyone involved in the study at the National Center for Child Health and Development and Tokyo Medical and Dental University for their cooperation. We are also grateful to Dr. Takahisa Watabe of Division of Otolaryngology of the National Center for Child Health and Development for his continuous support. Funding Funding for this research was provided by a Grant-in-Aid for Policy Planning and Evaluation Research from Japan’s Ministry of Health, Labour and Welfare (grant identifier 22AA2003 [awarded to KF]) and a Grant-in-Aid for Scientific Research (B) through the Japan Society for the Promotion of Science (JSPS KAKENHI, grant identifier 24K02666 [awarded to DS]). The funders did not influence the design or conduct of the study, the gathering or interpretation of data, the decision to submit the results for publication, or the drafting of the research paper. C ontributions Ai Ito-Shinjo: Conceptualization, data curation, methodology, formal analysis, and writing of the original draft. Daisuke Shinjo: Conceptualization, methodology, review writing, editing, project administration, and funding acquisition. Kiyohide Fushimi: Supervision, resources, review writing, and funding acquisition. All authors reviewed, edited and approved the final manuscript. Ethics declarations Ethical approval This study was performed in accordance with the Declaration of Helsinki. This study was conducted retrospectively using the Japanese Administrative Database. This study approved by the Institutional Review Board of the Tokyo Medical and Dental University (M2024-075). The board determined that informed consent was not required because the data were anonymized. 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Acad Pediatr 23:236-243 Tables Table 1. Characteristics of the study cohort. Characteristics Total N=1112 Age, years, median (IQR) 0 (0-6) <1 years old, n (%) 601 (54) Male, n (%) 596 (54) Comorbidities associated with tracheotomy, n (%) A Upper airway anomaly 233 (21) B Neurologic impairment 762 (69) C Prematurity 200 (18) D Trauma 42 ( 4) E Others 163 (15) Respiratory support at discharge, n (%) None 432 (39) Home oxygen therapy 259 (23) Ventilation support 421 (38) Tube nutrition at discharge, n (%) 495 (45) Complication of tracheostomy, n (%) 8 ( 1) Number of pediatric admissions*, n (%) ＜1652/year 279 (25) 1652-3137/year 568 (51) ≥ 3137/year 265 (24) Distance between home and hospital, n (%) ＜4.9 km 276 (25) 4.9-20.7 km 553 (51) ≥ 20.7 km 275 (25) N/A 8 ( 1) Clinical course classification, n (%) Planned tracheostomy 80 ( 7) Tracheostomy during hospitalization of after birth 333 (30) Unplanned tracheostomy 699 (63) Length of stay, days, median (IQR) 113 (58-221) Readmission within 180 days, n(%) 374 (34) Frequent out-of-hours ED visits in 180 days, n (%) 220 (20) IQR, interquartile range; ED, emergency department * The number of pediatric admissions was calculated using the number of pediatric patients per year as an indicator of the bed size of the ward for children. Table 2. Variables associated with readmission and frequent out-of-hours ED visits within 180 days of tracheostomy according to groups. Variables Readmission N=374 Non-readmission N=738 p-value ≧2 visits N=220 ＜2 visits N=892 p-value Age, years, median (IQR) 0 (0-3.0) 0 (0-8.0) <0.05 0 (0-2.0) 0 (0-8.0) <0.05 <1 year-old, n (%) 231 (62) 370 (50) <0.05 140 (64) 461 (52) <0.05 Male, n (%) 196 (52) 400 (54) 0.61 118 (54) 478 (54) 1.00 Comorbidities associated with tracheotomy, n (%) A Upper airway anomaly 76 (20) 157 (21) 0.76 60 (27) 241 (27) 0.93 B Neurologic impairment 284 (76) 478 (65) <0.05 156 (71) 606 (68) 0.42 C Prematurity 63 (17) 137 (19) 0.51 43 (20) 157 (18) 0.49 D Trauma 5 ( 1) 37 ( 5) <0.05 4 (1.8) 38 (4.3) 0.11 E Others 43 (12) 120 (16) <0.05 28 (13) 135 (15) 0.30 Respiratory support at discharge, n (%) <0.05 <0.05 None 110 (29) 322 (44) 63 (29) 369 (41) Only home oxygen therapy 167 (23) 92 (25) 71 (33) 188 (21) Ventilation support 172 (46) 249 (34) 86 (39) 335 (38) Tube nutrition at discharge, n (%) 202 (54) 293 (40) <0.05 110 (50) 385 (43) 0.07 Length of stay of initial admission, days, median (IQR) 133 (64-240) 107 (53-212) <0.05 112 (56-213) 113 (58-222) 0.93 Number of pediatric admissions, n (%) 0.82 0.10 ＜1652/year 95 (25) 184 (25) 61 (28) 215 (24) 1652-3137/year 185 (50) 383 (52) 129 (59) 424 (48) ≥ 3137/year 94 (25) 171 (23) 63 (29) 202 (23) Distance between home and hospital, n (%) <0.05 <0.05 ＜4.9 km 108 (29) 168 (23) 61 (28) 215 (24) 4.9-20.7 km 190 (51) 363 (49) 129 (59) 424 (48) ≥ 20.7 km 74 (20) 201 (27) 30 (14) 245 (28) N/A 2 ( 1) 6 ( 1) 0 ( 0) 8 ( 1) Clinical course classification, n (%) 0.11 <0.05 Planned tracheostomy 61 ( 8) 19 ( 5) 7 ( 3) 73 ( 8) Tracheostomy during hospitalization of after birth 120 (32) 213 (29) 76 (35) 266 (30) Unplanned tracheostomy 235 (63) 464 (63) 137 (62) 553 (62) IQR, interquartile range Table 3. Clinical features of patients with readmissions within 180 days of tracheostomy. Clinical features Total N=374 Length of stay of readmissions, days, median (IQR) 9.0 (5.0-16.0) Reason for readmissions, n (%) Respiratory 246 (66) Digestive 10 ( 3) Nervous system 28 ( 7) Infectious 20 ( 5) Others 70 (19) Complications of tracheostomy, n (%) 10 ( 3) IQR, interquartile range Additional Declarations No competing interests reported. Supplementary Files TableS1.docx Cite Share Download PDF Status: Published Journal Publication published 17 Jun, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 15 Feb, 2025 Reviews received at journal 07 Nov, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviewers agreed at journal 29 Oct, 2024 Reviewers agreed at journal 27 Aug, 2024 Reviewers invited by journal 26 Aug, 2024 Editor assigned by journal 22 Aug, 2024 Submission checks completed at journal 22 Aug, 2024 First submitted to journal 19 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4941267","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":357370427,"identity":"2a4356d9-da8f-4a9e-81a0-2fa0862d1289","order_by":0,"name":"Ai Ito-Shinjo","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"","lastName":"Ito-Shinjo","suffix":""},{"id":357370428,"identity":"df92c881-736f-4781-8256-191b25093f01","order_by":1,"name":"Daisuke Shinjo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIie3QMQrCMBiG4a8IuvzqWkHqFSIZRPQwdtFFpOAkLopQlx7Ak3SOBOwS6ZpR8QKKi6O2oOKSOgrmnf6EPJAEsNl+MUEQIIDBWR6AUr7JviUrJr4lz1Nl90mM1dL9VgbNPjoVGc4v4x7qa4FpYCANPRnIDQ3RjfxQb+MRXDUA3xgI08QkkXwMTkYkoAFOJpKqNwky0iokYvwmyAgrIg2dkyEx5a/cfTyitvIXxrfUUsWv1ajvsSQ5nmdxz/MSueOmH8tzIrxu8hickBcJ4Pa5LJ2Kic1ms/1Rd1+ETuSrYF8FAAAAAElFTkSuQmCC","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":true,"prefix":"","firstName":"Daisuke","middleName":"","lastName":"Shinjo","suffix":""},{"id":357370430,"identity":"d2f30ccf-f2da-41dd-8e9a-3afe4da508b4","order_by":2,"name":"Tomoo Nakamura","email":"","orcid":"","institution":"National Center for Child Health and Development","correspondingAuthor":false,"prefix":"","firstName":"Tomoo","middleName":"","lastName":"Nakamura","suffix":""},{"id":357370431,"identity":"bb2c5354-697e-4c85-adc0-7401690969a0","order_by":3,"name":"Mitsuru Kubota","email":"","orcid":"","institution":"National Center for Child Health and Development","correspondingAuthor":false,"prefix":"","firstName":"Mitsuru","middleName":"","lastName":"Kubota","suffix":""},{"id":357370433,"identity":"1350bfa9-68d5-4d65-a8ef-2284ef01b3ce","order_by":4,"name":"Kiyohide Fushimi","email":"","orcid":"","institution":"Tokyo Medical and Dental University","correspondingAuthor":false,"prefix":"","firstName":"Kiyohide","middleName":"","lastName":"Fushimi","suffix":""}],"badges":[],"createdAt":"2024-08-20 01:38:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4941267/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4941267/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-025-06242-1","type":"published","date":"2025-06-17T15:57:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66676844,"identity":"9938e9b9-5649-4a7e-91d8-eea3f77d8c0f","added_by":"auto","created_at":"2024-10-15 11:23:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":328877,"visible":true,"origin":"","legend":"\u003cp\u003eConstruction of the pediatric cohort that underwent tracheostomy.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4941267/v1/1ada07b0599d829bd994d3dd.png"},{"id":66676840,"identity":"640c1b72-834d-495a-91cf-2884b169f6de","added_by":"auto","created_at":"2024-10-15 11:23:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":406691,"visible":true,"origin":"","legend":"\u003cp\u003eMultiple regression analysis of odds of readmissions and out-of-hours ED visits within 180 days of tracheostomy.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4941267/v1/05b2d3f726e3c470d15c0a7b.png"},{"id":66676230,"identity":"1d52b8e8-4aa7-4933-9bd0-a4a460b444c2","added_by":"auto","created_at":"2024-10-15 11:15:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":391119,"visible":true,"origin":"","legend":"\u003cp\u003eMultiple regression analysis of odds of out-of-hours ED visits within 180 days of tracheostomy.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4941267/v1/2570452e1bf327e4cdddff83.png"},{"id":85231465,"identity":"b6d236cd-7149-4ef8-8ed7-946aa968557c","added_by":"auto","created_at":"2025-06-23 16:08:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2122173,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4941267/v1/e26f518c-7d96-438c-8402-97db67a9e170.pdf"},{"id":66676229,"identity":"833be1f6-1231-4512-8119-8f102aa86266","added_by":"auto","created_at":"2024-10-15 11:15:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15107,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4941267/v1/318275945c654a5fa0de491c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors associated with unplanned readmissions and frequent emergency department visits after pediatric tracheostomy: a nation-wide inpatient database study in Japan","fulltext":[{"header":"What is Known","content":"\u003cul\u003e\n \u003cli\u003eThe use of tracheostomy in children with medical complexity has increased, and these children are known to be frequent users of medical resources.\u003c/li\u003e\n \u003cli\u003eMulticenter studies dealing with the long-term outcomes of pediatric tracheostomy and risk factors associated with high medical resource use are still limited.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eUsing the nationwide database in Japan, this study identified several risk factors associated with unplanned readmissions and out-of-hours emergency department visits \u0026nbsp; (less than 1 years of ages, dependent on medical technologies, etc.).\u003c/li\u003e\n \u003cli\u003eThis study contributes for coordinating appropriate home care plans and reducing preventable medical resource use.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eTracheostomy is performed in patients with upper airway obstruction or respiratory failure requiring long-term ventilator support [1; 2]. In particular, the use of tracheostomy for children with medical complexity (CMC), such as children with neuro-impairments (NIs) who require home ventilator support, has increased [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA previous study reported that hospitalized CMCs accounted for less than 1% of the population; however, they required one-third of the medical costs of pediatric hospitalizations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The American Academy of Pediatrics recommends the importance of evaluating unplanned hospitalizations and emergency department visits for quality-improvement of the health care system around CMCs. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In recent years, the understanding of these high medical utilizers and improvement of care coordination has grown because of their potential to improve outcomes and reduce unnecessary medical healthcare utilization [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong CMCs who have severe and complex conditions or require ventilators, many visit the emergency department (ED) and are readmitted in the short term after tracheostomies [9; 10]. These reports indicate that children who undergo tracheostomy require the frequent use of medical resources. They were hospitalized for various reasons, including aspiration pneumonia and complications related to tracheostomy.\u003c/p\u003e \u003cp\u003eThe American Academy of Otolaryngology-Head and Neck Surgery Foundation recognizes the need to investigate risk factors for readmission and ED visits after tracheostomy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; however, the evidence is limited. A few multicenter studies deal with the outcomes of tracheostomy [9; 10] and a few reports investigate the risk factors for readmissions and frequent long-term ED visits after tracheostomy [4; 9; 10]. Hence, there is limited information on a large cohort of multicenter epidemiological data and the long-term outcomes of children who underwent tracheostomy in Japan [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Revealing the clinical features and risk factors of medical resource use in children is beneficial for improving health outcomes and healthcare plans [12; 13].\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to describe the clinical features of children who underwent tracheostomy in Japan and to determine the risk factors for unplanned readmission and frequent out-of-hour ED visits after index hospitalization when tracheostomies were performed using the Japanese administrative database.\u003c/p\u003e"},{"header":"2. Material and methods","content":"\u003cp\u003eThe cohort for this retrospective study was identified using the Japanese Administrative Database, Diagnosis Procedure Combination/per-diem payment system (DPC/PDPS). This database is a case-mix patient classification system linked to payments at acute care hospitals in Japan since 2003. Details of this database have been described previously [14; 15]. The DPC/PDPS covered 1730 hospitals and 488563 beds in 2018, and almost all acute inpatients were included, accounting for more than half of the 894,000 hospital beds in Japan [14; 16].\u003c/p\u003e \u003cp\u003ePatient clinical and administrative claims data were collected annually from hospitals. This database included information on: age; sex; diagnostic information using the International Statistical Classification of Diseases, Tenth Revision (ICD-10) code; all procedures; medical device use; medications; purpose of admission; duration of admission; outcome at discharge; and discharge destination. This database also included hospital information regarding the number of beds for pediatric patients.\u003c/p\u003e \u003cp\u003e This study was approved by the Institutional Review Board of the Tokyo Medical and Dental University (M2024-075). The board determined that informed consent was not required because the data were anonymized.\u003c/p\u003e \u003cp\u003eWe recruited children aged between 0 and 18 years who underwent tracheostomy (Japanese operative code: K386-00) and were discharged from Japanese hospitals between April 2016 and March 2019 to avoid the effect of the COVID-19 pandemic. Hospitalizations in which the patient underwent tracheostomy for the first time were defined as index hospitalizations. Patients who died during the index hospitalization, underwent tracheostomy closure (K396-00) during the index hospitalization, were transferred to other hospitals and post-acute care facilities, or were scheduled to visit other hospitals were excluded.\u003c/p\u003e \u003cp\u003eThe primary outcome was unplanned readmission for treatment within the same hospital during the first 180 days after the index hospitalization in patients who had undergone a tracheostomy. We only dealt with readmissions for treatment because CMCs sometimes use respite admissions after significant changes, such as starting mechanical ventilation in Japan. In general, complex cases are associated with background diseases and various conditions, leading to longer hospital stays and more visits and readmissions. As a large number of CMCs were expected in our cohort, we followed up for a longer period. We set the follow-up period at 180 days because the characteristics of DPC may not have been successfully followed up for a follow-up period of approximately 1 year. Our database included 30 days of unplanned readmissions data. We did not include details of the unplanned readmissions data between 31 and 180 days because there was no need to record whether readmissions during this period were planned or not in this database. Unplanned readmissions from 31 to 180 days after the index hospitalization were defined as flags of unplanned readmissions or emergent readmissions to treat at readmission because we had to rule out readmissions for respite as much as possible. Readmission was categorized using the ICD-10. The secondary outcome was the frequency of ED visits within the same hospital during the first 180 days after index hospitalization. Frequent out-of-hour ED visits were defined as two or more night/holiday ED visits according to previous reports [10; 17; 18].\u003c/p\u003e \u003cp\u003eIndividual- and hospital-level data were collected from the DPC and PDPS. Individual data included: age, sex, ICD-10 diagnosis, procedures, medical device use at discharge, length of hospital stay, admission status (planned or unplanned), purpose of admission, outcome at discharge, discharge destination, and the distance between the hospital and patient.\u003c/p\u003e \u003cp\u003eComorbidities were categorized into five groups according to previous studies: upper airway anomaly, neurological impairment, prematurity, trauma, and others [9; 19\u0026ndash;21] (Supplemental table 1). Respiratory support was categorized according to the degree of support, as follows: non-respiratory support, only home oxygen therapy (HOT) use, or home respirator use (with or without HOT). Tube-nutrition use included children who used all types of tube feeding, with or without gastrostomy. The diagnosis at readmission was categorized into five groups according to previous studies: respiratory, digestive, nervous system, infectious, and other [9; 10].\u003c/p\u003e \u003cp\u003eTracheostomy complications were defined as \u0026lsquo;Tracheostomy complications\u0026rsquo; (J950) and \u0026lsquo;Hemorrhage from other sites in the respiratory passages\u0026rsquo; (R048), based on ICD-10 codes. We used the Manhattan distance as the scale of the distance between the hospital and the patient\u0026rsquo;s home. Because some samples had no Manhattan distance data, we recruited straight-distance data. The indicator of bed size of the Pediatric ward was divided into lowest quartile (\u0026lt;\u0026thinsp;1652 pediatric patients/year), interquartile (1652\u0026ndash;3137 pediatric patients/year), and highest quartile (\u0026ge;\u0026thinsp;3137 pediatric patients/year). The clinical course classification was separated into three categories: planned tracheostomy (planned admission and receiving tracheostomy within 3 days after admission), tracheostomy during hospitalization after birth (admission within 0\u0026ndash;7 days-of-age), and unplanned tracheostomy (patients not eligible for the other two categories).\u003c/p\u003e \u003cp\u003eContinuous variables are presented as medians and interquartile ranges (IQRs) or means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SDs), depending on their distribution.\u003c/p\u003e \u003cp\u003eGroup comparisons between the readmission and non-readmission groups and between groups with and without frequent after-hour visits were analyzed using Pearson's chi-square test and the Kruskal-Wallis\u0026rsquo;s test. Multivariate logistic regression was used to estimate predictors associated with 180-day unscheduled hospital readmissions and after-hour ED visits. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). All analyses were two-tailed, and p-values less than .05 were considered statistically significant. Multicollinearity between covariates was determined using the variance inflation factor and tolerance values. All analyses were performed using EZR version 1.54.33.\u003c/p\u003e"},{"header":"3. Results","content":"\u003ch2\u003e3.1 Participant characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 2308 patients underwent tracheostomy during their index hospitalization in Japan between April 2016 and March 2019 (Figure 1). After excluding patients who met the exclusion criteria, 1112 patients were discharged to their homes and scheduled to visit the same hospital. There were no significant differences in characteristics between the study cohort and the excluded patients. \u0026nbsp;Table1 shows the characteristics of the study cohort. The median age at index hospitalization was 0 years (IQR:0-6 years), and 601 patients (54%) were under 1 year old. The most common comorbidity associated with tracheostomy was NI (69%), followed by upper airway anomalies (21%), and prematurity (18%). More than 60% of patients depended on respiratory support, and 45% used feeding tubes at discharge from their index discharge. Tracheostomy-related complications occurred in eight patients. The most common clinical course was an unplanned tracheostomy (63%).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.2 Unplanned readmissions within 180 days of tracheostomy\u003c/h2\u003e\n\u003cp\u003eAmong the 1112 patients, 374 (34%) were readmitted within 180 days of tracheostomy (Table 2). Children readmitted within 30 days were the most common group (172/374 patients). Fifteen percent were readmitted within 30 days, 25% within 90 days, and 32% within 150 days of tracheostomy. \u0026nbsp;The readmission group was younger than the non-readmission group (p\u0026lt;.05) and less than 1 years of age was more common in the readmission group than the non-readmission group (62% vs. 50%, respectively; p\u0026lt;.05). Tube nutrition at discharge was more common in the readmission group than in the non-readmission group (p\u0026lt;.05). Among the comorbidities, trauma was less common in the readmission group than in the non-readmission group (1% vs. 5%,respectively; p\u0026lt;.05). The most common reason for readmission was a respiratory disorder (54%), followed by a nervous system disorder (20%). The incidence of tracheostomy-related complications during readmission was only 12 cases (2%) (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 2 shows the multiple logistic regression analysis of the odds of readmission within 180 days after tracheostomy. We found that age less than 1 year\u0026nbsp;(OR:1.77; 95% CI:1.26-2.47; p\u0026lt;.05), tube feeding (OR:1.36; 95% CI:1.03-1.80; p\u0026lt;.05 ), NI (OR:1.52; 95% CI:1.02-2.25; p\u0026lt;.05), and\u0026nbsp;ventilation support\u0026nbsp;(OR: 1.94; 95% CI: 1.29-2.92; p\u0026lt;.05)) were risk factors associated with readmission within 180 days after tracheostomy.\u003c/p\u003e\n\u003ch2\u003e3.3 Frequent out-of-hours ED visits within 180 days of tracheostomy\u003c/h2\u003e\n\u003cp\u003eAmong the 1112 patients, 220 (20%) frequently visited the ED within 180 days of tracheostomy (Table 2). This group was younger than the group with no frequent ED visits (p\u0026lt;.05) and being less than 1 years old was also more common in this group than the group with no frequent ED visits (64% vs. 52%, respectively; p\u0026lt;.05). Using multiple logistic regression analysis (Figure 3), we found that age less than 1 year (OR:1.53; 95% CI:1.03-2.27; p\u0026lt;.05), HOT (OR:1.94; 95% CI: 1.29-2.92; p\u0026lt;.05), a hospital distance of 20.7 km or less (OR:0.41; 95% CI:0.25-0.66) , and unplanned tracheostomy (OR:2.38; 95% CI: 1.05-5.40; p\u0026lt;.05) were associated with out-of-hours ED visits 180 days of tracheostomy.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first nationwide study on unplanned readmission and out-of-hour ED visits among children who underwent tracheostomy in Japan. This study adds to previous studies by analyzing risk factors for readmissions and out-of-hour ED visits, considering not only factors related to patient characteristics but also other factors that may affect medical resource use, such as differences between hospitals based on bed size, distance to hospitals, and type of clinical course.\u003c/p\u003e \u003cp\u003eWe found that 20% of patients were readmitted within 90 days after tracheostomy, and more than 40% of patients were readmitted within 180 days after index hospitalization. While most previous studies were conducted over a short period, our results highlight the importance of long-term follow-up for children who undergo tracheostomy. The characteristics of our study cohort were similar to those in previous reports, with half of the cases being less than 1 years old, approximately 40% on mechanical ventilators and tube feeding, and almost 70% having NIs. Surprisingly, more than 60% of the tracheostomies were unplanned, which has not been reported previously. Appropriate assessment of tracheostomy and daily care in cases of deteriorating health conditions is important. Guidelines on the indications for pediatric tracheostomy in chronic conditions are required.\u003c/p\u003e \u003cp\u003eThe most common cause of readmission was respiratory-related diseases, and the frequency of tracheostomy-related complications was low in our cohort. This is similar to the low frequency of tracheostomy complications in previous reports, and readmissions for respiratory-related diseases, such as respiratory failure and airway infection, being the most common causes of readmissions [4; 9; 10]. This indicates the importance of expectoration, education of care, and prevention of respiratory infection among CMCs.\u003c/p\u003e \u003cp\u003eCompared with previous studies, the readmission rates were lower than those in other developed countries: 30 days (17% vs. 18\u0026ndash;45%, respectively) [1; 9; 22], 90 days (25% vs. 44%, respectively) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and 180 days (34% vs. 63\u0026ndash;66%, respectively) [10; 23] after tracheostomy. This is partly because this study was limited to readmissions to the same hospital and readmissions for treatment, which may have underestimated hospitalization rates. Moreover, differences in the indications for tracheostomy, discharge criteria, and healthcare systems may have influenced this disparity. Furthermore, most studies did not consider avoidable or unavoidable readmissions. Owing to the internationally high readmission rates from long-term assessments, further studies on unavoidable readmissions and long-term outcomes are required.\u003c/p\u003e \u003cp\u003eLess than 1 years of age, NI, tube feeding, and ventilation support were identified as risk factors associated with readmission within 180 days after tracheostomy. Infants and mechanical ventilators have been reported to be risk factors for readmission and frequent resource use in previous reports [10; 19; 24]. In the case of infants, because they are known to be immunologically vulnerable and their caregivers have just started to raise their child and are often unfamiliar with care, even if they have no medical technologies, they are potentially at risk of using hospital resources. Complex cases, such as those with NIs and children depending on medical technology, are known to use a large proportion of medical resources [6; 9]. For these children, it is advisable to prepare sufficient care training and dense care plans, such as home-visiting nurses or doctor plans, before initial discharge [25; 26].\u003c/p\u003e \u003cp\u003eIn our cohort, 220 (20%) patients visited the ED within 180 days of\u003c/p\u003e \u003cp\u003etracheostomy. Frequent ED visits are reportedly associated with readmission [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The risk factors tended to be similar to those for readmission, although children using only HOT had a higher risk of ED visits compared with those on mechanical ventilation, and patients living far from the hospital had a lower risk of ED visits. Since it has been reported that patients with long distances to hospitals often visited multiple hospitals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], it is possible that the frequency of visits was underestimated in this study. Additionally, because severely complex cases, such as children depending on home ventilators, are often supported by home-visiting doctors and nurses in Japan, home ventilators may not be a risk factor for ED visits.\u003c/p\u003e \u003cp\u003eWe also found that unplanned tracheostomy was associated with a higher risk of frequent out-of-hour ED visits than planned cases. While guidelines for the management of pediatric patients undergoing tracheostomy in the acute care setting exist [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], there has been no evidence of an association between the clinical course before tracheostomy and hospital resource use. Further research is needed to identify why unplanned tracheostomy are performed and why ED visits are frequent, which may reveal important factors in addressing this issue. In children with unstable airways, tracheostomy after appropriate evaluation during non-emergency conditions reduces the risk of frequent out-of-hour ED visits.\u003c/p\u003e \u003cp\u003eLess than 1 years of age was a common risk factor, and children depending on medical technologies have some risk of medical resource use. Emergency visits and subsequent hospital admissions have been reported to increase the length of hospital stay and lead to increased costs [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It is important to provide close care planning and patient education for children with these risk factors to minimize the use of medical resources, not only to improve patients\u0026rsquo; health outcomes and quality of life but also to address the issue of social costs. Furthermore, the care of children with medical technology, such as tracheostomy independence, places a heavy burden on families [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Further research into the needs of the family is required as it is necessary to secure personnel and improve the uneven distribution of home medical care in order to expand the welfare system and services so that the burden is not placed solely on the family to provide care.\u003c/p\u003e \u003cp\u003eThis study had a few limitations. First, due to the characteristics of this database, we were only able to track readmissions and visits to the same hospital. However, CMCs are generally less likely to be transferred to other hospitals; hence, we focused on patients who planned on attending outpatient clinics at the same hospital as the discharge destination. Second, disease classification was based on previous reports as there is no validated classification of diseases. Third, we were unable to obtain detailed information on the characteristics of the home ventilator, and we did not have data on the family background environment (structure, income, and educational standards of their parents). Fourth, regional differences in the density of support by home-visiting doctors and nurses may have been associated with readmissions; however, we could not account for this because we did not have detailed data on home care medicine. Fifth, we selected unplanned admissions among readmissions within 30 days after tracheostomy; however, between 31 and 90 days after the index discharge, we used admissions for treatments in the absence of the same information, which may have included a small number of admissions for respite. Finally, our database system did not capture daytime ED visits, and there were no data on the reasons for these visits; therefore, we were unable to investigate them.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eWe found that 43% of children required unplanned readmission after tracheostomy, and 20% experienced frequent out-of-hour ED visits 180 days of tracheostomy. We identified age less than 1 year, tube feeding, neuro impairment and ventilation support as risk factors associated with readmission, and we also revealed that age less than 1 year, HOT, and a hospital distance of 20.7 km or less, unplanned tracheostomy as risk factors associated with ED visits. Estimating these risk factors before the index discharge would be helpful in coordinating appropriate home care plans and reducing preventable medical resource use. This study may help improve health outcomes, healthcare plans, and evidence-based policymaking. Further research accounting for additionally factors may be required to validate our findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCMC; children with medical complexity, Cis; confidence intervals, ED; emergency department, HOT; home oxygen therapy, IQRs; medians and interquartile ranges, NI; neuro-impairments, ORs; odds ratios, SDs; standard deviations\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements and Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData cannot be disclosed to the public due to a license agreement and ethical issues in each participating facility. To request the dataset generated during this study, please contact the Office of Life Science and Bioethics Research Center via: Email:[email protected] Telephone: +81-3-3813-6111. The corresponding author is also available for data requests.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank everyone involved in the study at the National Center for Child Health and Development and Tokyo Medical and Dental University for their cooperation. We are also grateful to Dr. Takahisa Watabe of Division of Otolaryngology of the National Center for Child Health and Development for his continuous support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this research was provided by a Grant-in-Aid for Policy Planning and Evaluation Research from Japan\u0026rsquo;s Ministry of Health, Labour and Welfare (grant identifier 22AA2003 [awarded to KF]) and a Grant-in-Aid for Scientific Research (B) through the Japan Society for the Promotion of Science (JSPS KAKENHI, grant identifier 24K02666 [awarded to DS]). The funders did not influence the design or conduct of the study, the gathering or interpretation of data, the decision to submit the results for publication, or the drafting of the research paper.\u003c/p\u003e\n\u003cp\u003eC\u003cstrong\u003eontributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAi Ito-Shinjo: Conceptualization, data curation, methodology, formal analysis, and writing of the original draft. Daisuke Shinjo: Conceptualization, methodology, review writing, editing, project administration,\u0026nbsp;and funding acquisition. Kiyohide Fushimi: Supervision, resources, review writing, and funding acquisition.\u0026nbsp;All authors reviewed, edited and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the Declaration of Helsinki. This study was conducted retrospectively using the Japanese Administrative Database. This study approved by the Institutional Review Board of the Tokyo Medical and Dental University (M2024-075). The board determined that informed consent was not required because the data were anonymized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSpataro E, Durakovic N, Kallogjeri D, Nussenbaum B (2017) Complications and 30-day hospital readmission rates of patients undergoing tracheostomy: A prospective analysis. Laryngoscope 127:2746-2753\u003c/li\u003e\n\u003cli\u003eMahida JB, Asti L, Boss EF, Shah RK, Deans KJ, Minneci PC, Jatana KR (2016) Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality Improvement Program Pediatric. JAMA Otolaryngol Head Neck Surg 142:241-246\u003c/li\u003e\n\u003cli\u003eGraham RJ, Fleegler EW, Robinson WM (2007) Chronic ventilator need in the community: a 2005 pediatric census of Massachusetts. Pediatrics 119:e1280-1287\u003c/li\u003e\n\u003cli\u003eTarfa RA, Morris J, Melder KL, McCoy JL, Tobey ABJ (2021) Readmissions and mortality in pediatric tracheostomy patients: Are we doing enough? Int J Pediatr Otorhinolaryngol 145:110704\u003c/li\u003e\n\u003cli\u003eBerry JG, Graham RJ, Roberson DW, Rhein L, Graham DA, Zhou J, O\u0026apos;Brien J, Putney H, Goldmann DA (2010) Patient characteristics associated with in-hospital mortality in children following tracheotomy. Arch Dis Child 95:703-710\u003c/li\u003e\n\u003cli\u003eCohen E, Berry JG, Camacho X, Anderson G, Wodchis W, Guttmann A (2012) Patterns and costs of health care use of children with medical complexity. Pediatrics 130:e1463-1470\u003c/li\u003e\n\u003cli\u003eKuo DZ, Houtrow AJ, Council On Children With D (2016) Recognition and Management of Medical Complexity. Pediatrics 138\u003c/li\u003e\n\u003cli\u003eMitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, Brown CA, 3rd, Brandt C, Deakins K, Hartnick C, Merati A (2013) Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg 148:6-20\u003c/li\u003e\n\u003cli\u003eBerry JG, Graham DA, Graham RJ, Zhou J, Putney HL, O\u0026apos;Brien JE, Roberson DW, Goldmann DA (2009) Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics 124:563-572\u003c/li\u003e\n\u003cli\u003eBeams DR, Chorney SR, Kou YF, Teplitzky TB, Wynings EM, Johnson RF (2023) Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy. Laryngoscope 133:2018-2024\u003c/li\u003e\n\u003cli\u003eIshihara T, Tanaka H (2020) Factors affecting tracheostomy in critically ill paediatric patients in Japan: a data-based analysis. BMC Pediatr 20:237\u003c/li\u003e\n\u003cli\u003eNancy A. Murphy EBC (2016) Children with Complex Medical Conditions: an Under-Recognized Driver of the Pediatric Cost Crisis. Curr Treat Options Peds 2:289-295\u003c/li\u003e\n\u003cli\u003eBerry JG, Agrawal R, Kuo DZ, Cohen E, Risko W, Hall M, Casey P, Gordon J, Srivastava R (2011) Characteristics of hospitalizations for patients who use a structured clinical care program for children with medical complexity. J Pediatr 159:284-290\u003c/li\u003e\n\u003cli\u003eHayashida K, Murakami G, Matsuda S, Fushimi K (2021) History and Profile of Diagnosis Procedure Combination (DPC): Development of a Real Data Collection System for Acute Inpatient Care in Japan. J Epidemiol 31:1-11\u003c/li\u003e\n\u003cli\u003eShinjo D, Fushimi K (2015) Preoperative factors affecting cost and length of stay for isolated off-pump coronary artery bypass grafting: hierarchical linear model analysis. BMJ Open 5:e008750\u003c/li\u003e\n\u003cli\u003eShinjo D, Tachimori H, Maruyama-Sakurai K, Fujimori K, Inoue N, Fushimi K (2021) Consultation-liaison psychiatry in Japan: a nationwide retrospective observational study. BMC Psychiatry 21:235\u003c/li\u003e\n\u003cli\u003eSupat B, Brennan JJ, Vilke GM, Ishimine P, Hsia RY, Castillo EM (2019) Characterizing pediatric high frequency users of California emergency departments. Am J Emerg Med 37:1699-1704\u003c/li\u003e\n\u003cli\u003eAlpern ER, Clark AE, Alessandrini EA, Gorelick MH, Kittick M, Stanley RM, Dean JM, Teach SJ, Chamberlain JM, Pediatric Emergency Care Applied Research N (2014) Recurrent and high-frequency use of the emergency department by pediatric patients. Acad Emerg Med 21:365-373\u003c/li\u003e\n\u003cli\u003eYu H, Mamey MR, Russell CJ (2017) Factors associated with 30-day all-cause hospital readmission after tracheotomy in pediatric patients. Int J Pediatr Otorhinolaryngol 103:137-141\u003c/li\u003e\n\u003cli\u003eBerry JG, Poduri A, Bonkowsky JL, Zhou J, Graham DA, Welch C, Putney H, Srivastava R (2012) Trends in resource utilization by children with neurological impairment in the United States inpatient health care system: a repeat cross-sectional study. PLoS Med 9:e1001158\u003c/li\u003e\n\u003cli\u003eIsaiah A, Moyer K, Pereira KD (2016) Current Trends in Neonatal Tracheostomy. JAMA Otolaryngol Head Neck Surg 142:738-742\u003c/li\u003e\n\u003cli\u003eDavidson C, Jacob B, Brown A, Brooks R, Bailey C, Whitney C, Chorney S, Lenes-Voit F, Johnson RF (2021) Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients. Laryngoscope 131:E2469-E2474\u003c/li\u003e\n\u003cli\u003eGraf JM, Montagnino BA, Hueckel R, McPherson ML (2008) Pediatric tracheostomies: a recent experience from one academic center. Pediatr Crit Care Med 9:96-100\u003c/li\u003e\n\u003cli\u003eRogerson CM, Beardsley AL, Nitu ME, Cristea AI (2020) Health Care Resource Utilization for Children Requiring Prolonged Mechanical Ventilation via Tracheostomy. Respir Care 65:1147-1153\u003c/li\u003e\n\u003cli\u003eSobotka SA, Lynch E, Peek ME, Graham RJ (2020) Readmission drivers for children with medical complexity: Home nursing shortages cause health crises. Pediatr Pulmonol 55:1474-1480\u003c/li\u003e\n\u003cli\u003eKun SS, Edwards JD, Ward SL, Keens TG (2012) Hospital readmissions for newly discharged pediatric home mechanical ventilation patients. Pediatr Pulmonol 47:409-414\u003c/li\u003e\n\u003cli\u003eVolsko TA, Parker SW, Deakins K, Walsh BK, Fedor KL, Valika T, Ginier E, Strickland SL (2021) AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting. Respir Care 66:144-155\u003c/li\u003e\n\u003cli\u003eZhang J, Liu P, Narayanan AM, Chorney SR, Kou YF, Johnson RF (2024) Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis. OTO Open 8:e108\u003c/li\u003e\n\u003cli\u003eCardenas A, Esser K, Wright E, Netten K, Edwards A, Rose J, Vigod S, Cohen E, Orkin J (2023) Caring for the Caregiver (C4C): An Integrated Stepped Care Model for Caregivers of Children With Medical Complexity. Acad Pediatr 23:236-243\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of the study cohort.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"454\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN=1112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eAge, years, median (IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt;1 years old, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e601 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e596 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eComorbidities associated with tracheotomy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eA \u0026nbsp;Upper airway anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e233 (21)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eB \u0026nbsp;Neurologic impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e762 (69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eC \u0026nbsp;Prematurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e200 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eD \u0026nbsp;Trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e42 ( 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eE \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e163 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eRespiratory support at discharge, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e432 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e Home oxygen therapy\u0026nbsp; \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e259 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e Ventilation support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e421 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eTube nutrition at discharge, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e495 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eComplication of tracheostomy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e8 ( 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eNumber of pediatric admissions*, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;＜1652/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e279 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e \u0026nbsp; 1652-3137/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e568 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e \u0026nbsp; \u0026ge; 3137/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e265 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eDistance between home and hospital, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e＜4.9 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e276 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;4.9-20.7 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e553 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026ge; 20.7 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e275 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003e \u0026nbsp; N/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e8 ( 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical course classification, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003ePlanned tracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e80 ( 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eTracheostomy during hospitalization of after birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e333 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eUnplanned tracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e699 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eLength of stay, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e113 (58-221)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eReadmission within 180 days, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e374 (34)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"77.09251101321586%\" valign=\"bottom\"\u003e\n \u003cp\u003eFrequent out-of-hours ED visits in 180 days, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.90748898678414%\" valign=\"bottom\"\u003e\n \u003cp\u003e220 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR, interquartile range; ED, emergency department\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e* The number of pediatric admissions was calculated using the number of pediatric patients per year as an indicator of the bed size of the ward for children.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Variables associated with readmission and frequent out-of-hours ED visits within 180 days of tracheostomy according to groups.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003eReadmission\u003c/p\u003e\n \u003cp\u003eN=374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003eNon-readmission\u003c/p\u003e\n \u003cp\u003eN=738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e≧2 visits\u003c/p\u003e\n \u003cp\u003eN=220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e＜2 visits\u003c/p\u003e\n \u003cp\u003eN=892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eAge, years, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0-3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0-2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0-8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026lt;1 year-old, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e231 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e370 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e140 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e461 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e196 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e400 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e118 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e478 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eComorbidities associated with tracheotomy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eA \u0026nbsp;Upper airway anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;76 (20)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e157 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;60 (27)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e241 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eB \u0026nbsp;Neurologic impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e284 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e478 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e156 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e606 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eC \u0026nbsp;Prematurity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e63 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e137 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e43 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e157 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eD \u0026nbsp;Trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 ( 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e37 ( 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e38 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eE \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e43 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e120 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e28 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e135 (15)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eRespiratory support at discharge, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e110 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e322 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e63 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e369 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e Only home oxygen therapy\u0026nbsp; \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e167 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e92 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e71 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e188 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e Ventilation support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e172 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e249 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e86 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e335 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eTube nutrition at discharge, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e202 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e293 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e110 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e385 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eLength of stay of initial admission, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e133 (64-240)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e107 (53-212)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e112 (56-213)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e113 (58-222)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eNumber of pediatric admissions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; ＜1652/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e95 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e184 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e61 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e215 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 1652-3137/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e185 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e383 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e129 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e424 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge; 3137/year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e94 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e171 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e63 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e202 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eDistance between home and hospital, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e＜4.9 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e108 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e168 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e61 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e215 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;4.9-20.7 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e190 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e363 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e129 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e424 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge; 20.7 km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e74 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e201 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e30 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e245 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;N/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e2 ( 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e6 ( 1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 ( \u0026nbsp;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e8 ( \u0026nbsp;1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical course classification, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003ePlanned tracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e61 ( 8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e19 ( 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 ( \u0026nbsp;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e73 ( \u0026nbsp;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eTracheostomy during hospitalization of after birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e120 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e213 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e76 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e266 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"bottom\"\u003e\n \u003cp\u003eUnplanned tracheostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.930348258706468%\" valign=\"bottom\"\u003e\n \u003cp\u003e235 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.091210613598673%\" valign=\"bottom\"\u003e\n \u003cp\u003e464 (63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.940298507462687%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e137 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e553 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.779436152570481%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR, interquartile range\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Clinical features of patients with readmissions within 180 days of tracheostomy.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"463\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical features\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN=374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eLength of stay of readmissions, days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e9.0 (5.0-16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eReason for readmissions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eRespiratory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e246 (66)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eDigestive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e10 ( 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eNervous system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e28 ( 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eInfectious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 ( 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e70 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.4341252699784%\" valign=\"bottom\"\u003e\n \u003cp\u003eComplications of tracheostomy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"bottom\"\u003e\n \u003cp\u003e10 ( 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR, interquartile range\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"tracheostomy, readmission, emergency department visits, complications, health outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4941267/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4941267/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eChildren who undergo tracheostomy sometimes experience unexpected readmissions and frequent emergency department (ED) visits. Revealing the risk factors of medical resource use may help improve health outcomes. This study aimed to describe the clinical features of children who underwent tracheostomy and to determine the risk factors associated with unplanned readmission and frequent out-of-hour ED visits.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData of children aged between 0 and 18 years who underwent tracheostomy and were discharged between April 2016 and March 2019 were retrieved from the Japanese National Inpatient Database and retrospectively analyzed. Risk factors for readmission and frequent out-of-hour ED visits within 180 days of tracheostomy were estimated using multiple logistic regression analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1112 patients underwent tracheostomy during the study period. A total of 483 (43%) patients were readmitted and 220 (20%) visited the ED frequently. The multiple logistic regression analysis showed that less than 1 years-of-age (Odds ratio [OR]:1.77; 95% confidence interval [CI]:1.26\u0026ndash;2.47; p\u0026thinsp;\u0026lt;\u0026thinsp;.05), tube feeding (OR:1.36; 95% CI:1.03\u0026ndash;1.80; p\u0026thinsp;\u0026lt;\u0026thinsp;.05), neuro-impairment (OR:1.52; 95% CI:1.02\u0026ndash;2.25; p\u0026thinsp;\u0026lt;\u0026thinsp;05), and mechanical ventilation (OR:1.94; 95% CI:1.29\u0026ndash;2.92; p\u0026thinsp;\u0026lt;\u0026thinsp;.05) were risk factors for readmissions. Moreover, less than 1 years-of-age (OR:1.53; 95% CI:1.03\u0026ndash;2.27; p\u0026thinsp;\u0026lt;\u0026thinsp;.05), home oxygen therapy (OR:1.94; 95% CI: 1.29\u0026ndash;2.92; p\u0026thinsp;\u0026lt;\u0026thinsp;.05), and unplanned tracheostomy (OR:2.38; 95% CI: 1.05\u0026ndash;5.40; p\u0026thinsp;\u0026lt;\u0026thinsp;.05) were risk factors for ED visits.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study describes the clinical features and risk factors for readmission and frequent out-of-hour ED visits after tracheostomy. This study may help improve health outcomes, healthcare plans, and evidence-based policymaking.\u003c/p\u003e","manuscriptTitle":"Risk factors associated with unplanned readmissions and frequent emergency department visits after pediatric tracheostomy: a nation-wide inpatient database study in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 11:15:23","doi":"10.21203/rs.3.rs-4941267/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-15T17:05:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-07T15:13:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58209930805482221000768758100989307900","date":"2024-10-31T11:15:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106911675972145819077270716728122154481","date":"2024-10-31T08:58:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301668389746310666270719540858951525586","date":"2024-10-29T10:17:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112753220698345085027545367502987947430","date":"2024-08-27T06:03:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-26T06:59:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-23T00:19:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-23T00:07:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2024-08-20T01:37:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e31ec55c-258d-4b8b-888f-5a8f5f191dae","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T16:04:44+00:00","versionOfRecord":{"articleIdentity":"rs-4941267","link":"https://doi.org/10.1007/s00431-025-06242-1","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2025-06-17 15:57:39","publishedOnDateReadable":"June 17th, 2025"},"versionCreatedAt":"2024-10-15 11:15:23","video":"","vorDoi":"10.1007/s00431-025-06242-1","vorDoiUrl":"https://doi.org/10.1007/s00431-025-06242-1","workflowStages":[]},"version":"v1","identity":"rs-4941267","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4941267","identity":"rs-4941267","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}