K. L. Bailey1, Y. Seo1, E. Aguayo1, V. Dobaria1, Y. Sanaiha1, R. J. Shemin1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA
Introduction:
Extracorporeal membrane oxygenation (ECMO) is increasingly used as a life-sustaining measure in patients with acute or end-stage cardiac and/or respiratory failure. We aimed to analyze the national trends in cost and clinical outcomes for venoarterial and venovenous ECMO. We further assessed whether variations in the utilization of ECMO exist based on geography and hospital size.
Methods:
All adult ECMO patients in the 2008-2014 National Inpatient Sample (NIS) were analyzed. NIS is an all-payer inpatient database that estimates more than 35 million annual U.S. hospitalizations. Patient demographics, hospital characteristics, and outcomes including mortality, cost, and length of stay were evaluated using non-parametric tests for trends.
Results:
A national estimate of 18,685 adult ECMO patients were categorized by indication: 8,062 (43.2%) respiratory failure, 7,817 (41.8%) postcardiotomy, 1,198 (6.4%) lung transplant, 903 (4.8%) cardiogenic shock, and 706 (3.8%) heart transplant patients. Annual ECMO admissions increased significantly from 1,137 in 2008 to 5,240 in 2014 (P<0.001). The respiratory failure group showed the greatest increase from 416 cases in 2008 to 2,400 cases in 2014 (P=0.003). Average cost and length of stay for overall admissions increased significantly from $125,000+/-$12,457 to $178,677+/-$8,948 (P=0.013) and 21.8 to 24.0 days (P=0.04) respectively. Elixhauser scores measuring comorbidities increased from 3.17 to 4.14 over the study period. Mortality decreased from 61.4% to 46.0% among total admissions (P<0.001) and among all indications except for cardiogenic shock and heart transplantation. The heart transplant group had the highest percentage of neurologic complications (14.9%). ECMO admissions exhibited a persistent increase at hospitals in the South, West, and Midwest (P<0.001, P<0.001, and P=0.002, respectively) with the South having the largest fractional growth. While ECMO was utilized more frequently at medium and large hospitals (P<0.001), a smaller fraction of cases was performed at large centers in more recent years.
Conclusion:
The past decade has seen an exponential growth of ECMO at medium and large hospitals in multiple regions of the US, paralleling a significant improvement in outcomes across cardiac and respiratory indications. This is despite a higher risk profile of patients being placed on ECMO in more recent times. Developments in ECMO technology and care of critically ill patients are likely responsible for greater survival and longer lengths of stay. The rapid growth of this technology and costs of care warrant further standardization in order to achieve optimal outcomes in the present era of value-based healthcare delivery.
