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Immohr MB, Hettlich VH, Kindgen-Milles D, Brandenburger T, Feldt T, Aubin H, Tudorache I, Akhyari P, Lichtenberg A, Dalyanoglu H, Boeken U. Changes in Therapy and Outcome of Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19. Thorac Cardiovasc Surg 2024; 72:311-319. [PMID: 37146634 DOI: 10.1055/s-0043-57032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation (vv-ECMO) is related with poor outcome, especially in Germany. We aimed to analyze whether changes in vv-ECMO therapy during the pandemic were observed and lead to changes in the outcome of vv-ECMO patients. METHODS All patients undergoing vv-ECMO support for COVID-19 between 2020 and 2021 in a single center (n = 75) were retrospectively analyzed. Weaning from vv-ECMO and in-hospital mortality were defined as primary and peri-interventional adverse events as secondary endpoints of the study. RESULTS During the study period, four infective waves were observed in Germany. Patients were assigned correspondingly to four study groups: ECMO implantation between March 2020 and September 2020: first wave (n = 11); October 2020 to February 2021: second wave (n = 23); March 2021 to July 2021: third wave (n = 25); and August 2021 to December 2021: fourth wave (n = 20). Preferred cannulation technique changed within the second wave from femoro-femoral to femoro-jugular access (p < 0.01) and awake ECMO was implemented. Mean ECMO run time increased by more than 300% from 10.9 ± 9.6 (first wave) to 44.9 ± 47.0 days (fourth wave). Weaning of patients was achieved in less than 20% in the first wave but increased to approximately 40% since the second one. Furthermore, we observed a continuous numerically decrease of in-hospital mortality from 81.8 to 57.9% (p = 0.61). CONCLUSION Preference for femoro-jugular cannulation and awake ECMO combined with preexisting expertise and patient selection are considered to be associated with increased duration of ECMO support and numerically improved ECMO weaning and in-hospital mortality.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | | | - Detlef Kindgen-Milles
- Department of Anesthesiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Timo Brandenburger
- Department of Anesthesiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Torsten Feldt
- Department of Hepatology and Infectiology, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
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Rizvi SSA, Nagle M, Roberts B, McDermott L, Miller K, Pasquarello C, Braddock A, Choi C, Yang Q, Hirose H. Cardiac Extracorporeal Membrane Oxygenation in Community Cardiac Surgery Program: Are the Results Comparable? Cureus 2024; 16:e58947. [PMID: 38800214 PMCID: PMC11126332 DOI: 10.7759/cureus.58947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) outcomes in small centers are commonly considered less favorable than in large-volume centers. New ECMO protocols and procedures were established in our regional community hospital system as part of a cardiogenic shock initiative. This retrospective study aims to evaluate the outcomes of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in a community hospital system with cardiac surgery capability and assess whether protocol optimization and cannulation standards result in comparable outcomes to larger centers whether the outcomes of this new ECMO program at the community hospital setting were comparable to the United States averages. METHODS Our regional system comprises five hospitals with 1500 beds covering southwestern New Jersey, with only one of these hospitals having cardiac surgery and ECMO capability. In May 2021, the new ECMO program was initiated. Patients were screened by a multidisciplinary call, cannulated by our ECMO team, and subsequently treated by the designated team. We reviewed our cardiac ECMO outcomes over two years, from May 2021 to April 2023, in patients who required ECMO due to cardiogenic shock or as a part of extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS A total of 60 patients underwent cardiac ECMO, and all were VA ECMO, including 18 (30%) patients who required ECPR for cardiac arrest. The overall survival rate for our cardiac ECMO program turned out to be 48% (29/60), with 50% (22/42) in VA ECMO excluding ECPR and 39% (7/18) in the ECPR group. The hospital survival rate for the VA ECMO and ECPR groups was 36% (15/42) and 28% (5/18), respectively. The ELSO-reported national average for hospital survival is 48% for VA ECMO and 30% for ECPR. Considering these benchmarks, the hospital survival rate of our program did not significantly lag behind the national average. CONCLUSIONS With protocol, cannulation standards, and ECMO management optimized, the VA ECMO results of a community hospital system with cardiac surgery capability were not inferior to those of larger centers.
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Affiliation(s)
| | - Matthew Nagle
- Surgery, Virtua Our Lady of Lourdes Hospital, Camden, USA
| | - Brian Roberts
- Surgery, Virtua Our Lady of Lourdes Hospital, Camden, USA
| | | | | | | | | | - Chun Choi
- Surgery, Virtua Our Lady of Lourdes Hospital, Camden, USA
| | - Qiong Yang
- Surgery, Virtua Our Lady of Lourdes Hospital, Camden, USA
- Cardiovascular and Thoracic Surgery, Cleveland Clinic, Cleveland, USA
| | - Hitoshi Hirose
- Surgery, Virtua Our Lady of Lourdes Hospital, Camden, USA
- Cardiovascular and Thoracic Surgery, Cleveland Clinic, Cleveland, USA
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Sakowitz S, Bakhtiyar SS, Mallick S, Khoraminejad B, Olmedo M, Croman M, Benharash P, Lee H. Decreasing rates of colectomy for benign neoplasms: A nationwide analysis. PLoS One 2023; 18:e0293389. [PMID: 37878628 PMCID: PMC10599571 DOI: 10.1371/journal.pone.0293389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms. METHODS All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups. RESULTS Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001). CONCLUSIONS The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Manuel Olmedo
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Millicent Croman
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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Pozzi M, Payet C, Polazzi S, L'Hospital A, Obadia JF, Dueclos A. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database. Int J Cardiol 2023; 380:14-19. [PMID: 36940821 DOI: 10.1016/j.ijcard.2023.03.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/21/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND We aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). METHODS We conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. RESULTS During the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94-1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82-1.23; p = 0.995). CONCLUSIONS In this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.
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Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.
| | - Cécile Payet
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France; Health Data Department, Lyon University Hospital, Lyon, France
| | - Stephanie Polazzi
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France; Health Data Department, Lyon University Hospital, Lyon, France
| | | | - Jean Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Antoine Dueclos
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France; Health Data Department, Lyon University Hospital, Lyon, France
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Verma A, Hadaya J, Williamson C, Kronen E, Sakowitz S, Bakhtiyar SS, Chervu N, Benharash P. A contemporary analysis of the volume-outcome relationship for extracorporeal membrane oxygenation in the United States. Surgery 2023; 173:1405-1410. [PMID: 36914511 DOI: 10.1016/j.surg.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/02/2023] [Accepted: 02/06/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND A paradoxical increase in mortality following extracorporeal membrane oxygenation at high-volume centers has previously been demonstrated. We examined the association between annual hospital volume and outcomes within a contemporary, national cohort of extracorporeal membrane oxygenation patients. METHODS All adults requiring extracorporeal membrane oxygenation for postcardiotomy syndrome, cardiogenic shock, respiratory failure, or mixed cardiopulmonary failure were identified in the 2016 to 2019 Nationwide Readmissions Database. Patients undergoing heart and/or lung transplantation were excluded. A multivariable logistic regression with hospital extracorporeal membrane oxygenation volume parametrized as restricted cubic splines was developed to characterize the risk-adjusted association between volume and mortality. The volume corresponding to the maximum of the spline (43 cases/year) was used to categorize centers as low- or high-volume. RESULTS An estimated 26,377 patients met the study criteria, and 48.7% were managed at high-volume hospitals. Patients at low- and high-volume hospitals had similar age, sex, and rates of elective admission. Notably, patients at high-volume hospitals less frequently required extracorporeal membrane oxygenation for postcardiotomy syndrome but more commonly for respiratory failure. After risk adjustment, high-volume hospital status was associated with reduced odds of in-hospital mortality, relative to low-volume hospitals (adjusted odds ratio 0.81, 95% confidence interval 0.78-0.97). Interestingly, patients at high-volume hospitals faced a 5.2-day increment in length of stay (95% confidence interval 3.8-6.5) and $23,500 in attributable costs (95% confidence interval 8,300-38,700). CONCLUSION The present study found that greater extracorporeal membrane oxygenation volume was associated with decreased mortality but higher resource use. Our findings may help inform policies regarding access to and centralization of extracorporeal membrane oxygenation care in the United States.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA. https://twitter.com/arjun_ver
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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6
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Richardson S, Verma A, Sanaiha Y, Chervu NL, Pan C, Williamson CG, Benharash P. Racial disparities in outcomes for extracorporeal membrane oxygenation in the United States. Am J Surg 2023; 225:113-117. [PMID: 36180299 DOI: 10.1016/j.amjsurg.2022.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/09/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Racial disparities in extracorporeal membrane oxygenation (ECMO) outcomes in patients with a broad set of indications are not well documented. METHODS Adults requiring ECMO were identified in the 2016-2019 National Inpatient Sample. Patient and hospital characteristics, including mortality, clinical outcomes, and resource utilization were analyzed using multivariable regressions. RESULTS Of 43,190 adult ECMO patients, 67.8% were classified as White, 18.1% Black, and 10.4% Hispanic. Although mortality for Whites declined from 47.5 to 41.0% (P = 0.002), it remained steady for others. Compared to White, Asian/Pacific Islander (PI) race was linked to increased odds of mortalty (AOR = 1.4, 95% CI = 1.1-2.0). Black race was associated with increased odds of acute kidney injury (AOR = 1.4, 95%-CI: 1.2-1.7), while Hispanic race was linked to neurologic complications (AOR 21.6; 95% CI 1.2-2.3). Black and Hispanic race were also associated with increased incremental costs. CONCLUSIONS Race-based disparities in ECMO outcomes persist in the United States. Further work should aim to understand and mitigate the underlying reasons for such findings.
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Affiliation(s)
- Shannon Richardson
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Chelsea Pan
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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7
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Ho HT, Lin CP, Wu VCC, Hung KC, Cheng YT, Chang SH, Chu PH, Huang JL, Huang YT, Chen SW. Effect of Hospital Volume on Outcome of Extracorporeal Membrane Oxygenation Support - Nationwide Population-Based Cohort Study in Taiwan. Circ J 2022; 87:600-607. [PMID: 36223943 DOI: 10.1253/circj.cj-22-0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In modern critical care, extracorporeal membrane oxygenation (ECMO) is crucial in the management of severe respiratory and cardiac failure. Nationwide studies of the relationship between hospital volume and outcomes of ECMO use are unavailable.Methods and Results: Using Taiwan's National Health Insurance Research Database, we identified 11,734 adult patients who received ECMO support in 101 hospitals between January 1, 2001, and December 31, 2017. Outcomes included in-hospital mortality, 1-year mortality, and ECMO-related complications. Cox proportional hazards model, locally estimated scatterplot smoothing, and restricted cubic spline regression were used to analyze the volume-outcome relationship. The overall in-hospital mortality rate was 65.5%, and the 1-year mortality rate was 70.6% in this database. The 101 hospitals were divided into 4 groups based on annual volume. The in-hospital and 1-year mortality rates were significantly lower in the high-volume group (annual volume >40) than in the low-volume group (annual volume <10). CONCLUSIONS For critical care, high-volume hospitals have superior short-term and mid-term outcomes. To make the medical system equitable and reasonable, establishing a rapid and efficient nationwide referral system should be considered.
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Affiliation(s)
- Heng-Tsan Ho
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Chia-Pin Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Kuo-Chun Hung
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Shang-Hung Chang
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University.,Center of Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Jhen-Ling Huang
- Center of Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Yu-Tung Huang
- Center of Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University.,Center of Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University
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8
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Mazzeffi MA, Krajewski M, Shelton K, Dalia A, Najam F, Gutsche J, Nurok M. Measuring and Reporting Quality for Adult Extracorporeal Membrane Oxygenation Centers: Is It Possible and Is It Time? Anesth Analg 2022; 135:719-724. [DOI: 10.1213/ane.0000000000006080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Jäckel M, Kaier K, Rilinger J, Bemtgen X, Zotzmann V, Zehender M, von Zur Mühlen C, Stachon P, Bode C, Wengenmayer T, Staudacher DL. Annual hospital procedural volume and outcome in extracorporeal membrane oxygenation for respiratory failure. Artif Organs 2022; 46:2469-2477. [PMID: 35841283 DOI: 10.1111/aor.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The hospital mortality of patients suffering from pulmonary failure requiring venovenous extracorporeal membrane oxygenation (V-V ECMO) or extracorporeal carbon dioxide removal (ECCO2 R) is high. It is unclear whether outcome correlates with a hospital's annual procedural volume. METHODS Data on all V-V ECMO and ECCO2 R cases treated from 2007 to 2019 was retrieved from the German Institute for Medical Documentation and Information. Comorbidities and outcomes were assessed by DRG, OPS, and ICD codes. The study population was divided into 5 groups depending on annual hospital V-V ECMO and ECCO2 R volumes (<10 cases; 10-19 cases; 20-29 cases; 30-49 cases; ≥50 cases). Primary outcome was hospital mortality. RESULTS A total of 25,096 V-V ECMO and 3,607 ECCO2 R cases were analyzed. V-V ECMO hospitals increased from 89 in 2007 to 214 in 2019. Hospitals handling <10 cases annually increased especially (64 in 2007 to 149 in 2019). V-V ECMO cases rose from 807 in 2007 to 2,597 in 2019. Over 50% were treated in hospitals handling ≥30 cases annually. Hospital mortality was independent of the annual hospital procedural volume (55.3%; 61.3%; 59.8%; 60.2%; 56.3%, respectively, p=0.287). We detected no differences when comparing hospitals handling <30 cases to those with ≥30 annually (p=0.659). The numbers of ECCO2 R hospitals and cases has dropped since 2011 (287 in 2007 to 48 in 2019). No correlation between annual hospital procedural volume and hospital mortality was identified (p=0.914). CONCLUSION The number of hospitals treating patients requiring V-V ECMO and V-V ECMO cases rose from 2007 to 2019, while ECCO2 R hospitals and their case numbers decreased. We detected no correlation between annual hospital V-V ECMO or ECCO2 R volume and hospital mortality.
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Affiliation(s)
- Markus Jäckel
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany.,Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonathan Rilinger
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany.,Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Xavier Bemtgen
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Viviane Zotzmann
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Manfred Zehender
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany.,Center of Big Data Analysis in Cardiology (CeBAC), Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care (IMIT), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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10
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Ng PY, Ip A, Fang S, Lin JCR, Ling L, Chan KM, Leung KHA, Chan KCK, So D, Shum HP, Ngai CW, Chan WM, Sin WC. Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study. J Thorac Dis 2022; 14:1802-1814. [PMID: 35813733 PMCID: PMC9264048 DOI: 10.21037/jtd-21-1512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/10/2022] [Indexed: 11/06/2022]
Abstract
Background The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. Methods All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. “High-volume” centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while “low-volume” centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. Results A total of 911 patients received extracorporeal membrane oxygenation—297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61–1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54–1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). Conclusions In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.
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Affiliation(s)
- Pauline Yeung Ng
- Department of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - April Ip
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Shu Fang
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | | | - Lowell Ling
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Kai Man Chan
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | | | | | - Dominic So
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China
| | - Hoi Ping Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Chun Wai Ngai
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Wai Ming Chan
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China
| | - Wai Ching Sin
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, China.,Department of Anesthesiology, The University of Hong Kong, Hong Kong, China
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11
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Maine RG, Strassle P, Orleans B, Bryant MK, Raff L, Reid T, Charles A. Inpatient Mortality Among Patients With Acute Respiratory Distress Syndrome at ECMO and Non-ECMO Centers in the United States. Am Surg 2021:31348211063530. [PMID: 34957856 DOI: 10.1177/00031348211063530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A 2009 randomized control trial found patients with severe acute respiratory distress syndrome (ARDS) who transferred to an extra-corporeal membrane oxygenation therapy (ECMO) center had better survival, even if they did not receive ECMO. This study aimed to use a national US database to determine if care at ECMO centers offer a survival advantage in patients with ARDS with mechanical ventilation only. METHODS Hospitalizations of patients 18-64 years old who had ARDS and mechanical ventilation in the 2010-2016 Health care Cost and Utilization Project National Readmission Database were included. ECMO centers performed at least 1 veno-venous ECMO hospitalization annually; or >5, >20, and >50 on sensitivity analysis. Multivariable logistic regression compared inpatient mortality, after adjusting for timing of hospitalization, patient demographics, comorbidities, and hospital characteristics. RESULTS Of the 1 224 447 ARDS hospitalizations and mechanical ventilation, 41% were at ECMO centers. ECMO centers were more likely to be larger, private, non-profit, teaching hospitals. ARDS at admission was more common at non-ECMO centers (31% vs 23%, P < .0001); however, other patient demographics and comorbidities did not differ. After adjustment, no difference in inpatient mortality was seen between ECMO and non-ECMO centers (OR 0.99, 95% CI: 0.97, 1.02). This relationship did not change in sensitivity analyses. DISCUSSION Adult patients with ARDS requiring mechanical ventilation may not have improved outcomes if treated at an ECMO center and suggest that early transfer of all ARDS patients to ECMO centers may not be warranted. Further evaluation of ECMO center volume and illness severity is needed.
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Affiliation(s)
- Rebecca G Maine
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula Strassle
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brian Orleans
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Biostatistics, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary K Bryant
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren Raff
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Trista Reid
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, 2332University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Oude Lansink-Hartgring A, van Minnen O, Vermeulen KM, van den Bergh WM. Hospital Costs of Extracorporeal Membrane Oxygenation in Adults: A Systematic Review. PHARMACOECONOMICS - OPEN 2021; 5:613-623. [PMID: 34060061 PMCID: PMC8166371 DOI: 10.1007/s41669-021-00272-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 05/05/2023]
Abstract
BACKGROUND Costs associated with extracorporeal membrane oxygenation (ECMO) are an important factor in establishing cost effectiveness. In this systematic review, we aimed to determine the total hospital costs of ECMO for adults. METHODS The literature was retrieved from the PubMed/MEDLINE, EMBASE, and Web of Science databases from inception to 4 March 2020 using the search terms 'extracorporeal membrane oxygenation' combined with 'costs'; similar terms or phrases were then added to the search, i.e. 'Extracorporeal Life Support' or 'ECMO' or 'ECLS' combined with 'costs'. We included any type of study (e.g. randomized trial or observational cohort) evaluating hospital costs of ECMO in adults (age ≥18 years). RESULTS A total of 1768 unique articles were retrieved during our search. We assessed 74 full-text articles for eligibility, of which 14 articles were selected for inclusion in this review; six papers were from the US, five were from Europe, and one each from Japan, Australia, and Taiwan. The sample sizes ranged from 16 to 18,684 patients. One paper exclusively used prospective cost data collection, while all other papers used retrospective data collection. Five papers reported charges instead of costs. There was large variation in hospital costs, ranging from US$22,305 to US$334,608 (2019 values), largely depending on the indication for ECMO support and location. The highest reported costs were for lung transplant recipients who were receiving ECMO support in the US, and the lowest reported costs were for extracorporeal cardiopulmonary resuscitation patients presenting with non-shockable rhythm in Japan. The additional costs of ECMO patients compared with non-ECMO patients varied between US$2518 and US$200,658. Personnel costs varied between 11 and 52% of the total amount. CONCLUSIONS ECMO therapy is an advanced and expensive technology, although reported costs differ considerably depending on ECMO indication and whether charges or costs are measured. Combined with the ongoing gathering of outcome data, cost effectiveness per ECMO indication could be determined in the future.
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Affiliation(s)
- Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands.
| | - Olivier van Minnen
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands
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13
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Swol J, Brodie D, Willers A, Zakhary B, Belezzo J, Shinar Z, Weingart SD, Haft JW, Lorusso R, Peek GJ. Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers. Artif Organs 2021; 46:40-49. [PMID: 34738639 PMCID: PMC9298045 DOI: 10.1111/aor.14095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/12/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance. HYPOTHESIS Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS. RESULTS The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care. CONCLUSION Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.
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Affiliation(s)
- Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York, USA
| | - Anne Willers
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph Belezzo
- Emergency Room Sharp Memorial Hospital, San Diego, California, USA
| | - Zachary Shinar
- Emergency Room Sharp Memorial Hospital, San Diego, California, USA
| | - Scott D Weingart
- Department of Emergency Medicine, Division of Emergency Critical Care, Resuscitation and Acute Critical Care Unit, Stony Brook Hospital, Stony Brook, New York, USA
| | - Jonathan W Haft
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Giles J Peek
- UF Health Shands Children's Hospital, UF Health Congenital Heart Center, Gainesville, Florida, USA
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14
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Verma A, Hadaya J, Tran Z, Dobaria V, Madrigal J, Xia Y, Sanaiha Y, Mendelsohn AH, Benharash P. Incidence and Outcomes of Laryngeal Complications Following Adult Cardiac Surgery: A National Analysis. Dysphagia 2021; 37:1142-1150. [PMID: 34676486 PMCID: PMC9463246 DOI: 10.1007/s00455-021-10377-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
Laryngeal complications (LCs) following cardiac operations contribute to increased morbidity and resource utilization. Using a nationally representative cohort of cardiac surgical patients, we characterized the incidence of LC as well as its associated clinical and financial outcomes. All adults undergoing coronary artery bypass grafting and/or valvular operations were identified using the 2010–2017 Nationwide Readmissions Database. International Classification of Diseases 9th and 10th Revision diagnosis codes were used to identify LC. Trends were analyzed using a rank-based, non-parametric test (nptrend). Multivariable linear and logistic regressions were used to evaluate risk factors for LC, and its impact on mortality, complications, resource use and 30-day non-elective readmissions. Of an estimated 2,319,628 patients, 1.7% were diagnosed with perioperative LC, with rising incidence from 1.5% in 2010 to 1.8% in 2017 (nptrend < 0.001). After adjustment, female sex [adjusted odds ratio 1.08, 95% confidence interval (CI) 1.04–1.12], advancing age, and multi-valve procedures (1.51, 95% CI 1.36–1.67, reference: isolated CABG) were associated with increased odds of LC. Despite no risk-adjusted effect on mortality, LC was associated with increased odds of pneumonia (2.88, 95% CI 2.72–3.04), tracheostomy (4.84, 95% CI 4.44–5.26), and readmission (1.32, 95% CI 1.26–1.39). In addition, LC was associated with a 7.7-day increment (95% CI 7.4–8.0) in hospitalization duration and $24,200 (95% CI 23,000–25,400) in attributable costs. The present study found LC to be associated with increased perioperative sequelae and resource utilization. The development and application of active screening protocols for post-surgical LC are warranted to increase early detection and reduce associated morbidity.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Yu Xia
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Abie H. Mendelsohn
- Division of Laryngology, Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
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15
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Knudson KA, Funk M, Redeker NS, Andrews LK, Whittemore R, Mangi AA, Sadler LS. An unbelievable ordeal: The experiences of adult survivors treated with extracorporeal membrane oxygenation. Aust Crit Care 2021; 35:391-401. [PMID: 34474961 DOI: 10.1016/j.aucc.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue treatment option for adult patients with severe cardiac dysfunction or respiratory failure. While short-term patient outcomes, such as in-hospital mortality and complications, have been widely described, little is known about the illness or recovery experience from the perspectives of survivors. Subjective reports of health are important indicators of the full, long-term impact of critical illness and treatment with ECMO on survivors' lives. OBJECTIVE The objective of this study was to describe the experiences and needs of adults treated with ECMO, from onset of illness symptoms through the process of survivorship. METHODS This study was guided by the qualitative method of interpretive description. We conducted in-depth, semistructured interviews with 16 adult survivors of ECMO who were treated at two participating regional ECMO centres in the northeast United States. Additional data were collected from demographic questionnaires, field notes, memos, and medical record review. Development of interview guides and data analysis were informed by the Family Management Style Framework. Qualitative data were analysed using thematic analysis techniques. RESULTS The sample (n = 16) included 75% male participants; ages ranged from 23 to 65 years. Duration from hospital discharge to interviews ranged from 11 to 90 (M = 54; standard deviation = 28) months. Survivors progressed through three stages: Trauma and Vulnerability, Resiliency and Recovery, and Survivorship. Participants described short- and long-term impacts of the ECMO experience: all experienced physical challenges, two-thirds had at least one psychological or cognitive difficulty, and 25% were unable to return to work. All were deeply influenced by their own specific contexts, family support, and interactions with healthcare providers. CONCLUSIONS The ECMO experience is traumatic and complex. Recovery requires considerable time, perseverance, and support. Long-term sequelae include impairments in cognitive, mental, emotional, physical, and social health. Survivors could likely benefit from specialised posthospital health services that include integrated, comprehensive follow-up care.
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Affiliation(s)
- Krista A Knudson
- Institute for Translational Medicine, University of Chicago, 5841 S. Maryland Ave, W511, MC7100, Chicago, IL, 60637, United States; Rush University, 600 S. Paulina St, Chicago, IL, 60612, United States; Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Marjorie Funk
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Nancy S Redeker
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Laura K Andrews
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Robin Whittemore
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
| | - Abeel A Mangi
- Yale School of Medicine, 300 Cedar Street, New Haven, CT, 06511, United States; MedStar Heart and Vascular Institute, Suite 6D-15, 110 Irving Street NW, Washington, DC, 20010, United States.
| | - Lois S Sadler
- Yale School of Nursing, P.O. Box 27399, West Haven, CT, 06516-7399, United States.
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16
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Gandjian M, Williamson C, Xia Y, Maturana C, Chervu N, Verma A, Tran Z, Sanaiha Y, Benharash P. Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States. J Intensive Care Med 2021; 37:535-542. [PMID: 33783248 DOI: 10.1177/08850666211007062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort. MATERIALS AND METHODS The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals. RESULTS Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all P < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (β=+4.5 days) and hospitalization costs (β=+$32,880, all P < .01). CONCLUSIONS We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.
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Affiliation(s)
- Matthew Gandjian
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Catherine Williamson
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Yu Xia
- Division of Cardiac Surgery, 155697University of California, Los Angeles, CA, USA
| | - Carlos Maturana
- David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Arjun Verma
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Zachary Tran
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiac Surgery, 155697University of California, Los Angeles, CA, USA
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17
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Cavallaro G, Di Nardo M, Hoskote A, Tibboel D. Editorial: Neonatal ECMO in 2019: Where Are We Now? Where Next? Front Pediatr 2021; 9:796670. [PMID: 35059363 PMCID: PMC8764394 DOI: 10.3389/fped.2021.796670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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18
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Joyce CJ, Cook DA, Walsham J, Krishnan A, Lo W, Samaan J, Semark AJ, Pearson DC, Stroebel A, Provenzano S, McKeague R, Winearls JR. Low volume ECMO results study. CRIT CARE RESUSC 2020; 22:327-334. [PMID: 38046879 PMCID: PMC10692512 DOI: 10.51893/2020.4.oa5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To report extracorporeal membrane oxygenation (ECMO) experience at Princess Alexandra and Gold Coast University hospitals and compare mortality with benchmarks. Design: Case series of patients treated with ECMO. Setting: Two adult tertiary Australian intensive care units with low ECMO case volumes. Participants: Patients treated with ECMO, aged > 18 years. Main outcome measures: Patients were categorised into respiratory, cardiac, and extracorporeal cardiopulmonary resuscitation (eCPR) groups. Observed mortality was compared with mortality predicted using individual risk of death predictions from the Survival after Veno-arterial ECMO (SAVE) and Respiratory ECMO Survival Prediction (RESP) scores; mortality predicted when mortality predictions of the SAVE score were modified to be consistent with the validation cohort in the SAVE study (Alfred Hospital); and with mortality predicted when eCPR patients were all assigned a risk of death equal to Extracorporeal Life Support Organization (ELSO) Registry eCPR mortality. Results: Over 10 years, 86 patients were treated with ECMO. Eight deaths were observed in 49 patients with respiratory failure, below the 95% CI (13-24) for the deaths predicted by the RESP score (P < 0.001). Nine deaths were observed in 27 patients with cardiac failure, below the 95% CI (14-23) for the deaths predicted by the SAVE score (P < 0.001), but within the 95% CI (9-17) for the deaths predicted by the SAVE score modified to be consistent with the Alfred Hospital cohort (P > 0.05). Seven deaths were observed in the ten eCPR patients, within the 95% CI (4-10) predicted using the risk of death derived from the ELSO Registry. Conclusions: Mortality in two low volume ECMO centres was not inferior to benchmarks.
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Affiliation(s)
- Christopher J. Joyce
- Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - David A. Cook
- Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - James Walsham
- Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Anand Krishnan
- Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Wingchi Lo
- University of Queensland, Brisbane, QLD, Australia
- Cardiothoracic Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - John Samaan
- University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Andrew J. Semark
- University of Queensland, Brisbane, QLD, Australia
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - David C. Pearson
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Andrie Stroebel
- Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Sylvio Provenzano
- Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Ronan McKeague
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - James R. Winearls
- University of Queensland, Brisbane, QLD, Australia
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Intensive Care, St Andrew’s War Hospital, Brisbane, QLD, Australia
- Monash University, Melbourne, VIC, Australia
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19
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Minc SD, Hayanga HK, Thibault D, Woods K, Marone L, Badhwar V, Hayanga JWA. Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States. Semin Thorac Cardiovasc Surg 2020; 33:397-406. [PMID: 32977018 DOI: 10.1053/j.semtcvs.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022]
Abstract
Patients on extracorporeal membrane oxygenation (ECMO) who suffer vascular complications frequently accrue additional procedures and costs. We sought to evaluate the effect of ECMO-related vascular complications on hospital charges and in-hospital mortality. Adult discharges involving ECMO from 2004 to 2013 in the National Inpatient Sample were examined. There were 12,636 patients in the cohort. Vascular complications, focusing on arterial complications were identified using ICD-9-CM diagnosis and procedure codes. A multivariable survey linear regression model using median hospital charges was used to model the effect of vascular complications on charges. We used multivariable survey logistic regression to evaluate the effect of vascular complications on in-hospital mortality. Of the 12,636 patients examined, 6467 (51.2%) had ECMO-related vascular complications. Median charges in patients with vascular complications were $ 477,363 (interquartile range: 258,660-875,823) and were $ 282,298 (interquartile range: 130,030-578,027) without vascular complications. On multivariable analysis, patients with vascular complications had 24% higher median charges than patients without vascular complications (Ratio: 1.24; 95% confidence interval [CI]: 1.16-1.33; P < 0.0001) and 34% higher odds of experiencing in-hospital mortality than patients without vascular complications (adjusted odds ratio: 1.34; 95% CI:1.08-1.66; P = 0.009). Vascular complications occur in over half of ECMO patients and are associated with an increased risk of high hospital charges and in-hospital mortality. These findings support the need for identification and modification of risk factors for ECMO-related vascular complications. Furthermore, the standardization of protocols using evidence-based measures to mitigate vascular complications may improve overall ECMO outcomes.
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Affiliation(s)
- Samantha D Minc
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.
| | - Heather K Hayanga
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Kaitlin Woods
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Luke Marone
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Vinay Badhwar
- Division of Cardiac Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - J W Awori Hayanga
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Sanaiha Y, Khoubian JJ, Williamson CG, Aguayo E, Dobaria V, Srivastava N, Benharash P. Trends in Mortality and Costs of Pediatric Extracorporeal Life Support. Pediatrics 2020; 146:peds.2019-3564. [PMID: 32801159 DOI: 10.1542/peds.2019-3564] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. METHODS We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. RESULTS Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 (P < .001). Overall mortality decreased from 50.3% to 34.6% (P < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; P = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; P = .94). CONCLUSIONS Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Jonathan J Khoubian
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and.,Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
| | - Neeraj Srivastava
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratory, Division of Cardiac Surgery, and
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Becher PM, Goßling A, Schrage B, Twerenbold R, Fluschnik N, Seiffert M, Bernhardt AM, Reichenspurner H, Blankenberg S, Westermann D. Procedural volume and outcomes in patients undergoing VA-ECMO support. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:291. [PMID: 32503646 PMCID: PMC7275456 DOI: 10.1186/s13054-020-03016-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/25/2020] [Indexed: 01/11/2023]
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with critical cardiopulmonary failure. To investigate the association between hospital VA-ECMO procedure volume and outcomes in a large, nationwide registry. Methods By using administrative data from the German Federal Health Monitoring System, we analyzed all VA-ECMO procedures performed in Germany from 2013 to 2016 regarding the association of procedural volumes with outcomes and complications. Results During the study period, 10,207 VA-ECMO procedures were performed; mean age was 61 years, 43.4% had prior CPR, and 71.2% were male patients. Acute coronary syndrome was the primary diagnosis for VA-ECMO implantation (n = 6202, 60.8%). The majority of implantations (n = 5421) were performed at hospitals in the lowest volume category (≤ 50 implantations per year). There was a significant association between annualized volume of VA-ECMO procedures and 30-day in-hospital mortality for centers with lower vs. higher volume per year. Multivariable logistic regression showed an increased 30-day in-hospital mortality at hospitals with the lowest volume category (adjusted odds ratio 1.13, 95% confidence interval [CI] 1.01–1.27, p = 0.034). Similarly, higher likelihood for complications was observed at hospitals with lower vs. higher annual VA-ECMO volume (adjusted odds ratio 1.46, 95% CI 1.29–1.66, p = 0.001). Conclusions In this analysis of more than 10,000 VA-ECMO procedures for cardiogenic shock, the majority of implantations were performed at hospitals with the lowest annual volume. Thirty-day in-hospital mortality and likelihood for complications were higher at hospitals with the lowest annual VA-ECMO volume.
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Affiliation(s)
- Peter Moritz Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Fluschnik
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
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Impact of center volume on outcomes of surgical repair for type A acute aortic dissections. Surgery 2020; 168:185-192. [PMID: 32507629 DOI: 10.1016/j.surg.2020.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States. METHODS Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality. RESULTS An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively). CONCLUSION The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.
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Aguayo E, Kwon OJ, Dobaria V, Sanaiha Y, Hadaya J, Sareh S, Huynh A, Benharash P. Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support. Surgery 2020; 168:193-197. [PMID: 32507298 DOI: 10.1016/j.surg.2020.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.
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Affiliation(s)
- Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Oh Jin Kwon
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA; Department of Surgery, Harbor University of California-Los Angeles, Torrance, CA
| | - Ashley Huynh
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA; Division of Cardiac Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA.
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Hayanga JA, Aboagye J, Bush E, Canner J, Hayanga HK, Klingbeil A, McCarthy P, Fugett J, Abbas G, Badhwar V. Contemporary analysis of charges and mortality in the use of extracorporeal membrane oxygenation: A cautionary tale. ACTA ACUST UNITED AC 2020; 1:61-70. [PMID: 36003198 PMCID: PMC9390409 DOI: 10.1016/j.xjon.2020.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
Objective The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially. Costs and outcomes, however, vary considerably by indication. We sought to elucidate and quantify these differences. Methods Adult patients supported on ECMO between 2008 and 2016 were analyzed using the Nationwide Inpatient Sample. We divided the study period into an early (2008-2013) and late period (2013-2016). The primary outcome was hospital charges, and the secondary outcomes were mortality, length of stay (LOS), and duration of ECMO support. These were stratified by the 5 most common indications: postcardiotomy shock (PCS), cardiogenic shock (CS), severe acute respiratory failure (SARF), heart (HT), and lung transplantation (LT). Both patient and hospital characteristics were assessed. Charges were adjusted for inflation and analyzed using a generalized linear model with gamma distribution. Pairwise comparison with Bonferroni correction was used to evaluate the cost and multivariate logistic regression to assess the risk of mortality. Results Data pertaining to 15,829 adult patients were evaluated. Mean age of the entire cohort was 52.8 years, 8895 (56%) were white, and 10,278 (65%) were male. PCS was the predominant indication for ECMO (39%), followed by CS (37%). SARF accounted for 15% and HT and LT accounted for 3.9% and 5.4%, respectively. Mean LOS and duration of ECMO support were 23.4 days and 5.3 days respectively. Mean hospital charges per hospitalization for the entire cohort were USD 731,914 per patient. Charges per patient pertaining to hospitalizations in which ECMO was used in transplant patients were the highest: USD 1,448,931 and USD 1,574,378 (P = .99) for HT and LT, respectively. Charges were lower for the other indications: PCS USD 798,909, CS USD 655,099, and SARF USD 824,852. Overall mortality for the entire cohort was 55%. PCS and CS (53% vs 58%, P = .34) had similar survival, whereas SARF was 45%, LT was 39% and HT 32%. There were no differences in survival in these latter indications (SARF, LT and HT). The cumulative charges (proportion × hospital charges) reveal that PCS and CS (39% and 37%) account for both the majority of charges as well as the greatest mortality. Conversely, SARF and transplantation accounted for the smaller proportion of charges and the lower mortality. Patients undergoing HT had the longest LOS (51.7 days) and duration on ECMO (15.9 days), followed by LT (35.4 and 8.8 days respectively), and patients with SARF (28.6 and 6.6 respectively). LOS and duration of ECMO for those with PCS were 18.7 days and 4.8 days, respectively. Those on ECMO for CS were hospitalized for 19.7 days and spent an average of 3.8 days on ECMO. Mortality decreased, whereas charges increased in the late era. Conclusions The use of ECMO is associated with high hospital charges and a wide variation in outcomes. Hospitalizations, in which ECMO is used to support patients with cardiogenic shock (PCS and CS), are individually associated with lower LOS and charges. Cumulatively, however, these account for greater charges and greater mortality. Although mortality may be decreasing, overall charges are increasing with time. These variations may influence reimbursement decisions in value-based healthcare.
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Muguruma K, Kunisawa S, Fushimi K, Imanaka Y. Epidemiology and volume-outcome relationship of extracorporeal membrane oxygenation for respiratory failure in Japan: A retrospective observational study using a national administrative database. Acute Med Surg 2020; 7:e486. [PMID: 32076555 PMCID: PMC7013206 DOI: 10.1002/ams2.486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 12/25/2019] [Accepted: 01/05/2020] [Indexed: 01/19/2023] Open
Abstract
Aim To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications. Methods Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation. Results Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- (<8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively. Conclusions The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan.
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Affiliation(s)
- Kohei Muguruma
- Department of Healthcare Economics and Quality Management Graduate School of Medicine Kyoto University Kyoto City Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management Graduate School of Medicine Kyoto University Kyoto City Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics Graduate School of Medicine Tokyo Medical and Dental University Tokyo Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management Graduate School of Medicine Kyoto University Kyoto City Japan
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Ostermann M, Vincent JL. How much centralization of critical care services in the era of telemedicine? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:423. [PMID: 31878965 PMCID: PMC6933622 DOI: 10.1186/s13054-019-2705-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/16/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Marie B, Anselmi A, Flecher E, Nesseler N, Launey Y, Tadie JM, Verhoye JP. Impact of age on outcomes of patients assisted by veno-arterial or veno-venous extra-corporeal membrane oxygenation: 403 patients between 2005 and 2015. Perfusion 2019; 35:297-305. [PMID: 31554475 DOI: 10.1177/0267659119874258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To assess the impact of age on early outcomes and mortality in veno-arterial extra-corporeal membrane oxygenation and veno-venous extra-corporeal membrane oxygenation recipients, and to investigate predictors of mortality. METHODS Single-center retrospective study on prospectively collected data including all patients treated by veno-venous extra-corporeal membrane oxygenation and veno-arterial extra-corporeal membrane oxygenation (January 2005-July 2015). Outcomes were compared among two subgroups: aged less than 65 years (Group 1) versus more than 65 years (Group 2) and by type of support (veno-arterial extra-corporeal membrane oxygenation or veno-venous extra-corporeal membrane oxygenation). RESULTS Among 403 patients, 20.3% were treated by veno-venous extra-corporeal membrane oxygenation and 79.7% by veno-arterial extra-corporeal membrane oxygenation. Veno-arterial extra-corporeal membrane oxygenation group: 76.6% were included in Group 1 and were more severe (pH 7.30 ± 0.19 vs. 7.35 ± 0.13 in Group 2, p = 0.003; lactates 7.5 ± 5.6 mmol/L vs. 5.8 ± 4.5 mmol/L in Group 2, p = 0.003). Weaning rate was higher in Group 1 (63.8% vs. 45.3%, p = 0.0043). The 30-day survival was higher in Group 1 (52.0% vs. 25.3%, p < 0.001). Univariate analysis identified higher Simplified Acute Physiology Score II (p = 0.02) and noradrenaline (p = 0.04) to be associated with mortality. Veno-venous extra-corporeal membrane oxygenation group: 80.5% were in Group 1. Mean PaO2 was 73.5 ± 42.9 mm Hg versus 100.8 ± 80.3 mm Hg (p = 0.24); FiO2 90.1% ± 18% versus 89.4% ± 16.4% (p = 0.89); and 30-day survival 56.1% versus 25.0% (p = 0.048). CONCLUSION Patients older than 65 years have higher mortality after veno-arterial extra-corporeal membrane oxygenation or veno-venous extra-corporeal membrane oxygenation. This therapeutic strategy is feasible in the elderly, but comorbidities and clinical presentation have a major impact on prognosis and need to be seriously considered to avoid futile treatment.
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Affiliation(s)
- Basile Marie
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Amedeo Anselmi
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Erwan Flecher
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Nicolas Nesseler
- Department of Cardiovascular Surgery, Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Yoann Launey
- Department of Anesthesiology, Surgical Critical Care and Emergencies, Pontchaillou University Hospital, Rennes, France
| | - Jean-Marc Tadie
- Department of Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Jean-Philippe Verhoye
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
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Yan W, Yamashita MH. Commentary: Patient selection is key to improving postcardiotomy extracorporeal membrane oxygenation outcomes. J Thorac Cardiovasc Surg 2019; 159:1855-1856. [PMID: 31445756 DOI: 10.1016/j.jtcvs.2019.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Weiang Yan
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Michael H Yamashita
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
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Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA 2019; 322:557-568. [PMID: 31408142 DOI: 10.1001/jama.2019.9302] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice. OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. CONCLUSIONS AND RELEVANCE The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.
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Affiliation(s)
- Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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30
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Ingvarsdottir IL, Vidarsdottir H, Valsson F, Simonardottir L, Sigurdsson MI, Myrdal G, Geirsson A, Gudbjartsson T. Venovenous extracorporeal membrane oxygenation treatment in a low-volume and geographically isolated cardiothoracic centre. Acta Anaesthesiol Scand 2019; 63:879-884. [PMID: 30937908 DOI: 10.1111/aas.13367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/15/2019] [Accepted: 02/11/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) treatment is generally offered in large tertiary cardiothoracic referral centres. Here we present the indications and outcome of venovenous-ECMO (VV-ECMO) treatment in a low-volume, geographically isolated single-centre in Iceland, a country of 350 000 inhabitants. Our hypothesis was that patient survival in such a centre can be similar to that at high-volume centres. METHODS A retrospective study that included all patients treated with VV-ECMO in Iceland from 1991-2016 (n = 17). Information on demographics, indications and in-hospital survival was collected from patient charts and APACHE II and Murray scores were calculated. Information on long-term survival was collected from a centralized registry. RESULTS Seventeen patients were treated with VV-ECMO (nine males, median age 33 years, range 14-74), the indication for 16 patients was severe acute respiratory distress syndrome, most often following pneumonia (n = 6), H1N1-infection (n = 3) or drowning (n = 2). Median APACHE-II and Murray-scores were 20 and 3.5, respectively, and median duration of VV-ECMO treatment was 9 days (range 2-40 days). In total 11 patients (64,7%) survived the treatment, with 10 patients (58,8%) surviving hospital discharge, all of who were still alive at long-term follow-up, with a median follow-up time of 9 years (August 15th, 2017). CONCLUSION Venovenous-ECMO service can be provided in a low-volume and geographically isolated centre, like Iceland, with short- and long-term outcomes comparable to larger centres.
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Affiliation(s)
- Inga L. Ingvarsdottir
- Department of Anaesthesiology and Intensive Care Landspitali University Hospital Reykjavik Iceland
| | - Halla Vidarsdottir
- Cardiothoracic Surgery Landspitali University Hospital Reykjavik Iceland
| | - Felix Valsson
- Department of Anaesthesiology and Intensive Care Landspitali University Hospital Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | | | - Martin I. Sigurdsson
- Department of Anaesthesiology and Intensive Care Landspitali University Hospital Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Gunnar Myrdal
- Cardiothoracic Surgery Landspitali University Hospital Reykjavik Iceland
| | - Arnar Geirsson
- Cardiothoracic Surgery Landspitali University Hospital Reykjavik Iceland
| | - Tomas Gudbjartsson
- Cardiothoracic Surgery Landspitali University Hospital Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
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31
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Mazzeffi M, Del Rio JM, Gutsche J. Give Me Your Tired, Your Poor, Your Extracorporeal Membrane Oxygenation Patients. J Cardiothorac Vasc Anesth 2019; 33:3054-3055. [PMID: 31351876 DOI: 10.1053/j.jvca.2019.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - J Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jacob Gutsche
- Department of Anesthesiology, University of Pennsylvania School of Medicine, Philadelphia, PA
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32
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Sanaiha Y, Kavianpour B, Mardock A, Khoury H, Downey P, Rudasill S, Benharash P. Rehospitalization and resource use after inpatient admission for extracorporeal life support in the United States. Surgery 2019; 166:829-834. [PMID: 31277884 DOI: 10.1016/j.surg.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/22/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND With increasing dissemination and improved survival after extracorporeal life support, also called extracorporeal membrane oxygenation, the decrease in readmissions after hospitalization involving extracorporeal life support is an emerging priority. The present study aimed to identify predictors of early readmission after extracorporeal life support at a national level. METHODS This was a retrospective cohort study using the Nationwide Readmissions Database. All patients ≥18 years who underwent extracorporeal life support from 2010 to 2015 were identified. Patients were stratified into the following categories of extracorporeal life support: postcardiotomy, primary cardiogenic shock, cardiopulmonary failure, respiratory failure, transplantation, and miscellaneous. The primary outcome of the study was the rate of 90-day rehospitalization after extracorporeal life support admission. A multivariable logistic regression model was developed to predict the odds of unplanned 90-day readmission. Kaplan-Meier analyses were also performed. RESULTS An estimated 18,748 patients received extracorporeal life support with overall mortality of 50.2%. Of the patients who survived hospitalization, 30.2% were discharged to a skilled nursing facility, and 21.1% were readmitted within 90 days after discharge. After adjusting for patient and hospital characteristics, cardiogenic shock was associated with the greatest odds of mortality (adjusted odds ratio 1.6; 95% confidence interval, 1.09-1.46; C-statistic, 0.64). The cohort with respiratory failure had decreased odds of readmission (adjusted odds ratio 0.76; 95% confidence interval, 0.58-0.99). Discharge to skilled nursing facility (adjusted odds ratio 1.64; 95% confidence interval, 1.36-1.97) was independently associated with readmission. Cardiac and respiratory-related readmissions comprised the majority of unplanned 90-day rehospitalizations. CONCLUSION In this large analysis of readmissions after extracorporeal life support in adults, 21% of extracorporeal life support survivors were rehospitalized within 90 days of discharge. Disposition to a skilled nursing facility, but not advanced age nor female sex, was associated with readmission.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Alexandra Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peter Downey
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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33
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Sakai-Bizmark R, Mena LA, Kumamaru H, Kawachi I, Marr EH, Webber EJ, Seo HH, Friedlander SIM, Chang RKR. Impact of pediatric cardiac surgery regionalization on health care utilization and mortality. Health Serv Res 2019; 54:890-901. [PMID: 30916392 DOI: 10.1111/1475-6773.13137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery. DATA SOURCES/STUDY SETTING Statewide inpatient data from eleven states between 2000 and 2012. STUDY DESIGN Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles. DATA COLLECTION/EXTRACTION METHODS We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges. PRINCIPAL FINDINGS In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01). CONCLUSIONS Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.
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Affiliation(s)
- Rie Sakai-Bizmark
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Laurie A Mena
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chang School of Public Health, Boston, Massachusetts
| | - Emily H Marr
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Eliza J Webber
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hyun H Seo
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Anderson School of Management, University of California at Los Angeles, Los Angeles, California
| | - Scott I M Friedlander
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Ruey-Kang R Chang
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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