Extracorporeal life support in pediatric acute respiratory failure: we can afford it AND need it

U.S. and International In-Hospital Costs of Extracorporeal Membrane Oxygenation: a Systematic Review

CONTEXT

The in-hospital costs of extracorporeal membrane oxygenation (ECMO) have not been well established.

OBJECTIVE

To evaluate the in-hospital costs of ECMO technology in both US and non-US settings for all patient types.

DATA SOURCES

Systematic review of English-language articles, using the PubMed, Embase, Web of Science and EconLit databases. Searches consisted of the terms 'ECMO' AND 'health expenditures' or 'resource use' or 'costs' or 'cost analysis' or 'cost(-)effectiveness' or 'cost(-)benefit' or 'cost(-)utility' or 'economic(-)evaluation' or 'economic' or 'QALY' or 'cost per quality-adjusted life year'.

STUDY SELECTION

Only full scientific research articles were included. The exclusion criteria included papers that focused on pumpless ECMO, simulation training or decision support systems; papers that did not include human subjects or were not written in English; papers that did not mention ECMO, costs, economics or resource utilization; and papers that included only outside-hospital, infrastructure capital or device capital costs.

DATA EXTRACTION

Data extraction was completed by one author, using predefined criteria.

RESULTS

From the database searches, 1371 results were returned, 226 records underwent a full review and 18 studies were included in the final review. Three papers studied adult populations, two studied adult and paediatric populations, five studied only paediatric populations, one studied a paediatric and neonatal population, and the remaining seven exclusively examined ECMO in neonatal populations. The sample sizes ranged from 8 to 8753 patients. ECMO for respiratory conditions was the most common diagnosis category, followed by congenital diaphragmatic hernia (CDH) and then cardiac conditions. Most papers (n = 14) used retrospective cost collection. Only eight papers stated the perspective of the cost analysis. The results show a large variation in the cost of ECMO over multiple cost categories (e.g., range of total in-hospital costs of treatment: USD 42,554-537,554 [in 2013 values]). In the U.S.A., the reported costs of ECMO were highest for CDH repair, followed by cardiac conditions, and lowest for respiratory conditions. The US charges were highest for cardiac conditions. Outside the U.S.A., the ECMO cost was highest for cardiac conditions, followed by respiratory conditions, and lowest for CDH repair. No non-US studies reported charges.

CONCLUSION

The current literature shows that a large variation exists in the in-hospital cost estimates for ECMO. Further research is needed to understand how the diagnosis, setting and other factors relate to this variation in the cost of this technology. Reliable costing methodologies and cost information will be critical to inform policymakers and stakeholders wishing to maximize the value of advanced medical technologies such as ECMO.

Factors associated with survival in pediatric extracorporeal membrane oxygenation--a single-center experience

AIM

We aimed to examine outcomes of extracorporeal membrane oxygenation (ECMO) therapy in the pediatric population and identify pre-ECMO and on-ECMO characteristics that are associated with survival.

METHODS

We retrospectively reviewed the ECMO records at our institution between 1999 and 2008 and selected pediatric patients who were cannulated for respiratory failure or hemodynamic instability resistant to conventional interventions. We recorded details of pre-ECMO clinical characteristics, including blood gas variables and mechanical ventilatory support, and details of ECMO therapy including survival off ECMO and to hospital discharge. Predictors of survival were analyzed using logistic regression modeling and a prediction algorithm was developed.

RESULTS

Of the 445 ECMO runs, data from 58 consecutive patients were analyzed: 57% were successfully decannulated, and 48% survived to discharge from the hospital. The cohort included 32 (55%) female patients, 22 postoperative patients (38%), and 15 (26%) with an immunosuppressive condition, with a median age of 5 years and weight 19.5 kg, The mean duration of pre-ECMO respiratory support was 3 days, in the form of high-frequency oscillatory ventilation (n = 28, 48%) and conventional mechanical ventilation (n = 13, 22%). The median duration (interquartile range) of ECMO support was 142 hours (60, 321) or 5.9 days. Pre-ECMO pH above 7.2 (P < .001) and oxygenation index below 35 (P = .021) were associated with the highest survival rates. Pre-ECMO PaCO(2) and duration of mechanical ventilation were not associated with survival.

CONCLUSIONS

Based on our results, ECMO therapy should be considered early in children with oxygenation index greater than 35 with worsening metabolic status. The restriction of ECMO based on ventilator days alone needs to be revisited in this era of lung protective ventilation.