TRENDS IN U.S. EXTRACORPOREAL MEMBRANE

OXYGENATION UTILIZATION AND OUTCOMES: 2002-2012

Fenton H McCarthy, Katherine M McDermott, Ashley Hoedt, Vinay Kini, Jacob T Gutsche, Joyce W Wald,

Dawei Xie, Wilson Y Szeto, Michael Acker, Nimesh D Desai

Division of Cardiovascular SurgeryUniversity of Pennsylvania

95th AATS Annual MeetingApril 2015, Seattle WA

DISCLOSURES

None

BACKGROUND — ECMO UTILIZATION

Extracorporeal Life Support Organization (ELSO) and their associated registry

Paden et al ASAIO 2013.

Adult CardiacECMO

Adult RespiratoryECMO

Previous studies demonstrated progressively increased ECMO cost

Maxwell et al. JTCVS 2014

p < 0.01

Mill

ions

of D

olla

rsBACKGROUND — ECMO COST

QUESTIONS REMAIN REGARDING CURRENT ECMO USE IN ADULTS

1.Trajectory of ECMO use across the country

2.Perceived shifts in the primary indication for ECMO use

OBJECTIVEEvaluate contemporary

national trends in volume,

outcomes, and clinical

presentation of adult patients

in the NIS database

undergoing ECMO.

NIS DATA AND ECMO PATIENTS

• National Inpatient Sample (NIS)

excellent source to evaluated ECMO

outcomes

• Largest publicly available all payer

database

• 2012: 7-8M admissions, 1000 hospitals,

44 states

– 20% stratified sample

– Includes weights to facilitate national estimates

• Size permits study of rare

conditions/events

• NIS discharges from 2002-2012 of adult patients undergoing ECMO – Identified using ICD-9 procedural codes

– 39.65 (extracorporeal membrane

oxygenation)

– 39.66 (percutaneous extracorporeal

membrane oxygenation)

• Discharge weights within NIS sampling

frame used to estimate ECMO

hospitalizations (n=12,157)

METHODS

Six mutually-exclusive groups by ECMO indication:

1. Post-cardiotomy2. Heart transplant3. Lung transplant4. Cardiogenic shock5. Respiratory failure6. Cardiopulmonary failure

METHODS

• Primary outcome was survival as discharge – Entire adult population – Primary indication for ECMO

• A Mann–Kendall test was used to examine trends over time

• Means and frequencies were calculated using SAS software statistical techniques for survey data

METHODS

RESULTS — ECMO UTILIZATION AND MORTALITY 2002-2012

CHARACTERISTICS AND OUTCOMES OF ECMO ADMISSIONS BY ERAAll

(n=12,157)2002-2006 (n=2,639)

2007-2012 (n=9,519) p

Male (%) 62 57 62 0.03

White (%) 68 76 66 0.01

Age (mean, 95% CI)

51.9 (51.0 - 52.8)

53.5 (51.3 - 55.6)

51.4 (50.5 - 52.4)

0.05

Elective Admission (%)

28 40 24 <0.01

Hospital Type

Rural (%) 1 2 1 0.14

Uban, non-teaching (%)

9 13 8 0.07

Urban, teaching (%)

90 85 91 0.03

Mortality 56 52 58 0.12

Length of stay (days)

20.6 (18.8 - 22.4)

17.5 (14.6 - 20.4)

21.5 (14.3 - 18.2)

0.04

ECMO Insertion to Discharge (days)

15.7 (13.9 - 17.4)

13.4 (10.9 - 15.8)

16.2 (14.3 - 18.2)

 0.17

CHARACTERISTICS AND OUTCOMES OF ECMO ADMISSIONS BY ERAAll

(n=12,157)2002-2006 (n=2,639)

2007-2012 (n=9,519) p

Male (%) 62 57 62 0.03

White (%) 68 76 66 0.01

Age (mean, 95% CI)

51.9 (51.0 - 52.8)

53.5 (51.3 - 55.6)

51.4 (50.5 - 52.4)

0.05

Elective Admission (%)

28 40 24 <0.01

Hospital Type

Rural (%) 1 2 1 0.14

Uban, non-teaching (%)

9 13 8 0.07

Urban, teaching (%)

90 85 91 0.03

Mortality 56 52 58 0.12

Length of stay (days)

20.6 (18.8 - 22.4)

17.5 (14.6 - 20.4)

21.5 (14.3 - 18.2)

0.04

ECMO Insertion to Discharge (days)

15.7 (13.9 - 17.4)

13.4 (10.9 - 15.8)

16.2 (14.3 - 18.2)

 0.17

2007-2012: • Fewer women, whites, elective

admissions

• Younger patients

• More urban teaching admission, longer length of stays

• Similar survival

ECMO ADMISSIONS BY DIAGNOSTIC GROUP

• ECMO use in every diagnostic group increased significantly over the study period

• Significant changes in the case-mix included:–Decreased post-cardiotomy ECMO

use from 56.9% of all in 2002 to 37.9% in 2012 (p=0.026)

– Increased cardiopulmonary failure ECMO from 3.9% to 11.1% (p=0.026)

RESULTS

ECMO CLINICAL INDICATION

40%

4%6%

24%

17%

10%

2002 - 2012

57%

32%

8%4%

38%

5%4%

25%

16%

12%

2002

2012

ECMO INDICATION AND USE

2002

2012

Change in pie chart size proportional to increase in ECMO use in 2002 v 2012

(n = 352)

(n = 2,715)

IN-HOSPITAL MORTALITY BY DIAGNOSTIC GROUP

Mortality Mortality (95% CI) pCardiogenic Shock 0.59 (0.54 - 0.65) 0.445

Post-Cardiotomy 0.57 (0.52 - 0.62) 0.026 (Decreasing)

Cardiopulmonary Failure 0.55 (0.48 - 0.63) 0.026 (Increasing)

Acute Respiratory Failure 0.53 (0.48 - 0.58) 0.542

Lung Transplant 0.45 (0.35 - 0.56) 0.218

Heart Transplant 0.44 (0.35 - 0.53) 0.391

• From 2002-2012, national ECMO use increased significantly

• Increased use driven primarily by rising national ECMO utilization beginning in 2007.

• ECMO use increased for all indications but possibly recent changes case mix

CONCLUSIONS

• Mortality rates remained high but stable during this time period

• Within indication groups, some modest changes in mortality were identifiable

CONCLUSIONS

Hospital of the University of Pennsylvania c.1891

Thank You

IN-HOSPITAL MORTALITY BY DIAGNOSTIC GROUP 2007-2012

2007 – 2012  Pairwise Comparisons

Indication NMortality

(95% CI)

Cardiogenic Shock

Post-Cardiotomy

Cardiopulmonary Failure

Acute Respiratory Failure

Heart Transplant

Lung Transplant

Cardiogenic Shock

22210.63 (0.57 -

0.69). 0.4872 0.2239 0.0318 0.0042 0.0168

Post-Cardiotomy

36260.60 (0.55 -

0.65). . 0.4708 0.0996 0.0114 0.0369

Cardiopulmonary Failure

10120.56 (0.48 -

0.65). . . 0.6222 0.1 0.1539

Acute Respiratory Failure

16440.54 (0.48 -

0.60). . . . 0.1855 0.2282

Heart Transplant

3860.45 (0.34 -

0.55). . . . . 0.974

Lung Transplant

6300.44 (0.31 -

0.58). . . . . .

p p=0.018