Incremental effect of complications on mortality and hospital costs in adult ECMO patients.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS: Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS: Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION: In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.

Cannulation Strategy for Extracorporeal Membrane Oxygenation Does Not Influence Total Hospital Cost.

BACKGROUND: The Center for Medicare and Medicaid Services decreased reimbursement rates for peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and venovenous (VV) ECMO procedures in October 2018. Limited data are available describing hospital costs and clinical resources required to support ECMO patients. METHODS: All patients supported on ECMO at our institution between March 2017 and October 2018 were identified. Exclusion criteria were cannulation at referring hospitals, organ transplant recipients, and temporary right ventricular support. The cohort was stratified by the initial cannulation strategy. Outcomes were total hospital cost and clinical resource utilization. RESULTS: There were 29 patients supported on central VA, 72 on peripheral VA, and 37 on VV ECMO. Survival at 30 days was 48% for central vs 37% for peripheral vs 51% for VV. Hospital costs were $187,848 for central vs $178,069 for peripheral vs $172,994 for VV (P = .91). Mean hospital stay was 25.8 days for central vs 21.5 days for peripheral vs 26.2 days for VV (P = .49). Mean intensive care unit stay was 14.1 days for central vs 12.8 days for peripheral vs 7.7 days for VV (P = .25). Mean length of ECMO support was 6.5 days for central vs 6.2 days for peripheral vs 7.8 days for VV (P = .38). Mean ventilator time was 13.0 days for central vs 8.2 days for peripheral vs 10.0 days for VV (P = .06). Hemodialysis was used in 41% central patients, 47% peripheral, and 41% VV (P = .75). Theoretical ECMO reimbursement losses ranged from $1,970,698 to $5,648,219 annually under 2018 Center for Medicare and Medicaid Services rates. CONCLUSIONS: ECMO cannulation strategy has minimal impact on resource utilization and hospital cost.

Allocation of resources and development of guidelines for extracorporeal membrane oxygenation (ECMO): Experience from a pediatric center in the epicenter of the COVID-19 pandemic.

The rapid spread of coronavirus disease 2019 (COVID-19) has exceeded the standard capacity of many hospital systems and led to an unprecedented scarcity of resources, including the already limited resource of extracorporeal membrane oxygenation (ECMO). With the large amount of critically ill patients and the highly contagious nature of the virus, significant consideration of ECMO candidacy is crucial for both appropriate allocation of resources as well as ensuring protection of health care personnel. As a leading pediatric ECMO program in the epicenter of the pandemic, we established new protocols and guidelines in order to continue caring for our pediatric patients while accepting adult patients to lessen the burden of our hospital system which was above capacity. This article describes our changes in consultation, cannulation, and daily care of COVID-19 positive patients requiring ECMO as well as discusses strategies for ensuring safety of our ECMO healthcare personnel and optimal allocation of resources. LEVEL OF EVIDENCE: Level V.

Trends in Mortality and Costs of Pediatric Extracorporeal Life Support.

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.

Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support.

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.

Extracorporeal Membrane Oxygenation for Cardiac Indications in Adults: A Health Technology Assessment.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy used to stabilize patients with hemodynamic compromise such as refractory cardiogenic shock or cardiac arrest. When used for cardiac arrest, ECMO is also known as extracorporeal cardiopulmonary resuscitation (ECPR). We conducted a health technology assessment of venoarterial ECMO for adults (aged ≥ 18 years) with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) or with cardiogenic shock refractory to conventional medical management (i.e., drugs, mechanical support such as intra-aortic balloon pump and temporary ventricular assist devices). Our assessment included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding ECMO for these indications, and patient preferences and values. METHODS: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews and the Risk of Bias Among Nonrandomized Trials (ROBINS-I) tool for observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-effectiveness analysis with a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding ECMO in Ontario for patients with refractory cardiogenic shock or cardiac arrest. To contextualize the potential value of ECMO for cardiac indications, we spoke with patients and caregivers with direct experience with the procedure. RESULTS: We included one systematic review (with 13 observational studies) and two additional observational studies in the clinical review. Compared with traditional CPR for patients with refractory cardiac arrest, ECPR was associated with significantly improved 30-day survival (pooled risk ratio [RR] 1.54; 95% CI 1.03 to 2.30) (GRADE: Very Low) and significantly improved long-term survival (pooled RR 2.17; 95% CI 1.37 to 3.44) (GRADE: Low). Overall, ECPR was associated with significantly improved 30-day favourable neurological outcome in patients with refractory cardiac arrest compared with traditional CPR; pooled RR 2.02 (95% CI 1.29 to 3.16) (GRADE: Very Low). For patients with cardiogenic shock, ECMO was associated with a significant improvement in 30-day survival compared with intra-aortic balloon pump (pooled RR 2.11; 95% CI 1.23 to 3.61) (GRADE: Very Low). Compared with temporary percutaneous ventricular assist devices, ECMO was not associated with improved survival (pooled risk ratio 0.94; 95% CI 0.67 to 1.30) (GRADE: Very Low).We estimated the incremental cost-effectiveness ratio of ECPR compared with conventional CPR is $18,722 and $28,792 per life-year gained (LYG) for in-hospital and out-of-hospital cardiac arrest, respectively. We estimated the probability of ECPR being cost-effective versus conventional CPR is 93% and 60% at a willingness-to-pay of $50,000 per LYG for in-hospital and out-of-hospital cardiac arrest, respectively. We estimate that publicly funding ECMO in Ontario over the next 5 years would result in additional total costs of $1,673,811 for cardiogenic shock (treating 314 people), $2,195,517 for in-hospital cardiac arrest (treating 126 people), and $3,762,117 for out-of-hospital cardiac arrest (treating 247 people).The eight patients and family members with whom we spoke had limited ability to assess the impact of ECMO or report their impressions because of their critical medical situations when they encountered the procedure. All had been in hospital with acute hemodynamic instability. In the decision to receive the procedure, participants generally relied on the expertise and judgment of physicians. CONCLUSIONS: For adults treated for refractory cardiac arrest, ECPR may improve survival and likely improves long-term neurological outcomes compared with conventional cardiopulmonary resuscitation. For patients treated for cardiogenic shock, ECMO may improve 30-day survival compared with intra-aortic balloon pump, but there is considerable uncertainty.For adults with refractory cardiac arrest, ECPR may be cost-effective compared with conventional CPR. We estimate that publicly funding ECMO for people with cardiac arrest and cardiogenic shock in Ontario over the next 5 years would cost about $845,000 to $2.2 million per year.People with experience of ECMO for cardiac indications viewed it as a life-saving device and expressed gratitude that it was available and able to help stabilize their acute medical condition.

Impact of Confounding on Cost, Survival, and Length-of-Stay Outcomes for Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage 1 Palliation Surgery.

The objective of this analysis was to update trends in LOS and costs by survivorship and ECMO use among neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery using 2016 data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. We identified neonates ≤ 28 days old with HLHS undergoing Stage 1 surgery, defined as a Norwood procedure with modified Blalock-Taussig (BT) shunt, Sano modification, or both. Multivariable regression with year random effects was used to compare LOS and costs by hospital region, case volume, survivorship, and ECMO vs. no ECMO. An E-value analysis, an approach for conducting sensitivity analysis for unmeasured confounding, was performed to determine if unmeasured confounding contributed to the observed effects. Significant differences in total costs, LOS, and mortality were noted by hospital region, ECMO use, and sub-analyses of case volume. However, other than ECMO use and mortality, the maximum E-value confidence interval bound was 1.71, suggesting that these differences would disappear with an unmeasured confounder 1.71 times more associated with both the outcome and exposure (e.g., socioeconomic factors, environment, etc.) Our findings confirm previous literature demonstrating significant resource utilization among Norwood patients, particularly those undergoing ECMO use. Based on our E-value analysis, differences by hospital region and case volume can be explained by moderate unobserved confounding, rather than a reflection of the quality of care provided. Future analyses on surgical quality must account for unobserved factors to provide meaningful information for quality improvement.

Long-term survival and costs following extracorporeal membrane oxygenation in critically ill children-a population-based cohort study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding long-term survival and costs. METHODS: Population-based cohort study from Ontario, Canada (October 1, 2009 to March 31, 2017), of pediatric patients (< 18 years of age) receiving ECMO, identified through the use of an ECMO procedural code. Outcomes were identified through linkage to provincial health databases. Primary outcome was survival, measured to hospital discharge, as well as at 1 year, 2 years, and 5 years following ECMO initiation. We evaluated total patient costs in the first year following ECMO. RESULTS: We analyzed 342 pediatric patients. Mean age at ECMO initiation was 2.9 years (standard deviation [SD] = 5.0). Median time from hospital admission to ECMO initiation was 5 days (interquartile range [IQR] = 1-13 days). Overall survival to hospital discharge was 56.4%. Survival at 1 year, 2 years, and 5 years was 51.5%, 50.0%, and 42.1%, respectively. Among survivors, 99.5% were discharged home. Median total costs among all patients in the year following hospital admission were $147,957 (IQR $70,571-$300,295). Of these costs, the large proportion were attributable to the inpatient cost from the index admission (median $119,197, IQR $57,839-$250,675). CONCLUSIONS: Children requiring ECMO continue to have a significant in-hospital mortality, but reassuringly, there is little decrease in long-term survival at 1 year. Median costs among all patients were substantial, but largely reflect inpatient hospital costs, rather than post-discharge outpatient costs. This information provides value to providers and health systems, allowing for prognostication of short- and long-term outcomes, as well as long-term healthcare-related expenses for pediatric ECMO survivors.

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest.

BACKGROUND: The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown. METHODS: We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013-2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients' health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%. RESULTS: The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€). CONCLUSIONS: We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.

Evaluation of centrifugal blood pumps in term of hemodynamic performance using simulated neonatal and pediatric ECMO circuits.

The objective of this translational study was to evaluate the FDA-approved PediMag, CentriMag, and RotaFlow centrifugal blood pumps in terms of hemodynamic performance using simulated neonatal and pediatric extracorporeal membrane oxygenation (ECMO) circuits with different sizes of arterial and venous cannulae. Cost of disposable pump heads was another important variable for this particular study. The experimental circuit was composed of one of the centrifugal pump heads, a polymethylpentene membrane oxygenator, neonatal and pediatric arterial/venous cannulae, and 1/4-inch ID tubing. Circuits were primed with lactated Ringer's solution and packed human red blood cells (hematocrit 35%). Trials were conducted at 36°C using the three pump heads and different cannulae (arterial/venous cannulae: 8 Fr/18 Fr, 10 Fr/20 Fr, and 12 Fr/22 Fr) at various flow rates (200-2400 mL/min, 200 mL/min increments) and rotational speeds. Pseudo patient pressure was 60 mm Hg. Real-time pressure and flow data were recorded for analysis. The RotaFlow pump had a higher pressure head and flow range compared with the PediMag and CentriMag pumps at the same rotational speed and identical experimental settings (P < 0.001). The PediMag pump had lower flow output than others (P < 0.001). Small-caliber arterial cannulae and higher flow rates predictably created higher circuit pressures and pressure drops. There was no significant difference in hemodynamic energy delivered to the pseudo patient with each of the three pumps. The arterial cannula had the highest pressure drop and hemodynamic energy loss in the circuit when compared to the oxygenator and arterial tubing. The RotaFlow centrifugal pump had a significantly better hemodynamic performance when compared to the PediMag and CentriMag blood pumps at identical experimental conditions in simulated neonatal and pediatric ECMO settings. In addition, the cost of the RotaFlow pump head ($400) is 20 to 30-fold less than the other centrifugal pumps [CentriMag ($12 000) or PediMag ($8000)] that were evaluated in this translational study.

Mortality and costs following extracorporeal membrane oxygenation in critically ill adults: a population-based cohort study.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients. Little is known about population-level short- and long-term outcomes following ECMO, including healthcare use and health system cost across a wide range of sectors. METHODS: Population-based cohort study in Ontario, Canada (October 1, 2009-March 31, 2017) of adult patients (≥ 18 years) receiving ECMO for cardiorespiratory support. We captured outcomes through linkage to health administrative databases. Primary outcome was mortality during hospitalization, as well as at 7 days, 30 days, 1 year, 2 years, and 5 years following ECMO initiation. We analyzed health system costs (in Canadian dollars) in the 1 year following the date of the index admission. RESULTS: A total of 692 patients were included. Mean (standard deviation [SD]) age was 51.3 (16.0) years. Median (interquartile range [IQR]) time to ECMO initiation from date of admission was 2 (0-9) days. In-hospital mortality was 40.0%. Mortality at 1 year, 2 years, and 5 years was 45.1%, 49.0%, and 57.4%, respectively. Among survivors, 78.4% were discharged home, while 21.2% were discharged to continuing care. Median (IQR) total costs in the 1 year following admission among all patients were Canadian $130,157 (Canadian $58,645-Canadian $240,763), of which Canadian $91,192 (Canadian $38,507-Canadian $184,728) were attributed to inpatient care. CONCLUSIONS: Hospital mortality among critically ill adults receiving ECMO for advanced cardiopulmonary support is relatively high, but does not markedly increase in the years following discharge. Survivors are more likely to be discharged home than to continuing care. Median costs are high, but largely reflect inpatient hospital costs, and not costs incurred following discharge.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model.

BACKGROUND: This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment. METHODS: A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2-4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY). MEASUREMENTS AND MAIN RESULTS: Treating eligible patients with an ACCI below 2 points costs 8394 (95% CI: 4922-14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8825 (95% CI: 5192-15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5478-16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10,818 (95% CI: 6357-19,400) euro per extra QALY per IHCA patient. For WTP thresholds of 0-9500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most cost-effective strategy. CONCLUSIONS: Given that conventional WTP thresholds in Europe and North-America lie between 50,000-100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.

Rehospitalization and resource use after inpatient admission for extracorporeal life support in the United States.

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.

Will We Code for Default ECMO?

Cardiopulmonary resuscitation has become the default treatment for all patients who suffer cardiac arrest. The history of how this came to be suggests the clinical and ethical importance of establishing more humane and appropriate indications for extracorporeal membrane oxygenation and other aggressive therapies for patients at the end of life.

Acute Respiratory Distress Syndrome: Cost (Early and Long-Term).

Costs of care in the intensive care unit are a frequent area of concern in our current health care system. Utilization of critical care services in the United States, particularly near the end of life, has been steadily increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently experience prolonged hospitalizations and consume significant health care resources. Many patients are discharged with functional limitations and require significant postdischarge services. These patients have a high susceptibility to new complications which require significant additional health care resources. There is a slowly growing literature on the cost-effectiveness of the treatment of ARDS; despite its high costs, treatment remains a cost-effective intervention by most societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment may become less cost-effective. In addition, the provision of extracorporeal life support adds another layer of complexity to these cases. Small reductions in intensive care unit length of stay may benefit patients, but they do not lead to significant reductions in overall hospital costs. Early discharge to postacute care facilities can reduce hospital costs but is unlikely to significantly decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. However, the most significant cost-saving interventions are early recognition and treatment of conditions to potentially prevent the development of this serious complication.

Impact of first documented rhythm on cost-effectiveness of extracorporeal cardiopulmonary resuscitation.

OBJECTIVES: Recommendations for extracorporeal cardiopulmonary resuscitation (ECPR) state that appropriate patient selection is important for the sake of efficacy and cost-effectiveness of ECPR. It is not known whether first documented rhythm plays a prominent role in economic outcomes of patients with cardiac arrest who received ECPR. METHODS AND RESULTS: We reviewed the medical records of 120 consecutive patients who received extracorporeal membrane oxygenation (ECMO) assisted CPR due to refractory circulatory collapse between 2008 and 2016 in Urasoe General Hospital. The patients presented with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT; n = 59, 49.2%) or with asystole or pulseless electric activity (ASY/PEA; n = 61, 50.8%) as the first documented rhythm. Multivariate logistic regression analysis identified shorter duration from collapse to ECMO initiation (odds ratio, 1.95 per 10 min; 95% confidence interval, 1.32-2.89, p = 0.001), bystander CPR (odds ratio, 5.53; 95% confidence interval, 1.36-22.5, p = 0.017), and first documented rhythm of VF/VT (odds ratio, 3.93; 95% confidence interval, 1.30-11.8, p = 0.015) as clinical predictors for neurologically intact survival. Total hospital cost per life saved by ECPR for ASY/PEA was approximately twice that for VF/VT ($213,656 vs. $101,669). ECPR yielded Quality adjusted life years (QALYs) of 3.32 at a mean total cost of $39,634 for VF/VT and QALYs of 1.17 at a mean cost of $35,609 for ASY/PEA. The cost per QALYs was $11,081 for VF/VT and $29,447 for ASY/PEA. The incremental cost-effectiveness ratio of ECPR vs. conventional CPR was estimated to be $ 16,246 per QALY gained. CONCLUSION: ECPR for patients presenting with VF/VT was found to be highly cost-effective and ECPR for patients presenting with ASY/PEA was borderline cost-effective.