ECMO therapy out of reach for several socioeconomic groups

Socioeconomic disparities made some mechanically ventilated groups less likely to receive extracorporeal membrane oxygenation (ECMO) therapy in the years before the pandemic, according to a National Readmissions Database study.

Women were relatively 27% less likely to receive ECMO than their male counterparts (adjusted OR 0.73, 95% CI 0.70-0.75), while patients on Medicaid were nearly half as likely to be treated with the most advanced treatment for severe respiratory failure than those with private insurance (adjusted OR 0.55, 95% CI 0.52-0.57), reported Anuj Mehta, MD, of University of Colorado Denver Medical School, and colleagues.

Additionally, people living in the lowest income neighborhoods were 37% less likely to get ECMO than those in higher income neighborhoods (adjusted OR 0.63, 95% CI 0.60-0.67 ), according to the retrospective cohort study published in the Annals of the American Thoracic Society.

“We hypothesize that several factors contribute to the differential use of ECMO by gender, insurance, and neighborhood income that was observed in this study: reduced access, restrictive transfer practices, patient preferences, and implicit bias. from the supplier,” the band wrote.

The disparities persisted when intersectionality was taken into account in the study results. For example, patients were even less likely to receive ECMO, regardless of income. According to the researchers, it is access to care that perpetuates much of the various disparities present.

ECMO is an advanced, resource-intensive treatment that can simulate the function of the heart, lungs, or both in critically ill patients. ECMO use kept increasingwith significant increases seen from 2007, when there were approximately 352 ECMO hospitalizations in the United States, to 2012, when there were 2,715.

The use of ECMO has been extensive during the pandemic, often as a “last resort” for patients requiring respiratory support. In a study of nearly 60,000 COVID patients, 4,044 received ECMO treatment, with a mortality rate of 39%.

But most hospitals are still not capable of ECMO, with only about half of patients requiring mechanical ventilation admitted to hospitals equipped with the advanced form of life support.

“Hospitals capable of ECMO tend to be clustered in large cities and away from rural areas (less than 15 ECMO cases in rural hospitals in this study), and few hospitals with a safety net have ECMO capabilities,” the researchers explained.

In the present study, an analysis using multiple inpatient databases found that black patients were also less likely to be treated with ECMO than their white counterparts (adjusted OR 0.72, 95% CI 0.65- 0.79), but the researchers noted that “patients with Medicaid, those living in low-income neighborhoods, and patients identified as black are more likely to use safety net hospitals. Therefore, some of the disparity observed may be less related to specific patient selection patterns and more related to the availability of ECMO in certain types of hospitals and in certain geographic areas.

Mehta and her colleagues said closing the gaps in access to ECMO treatment will lead to a better understanding of these disparities.

“The goal is to really get people thinking about where certain disparities within critical care might live,” Mehta said in a Press release from the NIH, which helped fund the study. “The next step is to think about how we can investigate these disparities with better data and better sources, which supports the long-term goal of ensuring equitable care.”

The study was based on 2016-2019 data from the National Readmissions Database, with treatment confirmed by billing codes.

A total of 2,170,752 patients received mechanical ventilation only in the study, while 18,725 were treated with ECMO.

Women represented 36% of patients who received ECMO against 64% of men. Women also represented a smaller proportion of patients who received only mechanical ventilation, but to a lesser extent (45% versus 55%).

Regarding type of insurance in the ECMO group, most patients had private insurance (38%) or were Medicare recipients (37%), followed by Medicaid (18%) and other insurance or no insurance (7%). In the mechanical ventilation-only group, most had Medicare (58%), followed by Medicaid and private insurance (17% each) and other or no insurance (8%).

People living in a high-income neighborhood accounted for 25.1% of the ECMO group, compared with 17.3% of the mechanically ventilated-only group.

The researchers noted that ECMO patients were often younger than patients who received only mechanical ventilation (54 years versus 63 years), were more likely to have chronic heart failure (38% versus 27%) and less likely to have chronic lung disease (19% vs. 32%).

Limitations of this study include its inability to further disaggregate ECMO populations by “at-risk” status, lack of differentiation between hospital-assigned and self-identified racial demographics, and potential errors in classification of billing codes.