Shannon annon M. Fernando, nando, MD, , MSc 1, 1, ; ; Dania nial l Quresh eshi, i, MSc 2 ; ; Pet eter er Tanusep nuseputr utro, , MD, , MHS HSc 1,2,3 2,3 ; ; Edd ddy y Fan, n, MD, , Ph PhD 4 ; ; Laveena eena Munsh nshi, , MD, , MSc 4 ; ; Bra ram m Rochw chwerg erg, , MD, , MSc 5 ; ; Rober ert t Tala larico rico, , MSc 3 ; ; Damon mon C. Sca cales, les, MD, , PhD 3,4 3,4 ; ; Daniel niel Brodie, die, MD 6 ; ; Sonny y Dha hana nani, ni, MD 1 ; ; Anne-Marie Marie Guerg rgueri uerian an, , MD, , PhD 4 ; ; Sam D. Shemie mie, , MD 7 ; ; Kednap dnapa Tha havor orn, , PhD 1,2,3 2,3 ; ; and d Kwadw adwo o Kyerem eremant anteng, eng, MD, , MHA HA 1,2 ,2 From the 1 University of Ottawa, Ottawa, ON; 2 Ottawa Hospital Research Institute, Ottawa, ON; 3 ICES, Toronto, ON; 4 University of Toronto, Toronto, ON; 5 McMaster University, Hamilton, ON; 6 Columbia University College of Physicians and Surgeons, New York, NY; 7 McGill University, Montreal QC. @shanf anfern ernands ands
BACKGROUND • Extracorporeal membrane oxygenation (ECMO) is used for temporary cardiorespiratory support in critically ill patients • A “bridge” to recovery or transplant • Little known regarding long-term outcomes and costs associated with ECMO
STUDY OBJECTIVES • We conducted a population-based cohort study to evaluate the short- and long-term health outcomes and costs of critically ill adults receiving ECMO for cardiorespiratory support • Utilize the ICES databases to conduct population-based cohort analyses from Ontario, Canada (population of 13 million)
STUDY METHODS • Inclusion Criteria: • Adult patients (≥ 18 years of age) receiving ECMO in Ontario between Oct. 1, 2009 and Mar. 31, 2017 (Cost data to Mar. 31, 2016) • Patients captured using ECMO Intervention Code from Discharge Abstract Database AND OHIP billing code for ECMO (Z788) • Patients categorized as “Respiratory Failure”, “Cardiac Failure”, or “Other”, on the basis of primary ICD-10 diagnosis • Outcomes: • Mortality (In-hospital, 7-day, 30-day, 1-year, 2-year, 5-year) • Long-term Costs (1 st year following admission)
Ove verall rall Respirat rator ory Failure lure Cardiac iac Failur lure Other Variab iable le (n = 692 92) (n = 321) (n = 303 03) (n = 72) 2) Mortalit ality follo lowing ing ECMO Initi tiati ation on, , n (%) In-Hospital 277 (40.0) 98 (30.5) 153 (50.5) 26 (38.2) 7-day 176 (25.4) 44 (13.7) 117 (38.6) 15 (22.1) 30-day 252 (36.4) 82 (25.5) 149 (49.2) 21 (30.9) 1-year 312 (45.1) 119 (37.1) 163 (53.8) 30 (44.1) 2-year 339 (49.0) 138 (43.0) 168 (55.4) 33 (48.5) 5-year 147 (57.4) 62 (53.4) 69 (62.2) 16 (55.2) Hospital tal Length gth of Stay, , days, , median an (IQR) 22 (9-45) 26 (15-54) 15 (5-35) 22 (9-45) Ventric ricular ular Assis ist Devic vice e During ing Hospitali talizati ation, on, n (%) 92 (13.3) 15 (4.7) 75 (24.8) * Transplan lant During ing Hospitaliz talization ation, n (%) Heart Transplant 46 (6.6) 0 (0) 42 (13.9) 4 (5.6) Lung Transplant 193 (27.9) 173 (53.9) 13 (4.3) 7 (9.7) Transplant lant Patien ients ts Surviving viving to to Discharge, harge, n ( (%) Heart Transplant 30 (65.2) 0 (0) 28 (66.7) 2 (50.0) Lung Transplant 163 (84.5) 150 (92.0) 7 (53.8) 6 (85.7) Discha harge rge Dispos osit itio ion Among ong Surviv vivor ors, n (%) Home (without homecare) 174 (41.9) 106 (47.5) 60 (40.0) 8 (17.4) Home (with homecare) 153 (36.8) 72 (32.3) 61 (40.1) 20 (43.5) Long-term Care Facility 88 (21.2) 45 (20.2) 29 (19.3) 14 (30.4) Emergen gency Departm tmen ent Visit Follo lowing ing Dischar harge, ge, n (%) Within 30-days 82 (19.7) 43 (19.3) 26 (17.3) 13 (28.2) Within 90-days 157 (37.8) 90 (40.4) 48 (32.0) 19 (41.3) Within 1-year 270 (65.1) 153 (68.6) 91 (60.1) 26 (60.5) Hospital tal Readmis issions ions Follo lowing ing Discharge, harge, n (%) Within 30-days 67 (16.1) 41 (18.4) 19 (12.7) 7 (15.2) Within 90-days 125 (30.1 75 (33.6) 38 (25.3) 12 (26.1) Within 1-year 208 (50.1) 121 (54.3) 70 (46.7) 17 (37.0)
Mean n Cost sts s (SD) Medi dian an Cost sts s (IQR) R) Acut ute e Care e Sect ctor ors Inpatient (n = 550) $137,339 ($145,203) $91,192 ($38,507-$184,728) Emergency Department (n = 303) $647 ($892) $421 ($0-$946) Continu ntinuing ing Care e Sect ctor ors s Complex Continuing Care (n = 24) $1,395 ($11,462) $0 ($0-$0) Long-term Care (n = 2) $21 ($454) $0 ($0-$0) Rehabilitation (n = 105) $4,518 ($14,462) $0 ($0-$0) Home Care (n = 203) $1,130 ($3,028) $0 ($0-$679) Out utpati tient ent Care e Sectors Outpatient Clinics (n = 520) $3,643 ($3,867) $2,321 ($731-$5,852) Laboratory (OHIP) (n = 272) $216 ($355) $0 ($0-$314) Drugs (Ontario Drug Benefit Program) (n = 265) $4,324 ($9,155) $0 ($0-$3,953) Physician sician Billings ngs (n = 550) 0) $25,401 ($17,447) $22,191 ($12,665-$33,656) Tot otal al Costs ts $18 181,2 ,248 8 ($170, 70,180) 0) $13 130,157 7 ($58, 8,645-$240,7 40,763) 63)
CONCLUSIONS • In our population-based cohort, in-hospital mortality among critically ill adult patients receiving ECMO was 40.0%, and incremental increase in 1-year, 2-year, or 5-year mortality was minimal • ECMO was frequently used as a bridge to transplant • The majority of ECMO patients who survived to hospital discharge were discharged home • While ECMO patients accrued significant costs, the majority of these costs were attributable to the ECMO admission, and not costs following discharge
CONCLUSIONS Fernando ndo et et al ., ., Crit Care Med , 2018 18 Reardon don et et al ., Crit Care e Res Pract ct , 2018 18
LIMITATIONS • Highly selected population • Did not have data on ECMO configuration • Did not have data on complications of ECMO (hemorrhage, thrombosis, infection) • The large majority of patients came from three major centres (University Health Network, London Health Sciences Centre, University of Ottawa Heart Institute) • Limited by granularity of ICES data (e.g. no data on illness severity)
Inten ensi sive e Care e Med . 2019. 45 : 158 580-1589. 89.
ACKNOWLEDGEMENTS • Dr. Kwadwo Kyeremanteng • Dr. Peter Tanuseputro • Danial Qureshi and Robert Talarico • Drs. Eddy Fan, Laveena Munshi, Bram Rochwerg, Damon Scales, Daniel Brodie, Sonny Dhanani, Anne-Marie Guerguerian, Sam Shemie, Kednapa Thavorn
QUESTIONS/COMMENTS? @sh shan anfer ernands nands
Variab iable le Value ue Sex, n ( (%) Male 429 (62.0) Female 263 (38.0) Age, e, years, , mean n (SD) 51.3 (16.0) Incom ome, e, n (%) Lowest 129 (18.6) Low 142 (20.5) Middle 139 (20.1) High 138 (19.9) Highest 142 (20.5) Unknown * Ruralit lity, , n (%) Urban 612 (88.4) Rural 80 (11.6) Indic icati ation on for ECMO Respiratory Failure 321 (46.4) Cardiac Failure 303 (43.8) Other 68 (9.8) Time e to to ECMO from Admis ission, ion, days, , median ian (IQR) 2 (0-9) Charls lson on Comorbidit rbidity Index, , n (%) ≤ 2 531 (76.7) 3-4 119 (17.2) ≥ 5 42 (6.1) Comorb rbidi iditi ties es, , n ( (%) Arrhythmia 113 (16.3) Malignancy 127 (18.4) Congestive Heart Failure 229 (33.1) Chronic Obstructive Pulmonary Disease 130 (18.8) Coronary Artery Disease 187 (27.0) Dementia * Diabetes Mellitus 197 (28.5) Hypertension 350 (50.6) Chronic Kidney Disease 116 (16.8) Cerebrovascular Disease 24 (3.5)
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