Therapeutic study, level IV.

Background ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. Methods We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. Results COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. Conclusion ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

This investigation examines patients' experiences when policy changes of a managed care system require them to change health care providers. Continuity of care has been recognized as a major cornerstone of the ideal physician I patient relationship, particularly as it applies to primary care (Ware and Snyder 1975;Gonnella and Herman 1980; Weiss, Ramsey and McWhinney 1982;Weiss and Ramsey 1989;Hjortdahl and Laerum 1992;Emanuel and Dubler 1995). The radically changing landscape of managed care in the United States increasingly limits both patient and physician options for maintaining continuity in the doctor-patient relationship (Woolhandler and Himmelstein 1995). Considering patients' experiences of such policies allows for understanding the human costs of social change. We seek to describe the patients' response to the disruption in continuity of their primary medical care and to explore factors that may be associated with their perceptions of difficulty. Our study thus represents an initial effort to explore unintended consequences of increasing differentiation and bureaucracy in health care (Philipsen and Stevens, this issue) on the lives of individuals experiencing health care in a new social context.