ECMO utilization in infants with congenital diaphragmatic hernia in the USA

Abstract

BackgroundCongenital diaphragmatic hernia (CDH) is a cause of significant morbidity. CDH is the most common neonatal diagnosis requiring extracorporeal membrane oxygenation (ECMO).MethodsWe compared the different characteristics of ECMO and non-ECMO patients with CDH in a case-control study. Data were extracted from the Kids’ Inpatient Database. Records from 2006 to 2016 were used. Patients <28 days of age were selected. CDH infants (n=9217) were stratified based on whether they were treated with ECMO (n=348) or not (n=8869). Demographic data and hospital characteristics were collected. Categorical variables were analyzed using χ2 tests to determine associations between the ECMO-treated and non-ECMO-treated infants on demographic and clinical characteristics. Differences in hospitalization costs were analyzed using t-test. Multivariable logistic regression analyses were stratified by clinical and demographic characteristics to identify factors associated with ECMO. Significant variables were included in the model to determine predictors for ECMO.ResultsThe proportion of infants treated with ECMO was higher in White infants, and lower in Hispanics. The cost of hospitalization was higher with ECMO (p<0.0001). ECMO patients were more likely to be treated in their birth hospital (p<0.001), at an urban location (p<0.001) and more likely to have private insurance (p=0.011). After adjusting for confounders, odds of ECMO treatment remained lower in Hispanics (p=0.001) and self-payers (p=0.004).ConclusionThere was a decrease in the proportion of CDH infants needing ECMO use in the USA from 2006 to 2016. Disparities exist in ECMO use and mortality between different ethnic groups and regions of the USA.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature*

“…Of 17 studies examining insurance status, one from South Korea showed higher ECMO use in patients with NHI versus “medical aid” (164). Of 16 U.S. studies, four found no difference (31, 139, 159, 165), 10 showed greater use in patients with private insurance (vs government insurance) (28, 89, 129, 132, 137, 148, 154, 160, 166) or any insurance (vs uninsured) (167). One obstetric study observed higher ECMO use with government insurance (155), and another showed lower ECMO use in insured patients with COVID-19 (138).…”

“…Individual-level primary themes were: 1) differential access to care (28, 30, 33, 106, 114, 122, 168, 170), 2) varying clinical presentations (26, 27, 30, 31, 80, 92, 128, 161, 168), 3) different religious/cultural preferences (26, 27, 80, 89, 93, 168), or other unmeasured individual SDoH as confounders (30, 84, 96). Hospital-level mechanisms included: 1) provider-level treatment variation (26, 31, 80, 93, 167, 169) and 2) between-hospital variability in offering ECMO, timing of initiation, organizational structure, experience, and standardized care practices/processes (27, 30, 31, 80, 90, 106, 122, 123, 129–131, 154, 157, 161, 168–173). Specific systemic/structural factors such as legal frameworks, economic systems, and social policies included: 1) healthcare system adequacy (pay-for-performance measures [31, 122], disparate insurance access and quality [28, 32, 106, 128, 167] and, in countries with universal healthcare, need for enhanced systems to serve marginalized communities [30, 110, 114, 117]) and 2) geographic centralization, balancing consolidated expertise, and quality with accessibility of time-critical technology (106, 171–174).…”

“…Studies with cardiac disease, arrest, transplant, or shock observed patients from diverse backgrounds having lower ECMO use in seven (28,31,129,(148)(149)(150)(151) versus higher ECMO use in three (26,89,152). Two congenital diaphragmatic studies found contrasting results (153,154) and two obstetric studies showed higher ECMO use in patients from diverse backgrounds (155,156). None examined language and only one Saudi Arabian study examined immigration status with greater ECMO utilization with legal (vs illegal) entry but higher use in non-nationals (vs Saudi Arabians) (157).…”