The In-Hospital Cost of Ventricular Assist Device Therapy: Implications for Patient Selection

Abstract

Purpose: Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients to provide cardiac and/or respiratory support. Despite improvement in technology, experience, and management, the survival rate remains low. In the Extracorporeal Life Support Organization (ELSO) registry only 43% of adult ECMO patients survived to discharge, though readmission rates and reasons for readmission are not captured. These data are valuable to determine discharge planning and education for ECMO patients. This study retrospectively assessed readmission rates, reason for readmission, and outcomes within the first year of hospital discharge for survivors of ECMO therapy at an urban medical center. Methods: A retrospective chart review from patients who survived ECMO to discharge between January 2009 and July 2014 was conducted. ECMO duration, type (Veno-Arterial (VA)/ Veno-Venous (VV)), date of discharge, rate and reason for readmission, and mortality were recorded. Descriptive statistics were used for data analysis. Results: Complete data were available for 48 patients; 32 were recipients of VA ECMO, 13 of VV ECMO, and 3 were converted from VA to VV. Seventy-one percent (n= 34) of patients were readmitted within the first year of discharge (mean number of readmissions: 2.7; range 1-8). Eighty percent of readmissions were unplanned, and the majority of patients were readmitted with pulmonary illness (37%). Fifty-four percent (n= 26) of patients had an unplanned first readmission, mean number of days to readmission post-discharge was 84.59 (range 1-342 days). Eighty-one percent (n= 39) of patients survived one year post-discharge. Four patients died between discharge and 3 months; 1 patient died between 3 and 6 months; and 4 patients died between 6 and 12 months post-discharge. Conclusion: Eighty-one percent of the patients in our cohort who survived ECMO to discharge were still alive one year post-discharge. Several patients had unplanned readmissions within the first year. Findings suggest the need for careful monitoring and follow up post-discharge, particularly regarding pulmonary illness, due to increased risk for morbidity and readmission. Discharge education provided to patients and their families should highlight the increased risk for development of illness post-discharge, and the need for efficient follow up, should symptoms occur.

Effects of socioeconomic status on clinical outcomes with ventricular assist devices

“…We selected 21 days for our analysis as several studies have noted the median implant LOS to be 20 to 21 days . The need to focus on VAD implant LOS is underscored by the close relationship between LOS and total hospital cost, demonstrated across conditions and more recently determined to be the main driver of costs during the implant hospitalization with implant LOS explaining 77% of the cost variance at one center . Improving cost effectiveness of this life‐saving therapy will require continued refinement, not only in outpatient management, but also patient selection and identifying higher risk features.…”

“…[17][18][19] The need to focus on VAD implant LOS is underscored by the close relationship between LOS and total hospital cost, demonstrated across conditions 20 and more recently determined to be the main driver of costs during the implant hospitalization with implant LOS explaining 77% of the cost variance at one center. 21 Improving cost effectiveness of this life-saving therapy will require continued refinement, not only in outpatient management, but also patient selection and identifying higher risk features. While this has traditionally centered on assessing the risk of mortality and right ventricular failure, expanding this risk assessment beyond traditional medical parameters, while challenging, may be of great utility in identifying novel variables that may serve as potential targets for quality improvement and cost containment.…”