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Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs
Susan L Bratton1, Titus Chan, Cindy S Barrett
11Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah. 2Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. 3Division of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO. 4Quality and Informatics, Intermountain Medical Center, Salt Lake City, UT. 5Division of Pediatric Critical Care Medicine, Department of Pediatrics, Oregon Health Services University, Portland, OR. 6Department of Pediatrics, Harvard Medical School, Boston, MA. 7Department of Cardiology, Boston Children's Hospital, Boston, MA.
Insights
Extracorporeal membrane oxygenation (ECMO) use in pediatric cardiac surgery is linked to hospital volume, with higher volume centers using it more. ECMO use is associated with reduced surgical mortality, demonstrating its critical role in complex cases.
Area of Science:
- Pediatric Cardiac Surgery
- Extracorporeal Membrane Oxygenation (ECMO)
- Healthcare Quality Improvement
Background:
- Extracorporeal membrane oxygenation (ECMO) is utilized in a small fraction of pediatric cardiac surgery patients, but its application is more prevalent in higher-complexity procedures.
- Understanding ECMO utilization patterns relative to institutional surgical volume is crucial for optimizing care and resource allocation in pediatric cardiac surgery programs.
Purpose of the Study:
- To evaluate extracorporeal membrane oxygenation (ECMO) metrics indexed to annual cardiac surgical volume to better understand ECMO use among U.S. cardiac surgical programs.
- To assess the relationship between hospital surgical volume and ECMO utilization and its impact on surgical mortality in pediatric cardiac surgery.
Main Methods:
- A retrospective analysis was conducted on data from 43 U.S. Children's Hospitals within the Pediatric Health Information System.
- Patients under 19 years old undergoing cardiac surgery between January 2003 and July 2014 were included. Extracorporeal membrane oxygenation (ECMO) use and surgical mortality were risk-adjusted using the Risk Adjustment for Congenital Heart Surgery (RACHS-1) score.
- ECMO metrics were indexed to annual cardiac surgery cases, and hospitals were categorized into quintiles based on case volume for comparative analysis.
Main Results:
- Among 131,786 pediatric cardiac surgical patients, 2.9% received ECMO. Median risk-adjusted ECMO use was 2.8%, with significantly lower use in centers performing <150 annual cases (0.78%) compared to those with >275 cases (≥2.8%).
- ECMO use was associated with a median reduction in risk-adjusted surgical mortality from 5.0% to 3.5% (a 30.1% decrease). Median ECMO-associated surgical mortality was 1.3%.
- Approximately 36.7% of patients who died were supported by ECMO, highlighting its use in the most critical cases. Significant variation in ECMO use and mortality was observed across different hospital volume quintiles.
Conclusions:
- Risk-adjusted ECMO metrics, when indexed to annual surgical volume, offer a valuable tool for benchmarking and understanding ECMO utilization, efficacy, and its impact on pediatric cardiac surgery outcomes.
- Hospital volume is a significant factor influencing ECMO use in pediatric cardiac surgery, with lower-volume centers demonstrating less utilization.
- ECMO plays a vital role in improving survival rates for high-risk pediatric cardiac surgery patients, particularly in centers with higher surgical volumes.
Objectives:
Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs.
Design:
Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation.
Patients:
All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014.
Interventions:
None.
Measurements And Main Results:
Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume.
Conclusions:
Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
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