Disparities Exist in Patient Selection for ECMO, Study Finds

In a study that included health insurance data from more than 2 million adults with severe respiratory illnesses, researchers found that women, individuals on Medicaid, and those living in the lowest income neighborhoods were less likely to receive extracorporeal membrane oxygenation (ECMO).

Results of the US population–based, retrospective cohort study were published in the Annals of the American Thoracic Society.¹

ECMO is an advanced form of life support for adults with severe respiratory illness that simulates the function of the heart or lungs, giving the organs time to rest. Although advanced forms of therapies are known to have disparities, little was known about whether these disparities existed in treating patients with ECMO.

“The goal is to really get people thinking about where some disparities within critical care might live,” Anuj B. Mehta, MD, the first study author and an assistant professor of medicine within the Division of Pulmonary Sciences and Critical Care Medicine at Denver Health and Hospital Authority and the University of Colorado School of Medicine, said in a statement.² “The next step is to think about how we can investigate those disparities with better data and better sources, which supports the long-term goal of ensuring equitable care.”

The data assessed in this study came from the Nationwide Readmissions Database from 2016 to 2019. Using billing codes, the researchers were able to identify patients who received mechanical ventilation (MV) and/or ECMO.

Finally, the researchers compared gender, insurance, and income levels of patients treated with MV with patients treated with ECMO and determined the adjusted odds ratio (AOR) of receiving ECMO based on the patient’s background factors.

More than 2 million hospitalizations that involved MV were identified in the data, and ECMO was used in 18,725 cases. Among the patients treated with ECMO, 36.1% were female (AOR, 0.73; 95% CI, 0.70-0.75), and among patients treated with MV, only 44.5% were female.

Of the total number of patients treated with ECMO, 38.1% had private insurance, compared with 17.4% of patients with private insurance who received MV only. Additionally, patients with Medicaid insurance were less likely to receive ECMO than patients with private insurance (AOR, 0.55; 95% CI, 0.70-0.75).

Furthermore, 25.1% of patients who received ECMO lived in the highest income neighborhoods, while 17.3% of patients living in the highest income neighborhoods received MV only. Patients living in the highest income neighborhoods were more likely to receive ECMO compared to patients living in the lowest income neighborhoods (AOR, 0.63; 95% CI, 0.60-0.67).

Overall, the researchers believe the significance of these differences highlights a need to continue investigating disparities that exist in health care and to better understand the factors that are behind these outcomes.

"Despite growth in ECMO programs, little effort has been made to ensure equitable access despite multiple examples of disparities in the provision of other critical care resources and treatments,” the study authors wrote. “This study highlights multiple demographic disparities in adult patient selection for ECMO that might be driven by lack of access, restrictive transfer policies, patient preference, and implicit provider bias.”

References

1. Mehta AB, Taylor JK, Day G, et al. Annals of the American Thoracic Society. Disparities in adult patient selection for extracorporeal membrane oxygenation in the united states: a population-level study. Published online April 6, 2023. doi:10.1513/AnnalsATS.202212-1029OC

2. Disparities identified among patients receiving advanced pulmonary support. News release. National Heart, Lung, and Blood Institute. April 6, 2023. Accessed April 5, 2023. https://www.eurekalert.org/news-releases/984931?