Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address: https://twitter.com/arjun_ver.
Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
Surgery. 2023 Jun;173(6):1405-1410. doi: 10.1016/j.surg.2023.02.004. Epub 2023 Mar 11.
A paradoxical increase in mortality following extracorporeal membrane oxygenation at high-volume centers has previously been demonstrated. We examined the association between annual hospital volume and outcomes within a contemporary, national cohort of extracorporeal membrane oxygenation patients.
All adults requiring extracorporeal membrane oxygenation for postcardiotomy syndrome, cardiogenic shock, respiratory failure, or mixed cardiopulmonary failure were identified in the 2016 to 2019 Nationwide Readmissions Database. Patients undergoing heart and/or lung transplantation were excluded. A multivariable logistic regression with hospital extracorporeal membrane oxygenation volume parametrized as restricted cubic splines was developed to characterize the risk-adjusted association between volume and mortality. The volume corresponding to the maximum of the spline (43 cases/year) was used to categorize centers as low- or high-volume.
An estimated 26,377 patients met the study criteria, and 48.7% were managed at high-volume hospitals. Patients at low- and high-volume hospitals had similar age, sex, and rates of elective admission. Notably, patients at high-volume hospitals less frequently required extracorporeal membrane oxygenation for postcardiotomy syndrome but more commonly for respiratory failure. After risk adjustment, high-volume hospital status was associated with reduced odds of in-hospital mortality, relative to low-volume hospitals (adjusted odds ratio 0.81, 95% confidence interval 0.78-0.97). Interestingly, patients at high-volume hospitals faced a 5.2-day increment in length of stay (95% confidence interval 3.8-6.5) and $23,500 in attributable costs (95% confidence interval 8,300-38,700).
The present study found that greater extracorporeal membrane oxygenation volume was associated with decreased mortality but higher resource use. Our findings may help inform policies regarding access to and centralization of extracorporeal membrane oxygenation care in the United States.
先前已经证明，在高容量中心进行体外膜肺氧合后，死亡率会出现矛盾性增加。我们在一个当代的全国性体外膜肺氧合患者队列中，研究了医院年度容量与结局之间的关系。
在 2016 年至 2019 年的全国再入院数据库中，确定了所有因心脏手术后综合征、心源性休克、呼吸衰竭或混合心肺衰竭而需要体外膜肺氧合的成年人患者。排除接受心肺移植的患者。采用多变量逻辑回归，以受限立方样条形式参数化的医院体外膜肺氧合容量，对容量与死亡率之间的风险调整关联进行特征描述。使用样条最大值（43 例/年）对应的容量来对中心进行分类，分为低容量或高容量。
估计有 26377 名患者符合研究标准，其中 48.7%在高容量医院接受治疗。低容量和高容量医院的患者年龄、性别和择期入院率相似。值得注意的是，高容量医院的患者接受体外膜肺氧合治疗心脏手术后综合征的比例较低，但治疗呼吸衰竭的比例较高。经过风险调整后，与低容量医院相比，高容量医院的住院死亡率降低（调整后的优势比为 0.81，95%置信区间为 0.78-0.97）。有趣的是，高容量医院的患者住院时间增加了 5.2 天（95%置信区间为 3.8-6.5），且增加了 23500 美元的可归因费用（95%置信区间为 8000-38700）。
本研究发现，更大的体外膜肺氧合容量与死亡率降低相关，但与资源利用增加相关。我们的研究结果可能有助于为美国制定关于体外膜肺氧合治疗的获取和集中化政策提供信息。
