The in-hospital costs of extracorporeal membrane oxygenation (ECMO) have not been well established.
To evaluate the in-hospital costs of ECMO technology in both US and non-US settings for all patient types.
Systematic review of English-language articles, using the PubMed, Embase, Web of Science and EconLit databases. Searches consisted of the terms ‘ECMO’ AND ‘health expenditures’ or ‘resource use’ or ‘costs’ or ‘cost analysis’ or ‘cost(-)effectiveness’ or ‘cost(-)benefit’ or ‘cost(-)utility’ or ‘economic(-)evaluation’ or ‘economic’ or ‘QALY’ or ‘cost per quality-adjusted life year’.
Only full scientific research articles were included. The exclusion criteria included papers that focused on pumpless ECMO, simulation training or decision support systems; papers that did not include human subjects or were not written in English; papers that did not mention ECMO, costs, economics or resource utilization; and papers that included only outside-hospital, infrastructure capital or device capital costs.
Data extraction was completed by one author, using predefined criteria.
From the database searches, 1371 results were returned, 226 records underwent a full review and 18 studies were included in the final review. Three papers studied adult populations, two studied adult and paediatric populations, five studied only paediatric populations, one studied a paediatric and neonatal population, and the remaining seven exclusively examined ECMO in neonatal populations. The sample sizes ranged from 8 to 8753 patients. ECMO for respiratory conditions was the most common diagnosis category, followed by congenital diaphragmatic hernia (CDH) and then cardiac conditions. Most papers (n = 14) used retrospective cost collection. Only eight papers stated the perspective of the cost analysis. The results show a large variation in the cost of ECMO over multiple cost categories (e.g. range of total in-hospital costs of treatment: USD 42,554–537,554 [in 2013 values]). In the USA, the reported costs of ECMO were highest for CDH repair, followed by cardiac conditions, and lowest for respiratory conditions. The US charges were highest for cardiac conditions. Outside the USA, the ECMO cost was highest for cardiac conditions, followed by respiratory conditions, and lowest for CDH repair. No non-US studies reported charges.
The current literature shows that a large variation exists in the in-hospital cost estimates for ECMO. Further research is needed to understand how the diagnosis, setting and other factors relate to this variation in the cost of this technology. Reliable costing methodologies and cost information will be critical to inform policymakers and stakeholders wishing to maximize the value of advanced medical technologies such as ECMO.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price includes VAT (USA)
Tax calculation will be finalised during checkout.
Ayad O, Dietrich A, Mihalov L. Extracorporeal membrane oxygenation. Emerg Med Clin N Am. 2008;26(4):953–9, ix.
Nichani S. An overview of extracorporeal membrane oxygenation. Paediatr Child Health. 2010;21(4):170–6.
Gaffney AM, Wildhirt SM, Griffin MJ, Annich GM, Radomski MW. Extracorporeal life support. BMJ. 2010;341:c5317.
Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–6.
Brody H. Medicine’s ethical responsibility for health care reform—the top five list. N Engl J Med. 2010;362(4):283–5.
Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801–2.
Field D, Normand C, Elbourne D. Cost-effectiveness of inhaled nitric oxide in the treatment of neonatal respiratory failure in the US. Pediatrics. 2003;112(6 Pt 1):1422–3.
Spear RM, Fackler JC. Extracorporeal membrane oxygenation and pediatric acute respiratory distress syndrome: we can afford it, but we don’t need it. Crit Care Med. 1998;26(9):1486–7.
Moran JL, Chalwin RP, Graham PL. Extracorporeal membrane oxygenation (ECMO) reconsidered. Crit Care Resusc. 2010;12(2):131–5.
Vats A, Pettignano R, Culler S, Wright J. Extracorporeal life support in pediatric acute respiratory failure: we can afford it and need it. Crit Care Med. 2000;28(5):1690–1.
Wallace DJ, Milbrandt EB, Boujoukos A. Ave, CESAR, morituri te salutant! (Hail, CESAR, those who are about to die salute you!). Crit Care. 2010;14(2):308.
Zwischenberger JB, Lynch JE. Will CESAR answer the adult ECMO debate? Lancet. 2009;374(9698):1307–8.
Dalton HJ, Butt WW. Extracorporeal life support: an update of Rogers’ Textbook of Pediatric Intensive Care. Pediatr Crit Care Med. 2012;13(4):461–71.
Hartwig MG, Walczak R, Lin SS, Davis RD. Improved survival but marginal allograft function in patients treated with extracorporeal membrane oxygenation after lung transplantation. Ann Thorac Surg. 2012;93(2):366–71.
Freeman CL, Bennett TD, Casper TC, Larsen GY, Hubbard A, Wilkes J, et al. Pediatric and neonatal extracorporeal membrane oxygenation: does center volume impact mortality? Crit Care Med. 2014;42(3):512–9.
Combes A, Brodie D, Bartlett R, Brochard L, Brower R, Conrad S, et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Resp Crit Care. 2014;190(5):488–96.
Welte R, Feenstra T, Jager H, Leidl R. A decision chart for assessing and improving the transferability of economic evaluation results between countries. Pharmacoeconomics. 2004;22(13):857–76.
Organization for Economic Co-operation and Development. OECD stat extracts. Paris. 2014. http://stats.oecd.org. Accessed 1 May 2014.
Poley MJ, Stolk EA, Tibboel D, Molenaar JC, Busschbach JJ. The cost-effectiveness of treatment for congenital diaphragmatic hernia. J Pediatr Surg. 2002;37(9):1245–52.
Maxwell BG, Powers AJ, Sheikh AY, Lee PH, Lobato RL, Wong JK. Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998–2009. J Thorac Cardiovasc Surg. 2014;148(2):416–21.
Mishra V, Svennevig JL, Bugge JF, Andresen S, Mathisen A, Karlsen H, et al. Cost of extracorporeal membrane oxygenation: evidence from the Rikshospitalet University Hospital, Oslo, Norway. Eur J Cardiothorac Surg. 2010;37(2):339–42.
Law SP, Kim JJ, Decker JA, Price JF, Cabrera AG, Graves DE, et al. Hospital charges for pediatric heart transplant hospitalizations in the United States from 1997 to 2006. J Heart Lung Transpl. 2012;31(5):485–91.
Lowry AW, Morales DLS, Graves DE, Knudson JD, Shamszad P, Mott AR, et al. Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United States: analysis of the kids’ inpatient database. Pediatr Cardiol. 2013;34(6):1422–30.
Pawlik TD, Porta NF, Steinhorn RH, Ogata E, deRegnier RA. Medical and financial impact of a neonatal extracorporeal membrane oxygenation referral center in the nitric oxide era. Pediatrics. 2009;123(1):e17–24.
Peek GJ, Elbourne D, Mugford M, Tiruvoipati R, Wilson A, Allen E, et al. Randomised controlled trial and parallel economic evaluation of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Health Technol Assess. 2010;14(35):1–46.
Brown KL, Wray J, Wood TL, Mc Mahon AM, Burch M, Cairns J. Cost utility evaluation of extracorporeal membrane oxygenation as a bridge to transplant for children with end-stage heart failure due to dilated cardiomyopathy. J Heart Lung Transpl. 2009;28(1):32–8.
Metkus AP, Esserman L, Sola A, Harrison MR, Adzick NS. Cost per anomaly: what does a diaphragmatic hernia cost? J Pediatr Surg. 1995;30(2):226–30.
Tseng YH, Wu MY, Tsai FC, Chen HJ, Lin PJ. Costs associated with extracorporeal life support used in adults: a single-center study. Acta Cardiol Sin. 2011;27(4):221–8.
Truog WE, Castor CA, Sheffield MJ. Neonatal nitric oxide use: predictors of response and financial implications. J Perinatol. 2003;23(2):128–32.
Mahle WT, Forbess JM, Kirshbom PM, Cuadrado AR, Simsic JM, Kanter KR. Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children. J Thorac Cardiovasc Surg. 2005;129(5):1084–90.
Jacobs P, Finer NN, Robertson CM, Etches P, Hall EM, Saunders LD. A cost-effectiveness analysis of the application of nitric oxide versus oxygen gas for near-term newborns with respiratory failure: results from a Canadian randomized clinical trial. Crit Care Med. 2000;28(3):872–8.
Organization for Economic Co-operation and Development. OECD health data 2013: how does the United States compare. Paris: Organization for Economic Co-operation and Development; 2013.
Greiner W, Schöffski O, Graf vd Schulenburg JM. The transferability of international economic health-economic results to national study questions. HEPAC Health Econ Prev Care. 2000;1(2):94–102.
Wordsworth S, Ludbrook A. Comparing costing results in across country economic evaluations: the use of technology specific purchasing power parities. Health Econ. 2005;14(1):93–9.
Petrou S, Bischof M, Bennett C, Elbourne D, Field D, McNally H. Cost-effectiveness of neonatal extracorporeal membrane oxygenation based on 7-year results from the United Kingdom collaborative ECMO trial. Pediatrics. 2006;117(5):1640–9.
Crow S, Fischer AC, Schears RM. Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth. 2009;13(3):183–91.
Pearson GD, Short BL. An economic analysis of extracorporeal membrane oxygenation. J Intensive Care Med. 1987;2(2):116–20.
Schumacher RE, Roloff DW, Chapman R, Snedecor S, Bartlett RH. Extracorporeal membrane oxygenation in term newborns: a prospective cost-benefit analysis. ASAIO J. 1993;39(4):873–9.
Paden ML, Conrad SA, Rycus PT, Thiagarajan RR. Extracorporeal life support organization registry report 2012. ASAIO J. 2013;59(3):202–10.
Paden ML, Rycus PT, Thiagarajan RR. Update and outcomes in extracorporeal life support. Semin Perinatol. 2014;38(2):65–70.
Higgins AM, Pettila V, Harris AH, Bailey M, Lipman J, Seppelt IM, et al. The critical care costs of the influenza A/H1N1 2009 pandemic in Australia and New Zealand. Anaesth Intensive Care. 2011;39(3):384–91.
Jacobs P, Finer NN, Fassbender K, Hall E, Robertson CM. Cost-effectiveness of inhaled nitric oxide in near-term and term infants with respiratory failure: eighteen- to 24-month follow-up for Canadian patients. Crit Care Med. 2002;30(10):2330–4.
Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63.
Petrou S, Edwards L. Cost effectiveness analysis of neonatal extracorporeal membrane oxygenation based on four year results from the UK Collaborative ECMO Trial. Arch Dis Child. 2004;89(3):F263–8.
Roberts TE. Economic evaluation and randomised controlled trial of extracorporeal membrane oxygenation: UK collaborative trial. The Extracorporeal Membrane Oxygenation Economics Working Group. BMJ. 1998;317(7163):911–5.
Vats A, Pettignano R, Culler S, Wright J. Cost of extracorporeal life support in pediatric patients with acute respiratory failure. Crit Care Med. 1998;26(9):1587–92.
The authors have no financial or non-financial conflicts of interest. All authors contributed to the writing and revision of this article, and Michael J. Harvey is its guarantor. The authors would like to thank Mr. Anup Das for his helpful comments during the revision of the article.
Appendix 1: Electronic Search Strategy
Appendix 1: Electronic Search Strategy
|#||Search term||PubMed query translation|
|1||ECMO||‘extracorporeal membrane oxygenation’ [MeSH Terms] OR (‘extracorporeal’ [All Fields] AND ‘membrane’ [All Fields] AND ‘oxygenation’ [All Fields]) OR ‘extracorporeal membrane oxygenation’ [All Fields] OR ‘ecmo’ [All Fields]|
|2||Health expenditures||‘health expenditures‘ [MeSH Terms] OR (‘health‘ [All Fields] AND ‘expenditures‘ [All Fields]) OR ‘health expenditures‘ [All Fields]|
|3||Resource use||‘health resources’ [MeSH Terms] OR (‘health’ [All Fields] AND ‘resources’ [All Fields]) OR ‘health resources‘ [All Fields] OR ‘resource‘ [All Fields]|
|4||Costs||‘costs and cost analysis’ [MeSH Terms] OR (‘costs’ [All Fields] AND ‘cost’ [All Fields] AND ‘analysis’ [All Fields]) OR ‘costs and cost analysis‘ [All Fields] OR ‘costs‘ [All Fields]|
|5||Cost analysis||‘costs and cost analysis’ [MeSH Terms] OR (‘costs’ [All Fields] AND ‘cost’ [All Fields] AND ‘analysis’ [All Fields]) OR ‘costs and cost analysis‘ [All Fields] OR (‘cost‘ [All Fields] AND ‘analysis‘ [All Fields]) OR ‘cost analysis‘ [All Fields]|
|6||Cost effectiveness||‘cost-benefit analysis‘ [MeSH Terms] OR (‘cost-benefit‘ [All Fields] AND ‘analysis‘ [All Fields]) OR ‘cost-benefit analysis‘ [All Fields] OR (‘cost‘ [All Fields] AND ‘effectiveness‘ [All Fields]) OR ‘cost effectiveness‘ [All Fields]|
|7||Cost-effectiveness||Same as #6|
|8||Cost benefit||‘cost-benefit analysis’ [MeSH Terms] OR (‘cost-benefit’ [All Fields] AND ‘analysis’ [All Fields]) OR ‘cost-benefit analysis‘ [All Fields] OR (‘cost‘ [All Fields] AND ‘benefit‘ [All Fields]) OR ‘cost benefit‘ [All Fields]|
|9||Cost–benefit||Same as #8|
|10||Cost utility||(‘economics’ [Subheading] OR ‘economics’ [All Fields] OR ‘cost’ [All Fields] OR ‘costs and cost analysis’ [MeSH Terms] OR (‘costs‘ [All Fields] AND ‘cost‘ [All Fields] AND ‘analysis‘ [All Fields]) OR ‘costs and cost analysis‘ [All Fields]) AND ‘utility’ [All Fields]|
|11||Cost–utility||‘cost-utility’ [All Fields]|
|12||Economic evaluation||‘cost-benefit analysis‘ [MeSH Terms] OR (‘cost-benefit‘ [All Fields] AND ‘analysis‘ [All Fields]) OR ‘cost-benefit analysis‘ [All Fields] OR (‘economic‘ [All Fields] AND ‘evaluation‘ [All Fields]) OR ‘economic evaluation‘ [All Fields]|
|13||Economic||‘economics’ [MeSH Terms] OR ‘economics’ [All Fields] OR ‘economic’ [All Fields]|
|14||QALY||‘quality-adjusted life years’ [MeSH Terms] OR (‘quality-adjusted’ [All Fields] AND ‘life’ [All Fields] AND ‘years‘ [All Fields]) OR ‘quality-adjusted life years‘ [All Fields] OR ‘qaly‘ [All Fields]|
|15||Cost per quality-adjusted life year||(‘economics‘ [Subheading] OR ‘economics‘ [All Fields] OR ‘cost‘ [All Fields] OR ‘costs and cost analysis‘ [MeSH Terms] OR (‘costs‘ [All Fields] AND ‘cost‘ [All Fields] AND ‘analysis‘ [All Fields]) OR ‘costs and cost analysis‘ [All Fields]) AND (‘Pediatr Endocrinol Rev‘ [Journal] OR ‘per‘ [All Fields]) AND (‘quality-adjusted life years‘ [MeSH Terms] OR (‘quality-adjusted‘ [All Fields] AND ‘life‘ [All Fields] AND ‘years‘ [All Fields]) OR ‘quality-adjusted life years‘ [All Fields] OR (‘quality‘ [All Fields] AND ‘adjusted‘ [All Fields] AND ‘life‘ [All Fields] AND ‘year‘ [All Fields]) OR ‘quality adjusted life year‘ [All Fields])|
#1 AND #2
#1 AND #3
#1 AND #4
#1 AND #5
#1 AND #6
#1 AND #7
#1 AND #8
#1 AND #9
#1 AND #10
#1 AND #11
#1 AND #12
#1 AND #13
#1 AND #14
#1 AND #15
About this article
Cite this article
Harvey, M.J., Gaies, M.G. & Prosser, L.A. US and International In-Hospital Costs of Extracorporeal Membrane Oxygenation: a Systematic Review. Appl Health Econ Health Policy 13, 341–357 (2015). https://doi.org/10.1007/s40258-015-0170-9
- Incremental Cost
- Congenital Diaphragmatic Hernia
- Respiratory Condition
- Purchase Power Parity
- Extracorporeal Membrane Oxygenation