Skip to main content
SpringerLink
Log in

US and International In-Hospital Costs of Extracorporeal Membrane Oxygenation: a Systematic Review

  • Systematic Review
  • Published:
Applied Health Economics and Health Policy Aims and scope Submit manuscript

Abstract

Context

The in-hospital costs of extracorporeal membrane oxygenation (ECMO) have not been well established.

Objective

To evaluate the in-hospital costs of ECMO technology in both US and non-US settings for all patient types.

Data Sources

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’.

Study Selection

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

Data extraction was completed by one author, using predefined criteria.

Results

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.

Conclusion

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, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Ayad O, Dietrich A, Mihalov L. Extracorporeal membrane oxygenation. Emerg Med Clin N Am. 2008;26(4):953–9, ix.

  2. Nichani S. An overview of extracorporeal membrane oxygenation. Paediatr Child Health. 2010;21(4):170–6.

    Article  Google Scholar 

  3. Gaffney AM, Wildhirt SM, Griffin MJ, Annich GM, Radomski MW. Extracorporeal life support. BMJ. 2010;341:c5317.

    Article  PubMed  Google Scholar 

  4. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–6.

    Article  CAS  PubMed  Google Scholar 

  5. Brody H. Medicine’s ethical responsibility for health care reform—the top five list. N Engl J Med. 2010;362(4):283–5.

    Article  CAS  PubMed  Google Scholar 

  6. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801–2.

    Article  CAS  PubMed  Google Scholar 

  7. 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.

    Article  PubMed  Google Scholar 

  8. 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.

    Article  CAS  PubMed  Google Scholar 

  9. Moran JL, Chalwin RP, Graham PL. Extracorporeal membrane oxygenation (ECMO) reconsidered. Crit Care Resusc. 2010;12(2):131–5.

    PubMed  Google Scholar 

  10. 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.

    Article  CAS  PubMed  Google Scholar 

  11. 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.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Zwischenberger JB, Lynch JE. Will CESAR answer the adult ECMO debate? Lancet. 2009;374(9698):1307–8.

    Article  PubMed  Google Scholar 

  13. 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.

    Article  PubMed  Google Scholar 

  14. 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.

    Article  PubMed  Google Scholar 

  15. 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.

    Article  CAS  PubMed  Google Scholar 

  16. 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.

    Article  Google Scholar 

  17. 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.

    Article  PubMed  Google Scholar 

  18. Organization for Economic Co-operation and Development. OECD stat extracts. Paris. 2014. http://stats.oecd.org. Accessed 1 May 2014.

  19. 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.

    Article  PubMed  Google Scholar 

  20. 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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  22. 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.

    Article  Google Scholar 

  23. 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.

    Article  PubMed  Google Scholar 

  24. 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.

    Article  PubMed  Google Scholar 

  25. 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.

    Article  CAS  PubMed  Google Scholar 

  26. 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.

    Article  Google Scholar 

  27. 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.

    Article  CAS  PubMed  Google Scholar 

  28. 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.

    Google Scholar 

  29. Truog WE, Castor CA, Sheffield MJ. Neonatal nitric oxide use: predictors of response and financial implications. J Perinatol. 2003;23(2):128–32.

    Article  CAS  PubMed  Google Scholar 

  30. 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.

    Article  PubMed  Google Scholar 

  31. 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.

    Article  CAS  PubMed  Google Scholar 

  32. 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.

    Google Scholar 

  33. 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.

    Article  Google Scholar 

  34. 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.

    Article  PubMed  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. 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.

    Article  PubMed  Google Scholar 

  37. Pearson GD, Short BL. An economic analysis of extracorporeal membrane oxygenation. J Intensive Care Med. 1987;2(2):116–20.

    Article  Google Scholar 

  38. 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.

    Article  CAS  PubMed  Google Scholar 

  39. Paden ML, Conrad SA, Rycus PT, Thiagarajan RR. Extracorporeal life support organization registry report 2012. ASAIO J. 2013;59(3):202–10.

    Article  PubMed  Google Scholar 

  40. Paden ML, Rycus PT, Thiagarajan RR. Update and outcomes in extracorporeal life support. Semin Perinatol. 2014;38(2):65–70.

    Article  PubMed  Google Scholar 

  41. 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.

    CAS  PubMed  Google Scholar 

  42. 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.

    Article  CAS  PubMed  Google Scholar 

  43. 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.

    Article  PubMed  Google Scholar 

  44. 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.

    Article  CAS  Google Scholar 

  45. 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.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  46. 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.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

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.

Author information

Authors and Affiliations

  1. Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA

    Michael J. Harvey & Lisa A. Prosser

  2. Division of Pediatric Cardiology, University of Michigan Medical School, CS Mott Children’s Hospital, 1540 E. Hospital Drive, SPC 5204, Ann Arbor, MI, 48109, USA

    Michael G. Gaies

  3. Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan Medical School, 300 North Ingalls 6E14, Ann Arbor, MI, 48109-5456, USA

    Lisa A. Prosser

Authors
  1. Michael J. Harvey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael G. Gaies
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lisa A. Prosser
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael J. Harvey.

Appendix 1: Electronic Search Strategy

Appendix 1: Electronic Search Strategy

1.1 PubMed Database

#

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])

1.2 Searches Performed

  1. 1.

    #1 AND #2

  2. 2.

    #1 AND #3

  3. 3.

    #1 AND #4

  4. 4.

    #1 AND #5

  5. 5.

    #1 AND #6

  6. 6.

    #1 AND #7

  7. 7.

    #1 AND #8

  8. 8.

    #1 AND #9

  9. 9.

    #1 AND #10

  10. 10.

    #1 AND #11

  11. 11.

    #1 AND #12

  12. 12.

    #1 AND #13

  13. 13.

    #1 AND #14

  14. 14.

    #1 AND #15

1.3 Search Filters

None.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

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

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40258-015-0170-9

Keywords

Search

Navigation