Effect of hospital case volume on clinical outcomes of patients requiring extracorporeal membrane oxygenation: a territory-wide longitudinal observational study

Abstract

Background: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. Methods: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. “High-volume” centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while “low-volume” centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. Results: A total of 911 patients received extracorporeal membrane oxygenation—297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61–1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54–1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). Conclusions: In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.