Is It Time to Discuss Centralization of Extracorporeal Membrane Oxygenation Centers?

The use of extracorporeal membrane oxygenation (ECMO) to treat patients with severe respiratory failure, cardiac failure, and prolonged cardiac arrest has spread rapidly over the past several decades.^1–3 Recently, many hospitals in Asian countries, including Japan, Taiwan, and Korea, provide patients with ECMO regardless of hospital volume. Implementation of ECMO might not be difficult at hospitals that can perform percutaneous coronary intervention. However, the management of ECMO requires a high-quality, experienced, and multidisciplinary team.⁴ Is there a difference in ECMO care provided at high-volume and low-volume centers?

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In this issue of the Journal, Ho et al⁵ present an interesting volume–outcome relationship in their analysis of Taiwan’s national health insurance research database. They identified 11,734 adults aged >20 years who received ECMO at 101 hospitals in Taiwan between January 2001 and December 2017. Hospitals were divided into 4 groups according to annual ECMO volume: volume 1 (>40 cases each year), volume 2 (20–40 cases each year), volume 3 (10–20 cases each year), and volume 4 (<10 cases each year), comprising 4, 11, 12, and 74 hospitals respectively. In-hospital deaths were significantly fewer at high-volume (volume 1) hospitals (63.3%) than at volume 2 hospitals (65.9%), volume 3 hospitals (66.9%), and low-volume (volume 4) hospitals (67.1%). In addition, the 1-year mortality rate was significantly lower at high-volume (volume 1) hospitals (67.5%) than at volume 2 hospitals (70.9%), volume 3 hospitals (71.9%), and low-volume (volume 4) hospitals (73.4%). They concluded that high-volume hospitals have superior short-term and mid-term mortality rates.

Their results are consistent with previous reports from Korea⁶ and Germany.⁷ In addition to in-hospital deaths, their study showed that the 1-year mortality rate was lower at high-volume hospitals than at middle- and low-volume hospitals. This study provides evidence supporting the centralization of ECMO centers (Figure). In this study, a high-volume hospital was defined as one that administers ECMO to >40 patients/year, which seems too high for real-world settings. Only 4% of hospitals (4/101) achieved >40 cases per year in Taiwan, while 74% hospitals (74 /101) had <10 ECMO cases/year. In the Extracorporeal Life Support Organization Registry, which is the international voluntary database of patients treated with ECMO, 87% of participating hospitals had <6 ECMO cases/year.⁴ The volume targets should be carefully discussed.

Figure.

Centralization of the provision of extracorporeal membrane oxygenation (ECMO). Patients in cardiogenic shock or cardiac arrest will be rapidly placed on ECMO at either the scene or the nearest regional hospital, before being safely transported with the mobile ECMO team to the main ECMO center by ambulance or ECMO car.

Prompt implementation of ECMO is also crucial in patients with cardiac shock or cardiac arrest.^8,9 In some aspects, increasing the number of regional hospitals that can implement ECMO has benefited patients with cardiogenic shock or cardiac arrest by shortening the time from onset to ECMO initiation. Particularly for extracorporeal cardiopulmonary resuscitation, the incidence of out-of-hospital cardiac arrest is approximately 120,000 per year, with a median of 173 arrests (interquartile range, 146–216) per day in Japan.^10,11 Because cardiac arrest can occur at any time or place, the number of hospitals that can implement ECMO should be secured. However, the recent increase in the number of ECMO procedures nationwide did not translate into a survival benefit in Korea⁶ or Germany.⁷ To balance maintenance of high-quality care and prompt implementation of ECMO, the establishment of appropriate annual volume targets and safe patient transport systems might be needed. The safety and efficacy of interhospital patient transport by mobile ECMO teams have been reported in several countries.^12,13 It is time to discuss centralization of ECMO centers in Japan.

Competing Interests / Source of Fundings

T.N. declares no conflicts of interest with regards to the submitted work. T.N. received a Grant-in-Aid for Young Scientists (A) (20K17914) of the Japan Society for the Promotion of Science and the Uehara Memorial Foundation Overseas Research Fellowship unrelated the submitted work.

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