Women, Medicaid users less likely to receive ECMO treatment

Key takeaways:

• Demographics associated with low odds of receiving ECMO were being a woman, using Medicaid and residing in a low-income area.
• Several sensitivity analyses also showed the same disparities.

Low chances for extracorporeal membrane oxygenation treatment were found in women, those with Medicaid insurance and those residing in low-income areas, according to results published in Annals of the American Thoracic Society.

Anuj B. Mehta

“Our work adds to a growing body of literature highlighting sex, race, insurance and income disparities in all areas of health care but especially in advanced life sustaining therapies,” Anuj B. Mehta, MD, assistant professor of medicine within the division of pulmonary sciences and critical care medicine at Denver Health and Hospital Authority and the University of Colorado School of Medicine, told Healio. “Our hope is that this study makes physicians think more critically about how they treat critically ill patients and how they make decisions about referring them for advanced therapies. Given the limitations in this retrospective study, we also hope that these findings fuel new funding avenues to further investigate these types of disparities but, more importantly, develop interventions to ensure more equitable care.”

In a retrospective population-level cohort study, Mehta and colleagues analyzed 18,725 adults who received extracorporeal membrane oxygenation (ECMO) against 2,170,752 adults treated solely with mechanical ventilation to find out if there are disparities in who is chosen to receive ECMO. Data on these adults came from the 2016 to 2019 Nationwide Readmissions Database.

Researchers specifically looked at patient sex, insurance and median income of their neighborhood to find differences between the treatment option patient populations. They then calculated the probability for ECMO treatment using these factors through a hierarchical logistic regression.

In terms of sex, fewer women received ECMO than women who received mechanical ventilation (36.1% vs. 44.5%). This percentage of women treated with ECMO also demonstrates that more men (63.9%) received this option and that women had lower chances of receiving it (adjusted OR= 0.73; 95% CI, 0.7-0.75).

“Our research team was definitely surprised by the magnitude of the sex disparities in patient selection for ECMO, with female patients accounting for only one-third of all ECMO patients,” Mehta told Healio.

When put against patients solely receiving mechanical ventilation, more patients on ECMO had private insurance (17.4% vs. 38.1%) but less had Medicare (57.7% vs. 36.5%). According to researchers, the percentage of ECMO patients using private insurance was higher than that of patients on ECMO using Medicaid and Medicare, signaling a small likelihood that Medicaid users (aOR = 0.55; 95% CI, 0.52-0.57) and Medicare users (aOR = 0.5; 95% CI, 0.48-0.52) would receive this option.

Further, researchers found that residence in the highest income neighborhoods was more often observed in adults receiving ECMO vs. adults receiving mechanical ventilation (25.1% vs. 17.3%), and this corresponds with the decreased chances for ECMO observed in those with residence in the lowest income areas (aOR = 0.63; 95% CI, 0.6-0.67).

“Due to known access issues in rural communities and safety net hospitals, we had hypothesized that patients with Medicaid and patients living in lower income neighborhoods might be less likely to receive ECMO,” Mehta told Healio. “However, we were surprised by the degree of difference in patients with Medicaid in the larger mechanically ventilated populations compared to the ECMO population.”

Additionally, overlap of female sex and low neighborhood income demonstrated a greater decreased likelihood for ECMO (aOR = 0.5; 95% CI, 0.46-0.53), according to researchers.

Lastly, several sensitivity analyses were carried out using State Inpatient Databases (SIDs) of seven states from 2018 and 2019 to verify findings from the main analysis. After evaluating the SIDs database and limiting the patient population in various ways, researchers found the same results.

“In one of our sensitivity analyses, we restricted the cohort to patients only cared for in ECMO-capable hospitals and found virtually the same disparities,” Mehta told Healio. “In sum, we expected to find some disparities as disparities that are present in all areas of health care, but we were surprised by the magnitude of the differences and the presence of those disparities across multiple subgroups and sensitivity analyses.”

Importantly, Mehta told Healio the study had some limitations that could be addressed in future studies.

“We could only speculate about potential drivers of differences in ECMO utilization across different populations,” he said. “Perhaps the most important future studies would be ones that use both quantitative and qualitative methods to identify key drivers of the differences (eg, implicit bias, restrictive transfer practices, patient preferences, etc) such that targeted interventions can be developed to reduce the disparities.

“Our work should not be read in isolation,” Mehta added. “It is one part of the larger puzzle of health care disparities that exists in critical care and across all of health care.”

For more information:

Anuj B. Mehta, MD, can be reached at anuj.mehta@cuanschutz.edu.

Reference:

• Disparities identified among patients receiving advanced pulmonary support. https://www.nih.gov/news-events/news-releases/disparities-identified-among-patients-receiving-advanced-pulmonary-support. Published April 6, 2023. Accessed April 11, 2023.