Paediatric extracorporeal membrane oxygenation use by social determinants: a multicentre retrospective cohort study

Background

Social determinants of health have upstream effects on health-care access and decision making to influence outcomes. We aimed to study the use of extracorporeal membrane oxygenation (ECMO) in children according to social determinants of health.

Methods

This retrospective, multicentre cohort study used data from 47 children's hospitals in the USA that contributed to the Pediatric Health Information System. Children (aged <18 years) admitted to an intensive care unit in one of the study hospitals between Oct 1, 2015, and March 31, 2021, with extreme or major mortality risk and cardiac or respiratory diagnoses, were eligible for the study. Social determinants of health considered were Child Opportunity Index (COI; a multidimensional metric of neighbourhood conditions), race, ethnicity, type of health insurance, distance from home to hospital, and hospital region. We calculated relative risk ratios (RRR) using multivariable multinomial regression models to compare the outcome of ECMO use according to three categories: patients who received ECMO, patients who survived without ECMO, and patients who died without ECMO (ie, those who might have benefited from ECMO).

Findings

Of 829 445 children admitted to paediatric intensive care units during the study period, 309 937 (37·4%) met the inclusion criteria and were included in the study. 288 717 (93·2%) of 309 937 patients survived without ECMO, 12 542 (4·0%) died without ECMO, and 8678 (2·8%) received ECMO. Patients who received ECMO were younger and more likely to have a cardiac diagnosis than those who died without ECMO. A 5% greater adjusted risk of dying without ECMO (adjusted RRR [aRRR] 1·05 [95% CI 1·01–1·09]) was seen for every 10-point decrease in COI score. A greater risk of dying without ECMO than of receiving ECMO was observed in patients of Asian (aRRR 1·36 [95% CI 1·04–1·78]) or other (1·54 [1·09–2·18]) race, Hispanic ethnicity (1·70 [1·31–2·22]), and with public health insurance (1·33 [1·16–1·52]). The risk of dying without ECMO differed by distance from hospital (aRRR per 50 miles increase 0·98 [95% CI 0·96–0·99]), whereas patients in hospitals in the south (2·34 [1·02–5·38]) and west (3·74 [1·44–9·67]) had a greater risk of dying without ECMO than those in the midwest; only those in the west also had a greater risk of survival without ECMO (3·72 [1·40–9·90]).

Interpretation

There are disparities in ECMO use according to social determinants of health, with lower use among children from under-resourced neighbourhoods, from minoritised racial and ethnic backgrounds, and those with public health insurance. Interventions to promote equitable ECMO use can be derived using health equity frameworks.

Funding

None.