Impact of Center of Admission on Receipt of Extracorporeal Membrane Oxygenation Among Patients With Hypoxemic Respiratory Failure
Bibliographic record
Abstract
Background Given the resources and specialized training required to deliver extracorporeal membrane oxygenation (ECMO), the provision of ECMO often is centralized within expert centers. Spurred by recent evidence, the use of ECMO has increased dramatically. However, given the centralized nature of ECMO, it is possible that inequities in access exist. Research Question Does center of admission impact the likelihood of receiving ECMO among adults with moderate or severe acute hypoxemic respiratory failure (Pao 2 to Fio 2 ratio ≤ 200 mm Hg within 48 h of ventilation). Study Design and Methods We performed a retrospective cohort study using data from the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) and Reseau Europeen de Recherche en Ventilation Artificielle (REVA) Influenza A(H1N1) Registry databases. Using modified log-Poisson analysis, we estimated the likelihood of receiving extracorporeal membrane oxygenation (ECMO) (initiation at the admitting hospital or transfer for initiation), adjusting for disease severity over time. To explore unmeasured confounding, we evaluated the association between center of admission on three negative controls: neuromuscular blockade, prone positioning, and dialysis. Results Among 1,581 patients (37.7% female patients; mean age, 60.7 years), 76 patients (4.8%) received ECMO. Longitudinal analysis, adjusted for trends in disease severity, demonstrated that patients admitted to ECMO centers were two times more likely to receive ECMO than those admitted to non-ECMO centers (relative risk [RR], 2.00; 95% CI, 1.17-3.41). Patients at ECMO centers received ECMO 2 days earlier than those at non-ECMO centers: median time to initiation was 1 day (interquartile range, 1-5 days) vs 3 days (interquartile range, 2-5 days; P = .04). Center of admission was not associated with neuromuscular blockade (RR, 1.08; 95% CI, 0.90-1.30), prone positioning (RR, 0.93; 95% CI, 0.68-1.28), or dialysis (RR, 1.04; 95% CI, 0.84-1.27). Interpretation Adults with hypoxemic respiratory failure admitted to ECMO centers were twice as likely to receive ECMO as those admitted to non-ECMO centers. These finding raise concerns regarding equity in access to care and suggest a potential lower threshold among clinicians at ECMO centers for initiation of ECMO.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".