Marten J. Poley - Erasmus Universiteit Rotterdam

Cost-Effectiveness of Neonatal Extracorporeal Membrane Oxygenation in the Netherlands 795.4 DISCUSSIONThis paper has focused attention on the cost-effectiveness of neonatal ECMO inthe Netherlands. One of this study's major strengths lies in its inclusion of anational population of 244 consecutive ECMO-treated neonates. Another strengthwas the inclusion of a comparison group that consisted of adequately similar non-ECMO-treated infants, as (even though the outcome predicted by this modeldiffered from the actual outcome of our study in terms of survival or death) canbe concluded from applying the predictive outcome model described byToomasian et al. 39 The study shows that ECMO in severely ill newborns diagnosedwith CDH or MAS is highly cost-effective. The cost-effectiveness ratios are withinthe range reported for other commonly used treatments in the field of neonatalintensive care, 27,45-50 and, generally, compare favorably to other evaluated healthcare interventions that 'society' considers to be acceptable expenditure of scarceresources. 21,51ECMO appeared to be a labor-intensive and costly technique. Still, costs of ECMOtreatment are considerably lower in our study than in the American studies, whichrelied on charges and sometimes used cost-charge ratios to arrive at costs.Pearson and Short reported initial hospitalization costs of $ 91,804, Walsh-Sukyset al. $ 62,375, Metkus et al. $ 208,000 for CDH patients, and Schumacher et al.$ 53,700 in the late ECMO group. 17-20 Cost differences are even more impressivefor conventional treatment, the cost of which ranges from $ 59,268 to $ 93,524 inthe American studies. 17,19,20 These differences are probably for a large part due tothe fact that treatment costs are lower for many medical interventions in theNetherlands than in the USA. 52 More specifically, one possible explanation is theuse of inhaled nitric oxide (iNO), for which high prices have been charged in theUSA and which was available in the USA many years earlier than in theNetherlands. It is difficult to say whether these differences can be explained byvariations in the length of the average hospital stay, because the literaturefrequently does not give an account of these data, with a distinction madebetween the different diagnostic categories. What can be compared is theaverage length of an ECMO run. For the CDH patients in our study, the run timewas practically equal to the figure reported by the Extracorporeal Life SupportOrganization (ELSO) (mean, 229 hours). 53 However, for the infants with MAS, theaverage ECMO duration in this study outweighed that of the patients who appearin the ELSO database (163 v 129 hours). Unlike studies that found an increase inthe average length of an ECMO run since the 1990s, 26,54,55 which probably reflectsa more complex patient case mix, the length of bypass appeared to be stableover time in this study.We found survival probabilities of 52% (CDH) and 94% (MAS). These outcomesare nearly identical to those reported by ELSO. 53 Although not every study hasshown positive effects, especially in CDH patients, 56-58 there is growing evidencethat the introduction of ECMO accounts for enhanced survival rates in selected,