Abstract
ObjectiveOptimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States.DesignCross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008–2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims.SettingNonfederal acute care hospitals in the United States.Measurements and Main ResultsWe defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air.ConclusionsGeographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.
Highlights
An estimated 332,100 cases of severe respiratory from acute respiratory distress syndrome (ARDS) occur in the United States each year, resulting in approximately 133,500 deaths [1] as well as significant long-term morbidity [2,3]
A volume-outcome relationship exists for mechanically ventilated medical patients, with higher annual hospital volumes associated with improved patient outcomes [9]
We defined geographic access as the percentage of the adult population living within a one-hour driving radius of a high capability center, plus the percentage of the adult population living within a one-hour driving radius of hospitals that may refer patients to these centers
Summary
An estimated 332,100 cases of severe respiratory from acute respiratory distress syndrome (ARDS) occur in the United States each year, resulting in approximately 133,500 deaths [1] as well as significant long-term morbidity [2,3]. Treatment for ARDS and other forms of severe acute respiratory failure is resource intensive and requires specialized care for optimal patient outcomes [4,5,6,7]. This level of care is typically not available at all hospitals, suggesting that patient outcomes may be improved by directing more seriously ill patients to high capability centers [8]. There are no established hospital criteria for high capability centers for severe acute respiratory failure; candidate criteria include high mechanical ventilation hospital volumes or the ability to perform extracorporeal membrane oxygenation (ECMO). Patients treated at hospitals with ECMO capability have improved outcomes with severe ARDS [8] and a more than two-fold mortality benefit with influenza H1N1-associated ARDS [10]
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