Comment by xkbarkar | Hacker News Reader

Comment by xkbarkar | Hacker News Reader

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I feel the article makes ECMO sounds like a viable common treatment for lung ailments. I have personal experience with ECMO.

Disclaimer: I have no medical training. But I have had two loved ones in ECMO in my life.

An adult age 48 and a premature infant that weighed a little over 600 grams at birth.

The adult died after a very successful month in ECMO during routine change of tubes. Bled to death after a ruptured artery.

The infant survived and is thriving today.

ECMO is highly specialised, very expensive, incredibly intrusive and also requires large amounts of blood plasma. Blood plasma is not an abundant resource.

Just the cost is almost twice that of a standard, expensive cancer treatment.

"The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD". https://pubmed.ncbi.nlm.nih.gov/19699650/#:~:text=Results%3A...).

Cancer treatment cost example

https://www.asbestos.com/featured-stories/high-cost-of-cance....

So adding to the dangers of using ECMO it is also very very costly.

It doesn't make a lot of sense to promote ECMO as casually as this article does.

Hello - it's your friendly neighborhood health economist (and I have worked on a topic adjacent to ECMO machines).

ECMO is unambiguously cost effective (even at US prices!) for the infant. (I'm not defending US prices - needless to say if anything is cost effective at US prices it's passed the hardest cost effectiveness test.) It's also cost effective (even at US prices) for the older patient. Honestly the cited figure of $213,000 is nothing compared to the value of a statistical life (for the infant) or a bit under half of one (for the adult)

There should be more of these machines and they should be in wider use. The possible impact on heart attack mortality alone is enough to justify wider investment and exploratory use more broadly, even if the precise effects end up being smaller than that's cited in the article.

This is a great example of technological change pushing the boundaries of what's possible in health care. (And frankly... even though I am not defending US health care prices, a high price for this new technology is exactly the kind of signal you want to send to entrepreneurial types, several of whom appear in the article. If ECMO can be taken out of the ICU (by some future version of the machine) that seems highly likely to generate huge benefits.)

Sure, there are some moral issues to be worked out. Those issues would be much better worked out while a bunch of patients who would otherwise died are plugged into ECMO machines...

If we want to look at this purely in terms of economics then we have to "discount" the life years saved with a quality adjustment. Most elderly or chronically ill people who undergo ECMO treatment are never able to live independently again even if they are able to get off the machine.

I'm not saying that we shouldn't use ECMO in those cases. But we need to be realistic about probable outcomes and not expect anything like a cure.

You are correct and I’m happy to discount. The older of the two patients in the original example was under 50. That’s a lot of QALYs. Even at an implausibly high discount rate it makes sense.

The outcomes reported in the article are suggestive of a large decrease in mortality due to heart attack. Even assuming the effect is much smaller than reported, more widespread use of ecmo machines makes a lot of sense.

I’m not a domain expert, but I haven’t seen ECMO offered to ‘old’ patients (over ~70). Do you have data on ECMO recipients’ age?

> premature infant that weighed a little over 600 grams at birth [...] and is thriving today

I'm very glad this turned out so well.

Survival rates for infants that premature/small are ~60% (up from basically zero 50 years ago), and many of those who survive have serious long-term issues. Still, since the standard of care started improving in the 1990's, some are now healthy adults.

But many premature babies get weeks or months of distressing care, only to die or become permanent wards. It's extremely difficult for the family, the caregivers, and the child.

It seems a bit off if the health economists only value the lives saved, and do not discount for the pain and suffering of others.

ECMO is the main driver of this. The main issue with prematurity is the underdevelopment of the lungs, and ECMO can give them time to develop minimally.

The law and physician/family relations are the other driver. The presumption to continue best available medical care is extremely strong medically and emotionally, and it's hard to overcome even with sober and clear-eyed participants.

ECMO the machine provides choices that are really, really hard to handle, and it makes working in the NICU a life-altering choice.

I stopped tracking my cancer treatment costs (including surgery) after it broke the $600K mark. And my cancer was relatively common (colorectal) and only Stage II.

Wow. I wish you well. Was this out of pocket?

Fortunately no, I think my total out of pocket costs were around $10K or so; I don't remember the details too much because of chemo brain. We had pretty good health insurance through my wife's company.

Well that's good to hear - take care fellow traveller.

> Just the cost is almost twice that of a standard, expensive cancer treatment.

But unlike cancer treatment a lot of it is mechanical engineering and hence amenable to optimisation if the market were large enough.

But the cost of ECMO is not the machine, it's all things around it such as doctors and nurses, blood plasma, medication etc.

According to the OP link 82% of the cost is not machine related and also not reusable.

"On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%."

If the machine were better designed it would require less manual intervention and the manual work required would be simpler. This would require either fewer hours of expensive personell or it might allow the use of less expensive personell for routine work.

ECMO is not getting "optimized" any time soon. It is solidly a procedure that requires enormous human focus and labor to maintain the conditions that enable it.

And reusable

>Just the cost is almost twice that of a standard, expensive cancer treatment.

When you say that, do you mean one round of treatment or the whole treatment regimen?

My mother passed from cancer recently, and no joke: One round of chemo cost as much as a luxury car, at least a five figure sum; and in her case it was one round every one or twk weeks depending on her condition and schedule. The only reason we could afford it was because she was elderly and had Medicare and good insurance otherwise.

The link he used for cancer costs seems to exclude surgical costs. It also has some questionable hypotheticals, like:

If a cancer patient requires four chemo sessions a year, it could cost them up to $48,000 total, which is beyond the average annual income.

I, like your mother, had treatments weekly unless my white cell count was too low, or my weight loss for the week too low.

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