Medical aspects of lay resuscitations in Rotterdam

Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest

STUDY OBJECTIVE

To measure the incremental cost-effectiveness of various improvements to emergency medical services (EMS) systems aimed at increasing survival after out-of-hospital cardiac arrest.

METHODS

We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the various EMS systems, (2) costing of each component of EMS systems, (3) modeling of the relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteristics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components.

RESULTS

The incremental cost-effectiveness ratio for a 48-second improvement in mean response time in a one-tier EMS system yielded by the addition of more EMS providers was $368,000 per quality-adjusted life year (QALY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53,000 per QALY with pump vehicles or $159,000 per QALY with ambulances. Change from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40,000. Change from one-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94,000.

CONCLUSION

The most attractive options in terms of incremental cost-effectiveness were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time.

Long-term survival after successful out-of-hospital resuscitation

Between 1983 and 1989, 962 patients in Rotterdam were resuscitated outside hospital, of whom 240 (25%) could be discharged alive. A follow-up study was performed to determine prognosis in these patients. Of the 240 survivors of out-of-hospital resuscitation 80% survived after 1 year and 61% after 5 years. During the first year, 9% suffered from myocardial (re)infarction and 13% underwent coronary bypass surgery or angioplasty. Within the first 3 years after resuscitation 60% of the patients were readmitted to hospital. Permanent or temporary neurological deficits were observed in 30 patients (14%). Patients with a primary arrhythmia without myocardial infarction had a worse prognosis than patients with a cardiac arrest in the context of an infarct. Survival was better in patients in whom resuscitation was initiated by physicians or ambulance-nurses, than in patients resuscitated by lay-people. Multivariate analysis revealed that this difference could be explained by a larger proportion of patients with a primary arrhythmia in the latter group. Since long-term prognosis after out-of-hospital resuscitation is satisfactory, programmes for resuscitation courses should be stimulated. Such programmes should aim predominantly at relatives of patients with known heart disease, police officers and children.

Resuscitation of hospitalized patients

Effects of in-hospital resuscitations performed by a trained resuscitation team were studied over a 20-month period during which 1653 deaths were registered. Resuscitative attempts were made in 61 patients with a mean age of 71 years (range 0-86 years). The underlying disease was ischaemic heart disease in 38 cases and most arrests occurred in general wards. Twenty-one patients were initially resuscitated; 12, however, died after an average of 3.2 days while still in hospital. Nine patients were discharged and seven are still alive after two and a half years.