Cost effectiveness of defibrillation by targeted responders in public settings

Economic evaluation of automated external defibrillator deployment in public settings for out-of-hospital cardiac arrest: a systematic review

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major issue in aging populations. The use of automatic external defibrillators (AEDs) in public places improves cardiac arrest survival rates. The purpose of this study is to review economic evaluation studies of the use of AED technology in public settings for cardiac arrest resuscitation.

METHODS

Our search covered 1990-2021 and included PubMed, Cochrane Library, Embase, Scopus, and Web of Science. We included studies that analyzed cost-effectiveness, cost-utility and cost-benefit of the AED technology. Also, we performed the quality assessment of the studies through the checklist of quality assessment standard of health economic studies (QHES).

RESULTS

Our inclusion criteria were met by 25 studies. AEDs are found to be cost-effective in places with a high occurrence of cardiac arrest. In addition, proper integration of drones with AEDs into existing systems has the potential to significantly improve OHCA survival rates.

CONCLUSION

The present study found that putting AEDs in high-cardiac arrest and crowded areas reduces average costs. Despite this, the costs associated with acquiring and maintaining AEDs prevent their widespread use. Further research is needed to evaluate feasibility and explore innovative strategies for AED maintenance and accessibility.

Optimizing Outcomes After Out-of-Hospital Cardiac Arrest With Innovative Approaches to Public-Access Defibrillation: A Scientific Statement From the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: A scientific statement from the International Liaison Committee on Resuscitation

Out-of-hospital cardiac arrest is a global public health issue experienced by ≈3.8 million people annually. Only 8% to 12% survive to hospital discharge. Early defibrillation of shockable rhythms is associated with improved survival, but ensuring timely access to defibrillators has been a significant challenge. To date, the development of public-access defibrillation programs, involving the deployment of automated external defibrillators into the public space, has been the main strategy to address this challenge. Public-access defibrillator programs have been associated with improved outcomes for out-of-hospital cardiac arrest; however, the devices are used in <3% of episodes of out-of-hospital cardiac arrest. This scientific statement was commissioned by the International Liaison Committee on Resuscitation with 3 objectives: (1) identify known barriers to public-access defibrillator use and early defibrillation, (2) discuss established and novel strategies to address those barriers, and (3) identify high-priority knowledge gaps for future research to address. The writing group undertook systematic searches of the literature to inform this statement. Innovative strategies were identified that relate to enhanced public outreach, behavior change approaches, optimization of static public-access defibrillator deployment and housing, evolved automated external defibrillator technology and functionality, improved integration of public-access defibrillation with existing emergency dispatch protocols, and exploration of novel automated external defibrillator delivery vectors. We provide evidence- and consensus-based policy suggestions to enhance public-access defibrillation and guidance for future research in this area.

Alert system-supported lay defibrillation and basic life-support for cardiac arrest at home

Aims

Automated external defibrillators (AEDs) are placed in public, but the majority of out-of-hospital cardiac arrests (OHCA) occur at home.

Methods and results

In residential areas, 785 AEDs were placed and 5735 volunteer responders were recruited. For suspected OHCA, dispatchers activated nearby volunteer responders with text messages, directing two-thirds to an AED first and one-third directly to the patient. We analysed survival (primary outcome) and neurologically favourable survival to discharge, time to first defibrillation shock, and cardiopulmonary resuscitation (CPR) before Emergency Medical Service (EMS) arrival of patients in residences found with ventricular fibrillation (VF), before and after introduction of this text-message alert system. Survival from OHCAs in residences increased from 26% to 39% {adjusted relative risk (RR) 1.5 [95% confidence interval (CI): 1.03–2.0]}. RR for neurologically favourable survival was 1.4 (95% CI: 0.99–2.0). No CPR before ambulance arrival decreased from 22% to 9% (RR: 0.5, 95% CI: 0.3–0.7). Text-message-responders with AED administered shocks to 16% of all patients in VF in residences, while defibrillation by EMS decreased from 73% to 39% in residences (P < 0.001). Defibrillation by first responders in residences increased from 22 to 40% (P < 0.001). Use of public AEDs in residences remained unchanged (6% and 5%) (P = 0.81). Time from emergency call to defibrillation decreased from median 11.7 to 9.3 min; mean difference –2.6 (95% CI: –3.5 to –1.6).

Conclusion

Introducing volunteer responders directed to AEDs, dispatched by text-message was associated with significantly reduced time to first defibrillation, increased bystander CPR and increased overall survival for OHCA patients in residences found with VF.

Effect of Optimized Versus Guidelines-Based Automated External Defibrillator Placement on Out-of-Hospital Cardiac Arrest Coverage: An In Silico Trial

Background

Mathematical optimization of automated external defibrillator (AED) placement may improve AED accessibility and out‐of‐hospital cardiac arrest (OHCA) outcomes compared with American Heart Association (AHA) and European Resuscitation Council (ERC) placement guidelines. We conducted an in silico trial (simulated prospective cohort study) comparing mathematically optimized placements with placements derived from current AHA and ERC guidelines, which recommend placement in locations where OHCAs are usually witnessed.

Methods and Results

We identified all public OHCAs of presumed cardiac cause from 2008 to 2016 in Copenhagen, Denmark. For the control, we computationally simulated placing 24/7‐accessible AEDs at every unique, public, witnessed OHCA location at monthly intervals over the study period. The intervention consisted of an equal number of simulated AEDs placements, deployed monthly, at mathematically optimized locations, using a model that analyzed historical OHCAs before that month. For each approach, we calculated the number of OHCAs in the study period that occurred within a 100‐m route distance based on Copenhagen’s road network of an available AED after it was placed (“OHCA coverage”). Estimated impact on bystander defibrillation and 30‐day survival was calculated by multivariate logistic regression. The control scenario involved 393 AEDs at historical, public, witnessed OHCA locations, covering 15.8% of the 653 public OHCAs from 2008 to 2016. The optimized locations provided significantly higher coverage (24.2%; P<0.001). Estimated bystander defibrillation and 30‐day survival rates increased from 15.6% to 18.2% (P<0.05) and from 32.6% to 34.0% (P<0.05), respectively. As a baseline, the 1573 real AEDs in Copenhagen covered 14.4% of the OHCAs.

Conclusions

Mathematical optimization can significantly improve OHCA coverage and estimated clinical outcomes compared with a guidelines‐based approach to AED placement.

AED and text message responders density in residential areas for rapid response in out-of-hospital cardiac arrest

BACKGROUND

For out-of-hospital cardiac arrest (OHCA) in residential areas, a dispatcher driven alert-system using text messages (TM-system) directing local rescuers (TM-responders) to OHCA patients was implemented and the desired density of automated external defibrillators (AEDs) or TM-responders investigated.

METHODS

We included OHCA cases with the TM-system activated in residential areas between 2010-2017. For each case, densities/km² of activated AEDs and TM-responders within a 1000 m circle were calculated. Time intervals between 112-call and first defibrillation were calculated.

RESULTS

In total, 813 patients (45%) had a shockable initial rhythm. In 17% a TM-system AED delivered the first shock. With increasing AED density, the median time to shock decreased from 10:59 to 08:17 min. (p < 0.001) and shocks <6 min increased from 6% to 12% (p = 0.024). Increasing density of TM-responders was associated with a decrease in median time to shock from 10:59 to 08:20 min. (p < 0.001) and increase of shocks <6 min from 6% to 13% (p = 0.005). Increasing density of AEDs and TM-responders resulted in a decline of ambulance first defibrillation by 19% (p = 0.016) and 22% (p = 0.001), respectively. First responder AED defibrillation did not change significantly. Densities of >2 AEDs/km² did not result in further decrease of time to first shock but >10 TM-responders/km² resulted in more defibrillations <6 min.

CONCLUSION

With increasing AED and TM-responder density within a TM-system, time to defibrillation in residential areas decreased. AED and TM-responders only competed with ambulances, not with first responders. The recommended density of AEDs and TM-responders for earliest defibrillation is 2 AEDs/km² and >10 TM-responders/km².

Different defibrillation strategies in survivors after out-of-hospital cardiac arrest

BACKGROUND

In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival.

METHODS

We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded.

RESULTS

A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm.

CONCLUSION

Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.

Singapore Defibrillation Guidelines 2016

The most common initial rhythm in a sudden cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. This is potentially treatable with defibrillation, especially if provided early. However, any delay in defibrillation will result in a decline in survival. Defibrillation requires coordination with the cardiopulmonary resuscitation component for effective resuscitation. These two components, which form the key links in the chain of survival, have to be brought to the cardiac victim in a timely fashion. An effective chain of survival is needed in both the institution and community settings.

Bystander automated external defibrillator use and clinical outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis

AIM

To systematically review studies comparing bystander automated external defibrillator (AED) use to no AED use in regard to clinical outcomes in out-of-hospital cardiac arrest (OHCA), and to provide a descriptive summary of studies on the cost-effectiveness of bystander AED use.

METHODS

We searched Medline, Embase, the Web of Science, and the Cochrane Library for randomized trials and observational studies published before June 1, 2017. Meta-analyses were performed for patients with all rhythms, shockable rhythms, and non-shockable rhythms.

RESULTS

Forty-four observational studies, 3 randomized trials, and 13 cost-effectiveness studies were included. Meta-analysis of 6 observational studies without critical risk of bias showed that bystander AED use was associated with survival to hospital discharge (all rhythms OR: 1.73 [95%CI: 1.36, 2.18], shockable rhythms OR: 1.66 [95%CI: 1.54, 1.79]) and favorable neurological outcome (all rhythms OR: 2.12 [95%CI: 1.36, 3.29], shockable rhythms OR: 2.37 [95%CI: 1.58, 3.57]). There was no association between bystander AED use and neurological outcome for non-shockable rhythms (OR: 0.76 [95%CI: 0.10, 5.87]). The Public-Access Defibrillation trial found higher survival rates when volunteers were equipped with AEDs. The other trials found no survival difference, although their study settings differed. The quality of evidence was low for randomized trials and very low for observational studies. AEDs were cost-effective in settings with high cardiac arrest incidence, with most studies reporting ratios < $100,000 per quality-adjusted life years.

CONCLUSIONS

The evidence supports the association between bystander AED use and improved clinical outcomes, although the quality of evidence was low to very low.

Automated external defibrillator and operator performance in out-of-hospital cardiac arrest

AIM

An increasing number of failing automated external defibrillators (AEDs) is reported: AEDs not giving a shock or other malfunction. We assessed to what extent AEDs are 'failing' and whether this had a device-related or operator-related cause.

METHODS

We studied analysis periods from AEDs used between January 2012 and December 2014. For each analysis period we assessed the correctness of the (no)-shock advice (sensitivity/specificity) and reasons for an incorrect (no)-shock advice. If no shock was delivered after a shock advice, we assessed the reason for no-shock delivery.

RESULTS

We analyzed 1114 AED recordings with 3310 analysis periods (1091 shock advices; 2219 no-shock advices). Sensitivity for coarse ventricular fibrillation was 99% and specificity for non-shockable rhythm detection 98%. The AED gave an incorrect shock advice in 4% (44/1091) of all shock advices, due to device-related (n=15) and operator-related errors (n=28) (one unknown). Of these 44 shock advices, only 2 shocks caused a rhythm change. One percent (26/2219) of all no-shock advices was incorrect due to device-related (n=20) and operator-related errors (n=6). In 5% (59/1091) of all shock advices, no shock was delivered: operator failed to deliver shock (n=33), AED was removed (n=17), operator pushed 'off' button (n=8) and other (n=1). Of the 1073 analysis periods with a shockable rhythm, 67 (6%) did not receive an AED shock.

CONCLUSION

Errors associated with AED use are rare (4%) and when occurring are in 72% caused by the operator or circumstances of use. Fully automatic AEDs may prevent the majority of these errors.

Effective deployment of public-access automated external defibrillators to improve out-of-hospital cardiac arrest outcomes

Out‐of‐hospital cardiac arrest (OHCA) is a major health concern in Japan and other developed countries with aging populations. Improvements in OHCA outcomes require streamlining the chain of survival. Deployment of public‐access automated external defibrillators (PADs) and defibrillation by bystanders is one strategy that may streamline the chain by reducing the time to defibrillation in individuals with shockable rhythms. Although the effectiveness of PAD programs in increasing survival to discharge has been reported, there have been criticisms and concerns about the small population impact, cost‐effectiveness, and potential negative impact on those with nonshockable rhythms. This article reviews relevant literature regarding the effectiveness and concerns regarding PAD for OHCA.

Wearable cardioverter-defibrillator for prevention of sudden cardiac death after infected implantable cardioverter-defibrillator removal: A cost-effectiveness evaluation

BACKGROUND

Prevention of sudden cardiac arrest (SCA) after removal of an infected implantable cardioverter-defibrillator (ICD) is a challenging clinical dilemma. The cost-effectiveness of the wearable cardioverter-defibrillator (WCD) in this setting remains uncertain.

OBJECTIVE

The purpose of this study was to compare the cost-effectiveness of the WCD with discharge home, discharge to a skilled nursing facility, or inpatient monitoring for the prevention of SCA after infected ICD removal.

METHODS

A decision model was developed to compare the cost-effectiveness of use of the WCD to several different strategies for patients who undergo ICD removal. One-way and 2-way sensitivity analyses were performed to account for uncertainties.

RESULTS

In the base-case analysis, the incremental cost-effectiveness of the WCD strategy was $20,300 per life-year (LY) or $26,436 per quality-adjusted life-year (QALY) compared to discharge home without a WCD. Discharge to a skilled nursing facility and in-hospital monitoring resulted in higher costs and worse clinical outcomes. The incremental cost-effectiveness ratio was as low as $15,392/QALY if the WCD successfully terminated 95% of SCA events and exceeded the $50,000/QALY willingness-to-pay threshold if the efficacy was <69%.The WCD strategy remained cost-effective, assuming 5.6% 2-month SCA risk, as long as the time to reimplantation was at least 2 weeks.

CONCLUSION

The WCD likely is cost-effective in protecting patients against SCA after infected ICD removal while waiting for ICD reimplantation compared to keeping patients in the hospital or discharging them home or to a skilled nursing facility.

Cost-effectiveness of a national public access defibrillation programme

AIM

Proposed Irish legislation aimed at increasing survival from out-of-hospital-cardiac-arrest (OHCA) mandates the provision of automated external defibrillators (AEDs) in a comprehensive range of publicly accessible premises in urban and rural areas. This study estimated the clinical and cost effectiveness of the legislation, compared with alternative programme configurations involving more targeted AED placement.

METHODS

We used a cost-utility analysis to estimate the costs and consequences of public access defibrillation (PAD) programmes from a societal perspective, based on AED deployment by building type. Comparator programmes ranged from those that only included building types with the highest incidence of OHCA, to the comprehensive programme outline in the proposed legislation. Data on OHCA incidence and outcomes were obtained from the Irish Out-of-Hospital-Cardiac-Arrest Register (OHCAR). Costs were obtained from the Irish health service, device suppliers and training providers.

RESULTS

The incremental cost effectiveness ratio (ICER) for the most comprehensive PAD scheme was €928,450/QALY. The ICER for the most scaled-back programme involving AED placement in transport stations, medical practices, entertainment venues, schools (excluding primary) and fitness facilities was €95,640/QALY. A 40% increase in AED utilisation when OHCAs occur in a public area could potentially render this programme cost effective.

CONCLUSION

National PAD programmes involving widespread deployment of static AEDs are unlikely to be cost-effective. To improve cost-effectiveness any prospective programmes should target locations with the highest incidence of OHCA and be supported by efforts to increase AED utilisation, such as improving public awareness, increasing CPR and AED training, and establishing an EMS-linked AED register.

Monte Carlo simulation of the cost-effectiveness of sample size maintenance programs revealed the need to consider substitution sampling

OBJECTIVE

To assess the cost-effectiveness of sample size maintenance programs in a prospective cohort.

STUDY DESIGN AND SETTING

The Living with Diabetes Study in Queensland, Australia is a longitudinal survey providing a comprehensive examination of health care utilization and disease progression among people with diabetes. Data from this study were used to compare the cost-effectiveness of a program incorporating substitution sampling with two alternative programs: "no follow-up" and "usual practice."

RESULTS

A program involving substitution sampling was shown to be the most effective with an additional 3,556 complete responses (compared with a "no follow-up" program) and an additional 2,099 complete responses (compared with "usual practice"). An incremental analysis through a Monte Carlo simulation found substitution sampling to be the most cost-effective option for maintaining sample size with an incremental cost-effective ratio of $54.87 (95% uncertainty interval $52.68-$57.25) compared with $87.58 ($77.89-$100.09) for "usual practice."

CONCLUSIONS

Based on the available data, a program involving substitution sampling is economically justified and should be considered in any approach with the aim of maintaining sample size. There is, however, a continuing need to evaluate the effectiveness of this option on other outcome measures, such as bias.

Favourable cost-benefit in an early defibrillation programme using dual dispatch of ambulance and fire services in out-of-hospital cardiac arrest

AIMS

Out-of-hospital cardiac arrest is fatal without treatment, and time to defibrillation is an extremely important factor in relation to survival. We performed a cost-benefit analysis of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm, Sweden.

METHODS AND RESULTS

A cost-benefit analysis was performed to evaluate the effects of dual dispatch defibrillation. The increased survival rates were estimated from a real-world implemented intervention, and the monetary value of a life (<euro> 2.2 million) was applied to this benefit by using results from a recent stated-preference study. The estimated costs include defibrillators (including expendables/maintenance), training, hospitalisation/health care, fire service call-outs, overhead resources and the dispatch centre. The estimated number of additional saved lives was 16 per year, yielding a benefit-cost ratio of 36. The cost per quality-adjusted life years (QALY) was estimated to be <euro> 13,000, and the cost per saved life was <euro> 60,000.

CONCLUSIONS

The intervention of dual dispatch defibrillation by ambulance and fire services in the County of Stockholm had positive economic effects. For the cost-benefit analysis, the return on investment was high and the cost-effectiveness showed levels below the threshold value for economic efficiency used in Sweden. The cost-utility analysis categorises the cost per QALY as medium.

The introduction of public access defibrillation to a university community: the University of Virginia public access defibrillation program

The use of the automatic external defibrillator (AED) can significantly reduce the time to defibrillation in patients with sudden cardiac death. This early defibrillation via the AED can also improve patient outcome, including survival and neurologic status among survivors. We undertook the addition of a public access defibrillation program at a large mid-Atlantic university. In our design of the system, we found little useful information to guide us in the development and construction our system. This article is a review of the process of public access defibrillation AED system development such that other medical and academic leaders at similar institutions can more easily develop such systems.

CPR in the nursing home: fool's errand or looming dilemma?

BACKGROUND

The indications for CPR (cardiopulmonary resuscitation) have expanded greatly since the technique was introduced and theoretically it can be attempted on all prior to death. Policy initiatives (such as the British Medical Association/Royal College of Nursing guidelines) have attempted to provide a clinical rationale for the withholding of inappropriate CPR. Traditionally a care home was felt to be an inappropriate environment to attempt CPR but increased use of advance directives may bring the issue to the fore in this setting.

AIMS

We elicited the views of managers of care homes regarding resuscitation strategies in hypothetical situations and in actual practice.

METHOD

A purpose designed questionnaire in two parts was compiled, gathering factual information and employing a Likert scale to gauge opinion about this issue. The survey was conducted among 187 continuing care homes in South London the subjects being the care managers of the homes surveyed.

RESULTS AND CONCLUSION

Responses were obtained from 86 care homes. Care managers would resuscitate 66% of cases of witnessed cardiac arrest but few efforts were reported. Policies in assigning 'Do not resuscitate' orders were referred to by only 9% of homes but 80% of facilities would welcome them, yet 50% would exclude the patient from this discussion. Clear policy guidelines are required for continuing care homes, and advance statements about CPR as part of residents care plans could reduce inappropriate resuscitative efforts and hospital transfers.

The effectiveness and cost effectiveness of public-access defibrillation

Many sudden cardiac deaths are due to ventricular fibrillation (VF). The use of defibrillators in hospitals or by outpatient emergency medical services (EMS) personnel can save many cardiac-arrest victims. Automated external defibrillators (AEDs) permit defibrillation by trained first responders and laypersons. AEDs are available at most public venues, and vast sums of money are spent installing and maintaining these devices. AEDs have been evaluated in a variety of public and private settings. AEDs accurately identify malignant ventricular tachyarrhythmias and frequently result in successful defibrillation. Prompt application of an AED shows a greater number of patients in VF compared with initial rhythms documented by later-arriving EMS personnel. Survival is greatest when the AED is placed within 3 to 5 minutes of a witnessed collapse. Community-based studies show increased cardiac-arrest survival when first responders are equipped with AEDs rather than waiting for paramedics to defibrillate. Wide dissemination of AEDs throughout a community increases survival from cardiac arrest when the AED is used; however, the AEDs are utilized in a very small percentage of all out-of-hospital cardiac arrests. AEDs save very few lives in residential units such as private homes or apartment complexes. AEDs are cost effective at sites where there is a high density of both potential victims and resuscitators. Placement at golf courses, health clubs, and similar venues is not cost effective; however, the visible devices are good for public awareness of the problem of sudden cardiac death and provide reassurance to patrons.

Differences between out-of-hospital cardiac arrest in residential and public locations and implications for public-access defibrillation

BACKGROUND

The majority of out-of-hospital cardiac arrests (OHCAs) occur in residential locations, but knowledge about strategic placement of automated external defibrillators in residential areas is lacking. We examined whether residential OHCA areas suitable for placement of automated external defibrillators could be identified on the basis of demographic characteristics and characterized individuals with OHCA in residential locations.

METHODS AND RESULTS

We studied 4828 OHCAs in Copenhagen between 1994 and 2005. The incidence and characteristics of OHCA were examined in every 100 x 100-m (109.4 x 109.4-yd) residential area according to its underlying demographic characteristics. By combining > or =2 demographic characteristics, it was possible to identify 100 x 100-m (109.4 x 109.4-yd) areas with at least 1 arrest every 5.6 years (characterized by >300 persons per area and lowest income) to 1 arrest every 4.3 years (characterized by >300 persons per area, lowest income, low education, and highest age). These areas covered 9.0% and 0.8% of all residential OHCAs, respectively. Individuals with OHCA in residential locations differed from public ones in that the patients were older (70.6 versus 60.6 years; P<0.0001), the ambulance response interval was longer (6.0 versus 5.0 minutes; P<0.0001), arrests occurred more often at night (21.2% versus 11.2%; P<0.0001), the patients had ventricular fibrillation less often (12.8% versus 38.1%; P<0.0001), and the patients had a worse 30-day survival rate (3.2% versus 13.9%; P<0.0001).

CONCLUSIONS

On the basis of simple demographic characteristics of a city center, we could identify residential areas suitable for automated external defibrillator placement. Individuals with OHCA in residential locations were more likely to have characteristics associated with poor outcome compared with public arrests.

Hospital costs and revenue are similar for resuscitated out-of-hospital cardiac arrest and ST-segment acute myocardial infarction patients

OBJECTIVES

Care provided to patients who survive to hospital admission after out-of-hospital cardiac arrest (OOHCA) is sometimes viewed as expensive and a poor use of hospital resources. The objective was to describe financial parameters of care for patients resuscitated from OOHCA.

METHODS

This was a retrospective review of OOHCA patients admitted to one academic teaching hospital from January 2004 to October 2007. Demographic data, length of stay (LOS), and discharge disposition were obtained for all patients. Financial parameters of patient care including total cost, net revenue, and operating margin were calculated by hospital cost accounting and reported as median and interquartile range (IQR). Groups were dichotomized by survival to discharge for subgroup analysis. To provide a reference group for context, similar financial data were obtained for ST-segment elevation myocardial infarction (STEMI) patients admitted during the same time period, reported with medians and IQRs.

RESULTS

During the study period, there were 72 admitted OOCHA patients and 404 STEMI patients. OOCHA and STEMI groups were similar for age, sex, and insurance type. Overall, 27 (38.6%) OOHCA patients survived to hospital discharge. Median LOS for OOHCA patients was 4 days (IQR = 1-8 days), with most of those hospitalized for <or=4 days (n = 34, 81.0% dying or discharged to hospice care). Median net revenue ($17,334 [IQR $7,015-$37,516] vs. $16,466 [IQR = $14,304-$23,678], p = 0.64) and operating margin ($7,019 [IQR = $1,875-$15,997] vs. $7,098 [IQR = $3,767-$11,138], p = 0.83) for all OOHCA patients were not different from STEMI patients. Net income for OOCHA patients was not different than for STEMI patients (-$322 vs. $114, p = 0.72).

CONCLUSIONS

Financial parameters for OOHCA patients are similar to those of STEMI patients. Financial issues should not be a negative incentive to providing care for these patients.

Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes

BACKGROUND

Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness.

OBJECTIVE

To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening.

DESIGN

Decision-analysis, cost-effectiveness model.

DATA SOURCES

Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data.

TARGET POPULATION

Competitive athletes in high school and college aged 14 to 22 years.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease.

OUTCOME MEASURE

Incremental health care cost per life-year gained.

RESULTS OF BASE-CASE ANALYSIS

Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000).

RESULTS OF SENSITIVITY ANALYSIS

Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening.

LIMITATIONS

Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries.

CONCLUSION

Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective.

PRIMARY FUNDING SOURCE

Stanford Cardiovascular Institute and the Breetwor Foundation.

Location of cardiac arrest in a city center: strategic placement of automated external defibrillators in public locations

BACKGROUND

Public-access defibrillation with automated external defibrillators (AEDs) is being implemented in many countries worldwide with considerable financial implications. The potential benefit and economic consequences of focused or unfocused AED deployment are unknown.

METHODS AND RESULTS

All cardiac arrests in public in Copenhagen, Denmark, from 1994 through 2005 were geographically located, as were 104 public AEDs placed by local initiatives. In accordance with European Resuscitation Council and American Heart Association (AHA) guidelines, areas with a high incidence of cardiac arrests were defined as those with 1 cardiac arrest every 2 or 5 years, respectively. There were 1274 cardiac arrests in public locations. According to the European Resuscitation Council or AHA guidelines, AEDs needed to be deployed in 1.2% and 10.6% of the city area, providing coverage for 19.5% (n=249) and 66.8% (n=851) of all cardiac arrests, respectively. The excessive cost of such AED deployments was estimated to be $33 100 or $41 000 per additional quality-adjusted life year, whereas unguided AED placement covering the entire city had an estimated cost of $108 700 per quality-adjusted life year. Areas with major train stations (1.8 arrests every 5 years per area), large public squares, and pedestrianized areas (0.6 arrests every 5 years per area) were main predictors of frequent cardiac arrests.

CONCLUSIONS

To achieve wide AED coverage, AEDs need to be more widely distributed than recommended by the European Resuscitation Council guidelines but consistent with the American Heart Association guidelines. Strategic placement of AEDs is pivotal for public-access defibrillation, whereas with unguided initiatives, AEDs are likely to be placed inappropriately.

Community public access sites: compliance with American Heart Association recommendations

BACKGROUND

Public access defibrillation (PAD) programs are a major goal of the American Heart Association (AHA) to ensure that automated external defibrillators and trained lay rescuers are available in public areas where sudden cardiac arrest (SCA) is likely to occur. The Johnson County Early Defibrillation Task Force (JCEDTF) is a volunteer organization which distributed AEDs throughout Johnson County, Iowa. JCEDTF was responsible for initial training but ongoing support was the responsibility of each site.

OBJECTIVE

The purpose of this study was to evaluate compliance of community PAD sites to recommendations for site maintenance as proposed by the American Heart Association (AHA).

METHODS

Thirty-two surveys were distributed to community PAD sites that received assistance from JCEDTF. PAD sites were categorized into business, educational, or community sites. A twenty-five point scoring system to assess PDA programs was developed based on AHA recommendations. On-site evaluations were conducted to verify survey results and assess barriers to an effective PAD site. Differences among the three categories were measured with ANOVA.

RESULTS

No site was able to comply with all the AHA guidelines for a PAD site. The mean score among all sites was 57% of possible points with no significant differences among the three categories. Business sites were more compliant with ongoing training compared to educational and community sites (p<0.022).

CONCLUSIONS

Community PAD sites in Johnson County currently do not comply with the recommendations for effective PAD sites. After initial training and establishment of community PAD sites, better methods for assuring ongoing training and maintenance are needed for sites to be effective.

Fire fighters as basic life support responders: a study of successful implementation

BACKGROUND

First responders are recommended as a supplement to the Emergency Medical Services (EMS) in order to achieve early defibrillation. Practical and organisational aspects are essential when trying to implement new parts in the "Chain of Survival"; areas to address include minimizing dispatch time, ensuring efficient and quick communication, and choosing areas with appropriate driving distances. The aim of this study was to implement a system using Basic Life Support (BLS) responders equipped with an automatic external defibrillator in an area with relatively short emergency medical services' response times. Success criteria for implementation was defined as arrival of the BLS responders before the EMS, attachment (and use) of the AED, and successful defibrillation.

METHODS

This was a prospective observational study from September 1, 2005 to December 31, 2007 (28 months) in the city of Aarhus, Denmark. The BLS responder system was implemented in an area up to three kilometres (driving distance) from the central fire station, encompassing approximately 81,500 inhabitants. The team trained on each shift and response times were reduced by choice of area and by sending the alarm directly to the fire brigade dispatcher.

RESULTS

The BLS responders had 1076 patient contacts. The median response time was 3.5 minutes (25th percentile 2.75, 75th percentile 4.25). The BLS responders arrived before EMS in 789 of the 1076 patient contacts (73%). Cardiac arrest was diagnosed in 53 cases, the AED was attached in 29 cases, and a shockable rhythm was detected in nine cases. Eight were defibrillated using an AED. Seven of the eight obtained return of spontaneous circulation (ROSC). Six of the seven obtaining ROSC survived more than 30 days.

CONCLUSION

In this study, the implementation of BLS responders may have resulted in successful resuscitations. On basis of the close corporation between all participants in the chain of survival this project contributed to the first link: short response time and trained personnel to ensure early defibrillation.

Marketing defibrillation training programs and bystander intervention support

This exploratory study identifies perceptions of and participation in resuscitation training programs, and bystanders' willingness to resuscitate cardiac arrest victims. While most of the study's participants greatly appreciate the importance of saving someone's life, many indicated that they did not feel comfortable assuming this role. The findings also demonstrate there is a relationship between type of victim and bystanders' willingness to intervene. Yet, bystander intervention discomfort can be overcome with cardiopulmonary resuscitation and defibrillation training, particularly when the victim is a coworker or stranger. Further implications of these findings are discussed and modifications to public access defibrillation (PAD) training programs' strategy and communications are proposed.

Measuring the value of public health systems: the disconnect between health economists and public health practitioners

We investigated ways of defining and measuring the value of services provided by governmental public health systems. Our data sources included literature syntheses and qualitative interviews of public health professionals. Our examination of the health economic literature revealed growing attempts to measure value of public health services explicitly, but few studies have addressed systems or infrastructure. Interview responses demonstrated no consensus on metrics and no connection to the academic literature. Key challenges for practitioners include developing rigorous, data-driven methods and skilled staff; being politically willing to base allocation decisions on economic evaluation; and developing metrics to capture "intangibles" (e.g., social justice and reassurance value). Academic researchers evaluating the economics of public health investments should increase focus on the working needs of public health professionals.

The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers

OBJECTIVE

To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative (HDC), a national collaborative quality improvement (QI) program conducted in community health centers (HCs).

DATA SOURCES/STUDY SETTING

Data regarding the impact of the Diabetes HDC program came from a serial cross-sectional follow-up study (1998, 2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies.

STUDY DESIGN

We conducted a societal cost-effectiveness analysis, incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes.

DATA COLLECTION/EXTRACTION METHODS

Data on diabetes care processes and risk factor levels were extracted from medical charts of randomly selected patients.

PRINCIPAL FINDINGS

From 1998 to 2002, multiple processes of care (e.g., glycosylated hemoglobin testing [HbA1C] [71-->92 percent] and ACE inhibitor prescribing [33-->55 percent]) and risk factor levels (e.g., 1998 mean HbA1C 8.53 percent, mean difference 0.45 percent [95 percent confidence intervals -0.72, -0.17]) improved significantly. With these improvements, the HDC was estimated to reduce the lifetime incidence of blindness (17-->15 percent), end-stage renal disease (18-->15 percent), and coronary artery disease (28-->24 percent). The average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was $33,386/QALY.

CONCLUSIONS

During the first 4 years of the HDC, multiple improvements in diabetes care were observed. If these improvements are maintained or enhanced over the lifetime of patients, the HDC program will be cost-effective for society based on traditionally accepted thresholds.

[Public access defibrillation. Limited use by trained first responders and laymen]

As ventricular fibrillation is the most frequent initial heart rhythm causing out-of-hospital sudden cardiac arrest, defibrillation is of essential significance. Automated external defibrillators (AEDs) have been available for some years and as a result defibrillation can be carried out by individuals other than physicians and healthcare providers such as trained first responders and untrained lay rescuers. This so-called public access defibrillation nourished hope of progress in the treatment of sudden cardiac arrest. However, several limitations exist, such as low frequency of sudden cardiac arrest in public, rare use of publicly placed AEDs, low cost effectiveness, legal requirements and insufficient public willingness to help. Due to these restrictions of public access defibrillation other measures are more promising than the attempt at general distribution of AEDs. These measures are primary or secondary prophylaxis of sudden cardiac arrest, general knowledge of adequate activation of emergency medical services, implementation of first responder teams equipped with AEDs and particularly a better education in and application of the well-established principles of cardiopulmonary resuscitation.

Assessing automated external defibrillators in preventing deaths from sudden cardiac arrest: An economic evaluation

Objectives:The aim of this study was to evaluate the cost-effectiveness of on-site automated external defibrillators (AEDs) in the initial management of cardiac arrest in Ontario.

Methods:This was a cost-effectiveness analysis based on published literature and data from the Canadian Institute of Health Information. The participants were fictitious male and female cardiac arrest patients who were initially managed with on-site AEDs, compared with similar patients managed without on-site AEDs. This group included a subgroup of high-risk patients (i.e., heart failure and left ventricular ejection fraction <35 percent). The analysis was conducted in a variety of settings including hospitals and homes in Ontario, Canada. The main outcome evaluated was cost per quality-adjusted life-year (QALY) gained from a payer's perspective.

Results:Cost per QALY (all costs reported in Canadian dollars) was $12,768 when AEDs were deployed in hospitals, $511,766 when deployed in office buildings, $2,360,023 when deployed in apartment buildings, $87,569 when deployed in homes of high-risk patients, and $1,529,371 when deployed in homes of people older than 55 years of age.

Conclusions:Indiscriminate deployment of AEDs is not a cost-effective means of improving health outcomes of cardiac arrest. Their use should be restricted to emergency response programs, high-risk sites (such as hospitals), and high-risk patients.

Cost-effectiveness of automated external defibrillators in public places: pro

PURPOSE OF REVIEW

Placement of automated external defibrillators in public facilities is a cost-effective treatment for out-of-hospital cardiac arrests. This review describes the literature citing the benefits of early defibrillation, ease of use, and relative cost of automated external defibrillators.

RECENT FINDINGS

Placement of automated external defibrillators in public places was recommended by the American Heart Association in the early 1990s. Compared with waiting for traditional emergency medical services, immediate use of automated external defibrillators by laypersons can dramatically increase survival to hospital discharge rates. Placement of automated external defibrillators at locations such as casinos, airports, and airplanes that are frequented by large numbers of at-risk people is cost-effective compared with other economically acceptable health measures. Studies using simulations to predict numbers of quality-adjusted life years that would be gained from implementation of public access defibrillation programs in high-incidence locations find that the cost would be less than the typically acceptable 50,000 dollars per quality-adjusted life year. The cost estimates, however, depend on the incidence of cardiac arrest at the sites, with low-incidence sites being prohibitively expensive.

SUMMARY

Automated external defibrillators appear to be cost-effective in locations with high incidences of cardiac arrest.

Cost-effectiveness of automated external defibrillators in public places: con

PURPOSE OF REVIEW

To discuss the clinical effectiveness, public health impact and cost-effectiveness of public access defibrillation.

RECENT FINDINGS

High rates of survival from prehospital ventricular fibrillation have been documented in patients treated by first responders using automated external defibrillators. The recent Public Access Defibrillation trial demonstrated a doubling of cardiac arrest survival in community units where volunteers trained in cardiopulmonary resuscitation were additionally equipped with automated external defibrillators. The cost-effectiveness analysis of the Public Access Defibrillation trial has not yet been published, and previous analyses have lacked full data on cost, outcome, or both. Data from many sources indicate that automated external defibrillator placement at sites with an expected rate of one cardiac arrest per defibrillator per 5 years, as recommended by the American Heart Association, addresses only around 1-2% of prehospital arrests, and will have a minimal impact on population survival.

SUMMARY

While highly targeted provision of automated external defibrillators in areas of greatest risk, such as casinos and airports, may be cost-effective, it will have little impact at a population level. Provision of more widespread public access defibrillation to sites with lower incidence of cardiac arrest is unlikely to be cost-effective, and may represent poorer value for money than alternative healthcare interventions in coronary artery disease.

La desfibrilación temprana en la comunidad: romper barreras para salvar vidas

It is considered that in Spain, every year, we have more than 24,500 out-of-hospital cardiac arrests. Around 85% of these are secondary to ventricular fibrillation, with possibility of reversion in more than 90% if defibrillation is performed in the first minute of arrhythmia. However, if we delay this defibrillation, survival possibilities disappear in a few minutes. Clinical advances in last decades have not achieved satisfactory results in the treatment of cardiac arrest as survival rates at hospital discharge do not exceed 7%. Aware of this situation, the International Scientific Societies are recommending decreasing time to defibrillation, advising, at best, a time less than five minutes between the 112-call (emergency) and adequate electric discharge. Development of automated defibrillators in Emergency Medical Systems and their use by <<first responders>> of <<non-health care>> emergency services (police, fire fighters, etc) contribute to reach this objective. Because of this, Emergency Medical Systems are modifying their assistance strategies, to implement the early defibrillation as <<key to survival>>. Literature showed the effective value of automated defibrillators in the public areas but their efficiency level is less than that reached with the Emergency Services. Efficiency depends on multiple factors such as type of installation, accessibility level to emergency medical services or incidence rate of sudden cardiac arrest. Thus, their introduction should be preceded by a cost-effectiveness study. Effectiveness of automated defibrillators at home, where up to 80% of cardiac arrest are produced, has still not been evaluated. Nevertheless, in the USA, its marketing with this indication has been authorized.

Economic value of out-of-hospital emergency care: a structured literature review

STUDY OBJECTIVE

The evaluation of the impact of out-of-hospital emergency care is a relatively new research focus. As such, there is a compelling need to determine how finite health care resources should be used in this setting. The objective of this study is to conduct a structured review of published economic evaluations of out-of-hospital emergency care to assess its economic value.

METHODS

A structured literature search and structured review of articles pertaining to the economic value of out-of-hospital care was performed. The bibliographic database MEDLINE was searched for pertinent English-language articles published between 1966 and 2003. The search used the medical subject headings "emergency medical services" and "emergency medical technician" and was limited to the subheading "economics" and crossed with the medical subject heading "economics." The titles generated by this search were systematically reviewed and limited by topic. Abstracts from the identified titles were reviewed to select a final set of pertinent articles. These articles were further limited based on explicit inclusion and exclusion criteria. Authors used a previously published structured evaluation tool to review the final set of identified articles for quality and content.

RESULTS

The initial MEDLINE search identified 3,533 citations. From this set, 535 potentially relevant abstracts were reviewed. From the abstract review, 46 articles were identified, along with an additional 14 from searching the secondary references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review. These studies predominantly addressed the cost of cardiac arrest (n=13, 41%), major trauma (n=8, 25%), and emergency medical services treatment in general (n=8, 25%). Only 14 studies considered the costs and consequences of competing alternatives. Of these, 2 were cost-benefit and 12 were cost-effectiveness evaluations. Two of the 14 studies met all 10 criteria for high-quality economic evaluation, whereas 2 others met none.

CONCLUSION

There is a paucity of out-of-hospital care literature that addresses cost and economic value. The extant literature is limited in scope, poor in quality, and evaluates small subsets of out-of-hospital emergency care costs. Favorable cost-effectiveness has not been firmly established for most aspects of out-of-hospital emergency care.