Procedural sedation for direct current cardioversion: a feasibility study between two management strategies in the emergency department

BACKGROUND

A cardiologist-only approach to procedural sedation with midazolam in the setting of elective cardioversion (DCC) for AF has already been proven as safe as sedation with propofol and anaesthesiologist assistance. No data exist regarding the safety of such a strategy during emergency procedures. The aim of this study is to compare the feasibility of sedation with midazolam, administered by a cardiologist, to an anaesthesiologist-assisted protocol with propofol in emergency DCC.

METHODS

Single centre, prospective, open blinded, randomized study including all consecutive patients admitted to the Emergency Department requiring urgent or emergency DCC. Patients were randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the midazolam group were managed by the cardiologist only, while patients treated with propofol group underwent DCC with anaesthesiologist assistance.

RESULTS

Sixty-nine patients were enrolled and split into two groups. Eighteen patients (26.1%) experienced peri-procedural adverse events (bradycardia, severe hypotension and severe hypoxia), which were similar between the two groups and all successfully managed by the cardiologist. No deaths, stroke or need for invasive ventilation were registered. Patients treated with propofol experienced a greater decrease in systolic and diastolic blood pressure when compared with those treated with midazolam. As the procedure was shorter when midazolam was used, the median cost of urgent/emergency DCC with midazolam was estimated to be 129.0 € (1st-3rd quartiles 114.6-151.6) and 195.6 € (1st-3rd quartiles 147.3-726.7) with propofol (p < .001).

CONCLUSIONS

Procedural sedation with midazolam given by the cardiologist alone was feasible, well-tolerated and cost-effective in emergency DCC.

Edoxaban therapy increases treatment satisfaction and reduces utilization of healthcare resources: an analysis from the EdoxabaN vs. warfarin in subjectS UndeRgoing cardiovErsion of atrial fibrillation (ENSURE-AF) study

Aims

The EdoxabaN vs. warfarin in subjectS UndeRgoing cardiovErsion of atrial fibrillation (ENSURE-AF) (NCT02072434) study was a multicentre prospective, randomized, open-label, blinded-endpoint evaluation (PROBE) trial comparing edoxaban with enoxaparin/warfarin followed by warfarin alone in 2199 non-valvular atrial fibrillation patients undergoing electrical cardioversion and showed comparable rates of bleeding and thromboembolism between treatments. This prespecified ancillary analysis investigated the impact of edoxaban therapy on treatment satisfaction and utilization of healthcare services.

Methods and results

The Perception of Anticoagulant Treatment Questionnaire (PACT-Q2) was completed by study patients on Day 28 post-cardioversion. Higher scores represent greater satisfaction. Healthcare resource utilizations were collected from randomization to Day 28 post-cardioversion. Data from patients who received at least one dose of study drugs were analysed. Patients treated with edoxaban were more satisfied than enoxaparin/warfarin in both PACT-Q treatment satisfaction and convenience scores (P < 0.001 for both). Differences in treatment satisfaction scores were greater in patients who underwent non-transoesophageal echocardiography (TOE)-guided cardioversion than in patients who underwent TOE-guided cardioversion. Edoxaban was associated with fewer clinic visits (4.75 visits vs. 7.60 visits; P < 0.001) and fewer hospital days (3.43 days vs. 5.41 days; P < 0.05). Rates of hospitalizations and emergency room visits were not significantly different. Overall, edoxaban therapy was estimated to reduce healthcare costs by €107.73, €437.92, €336.75, and $246.32 per patient in German, Spanish, Italian, and US settings, respectively.

Conclusions

The convenience of edoxaban therapy over warfarin in patients undergoing cardioversion may provide greater treatment satisfaction and cost savings to the healthcare system.

The Impact of Cryoballoon Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation on Healthcare Utilization and Costs: An Economic Analysis From the FIRE AND ICE Trial

Background

This study sought to assess payer costs following cryoballoon or radiofrequency current (RFC) catheter ablation of paroxysmal atrial fibrillation in the randomized FIRE AND ICE trial.

Methods and Results

A trial period analysis of healthcare costs evaluated the impact of ablation modality (cryoballoon versus RFC) on differences in resource use and associated payer costs. Analyses were based on repeat interventions, rehospitalizations, and cardioversions during the trial, with unit costs based on 3 national healthcare systems (Germany [€], the United Kingdom [£], and the United States [$]). Total payer costs were calculated by applying standard unit costs to hospital stays, using International Classification of Diseases, 10th Revision diagnoses and procedure codes that were mapped to country‐specific diagnosis‐related groups. Patients (N=750) randomized 1:1 to cryoballoon (n=374) or RFC (n=376) ablation were followed for a mean of 1.5 years. Resource use was lower in the cryoballoon than the RFC group (205 hospitalizations and/or interventions in 122 patients versus 268 events in 154 patients). The cost differences per patient in mean total payer costs during follow‐up were €640, £364, and $925 in favor of cryoballoon ablation (P=0.012, 0.013, and 0.016, respectively). This resulted in trial period total cost savings of €245 000, £140 000, and $355 000.

Conclusions

When compared with RFC ablation, cryoballoon ablation was associated with a reduction in resource use and payer costs. In all 3 national healthcare systems analyzed, this reduction resulted in substantial trial period cost savings, primarily attributable to fewer repeat ablations and a reduction in cardiovascular rehospitalizations with cryoballoon ablation.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Identifier: NCT01490814.

Seeking an Explanation for the Poor Uptake of In-Hospital AED Programs

The automated external defibrillator (AED) has been adopted by emergency service personnel as a first-line intervention in the management of out-of-hospital cardiac arrest (OHCA). AED leads to more successful Advanced Cardiac Life Support; consequently, national resuscitation organisations worldwide have recommended that nurses and doctors also integrate AEDs as a component of their basic life-support response to cardiac arrest. Despite these recommendations, the implementation of AED programs within hospitals has been generally sporadic and isolated. A continuation of this situation will most likely disturb and perplex nurses and patients, as they are key stakeholders with respect to upholding recommended BLS practices. In the absence of any explanation from change agents within hospitals, this paper seeks, by way of a pilot study and a review of the literature, to identify the extent of the problem and identify factors contributing to the relatively slow uptake of this device. We argue that nurses and other first responders to in-hospital cardiac arrest (CA) have much to gain, in the context of Occupational Health Safety and Welfare (OHS and W), from ready access to AEDs. Cost factors are also considered, with initial cost of AED purchase likely to be a major concern for managers of hospital budgets. The issues we discuss in this paper clearly support the need for further research to (a) explain the nature of public hospital resistance to AEDs and (b) to consider whether AEDs will provide practical advantages to public hospitals from an occupational, social and economic perspective.

Medical and pharmacy coverage decision making at the population level

Medicare is one of the largest health care payers in the United States. As a result, its decisions about coverage have profound implications for patient access to care. In this commentary, the authors describe how Medicare used evidence on heterogeneity of treatment effects to make population-based decisions on health care coverage for implantable cardiac defibrillators. This case is discussed in the context of the rapidly expanding availability of comparative effectiveness research. While there is a potential tension between population-based and patient-centered decision making, the expanded diversity of populations and settings included in comparative effectiveness research can provide useful information for making more discerning and informed policy and clinical decisions.

Cost effectiveness of antiarrhythmic medications in patients suffering from atrial fibrillation

Atrial fibrillation (AF), a supraventricular tachycardia disorder, is the most common sustained cardiac arrhythmia affecting 1-2 % of the general population. Prevalence is highly related to age, with every fourth individual older than 40 years old developing AF during his lifetime. Due to an aging population, the prevalence of AF is estimated to at least double within the next 50 years. This article presents AF-related cost-of-illness studies and reviews 19 cost-effectiveness studies and six cost studies published roughly over the past decade, which have compared different antiarrhythmic medications for AF. A systematic literature search for studies published between June 2000 and December 2011 was conducted in PubMed using the combination of keywords ((atrial fibrillation OR atrial flutter) AND cost). Current cost-effectiveness analyses of dronedarone and the pill-in-the-pocket strategy are subject to substantial uncertainties with regard to clinical benefit. Comparing rate control with rhythm control, a cost-effectiveness advantage for rate control was shown in several but not all studies. Within antiarrhythmic drug treatments, magnesium added onto ibutilide was shown to be more cost effective than ibutilide alone. Comparing chemical and electrical cardioversion, the latter was recommended as more cost effective from the healthcare system perspective in all reviewed studies but one. Catheter ablation appeared more cost effective than antiarrhythmic drugs in the medium to long run after 3.2-63.9 years. Admissions to hospital, inpatient care and interventional procedures as well as mortality benefit are key drivers for the cost effectiveness of AF medications. No clear cost-effectiveness advantage emerged for one specific antiarrhythmic drug from the studies that compared antiarrhythmic agents. Rate control as well as catheter ablation appear more cost effective than rhythm control in the treatment of AF. Rate control treatment also seems more cost effective than electrical cardioversion in AF patients.

[Clinico-economical aspects of cardioversion of paroxysmal atrial fibrillation at phehospital stage and during hospitalization]

We carried out clinico-economical analysis of 2 tactics of rhythm restoration in patients with paroxysmal atrial fibrillation (AF) lasting less than 48 hours: cardioversion at prehospital stage with intravenous procainamide and inhospital cardioversion with any method. This retrospective study was based on the data from department of urgent aid of an outpatient clinic. The results showed that within 48 hours inhospital was a was more effective, safe, and more economically profitable compared with administration of procainamide at prehospital stage. Intravenous procainamide resulted in effective cardioversion in 70.6% of patients. It was associated with arterial hypotension and proarrhythmogenic action in 14,7% of cases. Patients with effective cardioversion with procainamide had lesser mean values of left ventricular anterior-posterior dimension (echocardiography) and shorter duration of arrhythmia.

Characterization and financial impact of implantable cardioverter-defibrillator patients without interventions 5 years after implantation

BACKGROUND

Implantable cardioverter defibrillators (ICD's) are increasingly used for primary and secondary prevention of sudden cardiac death. However, data on how many ICD patients indeed receive appropriate ICD therapy during long-term follow-up is scarce.

AIM

The aim of our study was to determine the number of patients without appropriate ICD therapy 5 years after ICD implantation, to identify predicting factors, to assess the occurrence of late first ICD therapy and to quantify the financial impact of ICD therapy in a real-world setting.

DESIGN

Prospective observational study.

METHODS

We prospectively enrolled 322 consecutive ICD patients. Baseline data were collected at implantation and patients were followed for a median of 7.3 years (IQR 5.8-9.2 years). Time to first appropriate ICD therapy (either antitachycardia pacing or cardioversion) was documented.

RESULTS

Five years after implantation, 139 patients (43%) had not received appropriate ICD therapy. In multivariable analysis, a primary prevention indication and negative electrophysiological studies prior to ICD implantation were independent predictors of freedom from ICD therapy. Of the patients without ICD therapy, 5 years after implantation, 25% had experienced inappropriate ICD shocks. Two hundred and seven devices (1.5 devices per patient) were needed for the 139 patients without ICD intervention within 5 years, accounting for € 31,784 per patient. During an additional follow-up of 3 years, 12% of the patients with unused ICD received a late first appropriate ICD therapy.

CONCLUSION

About half of the ICD patients receive appropriate ICD therapy within 5 years after implantation. Furthermore, there is a significant proportion of patients receiving late first shocks after five initially uneventful years.

[Cardiac resynchronization therapy with defibrillation capability: considerations on a not yet proven therapeutic superiority]

Cardiac resynchronization therapy (CRT) has proven a very useful tool to treat heart failure (HF). In HF patients with severely depressed left ventricular dysfunction and ventricular dyssynchrony who remain symptomatic despite optimal medical therapy, the "reverse remodeling" induced by CRT leads to a significant improvement of survival and quality of life. The addition of the cardioversion-defibrillation function to CRT (CRT-D) is considered a further beneficial effect to reduce overall mortality secondary to a decrease in sudden death rate. Unfortunately, the amount of this additional benefit is still uncertain; in particular, how much the cardioversion-defibrillation function contributes to prolong patient survival remains to be elucidated. Such uncertainty leads to a different therapeutic approach to HF patients, i.e., an extended or restricted use of CRT-D devices. Even the most recent guidelines do not provide a clear answer to this question. The present review summarizes the current evidence regarding efficacy, effectiveness, safety, and cost-effectiveness of CRT and CRT-D, and suggests some practical solutions to the appropriate use of CRT-D on the basis of clinical, ethical and socio-economic considerations.

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.

The costs of care in atrial fibrillation and the effect of treatment modalities in Germany

OBJECTIVE

Atrial fibrillation (AF) is an increasing burden on health-care systems because of an aging population. This study aimed to estimate health-care resource use and costs of treating AF in Germany.

METHOD

A 6-month multicenter prospective observational cohort study with additional 3-month retrospective clinical data collection was performed in physician practices. AF-related resource use was documented by 3-month retrospective and 6-month prospective clinical data from physician charts and prospectively by patient questionnaires at 3 and 6 months. Cost calculation was from the health-care payer perspective.

RESULTS

A total of 361 patients (mean age 71 +/- 9 years, 61% male) were recruited from 45 physician practices. Of 311 (86.1%) patients with complete data, 75% had persistent AF; oral anticoagulation and/or aspirin were prescribed in 98%. A rhythm-control strategy was applied in 27%, rate control in 58%, and 15% received neither antiarrhythmic medication nor cardioversion. A higher proportion of rhythm-control patients had paroxysmal AF (P < 0.001). Mean annual AF-related per-patient cost was 827 Euro +/- 1476 (median 386 Euro). 50% of total costs were incurred by 11% of patients, driven by AF-related hospitalizations (44%). Antiarrhythmics and stroke prophylaxis accounted for 20% and 15% of expenditures, respectively. Mean annualized costs were higher for rhythm-control patients than for rate-control patients or those without antiarrhythmic treatment (1572 vs. 780 vs. 544 Euro, P < 0.001).

CONCLUSION

This evaluation provides an overview of current treatment modalities and cost of AF management in Germany. Efforts to reduce the economic burden of AF should focus on avoidance of AF hospital admissions and optimization of stroke prevention and rhythm control.

The quick-implantable-defibrillator trial

AIMS

Earlier ICD therapy included an electrophysiological study (EPS), an extensive defibrillation threshold test (DFT), and a pre-discharge test. Now that ICD-therapy is widely accepted, an EPS is no longer performed in most patients, extensive DFT-tests have been reduced to a minimum of two effective shocks and discharge tests have been discarded in most centres. However, it has never been demonstrated prospectively that this simplification is safe.

METHODS AND RESULTS

The Quick-Implantable-Defibrillator (Quick-ICD) Trial was a prospective multi-centre trial, which randomized patients, who had survived a cardiac arrest (SCD) or an unstable ventricular tachycardia (VT), to two different clinical strategies: (a) The extensive strategy included an EPS, an extensive DFT-test, and a pre-discharge test; (b) In the simplified approach (quick strategy) the ICD was implanted without an EPS and a pre-discharge test. Two effective shocks during implantation at 21 J were sufficient. The primary endpoint of this trial was a cluster of adverse events related to the diagnostic approach and to ICD-therapy. One hundred and ninety patients were included, 97 randomized to the extensive-, 93 to the quick strategy. Mean follow-up was 12 +/- 7 months. Twenty-seven patients reached the endpoint in the quick group and 32 in the extensive group. During follow-up, the event-free survival was equal in the two study arms (test for equivalence, P = 0.0044). The initial hospital stay was significantly shorter in the quick population (8.4 +/- 4.7 vs. 11.2 +/- 7.4 days, P = 0.004)

CONCLUSION

It is safe and cost-effective to implant an ICD without an EPS, an extensive DFT-, and a pre-discharge test in carefully selected patients after survived SCD or unstable VTs.

[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.

The cost comparison of rhythm and rate control strategies in persistent atrial fibrillation

Our sub study was designed to analyze the cost effectiveness of two alternative treatment strategies with a view to improved allocation of the limited therapeutic resources. To that effect we conducted detailed analysis of the related costs and other relevant data collected in the course of the HOT CAFE study.

METHODS

The prospective costs related to 205 patients randomly assigned to rhythm or rate control were traced over a 12 month period. Since, both strategies produced similar clinical outcomes a cost minimization analysis was undertaken. The cost of diagnostic and treatment procedures, including hospitalization, outpatient visits, drugs and physicians consultations were estimated for both groups.

RESULTS

The study population comprised 205 patients (mean age 60.8 year; 35% females). A hundred and one patients were randomly assigned to the rate control group with the pharmacological heart rate frequency optimization treatment combined with Holter monitoring. A hundred and four patients were randomized to sinus rhythm (SR) restoration with its subsequent maintenance with sequential antiarrhythmic drug treatment. There was no significant difference in the composite primary end-point (all-cause mortality, number of thromboembolic and major bleeding events). The hospital admissions rate was significantly higher in the rhythm control than the rate control arm (202 vs. 5, respectively). The conservative strategy involving pharmacological ventricular rate control proved to be less costly than rhythm control (1225 euros vs. 2526 euros; p<0.001). The main cost driver behind the established difference was the cardioversion related hospitalization.

CONCLUSIONS

The cost effectiveness appraisal seems to have supported the rate control strategy as less costly due to the lower hospitalization rate as a major cost carrier.

Expansion of Heart Failure Device Therapy Into a Rural Indigent Population in Louisiana: Potential Economic and Health Policy Implications

BACKGROUND

Research regarding the use of implantable devices in patients with congestive heart failure (CHF) has shown mortality benefits. The Center for Medicare and Medicaid Services (CMS) approved new criteria for expanding coverage for such therapies. The purpose of this study was to determine the percentages of CHF patients in a rural, indigent heart failure population that would be eligible for implantable defibrillators (ICD) and cardiac resynchronization therapy (CRT) based on the new CMS criteria.

METHODS AND RESULTS

The new CMS guidelines were applied to information compiled in a database for 451 CHF disease management patients, at Leonard J. Chabert Medical Center. Results show that, annually, 32% of the newly identified CHF patient population would be eligible for ICD therapy and 7.3% would be eligible for CRT therapy.

CONCLUSIONS

Providers of health care to the indigent may lack sufficient resources for the devices and the infrastructure for device implantation and follow-up.

Primary Prevention of Sudden Cardiac Death: Can We Afford the Cost of Cardioverter-Defibrillators? Data from the Search-MI Registry-Italian Sub-study

BACKGROUND

Large randomized trials show that in appropriately selected patients with left ventricular dysfunction, implantable cardioverter-defibrillators (ICDs) can improve overall survival at 2-5 years. Since direct implementation of the criteria used in the MADIT II and SCD-HeFT will lead to a marked rise in ICD implants, there is a growing fear that increased use of ICDs may cause a dramatic burden to health care systems. The ICD has traditionally been seen as an expensive form of treatment, which is difficult to accept at the first look. This is mainly due to the nonlinear character of the ICD investment, characterized by high initial expenditure, followed by a deferred pay-off in terms of clinical benefits. Cost-effectiveness analysis may help provide a different perspective on the problem of ICD cost, as may estimation of the daily cost of ICD treatment, assuming a time horizon of 5-7 years--a particularly interesting subject for further registry studies.

METHODS AND RESULTS

Based on real expenditure data from 2002 to 2005, as recorded in the Search-MI Registry-Italian Sub-study of patients implanted on MADIT II indications, we estimated the daily costs associated with the device and leads. Over a 5-7 year time horizon, the average daily cost was estimated to be euro 4.60-euro 6.70. Translation of these figures into U.S. market conditions suggests a daily cost of around $7.90-$11.40.

CONCLUSIONS

These findings appear useful to help evaluate the affordability of ICD in comparison with other therapeutic options in a context of limited available economic resources.

Cost Effectiveness of Cardiac Resynchronization Therapy in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Trial

OBJECTIVES

The analysis goal was to estimate incremental cost-effectiveness ratios (ICERs) for the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial patients who received cardiac resynchronization therapy (CRT) via pacemaker (CRT-P) or pacemaker-defibrillator (CRT-D) in combination with optimal pharmacological therapy (OPT) relative to patients with OPT alone.

BACKGROUND

In the COMPANION trial, CRT-P and CRT-D reduced the combined risk of all-cause mortality or first hospitalization among patients with advanced heart failure and intraventricular conduction delays, but the cost effectiveness of the therapy remains unknown.

METHODS

In this analysis, intent-to-treat trial data were modeled to estimate the cost effectiveness of CRT-D and CRT-P relative to OPT over a base-case seven-year treatment episode. Exponential survival curves were derived from trial data and adjusted by quality-of-life trial results to yield quality-adjusted life-years (QALYs). For the first two years, follow-up hospitalizations were based on trial data. The model assumed equalized hospitalization rates beyond two years. Initial implantation and follow-up hospitalization costs were estimated using Medicare data.

RESULTS

Over two years, follow-up hospitalization costs were reduced by 29% for CRT-D and 37% for CRT-P. Extending the cost-effectiveness analysis to a seven-year base-case time period, the ICER for CRT-P was 19,600 dollars per QALY and the ICER for CRT-D was 43,000 dollars per QALY relative to OPT.

CONCLUSIONS

For the COMPANION trial patients, the use of CRT-P and CRT-D was associated with a cost-effectiveness ratio below generally accepted benchmarks for therapeutic interventions of 50,000 dollars per QALY to 100,000 dollars per QALY. This suggests that the clinical benefits of CRT-P and CRT-D can be achieved at a reasonable cost.

Outpatient electrical cardioversion of atrial fibrillation: Efficacy, safety and patients' quality of life

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia. To lower costs and to reduce hospitalization electrical cardioversion (CV) is frequently performed in an outpatient setting although data on safety and patient-acceptance are sparse. Aims of this study were to fill this gap by evaluating efficacy, complication rate, quality of life after CV and patient-acceptance of outpatient CV.

METHODS

One-hundred and eleven consecutive patients with persistent AF were included. Patients were under continuous monitoring throughout the procedure and 3 h after. CV was done in deep sedation using rising energies (200->360 J). Quality of life (QoL), late adverse events and patient-acceptance were assessed 4 weeks after CV.

RESULTS

AF could be terminated with a mean of 1.4 shocks in all patients. Acute adverse events could be observed in 3.6%. Late adverse events were noted in 8.2%. Seventy-four percent of the patients felt "good" or "very good" the day of CV. Eighty-nine percent of the patients would undergo a CV again and in case of a further CV 69% of the patients would prefer an outpatient setting. Patients with a lower QoL-classification had longer duration of atrial fibrillation (median 1 vs. 3 months, p<0.05). No other clinical predictor for adverse events or a low QoL-classification could be identified.

CONCLUSION

Electrical CV of persistent AF in an outpatient setting is feasible, safe and has a high patient-acceptance.

Effectiveness of automated external defibrillators in high schools in greater Boston

A program using a strategy of donating a single automatic external defibrillator to 35 schools in the Boston area resulted in compliance with American Heart Association guidelines on automatic external defibrillator placement and training and 2 successful resuscitations from sudden cardiac arrest. Participating schools indicated a high degree of satisfaction with the program.

Automated external defibrillators for home use

The Philips HeartStart Home Defibrillator is an automated external defibrillator (AED) that is approved for home use by untrained users. Most cardiac arrests occur in the home, so a rapid response with cardiopulmonary resuscitation (CPR) and defibrillation is critical for survival. No prospective studies demonstrate that the use of AEDs in the home by untrained persons improves health outcomes. Further investigation is needed to determine the benefit and harm of AEDs in the home.

Localization of out-of-hospital cardiac arrest in Göteborg 1994–2002 and implications for public access defibrillation

PURPOSE

The purpose of this study was to report the locality of out-of-hospital cardiac arrest (OHCA) in the city of Goteborg and to identify implications for public access defibrillation (PAD).

METHODS

Ambulance run reports for the years 1994-2002 were studied retrospectively and manually to establish the location of the cardiac arrest.

RESULTS

The location could be identified in 2194 of 2197 patients (99.9%). One thousand four hundred and twenty-nine (65%) of the arrests took place in the victims' homes. Two hundred eighty-five (13%) were outdoors and 57 (3%) in cars. Fifty-one (2%) took place en route in ambulances. These arrests were regarded not to be generally suitable for PAD. One hundred thirty-five (6%) of the arrests happened in a public building. Eighteen of these 135 were in 15 different general practitioners' offices. A ferry terminal had 11 cardiac arrests. One hundred fifty (7%) of the arrests took place in different care facilities. Twenty-one (1%) patients had their cardiac arrest in public transport locations. Twenty-two (1%) patients arrested at work in 20 different sites. In total, 17% of the cardiac arrests were regarded as generally suitable for PAD. Several sites with more than one cardiac arrest in five years could be identified and 54 patients (2.5%) had their cardiac arrest in these high-incidence sites.

CONCLUSION

Among patients suffering from out-of-hospital cardiac arrest in Goteborg in whom resuscitation efforts were attempted 17% of all cardiac arrests were regarded as generally suitable for PAD. According to previous suggestions, the indication for public access defibrillation is in a place with a reasonable probability of use of one AED in 5 years. Several high-incidence sites that probably would benefit from defibrillator availability could be identified, and 54 patients (2.5%) arrested in these sites.

Cardioversion and the use of sedation

Nurse led cardioversion services have achieved significant reductions in both cost and waiting time. However, the question of safety of the procedure raises several areas of concern.

Synchronized emergency department cardioversion of atrial dysrhythmias saves time, money and resources

The strategy of elective synchronized cardioversion (EDCV) of new onset atrial fibrillation/flutter (AF/flutter) compares favorably to that of Emergency Department (ED) rate control and inpatient admission. This 1-year study comprised consecutive ED synchronized cardioversions performed on patients with new onset (< 48 h) AF/flutter; all were hemodynamically stable. A control group was obtained by chart review of all patients meeting the inclusion criteria admitted in the same year who were managed with rate control in the ED and inpatient admission. Thirty ED cardioversions were performed on 24 patients. Twenty-nine of 30 (97%) of ED cardioversions were successful. The mean hospital length of stay (LOS) for the EDCV group, including those admitted, was 22.8 h (95% CI: 1.7-44.0) compared to the control group: 55.6 h (all admitted) (95% CI: 41.6-69.6). Median LOS for the entire EDCV group was 4 h, compared with 39.3 h for the controls (p < 0.001). There was also a significant difference in median hospital charge, including ED care: EDCV group: $1598 vs. controls $4271 (p < 0.001). All of the study patients were contacted by telephone a minimum of 4 weeks after cardioversion to assess for complications, recidivism, and satisfaction. There were no complications in the EDCV group, and all expressed satisfaction with the procedure. Elective synchronized cardioversion in the ED is an effective strategy for management of new-onset AF/flutter and is associated with significant decreases in charges and length of stay as well as a high degree of patient satisfaction.

Rate control versus rhythm control

PURPOSE OF REVIEW

The results of five randomized clinical trials comparing rate control with rhythm control in the management of atrial fibrillation have been published recently. The purpose of this report is to review their main results and selected subanalyses and other related data to offer practical recommendations regarding the treatment of patients with this common arrhythmia.

RECENT FINDINGS

In the aggregate, the five trials enrolled a total of 5175 subjects and accumulated 16,186 patient-years of follow-up. All these trials have had similar results in that each of them failed to demonstrate a clear advantage of the rhythm control approach over that of rate control. The largest of the studies, the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study, enrolled 79% of all the cases in the five trials and accounts for 88% of the cumulative follow-up experience and for 92% of all deaths. Among AFFIRM participants, antiarrhythmic drug use did not improve survival, stroke risk, quality of life, or functional capacity but was associated with increased resource use. In several of the trials, however, the presence of sinus rhythm was associated with improved outcomes.

SUMMARY

The evidence is now overwhelming that for most patients with atrial fibrillation, rhythm control using currently available antiarrhythmic drugs is more expensive but not more effective than the rate control strategy in the prevention of major adverse events. Further research is needed to determine whether maintaining sinus rhythm by other means can improve outcomes.

The safety and effectiveness of a nurse led cardioversion service under sedation

OBJECTIVE

To assess the safety and effectiveness of nurse led elective cardioversion of atrial fibrillation under sedation.

DESIGN

Prospective, longitudinal study.

SETTING

Cardiac catheterisation laboratory and recovery area of a district general hospital.

PATIENTS

300 patients referred for elective cardioversion of persistent atrial fibrillation.

INTERVENTIONS

Pre-procedure evaluations (history, physical examination, blood tests), consent, sedation administration, cardioversions, and post-procedure monitoring until discharge by advanced life support certified coronary care unit nurses trained in the techniques. A doctor was immediately available if required but not present.

MAIN OUTCOME MEASURES

Success rates at discharge and at six weeks, energy delivered, number of shocks, dose of sedation, immediate, 24, and 48 hour patient perceptions, complications, waiting times, and cost effectiveness.

RESULTS

Cardioversion success rate was 87% at discharge and 48% at six weeks. Mean (SD) cumulative energy was 497 (282) J and number of shocks 1.6 (0.8). Mean (SD) dose of sedation was 23 (9) mg intravenous diazepam. No patient required reversal of sedation, airway support, or medical intervention. Ninety eight per cent of patients had no pain or recall of the procedure. Four patients who were adequately anticoagulated experienced embolic phenomena. Ninety eight per cent of patients would repeat the procedure if necessary. Without requirement for a physician or anaesthetist, waiting times for elective cardioversion fell from three months to under four weeks. There was a significant reduction in the estimated cost of the procedure from 337 pounds sterling with general anaesthesia to 130 pounds sterling with nurse led sedation and cardioversion (p < 0.001).

CONCLUSION

With appropriate training, a nurse led cardioversion service with sedation is safe, effective, well tolerated, and cost efficient.

Cost-effectiveness of rhythm versus rate control in atrial fibrillation

BACKGROUND

Atrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control over rate control. Consequently, economic factors often play a role in guiding treatment selection.

OBJECTIVE

To estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM).

DESIGN

Retrospective economic evaluation. Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane.

DATA SOURCES

Data on survival and use of health care resources were obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases.

TARGET POPULATION

Patients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM.

TIME HORIZON

Mean follow-up of 3.5 years.

PERSPECTIVE

Third-party payer.

INTERVENTIONS

Management of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control).

OUTCOME MEASURES

Mean survival, resource use, costs, and cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

A mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs 5077 dollars less per person than rhythm control.

RESULTS OF SENSITIVITY ANALYSIS

Cost savings ranged from 2189 dollars o 5481 dollars per person. Rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions.

LIMITATIONS

Resource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation.

CONCLUSION

Rate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to those enrolled in AFFIRM.

Lay rescuer automated external defibrillator programs for children and adolescents

This article summarizes the controversies regarding the establishment of lay rescuer automated external defibrillator (AED) programs in schools. It describes the elements of one successful program and provides recommendations for critical elements of AED programs in schools, using the recommendations that were described by the American Heart Association statement and experience gained in the establishment of AED programs in high schools in Wisconsin.

Cost-effectiveness of cardiac resynchronization therapy in patients with symptomatic heart failure

BACKGROUND

Heart failure is a common, costly, and debilitating illness. Resynchronization of ventricular contraction in patients with heart failure improves ejection fraction. The long-term morbidity and costs associated with such cardiac resynchronization therapy remain unclear.

OBJECTIVE

To assess the incremental cost-effectiveness of cardiac resynchronization therapy.

DESIGN

Markov model with Monte Carlo simulation. Future costs and effects were discounted at 3%.

DATA SOURCES

Effects data were obtained from a concurrent systematic review. Health-related quality-of-life and cost data were obtained from publicly available data or from surveys.

TARGET POPULATION

Patients with reduced ventricular function and prolonged QRS.

TIME HORIZON

Lifetime.

PERSPECTIVE

U.S. health care system.

INTERVENTIONS

Cardiac resynchronization therapy versus medical therapy.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.

RESULTS OF BASE-CASE ANALYSIS

Medical therapy yielded a median of 2.64 (interquartile range, 2.47 to 2.82) discounted QALYs and a median discounted lifetime cost of 34,400 dollars (interquartile range, 31,100 dollars to 37,700 dollars). Cardiac resynchronization therapy was associated with a median incremental cost of 107,800 dollars(interquartile range, 79,800 dollars to 156,500 dollars) per additional QALY.

RESULTS OF SENSITIVITY ANALYSIS

Results were sensitive to changes in several variables, including the relative risk for death or hospitalization.

LIMITATIONS

These results apply to patients who meet the inclusion criteria of the currently completed trials.

CONCLUSIONS

The incremental cost per QALY for cardiac resynchronization is similar to that of other commonly used interventions but is sensitive to changes in several key variables. Resynchronization therapy should not be considered in patients with comorbid illness that shortens life expectancy.

Rate control is more cost-effective than rhythm control for patients with persistent atrial fibrillation ? results from the RAte Control versus Electrical cardioversion (RACE) study

Aims To evaluate costs between a rate and rhythm control strategy in persistent atrial fibrillation. Methods and results In a prospective substudy of RACE (Rate control versus electrical cardioversion for persistent atrial fibrillation) in 428 of the total 522 patients (206 rate control and 222 rhythm control), a cost-minimisation and cost-effectiveness analysis was performed to assess cost-effectiveness of the treatment strategies. After a mean follow-up of 2.3+/-0.6 years, the primary endpoint (cardiovascular morbidity and mortality) occurred in 17.5% (36/202) of the rate control patients and in 21.2% (47/222) of the rhythm control patients. Mean costs per patient under rate control were euro 7386 and euro 8284 under rhythm control. Cost-effectiveness analysis showed that per avoided endpoint under rate control, the cost savings were euro 24944. Under rhythm control, more costs were generated due to electrical cardioversions, hospital admissions and anti-arrhythmic medication. Costs were higher in older patients, patients with underlying heart disease, those who reached a primary endpoint and women. Heart rhythm at the end of study, did not influence costs. Conclusions Rate control is more cost-effective than rhythm control for treatment of persistent atrial fibrillation. Underlying heart disease but not heart rhythm largely accounts for costs.

The benefits and use of shock advisory defibrillators in hospitals

Survival to discharge following a cardiac arrest is dependent on rapid and effective basic and advanced life support. Paramount to a rapid response is access to sufficiently trained health care providers, who have a duty to perform basic life support and initiate early defibrillation. In hospitals, defibrillation remains the domain of specially prepared staff and the type of defibrillator used might be crucial to rapid and effective defibrillation. The advent of automatic external defibrillators has increased the range of people who can use a defibrillator successfully. For nurses, arguably a lack of familiarity about the benefits of and the use of automatic external defibrillators are the greatest barriers to nurse-initiated defibrillation programmes. This paper explores the use of automatic external defibrillators, their relationship to the associated defibrillator waveforms and the benefits of their use by registered nurses within the hospital setting.

Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation

OBJECTIVES

The aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period.

BACKGROUND

The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored.

METHODS

Two economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies.

RESULTS

A total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively (6,508 dollars vs. 6,239 dollars; difference of 269 dollars; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups.

CONCLUSIONS

In patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy.

The debate on public place defibrillators: charged but shockingly ill informed

There is growing interest in developing strategies which will enable defibrillation to be administered while waiting for the emergency medical service to arrive.

Cost effectiveness and cost utility model of public place defibrillators in improving survival after prehospital cardiopulmonary arrest

OBJECTIVE

To determine the cost effectiveness and cost utility of locating defibrillators in all major airports, railway stations, and bus stations throughout Scotland.

DESIGN

Economic modelling exercise with data from Heartstart (Scotland). Parameters used in economic model included direct costs derived for increased accident and emergency attendances, increased hospital bed days, purchase and maintenance of defibrillators, and training in their use; life years gained calculated from increased discharges from hospital and mean survival after discharge; utility (quality of life) obtained from published data. Sensitivity analyses tested the robustness of model. Future gains discounted at 1.5% a year and future costs at 6%.

SETTING

Whole of Scotland.

SUBJECTS

Records of all prehospital cardiac arrests due to presumed heart disease that occurred in a major airport, railway, or bus station between May 1991 and March 1998 and were not witnessed by ambulance or medical staff.

MAIN OUTCOME MEASURES

Observed survival to hospital admission and observed survival to discharge. Predicted survival calculated by applying observed survival in patients attended by ambulance staff within three minutes to those who waited longer.

RESULTS

The total discounted direct costs were 18 325 pounds sterling a year. The cost per life year gained was 29 625 pounds sterling (49 625 dollars, 43 151 Euros) and the cost per quality adjusted life year (QALY) gained was pound 41 146 (68 924 dollars, 59 932 Euros). More widespread provision of public place defibrillators would increase these figures.

CONCLUSIONS

The cost per QALY calculated for public place defibrillators represents poorer value for money than some alternative strategies for improving survival after prehospital cardiopulmonary arrest, such as the use of other trained first responders. The figure exceeds the commonly discussed cut off levels for funding in the United Kingdom and United States of pound 30 000 and 50 000 dollars per QALY, respectively.

Cost-effectiveness of automated external defibrillator deployment in selected public locations

OBJECTIVE

The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates.

DESIGN

Markov Decision Model employing a societal perspective.

SETTING

Selected public locations in the United States.

PATIENTS

A simulated cohort of the American public.

INTERVENTION

Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival.

RESULTS

Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY.

CONCLUSIONS

AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.

Cost effectiveness of defibrillation by targeted responders in public settings

BACKGROUND

Out-of-hospital cardiac arrest is frequent and has poor outcomes. Defibrillation by trained targeted nontraditional responders improves survival versus historical controls, but it is unclear whether such defibrillation is a good value for the money. Therefore, this study estimated the incremental cost effectiveness of defibrillation by targeted nontraditional responders in public settings by using decision analysis.

METHODS AND RESULTS

A Markov model evaluated the potential cost effectiveness of standard emergency medical services (EMS) versus targeted nontraditional responders. Standard EMS included first-responder defibrillation followed by advanced life support. Targeted nontraditional responders included standard EMS supplemented by defibrillation by trained lay responders. The analysis adopted a US societal perspective. Input data were derived from published or publicly available data. Future costs and effects were discounted at 3%. Monte Carlo simulation and sensitivity analyses assessed the robustness of results. Standard EMS had a median of 0.47 (interquartile range [IQR]=0.32 to 0.69) quality-adjusted life years and a median of 14 100 dollars (IQR=8600 dollars to 21 900 dollars) costs per arrest. Targeted nontraditional responders in casinos had an incremental cost of a median 56 700 dollars (IQR=44 100 dollars to 77 200 dollars) per additional quality-adjusted life year. The results were sensitive to changes in time to defibrillation, incidence of arrest, and number of devices required to implement rapid defibrillation.

CONCLUSIONS

Where cardiac arrest is frequent and response time intervals are short, rapid defibrillation by targeted nontraditional responders may be a good value for the money compared with standard EMS. The incidence of arrest should be considered when choosing locations to implement public access defibrillation.