Cost-effectiveness analysis of a rural/urban first-responder defibrillation program

A systematic review of cost-effectiveness of treating out of hospital cardiac arrest and the implications for resource-limited health systems

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources.

OBJECTIVE

To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings.

METHODS

The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Six databases (PubMed, EMBASE, Global Health, Cochrane, Global Index Medicus, and Tuft's Cost-Effectiveness Registry) were searched in September 2023. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints.

RESULTS

Four hundred and sixty-eight unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in termination of resuscitation protocols, professional prehospital defibrillator use, and CPR training followed by the distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment.

CONCLUSION

Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.

A review on initiatives for the management of daily medical emergencies prior to the arrival of emergency medical services

Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage-creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic-as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.

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.

Health System Costs of Out-of-Hospital Cardiac Arrest in Relation to Time to Shock

BACKGROUND

Early defibrillation results in higher admission rates and healthcare costs. This study determined the healthcare resources used and related medical costs after out-of-hospital cardiac arrest (OHCA) in relation to time to shock. We assessed the incremental healthcare costs per life gained from reduction in time to shock of 2, 4, and 6 minutes.

METHODS AND RESULTS

Clinical and costs data of patients in witnessed OHCA with ventricular fibrillation as initial rhythm were collected. Each patient's time to shock was estimated and assigned to 1 of 3 categories: < or =7 minutes (early), 7 to 12 minutes (intermediate), and >12 minutes (late). Incremental cost-effectiveness analysis and Monte Carlo simulation compared scenarios of reduction in time to shock of 2, 4, and 6 minutes. Six-month survival was 22%. Mean prehospital, in-hospital, and posthospital costs in the first half-year after OHCA were 559 Euros, 6869 Euros and 666 Euros. Mean costs were 28,636 Euros per survivor and 2384 Euros per nonsurvivor. Among patients shocked early (n=24), 46% survived, with costs averaging 20,253 Euros. Of the intermediate group (n=149), 26% survived, with costs averaging 31,467 Euros. Among patients shocked late (n=135), 13% survived, with costs averaging 27,781 Euros. The point estimates of the incremental cost-effectiveness ratios of reduction of time to shock of 2, 4, and 6 minutes compared with baseline were 17,508 Euros, 14,303 Euros, and 12,708 Euros per life saved, respectively.

CONCLUSIONS

Costs per survivor were lowest with the shortest time to shock because of shorter stay in the intensive care unit. Reducing the time to defibrillation increases the healthcare costs by an acceptable amount according to current standards and is economically attractive.

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.

Willingness of high school students to perform cardiopulmonary resuscitation and automated external defibrillation

OBJECTIVE

To evaluate the willingness of high school students to perform cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED).

METHODS

A convenience sample of high school students was surveyed regarding how they would respond if they witnessed a cardiac arrest. Participants were first shown a video segment on the operation of an automated external defibrillator. They were then shown a series of video clips depicting six different cardiac arrest scenarios: motor vehicle collision (MVC) with facial bleeding, pediatric drowning, intravenous (IV) drug user, choking family member, victim of differing race, and victim with facial vomitus. Following each video, the subjects were asked how they would respond had they actually witnessed a similar event.

RESULTS

With parental permission and institutional review board approval, 683 students participated, representing 6.8% of the total student body. Of these, 585 (86%) were trained in CPR and 142 (21%) in AED. One hundred six participants (16%) had witnessed a cardiac arrest prior to the survey. Of these, 24 (23%) had intervened in some way. Twenty (19%) had performed mouth-to-mouth resuscitation (MMR), 15 (14%) had performed chest compressions (CC), and one (0.9%) had performed AED. Across all six mock scenarios and all 683 respondents collectively (4,098 simulated cardiac arrest events), the respondents indicated they would be willing to perform AED 1,308 times (32%). In comparison, the respondents indicated they would be willing to perform MMR 1,768 times (43%) and CC 2,249 times (55%). More respondents were willing to intervene on behalf of a child or family member, while fewer were willing to act in the setting of blood, vomitus, or an IV drug user (p < 0.05). There was no association between willingness to intervene and prior experience with any of the interventions. Fear of infection, legal consequences, and fear of harming the patient were the most frequently cited reasons for not intervening.

CONCLUSIONS

Among high school students, few are willing to perform automated external defibrillation. Willingness to perform MMR and CC appears to depend on the circumstances.

Resource reallocation in an emergency medical service system using computer simulation

Emergency medical service (EMS) policy makers must seek to achieve maximum effectiveness with finite resources. This research establishes an EMS computer simulation model using eM-Plant software. The simulation model is based on Taipei city's EMS system with input data from prehospital care records from December 2000; it manipulates resource allocation levels and rates of idle errands. Presently, EMS ambulance utilization is about 8.78%. On average, 20.89 minutes are required to transport a patient to the hospital. Computer simulations showed that reducing the number of ambulances to one at each of the 36 response units increases the utilization rate to 15.47% but does not compromise the current service quality level. Thus, ambulance utilization improves, times of patients waiting for pre-hospital care and arrival at hospitals are only slightly affected, and considerable cost savings result. This study provides a research methodology and suggests specific policy directions for resource allocation in EMS. Limiting the number of ambulances to one per response unit reduces costs, increases efficiency, and yet maintains the same operational pattern of medical service.