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Qvist Kristensen L, van Tulder MW, Eiskjær H, Sørensen L, Wulff Risør B, Gregersen Oestergaard L. Cost of out-of-hospital cardiac arrest survivors compared with matched control groups. Resuscitation 2024; 199:110239. [PMID: 38750785 DOI: 10.1016/j.resuscitation.2024.110239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Societal costs of out-of-hospital cardiac arrest (OHCA) survivors may be extensive due to high health care utilization and sick leave. Knowledge of the costs of OHCA survivors may guide decision-makers to prioritize health resources. AIM The aims of the study were to evaluate the costs of OHCA survivors from a societal perspective, and to compare these costs to the costs of individuals with non-cardiac arrest myocardial infarction (MI) and individuals with no cardiac disease (non-CD). METHODS From the Danish OHCA Registers, survivors, with a cardiac arrest between 2005-2018 were identified. Each case was assigned one MI control and one non-CD control, matched on gender and age. Based on register data, costs of healthcare utilization, sick leave, vocational rehabilitation, disability pension and other social benefits one year before event and five years after, were estimated. RESULTS In total 5,646 OHCA survivors were identified with associated control groups. The mean costs for OHCA survivors during the 6-year period were €119,106 (95%CI: 116,297-121,916), with €83,472 (95%CI: 81,392-85,552) being healthcare costs. Mean costs of OHCA survivors were €49,132 higher than the MI-control group and €100,583 higher than the non-CD control group. CONCLUSIONS Total costs of OHCA survivors were considerably higher than costs of MI- and non-CD controls. Hospital costs were highest during the first year after event, and work inability during the second to fifth year with sick leave and later disability pension as main burdens.
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Affiliation(s)
- Lola Qvist Kristensen
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99. 8200 Aarhus N, Denmark; Faculty of Health, Aarhus University, Vennelyst Boulevard, 8000 Aarhus, Denmark.
| | - Maurits W van Tulder
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99. 8200 Aarhus N, Denmark; Health Technology Assessment, Faculty Behavioural and Movement Sciences, Vrije Universiteit, Van der Boechorststraat, 1081 BT Amsterdam, the Netherlands
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99. 8200 Aarhus N, Denmark
| | - Lotte Sørensen
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99. 8200 Aarhus N, Denmark
| | - Bettina Wulff Risør
- Central Denmark Region, DEFACTUM, Evald Krogs Gade 16A, 8000 Aarhus C, Denmark; Aalborg University, Department of Clinical Medicine, Danish Centre for Health Services Research, Selma Lagerløfsvej 249, 9260 Gistrup, Denmark
| | - Lisa Gregersen Oestergaard
- Central Denmark Region, DEFACTUM, Evald Krogs Gade 16A, 8000 Aarhus C, Denmark; Department of Public Health, Aarhus University, Vennelyst Boulevard, 8000 Aarhus, Denmark
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Wang SA, Lee HW, Ko YC, Sun JT, Matsuyama T, Lin CH, Hsieh MJ, Chiang WC, Ma MHM. Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis. J Formos Med Assoc 2024; 123:561-570. [PMID: 37838538 DOI: 10.1016/j.jfma.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/04/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND/PURPOSE This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA). METHODS We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed. RESULTS From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07-1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04-1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16-1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes. CONCLUSION Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion.
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Affiliation(s)
- Shao-An Wang
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Hong-Wei Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chih Ko
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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Lescroart M, Pequignot B, Orlowski S, Reynette N, Martini B, Albuisson E, Tran N, Grandmougin D, Levy B. Albumin Infusion Reduces Fluid Loading for Postresuscitation Syndrome in a Pig Model of Refractory Cardiac Arrest Resuscitated With Venoarterial Extra Corporeal Membrane Oxygenation. ASAIO J 2024; 70:185-192. [PMID: 37856703 DOI: 10.1097/mat.0000000000002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Hemodynamic instability in postresuscitation syndrome worsens survival and neurological outcomes. Venoarterial extracorporeal membrane oxygenation (VA ECMO) for refractory cardiac arrest might improve outcomes. Hemodynamical support under VA ECMO relies on norepinephrine and crystalloids. The present work aims to assess the effects of albumin (ALB) infusion in a swine model of ischemic refractory cardiac arrest implanted by VA ECMO. Cardiac arrest was performed in 18 pigs and VA ECMO was initiated after 30 minutes cardiopulmonary resuscitation (CPR). Pigs were randomly assigned to standard care (norepinephrine + crystalloids) versus ALB group (ALB + standard care). Hemodynamical assessments were performed over 6 hours. Severe hypoalbuminemia was observed in the control group and could be reversed with ALB infusion. Total crystalloid load was significantly reduced with ALB infusion (1,000 [1,000-2,278] ml vs. 17,000 [10,000-19,000] ml, ALB versus control group, respectively, p < 0.001). There was no significant impact with regard to lactate clearance (29.16% [12.5-39.32] and 10.09% [6.78-29.36] for control versus ALB groups, respectively, p = 0.185), sublingual capillary microvascular parameters, or cerebral near-infrared spectrometer (NIRS) values. Compared to standard care, ALB infusion was highly effective in reducing fluid loading in a porcine model of postresuscitation syndrome after refractory cardiac arrest treated with VA ECMO.
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Affiliation(s)
- Mickaël Lescroart
- From the Service de Medecine intensive et réanimation, CHRU Nancy, Hôpital Brabois, Vandoeuvre les Nancy, France
- Groupe Choc, Equipe 2, INSERM U 1116, Faculté de Médecine, Vandoeuvre les Nancy, France
- Faculté de Médecine, Université de Lorraine, Nancy, France
| | - Benjamin Pequignot
- From the Service de Medecine intensive et réanimation, CHRU Nancy, Hôpital Brabois, Vandoeuvre les Nancy, France
- Groupe Choc, Equipe 2, INSERM U 1116, Faculté de Médecine, Vandoeuvre les Nancy, France
- Faculté de Médecine, Université de Lorraine, Nancy, France
| | - Sophie Orlowski
- Groupe Choc, Equipe 2, INSERM U 1116, Faculté de Médecine, Vandoeuvre les Nancy, France
- Faculté de Médecine, Université de Lorraine, Nancy, France
- Service de Biochimie, Pôle Laboratoires Hôpital Central, CHRU de Nancy, Nancy, France
| | - Nathan Reynette
- Faculté de médecine, Ecole de Chirurgie, Université de Lorraine, Nancy, France
| | - Bana Martini
- Faculté de médecine, Ecole de Chirurgie, Université de Lorraine, Nancy, France
| | - Eliane Albuisson
- Faculté de Médecine, Université de Lorraine, Nancy, France
- Plateforme d'aide à la recherche clinique (PARC), ESPRI-Biobase, Hôpital de Brabois, CHRU de Nancy, Vandoeuvre les Nancy, France
| | - N'Guyen Tran
- Faculté de Médecine, Université de Lorraine, Nancy, France
- Faculté de médecine, Ecole de Chirurgie, Université de Lorraine, Nancy, France
| | - Daniel Grandmougin
- Groupe Choc, Equipe 2, INSERM U 1116, Faculté de Médecine, Vandoeuvre les Nancy, France
- CHRU Nancy, Service de Chirurgie Cardiaque, Hôpital Brabois, Vandoeuvre les Nancy, France
| | - Bruno Levy
- From the Service de Medecine intensive et réanimation, CHRU Nancy, Hôpital Brabois, Vandoeuvre les Nancy, France
- Groupe Choc, Equipe 2, INSERM U 1116, Faculté de Médecine, Vandoeuvre les Nancy, France
- Faculté de Médecine, Université de Lorraine, Nancy, France
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Pareek N, Rees P, Quinn T, Vopelius-Feldt JV, Gallagher S, Mozid A, Johnson T, Gudde E, Simpson R, Glover G, Davies J, Curzen N, Keeble TR. British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care. Interv Cardiol 2022; 17:e18. [PMID: 36644626 PMCID: PMC9820135 DOI: 10.15420/icr.2022.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/10/2022] [Indexed: 11/11/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.
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Affiliation(s)
- Nilesh Pareek
- King's College Hospital NHS Foundation TrustLondon, UK,School of Cardiovascular Medicine and Sciences, British Heart Failure Centre of Excellence, King's College LondonLondon, UK
| | - Paul Rees
- Barts Interventional Group, Barts Heart CentreLondon, UK,Academic Department of Military Medicine, Defence Medical ServicesLondon, UK
| | - Tom Quinn
- Emergency, Cardiovascular and Critical Care Research Group, Kingston University and St. George's, University of LondonLondon, UK
| | | | - Sean Gallagher
- Department of Cardiology, University Hospital of WalesCardiff, UK
| | - Abdul Mozid
- Leeds Teaching Hospitals NHS Foundation TrustLeeds, UK
| | - Tom Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation TrustUK
| | - Ellie Gudde
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Guy Glover
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation TrustLondon, UK
| | - John Davies
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
| | - Nick Curzen
- Faculty of Medicine, University of SouthamptonSouthampton, UK,Cardiothoracic Care Group, University Hospital SouthamptonSouthampton, UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, MSE TrustBasildon, Essex, UK,Medical Technology Research Centre, Anglia Ruskin School of MedicineChelmsford, Essex, UK
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Location of out-of-hospital cardiac arrests and automated external defibrillators in relation to schools in an English ambulance service region. Resusc Plus 2022; 11:100279. [PMID: 35911779 PMCID: PMC9335389 DOI: 10.1016/j.resplu.2022.100279] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) remains low both in England and worldwide. About a third of all OHCAs occur within 300 m of a school. Considering the usage rates of public access defibrillators there is significant potential for increasing their use. Improving access to automated external defibrillators (AED) in schools and their registration with Emergency Medical Services could lead to greater use. A strategy for placing AEDs in schools is likely to be cost-effective.
Introduction This study sought to identify the availability of automated external defibrillators (AEDs) in schools in the region served by West Midlands Ambulance Service University NHS Trust (WMAS), United Kingdom, and the number of out-of-hospital cardiac arrests (OHCA) that occurred at or near to schools. A secondary aim was to explore the cost effectiveness of school-based defibrillators. Methods This observational study used data from the national registry for OHCA (University of Warwick) to identify cases occurring at or near schools between January 2014 and December 2016 in WMAS region (n = 11,399). A school survey (n = 2,453) was carried out in September 2017 to determine the presence of AEDs and their registration status with WMAS. Geographical Information System mapping software identified OHCAs occurring within a 300-metre radius of a school. An economic analysis calculated the cost effectiveness of school-based AEDs. Results A total of 39 (0.34%) of all OHCAs occurred in schools, although 4,250 (37.3%) of OHCAs in the region were estimated to have occurred within 300 metres of a school. Of 323 school survey responses, 184 (57%) had an AED present, of which 24 (13.0%) were available 24 h/day. Economic modelling of a school-based AED programme showed additional quality-adjusted life years (QALY) of 0.26 over the lifetime of cardiac arrest survivors compared with no AED programme. The incremental cost-effectiveness ratio (ICER) was £8,916 per QALY gained. Conclusion Cardiac arrests in schools are rare. Registering AEDs with local Emergency Medical Services and improving their accessibility within their local community would increase their utility.
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Liao MT, Lin MH, Tsai HE, Wu JH, Caffrey JL, Lin JW, Wang CH, Yu HY, Chen YS. Risk stratification and cost-effectiveness analysis of adult patients receiving extracorporeal membrane oxygenation. J Eval Clin Pract 2022; 28:615-623. [PMID: 35365930 DOI: 10.1111/jep.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES A more effective allocation of critical care resources is important as the cost of intensive care increases. A model has been developed to predict the probability of in-hospital death among patients who received extracorporeal membrane oxygenation (ECMO). Cost-effectiveness analyses (CEA) were performed regarding the relationship between hospitalization expenses and predicted survival outcomes. METHODS Adult patients who received ECMO in a medical center in Taiwan (2005-2016) were included. A logistic regression model was applied to a spectrum of clinical measures obtained before and during ECMO institutions to identify the risk variables for in-hospital mortality. CEA were reported as a predictive risk in quintiles and defined as the cost of each quality-adjusted life-year (QALY). The distribution of the cost-effectiveness ratio (CER) was measured by the ellipse and acceptability curve methods. RESULTS A total of 919 patients (659 males, mean age: 53.7 years) were enrolled. Ten variables emerged as significant predictors of in-hospital death. The area under the receiver operating characteristic curve was 0.75 (95% confidence interval: 0.72-0.79). In-hospital and total follow-up times were 40,366 and 660,205 person-days, respectively. The total in-hospital expense was $31,818,701 USD and the total effectiveness was 1687.3 QALY. For the lowest to the highest risk quintile, the mean mortality risks were 0.30, 0.48, 0.61, 0.75, and 0.88, and mean adjusted CER were $24,230, $43,042, $54,929, $84,973, and $149,095 per QALY, respectively. CONCLUSIONS The efficient allocation of limited and costly resources is most important when one is forced to decide between groups of critically ill patients. The current analyses of ECMO outcomes should assist in identifying candidates with the greatest prospect for survival while avoiding futile treatments.
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Affiliation(s)
- Min-Tsun Liao
- Division of Cardiology, Department of Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan.,Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Hsien Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsiao-En Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Jo-Hsuan Wu
- Viterbi Family Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California, San Diego, California, USA
| | - James L Caffrey
- Physiology and Cardiovascular Research Institute, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Jou-Wei Lin
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin County, Taiwan
| | - Chih-Hsien Wang
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsi-Yu Yu
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yih-Sharng Chen
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
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Javanbakht M, Mashayekhi A, Hemami MR, Branagan-Harris M, Keeble TR, Yaghoubi M. Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England. PHARMACOECONOMICS - OPEN 2022; 6:549-562. [PMID: 35503202 PMCID: PMC9283555 DOI: 10.1007/s41669-022-00333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been shown to improve neurological outcomes and survival in patients resuscitated from cardiac arrest; however, the cost effectiveness of multiple TTM methods is not well studied. OBJECTIVE This study aimed to evaluate the cost effectiveness of intravascular temperature management (IVTM) using Thermogard XP compared with surface cooling methods after cardiac arrest in the England from the perspectives of the UK national health service and Personal Social Services. METHODS We developed a multi-state Markov model that evaluated IVTM (Thermogard XP) compared with surface cooling using two different devices (Blanketrol III and Arctic Sun 5000) over a short-term and lifetime time horizon. Model input parameters were obtained from the literature and local databases. We assumed a hypothetical cohort of 1000 patients who required TTM after cardiac arrest per year in the England. The outcomes were costs (in £, year 2019 values) and quality-adjusted life-years (QALYs), discounted at 3.5% annually. Deterministic and probabilistic sensitivity analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results. RESULTS The cost-effectiveness analysis determined that Thermogard XP resulted in direct cost savings of £2339 and £2925 (per patient) compared with Blanketrol III and Arctic Sun 5000, respectively, and a gain of 0.98 QALYs over the patient lifetime. The probabilistic sensitivity analysis demonstrated that the probability of Thermogard XP being cost saving would be 69.2% and 65.3% versus the Arctic Sun 5000 and Blanketrol III, respectively. CONCLUSION Implementation of IVTM using Thermogard XP can lead to cost savings and improved patient quality of life versus surface cooling methods.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, Southampton, UK
| | | | | | | | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon, UK
- MTRC, Anglia Ruskin School of Medicine, Chelmsford, UK
| | - Mohsen Yaghoubi
- Mercer University College of Pharmacy, 3001 Mercer University Dr, Atlanta, GA, 30341, USA.
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Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus 2022; 10:100230. [PMID: 35434669 PMCID: PMC9010695 DOI: 10.1016/j.resplu.2022.100230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022] Open
Abstract
Aim The aim of this study was to describe the survival and neurological outcome in patients with OHCA treated with and without mechanical circulatory support (MCS). Methods This was a retrospective observational cohort study on patients with OHCA admitted to Aarhus University Hospital, Denmark, between January 2015 and December 2019. Kaplan-Meier estimates were used to evaluate 30-day and 30–180-day survival. Cox regression analysis was used to assess the association between covariates and one-year mortality. Results Among 1,015 patients admitted, 698 achieved return of spontaneous circulation (ROSC) before admission, 101 patients with refractory OHCA received mechanical circulatory support (MCS) and the remaining 216 patients with refractory OHCA did not receive MCS treatment. Survival to hospital discharge was 47% (478/1015). Good neurological outcome defined as Cerebral Performance Categories 1–2 were seen among 92% (438/478) of the patients discharged from hospital. Median low-flow was 15 [8–22] minutes in the ROSC group and 105 [94–123] minutes in the MCS group. Mortality rates were high within the first 30 days, however; 30–180-day survival in patients discharged remained constant over time in both patients with ROSC on admission and patients admitted with MCS. Advanced age > 70 years (hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.11–3.49), pulseless electrical activity (HR 2.39, 95% CI 1.25–4.60) and asystole HR 2.70, 95% CI 1.25–5.95) as initial rhythms were associated with one-year mortality in patients with ROSC. Conclusions Short-term survival rates were high among patients with ROSC and patients receiving MCS. Among patients who survived to day 30, landmark analyses showed comparable 180-day survival in the two groups despite long low-flow times in the MCS group. Advanced age and initial non-shockable rhythms were independent predictors of one-year mortality in patients with ROSC on admission.
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Affiliation(s)
- Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- Corresponding author at: Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark.
| | - Morten Thingemann Bøtker
- Aarhus University, Aarhus, Denmark
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Steffen Christensen
- Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Mariann Tang
- Aarhus University, Aarhus, Denmark
- Department of Thoracic and Vascular Surgery, Aarhus University Hospital, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- The Danish Heart Foundation, Denmark
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Camaro C, Bonnes JL, Adang EM, Spoormans EM, Janssens GN, van der Hoeven NW, Jewbali LS, Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJ, van der Harst P, van der Horst IC, Voskuil M, van der Heijden JJ, Beishuizen B, Stoel M, van der Hoeven H, Henriques JP, Vlaar AP, Vink MA, van den Bogaard B, Heestermans TA, de Ruijter W, Delnoij TS, Crijns HJ, Jessurun GA, Oemrawsingh PV, Gosselink MT, Plomp K, Magro M, Elbers PW, van de Ven PM, Lemkes JS, van Royen N. Cost Analysis From a Randomized Comparison of Immediate Versus Delayed Angiography After Cardiac Arrest. J Am Heart Assoc 2022; 11:e022238. [PMID: 35195012 PMCID: PMC9075079 DOI: 10.1161/jaha.121.022238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In patients with out-of-hospital cardiac arrest without ST-segment elevation, immediate coronary angiography did not improve clinical outcomes when compared with delayed angiography in the COACT (Coronary Angiography After Cardiac Arrest) trial. Whether 1 of the 2 strategies has benefits in terms of health care resource use and costs is currently unknown. We assess the health care resource use and costs in patients with out-of-hospital cardiac arrest. Methods and Results A total of 538 patients were randomly assigned to a strategy of either immediate or delayed coronary angiography. Detailed health care resource use and cost-prices were collected from the initial hospital episode. A generalized linear model and a gamma distribution were performed. Generic quality of life was measured with the RAND-36 and collected at 12-month follow-up. Overall total mean costs were similar between both groups (EUR 33 575±19 612 versus EUR 33 880±21 044; P=0.86). Generalized linear model: (β, 0.991; 95% CI, 0.894-1.099; P=0.86). Mean procedural costs (coronary angiography and percutaneous coronary intervention, coronary artery bypass graft) were higher in the immediate angiography group (EUR 4384±3447 versus EUR 3028±4220; P<0.001). Costs concerning intensive care unit and ward stay did not show any significant difference. The RAND-36 questionnaire did not differ between both groups. Conclusions The mean total costs between patients with out-of-hospital cardiac arrest randomly assigned to an immediate angiography or a delayed invasive strategy were similar during the initial hospital stay. With respect to the higher invasive procedure costs in the immediate group, a strategy awaiting neurological recovery followed by coronary angiography and planned revascularization may be considered. Registration URL: https://trialregister.nl; Unique identifier: NL4857.
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Holmström E, Efendijev I, Raj R, Pekkarinen PT, Litonius E, Skrifvars MB. Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs. Scand J Trauma Resusc Emerg Med 2021; 29:103. [PMID: 34321064 PMCID: PMC8317381 DOI: 10.1186/s13049-021-00923-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital. Methods This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome. Results This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001). Conclusions The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00923-0.
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Affiliation(s)
- Ester Holmström
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Ilmar Efendijev
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka T Pekkarinen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Erik Litonius
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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11
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Pareek N, Kordis P, Beckley-Hoelscher N, Pimenta D, Kocjancic ST, Jazbec A, Nevett J, Fothergill R, Kalra S, Lockie T, Shah AM, Byrne J, Noc M, MacCarthy P. A practical risk score for early prediction of neurological outcome after out-of-hospital cardiac arrest: MIRACLE2. Eur Heart J 2021; 41:4508-4517. [PMID: 32731260 DOI: 10.1093/eurheartj/ehaa570] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/25/2020] [Accepted: 07/01/2020] [Indexed: 02/02/2023] Open
Abstract
AIMS The purpose of this study was to develop a practical risk score to predict poor neurological outcome after out-of-hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre. METHODS AND RESULTS From May 2012 to December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King's Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multivariable logistic regression to identify predictors of the primary outcome to derive a risk score. This was externally validated in two independent cohorts comprising 473 patients. The primary endpoint was poor neurological outcome at 6-month follow-up (Cerebral Performance Category 3-5). Seven independent predictors of outcome were identified: missed (unwitnessed) arrest, initial non-shockable rhythm, non-reactivity of pupils, age (60-80 years-1 point; >80 years-3 points), changing intra-arrest rhythms, low pH <7.20, and epinephrine administration (2 points). The MIRACLE2 score had an area under the curve (AUC) of 0.90 in the development and 0.84/0.91 in the validation cohorts. Three risk groups were defined-low risk (MIRACLE2 ≤2-5.6% risk of poor outcome); intermediate risk (MIRACLE2 of 3-4-55.4% of poor outcome); and high risk (MIRACLE2 ≥5-92.3% risk of poor outcome). The MIRACLE2 score had superior discrimination than the OHCA [median AUC 0.83 (0.818-0.840); P < 0.001] and Cardiac Arrest Hospital Prognosis models [median AUC 0.87 (0.860-0.870; P = 0.001] and equivalent performance with the Target Temperature Management score [median AUC 0.88 (0.876-0.887); P = 0.092]. CONCLUSIONS The MIRACLE2 is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission.
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Affiliation(s)
- Nilesh Pareek
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE59RS, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, 125 Coldharbour Lane, London SE5 9NU, UK
| | - Peter Kordis
- Centre for Intensive Internal Medicine, University Medical Center, Zaloska 7, Ljubljana 1000, Slovenia
| | | | - Dominic Pimenta
- Department of Cardiology, Royal Free Hospital NHS Foundation Trust, Pond St, Hampstead, London NW3 2QG, UK
| | - Spela Tadel Kocjancic
- Centre for Intensive Internal Medicine, University Medical Center, Zaloska 7, Ljubljana 1000, Slovenia
| | - Anja Jazbec
- Centre for Intensive Internal Medicine, University Medical Center, Zaloska 7, Ljubljana 1000, Slovenia
| | - Joanne Nevett
- London Ambulance Service NHS Trust, 220 Waterloo Rd, London SE1 8SD, UK
| | | | - Sundeep Kalra
- Department of Cardiology, Royal Free Hospital NHS Foundation Trust, Pond St, Hampstead, London NW3 2QG, UK
| | - Tim Lockie
- Department of Cardiology, Royal Free Hospital NHS Foundation Trust, Pond St, Hampstead, London NW3 2QG, UK
| | - Ajay M Shah
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE59RS, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, 125 Coldharbour Lane, London SE5 9NU, UK
| | - Jonathan Byrne
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE59RS, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, 125 Coldharbour Lane, London SE5 9NU, UK
| | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Zaloska 7, Ljubljana 1000, Slovenia
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE59RS, UK.,School of Cardiovascular Medicine and Sciences, BHF Centre of Excellence, King's College London, 125 Coldharbour Lane, London SE5 9NU, UK
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12
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Lau VI, Xie F, Basmaji J, Cook DJ, Fowler R, Kiflen M, Sirotich E, Iansavichene A, Bagshaw SM, Wilcox ME, Lamontagne F, Ferguson N, Rochwerg B. Health-Related Quality-of-Life and Cost Utility Analyses in Critical Care: A Systematic Review. Crit Care Med 2021; 49:575-588. [PMID: 33591013 DOI: 10.1097/ccm.0000000000004851] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured. DESIGN Systematic review. DATA SOURCES We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020. SETTING Adult ICUs. PATIENTS Adult critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies. CONCLUSIONS We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care.
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Affiliation(s)
- Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - Michel Kiflen
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emily Sirotich
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - François Lamontagne
- Centre de Recherche du CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
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13
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Vercammen S, Moens E. Cost-effectiveness of a novel smartphone application to mobilize first responders after witnessed OHCA in Belgium. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:52. [PMID: 33292296 PMCID: PMC7673090 DOI: 10.1186/s12962-020-00248-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 11/03/2020] [Indexed: 11/13/2022] Open
Abstract
Background EVapp (Emergency Volunteer Application) is a Belgian smartphone application that mobilizes volunteers to perform cardiopulmonary resuscitation (CPR) and defibrillation with publicly available automatic external defibrillators (AED) after an emergency call for suspected out of hospital cardiac arrest (OHCA). The aim is to bridge the time before the arrival of the emergency services. Methods An accessible model was developed, using literature data, to simulate survival and cost-effectiveness of nation-wide EVapp implementation. Initial validation was performed using field data from a first pilot study of EVapp implementation in a city in Flanders, covering 2.5 years of implementation. Results Simulation of nation-wide EVapp implementation resulted in an additional yearly 910 QALY gained over the current baseline case scenario (worst case 632; best case 3204). The cost per QALY associated with EVapp implementation was comparable to the baseline scenario, i.e., 17 vs 18 k€ QALY−1. Conclusions EVapp implementation was associated with a positive balance on amount of QALY gained and cost of QALY. This was a consequence of both the lower healthcare costs for patients with good neurological outcome and the more efficient use of yet available resources, which did not outweigh the costs of operation.
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Affiliation(s)
- Steven Vercammen
- EVapp vzw, AA Tower - 8th floor, Technologiepark 122 (zone C2a), 9052, Zwijnaarde, België.
| | - Esther Moens
- UGent, Sint-Pietersnieuwstraat 25, 9000, Gent, Belgium
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14
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Gue YX, Sayers M, Whitby BT, Kanji R, Adatia K, Smith R, Davies WR, Perperoglou A, Potpara TS, Lip GYH, Gorog DA. Usefulness of the NULL-PLEASE Score to Predict Survival in Out-of-Hospital Cardiac Arrest. Am J Med 2020; 133:1328-1335. [PMID: 32387318 DOI: 10.1016/j.amjmed.2020.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Out-of-hospital cardiac arrest (OHCA) carries a very high mortality rate even after successful cardiopulmonary resuscitation. Currently, information given to relatives about prognosis following resuscitation is often emotive and subjective, and varies with clinician experience. We aimed to validate the NULL-PLEASE score to predict survival following OHCA. METHODS A multicenter cohort study was conducted, with retrospective and prospective validation in consecutive unselected patients presenting with OHCA. The NULL-PLEASE score was calculated by attributing points to the following variables: Nonshockable initial rhythm, Unwitnessed arrest, Long low-flow period, Long no-flow period, pH <7.2, Lactate >7.0 mmol/L, End-stage renal failure, Age ≥85 years, Still resuscitation, and Extracardiac cause. The primary outcome was in-hospital death. RESULTS We assessed 700 patients admitted with OHCA, of whom 47% survived to discharge. In 300 patients we performed a retrospective validation, followed by prospective validation in 400 patients. The NULL-PLEASE score was lower in patients who survived compared with those who died (0 [interquartile range 0-1] vs 4 [interquartile range 2-4], P < .0005) and strongly predictive of in-hospital death (C-statistic 0.874; 95% confidence interval, 0.848-0.899). Patients with a score ≥3 had a 24-fold increased risk of death (odds ratio 23.6; 95% confidence interval, 14.840-37.5; P < .0005) compared with those with lower scores. A score ≥3 has a 91% positive predictive value for in-hospital death, while a score <3 predicts a 71% chance of survival. CONCLUSION The easy-to-use NULL-PLEASE score predicts in-hospital mortality with high specificity and can help clinicians explain the prognosis to relatives in an easy-to-understand, objective fashion, to realistically prepare them for the future.
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Affiliation(s)
- Ying X Gue
- University of Hertfordshire, United Kingdom; East and North Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Max Sayers
- Royal Brompton & Harefield NHS Trust, Harefield, United Kingdom
| | | | - Rahim Kanji
- East and North Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Krishma Adatia
- East and North Hertfordshire NHS Trust, Hertfordshire, United Kingdom
| | - Robert Smith
- Royal Brompton & Harefield NHS Trust, Harefield, United Kingdom
| | - William R Davies
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Tatjana S Potpara
- Clinical Centre of Serbia & School of Medicine, Belgrade University, Belgrade, Serbia
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Diana A Gorog
- University of Hertfordshire, United Kingdom; East and North Hertfordshire NHS Trust, Hertfordshire, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
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15
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Matsuoka Y, Goto R, Atsumi T, Morimura N, Nagao K, Tahara Y, Asai Y, Yokota H, Ariyoshi K, Yamamoto Y, Sakamoto T. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study. Resuscitation 2020; 157:32-38. [PMID: 33080369 DOI: 10.1016/j.resuscitation.2020.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/17/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). METHODS We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). RESULTS ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. CONCLUSIONS ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.
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Affiliation(s)
- Yoshinori Matsuoka
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan; Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
| | - Rei Goto
- Graduate School of Business Administration, Keio University, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama, Kanagawa 223-8526, Japan
| | - Takahiro Atsumi
- Department of Emergency Medicine, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Naka-ku, Hamamatsu, Shizuoka 430-8558, Japan
| | - Naoto Morimura
- Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Ken Nagao
- Cardiovascular Center, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8309, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565, Japan
| | - Yasufumi Asai
- Department of Traumatology and Critical Care Medicine, School of Medicine, Sapporo Medical University, S1W17, Chuo-ku, Sapporo, Hokkaido 060-8556, Japan
| | - Hiroyuki Yokota
- Graduate School of Medical and Health Science, Nippon Sports Science University, 1221-1 Kamoshida-cho, Aoba-ku, Yokohama, Kanagawa 227-0033, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, School of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8606, Japan
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16
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Steinberg A, Callaway C, Dezfulian C, Elmer J. Are providers overconfident in predicting outcome after cardiac arrest? Resuscitation 2020; 153:97-104. [PMID: 32544415 DOI: 10.1016/j.resuscitation.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/24/2020] [Accepted: 06/04/2020] [Indexed: 01/28/2023]
Abstract
AIM To quantify the accuracy of health care providers' predictions of survival and function at hospital discharge in a prospective cohort of patients resuscitated from cardiac arrest. To test whether self-reported confidence in their predictions was associated with increased accuracy and whether this relationship varied across providers. METHODOLOGY We presented critical care and neurology providers with clinical vignettes using real data from post-arrest patients. We asked providers to predict survival, function at discharge, and report their confidence in these predictions. We used mixed effects models to explore predictors of confidence, accuracy, and the relationship between the two. RESULTS We completed 470 assessments of 62 patients with 65 providers. Of patients, 49 (78%) died and 9 (15%) had functionally favourable survival. Providers accurately predicted survival in 308/470 (66%) assessments. In most errors (146/162, 90%), providers incorrectly predicted survival. Providers accurately predicted function in 349/470 (74%) assessments. In most errors (114/121, 94%), providers incorrectly predicted favourable functional recovery. Providers were confident (median confidence predicting survival 80 [IQR 60-90]; median confidence predicting function 80 [IQR 60-95]). Confidence explained 9% and 18% of variation in accuracy predicting survival and function, respectively. We observed significant between-provider variability in accuracy (median odds ratio (MOR) for predicting survival 2.93, 95%CI 1.94-5.52; MOR for predicting function 5.42, 95%CI 3.01-13.2). CONCLUSIONS Providers varied in accuracy predicting post-arrest outcomes and most errors were optimistic. Self-reported confidence explained little variation in accuracy.
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Affiliation(s)
- Alexis Steinberg
- University of Pittsburgh, Department of Critical Care Medicine and Neurology, Pittsburgh, PA, USA.
| | - Clifton Callaway
- University of Pittsburgh, Department of Emergency Medicine, Pittsburgh, PA, USA.
| | - Cameron Dezfulian
- University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- University of Pittsburgh, Department of Critical Care Medicine, Emergency Medicine and Neurology, Pittsburgh, PA, USA.
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17
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Geri G, Scales DC, Koh M, Wijeysundera HC, Lin S, Feldman M, Cheskes S, Dorian P, Isaranuwatchai W, Morrison LJ, Ko DT. Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest. Resuscitation 2020; 153:234-242. [PMID: 32422247 DOI: 10.1016/j.resuscitation.2020.04.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 04/13/2020] [Accepted: 04/23/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The management of out-of-hospital cardiac arrest (OHCA) patients requires the coordination of prehospital, in-hospital and post-discharge teams. Data reporting a comprehensive analysis of all costs associated with treating OHCA are scarce. We aimed to describe the total costs (and their components) related to the management of OHCA patients. PATIENT AND METHODS We performed an analysis on a merged database of the Toronto Regional RescuNet Epistry database (prehospital data) and administrative population-based databases in Ontario. All non-traumatic OHCA patients over 18 years of age treated by the EMS between January 1, 2006, and March 31, 2014, were included in this study. The primary outcome was per patient longitudinal cumulative healthcare costs, from time of collapse to a maximum follow-up until death or 30 days after the event. We included all available cost sectors, from the perspective of the health system payer. We used multivariable generalized linear models with a logarithmic link and a gamma distribution to determine predictors of healthcare costs. RESULTS 25,826/44,637 patients were treated by EMS services for an OHCA (mostly male 64.4%, mean age 70.1). 11,727 (45%) were pronounced dead on scene, 8359 (32%) died in the emergency department, 3640 (14%) were admitted to hospital but died before day-30, and 2100 (8.1%) were still alive at day-30. Total cost was $690 [interquartile range (IQR) $308, $1742] per patient; ranging from $290 [IQR $188, $390] for patients who were pronounced on scene to $39,216 [IQR 21,802, 62,093] for patients who were still alive at day-30. In-hospital costs accounted for 93% of total costs. After adjustment for age and gender, rate of patient survival was the main driver of total costs: the rate ratio was 3.88 (95% confidence interval 3.80, 3.95), 49.46 and 148.89 for patients who died in the ED, patients who died after the ED but within 30 days, and patients who were still alive at day-30 compared to patients who were pronounced dead on scene, respectively. Factors independently associated with costs were the number of prehospital teams (rate ratio (RR) 5.50 [5.32, 5.67] for being treated by 4 teams vs. 1), the need for hospital transfer (RR 2.38 [2.01, 2.82]), coronary angiography (RR 1.43 [1.27, 1.62]) and targeted temperature management (RR 1.25 [1.09, 1.44]). CONCLUSION Survival is the main driver of total costs of treating OHCA patients in a large Canadian health system. Inpatient costs accounted for the majority of the total costs; potentially modifiable factors include the number of prehospital teams that arrive to the scene of the arrest and the need for between-hospital transfers after successful resuscitation.
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Affiliation(s)
- Guillaume Geri
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | - Damon C Scales
- ICES, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Harindra C Wijeysundera
- ICES, Toronto, Ontario, Canada; Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Steve Lin
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Feldman
- Sunnybrook Centre for Prehospital Medicine, Sunnybrook health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research, The HUB Health Research Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Dennis T Ko
- Rescu, Li Ka Shing Knowledge Institute at St Michael's Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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18
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Abstract
OBJECTIVES Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING Critical care units. PATIENTS OR SUBJECTS Critical care patients. INTERVENTIONS Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.
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Aung YN, Nur AM, Ismail A, Aljunid SM. Determining the Cost and Length of Stay at Intensive Care Units and the Factors Influencing Them in a Teaching Hospital in Malaysia. Value Health Reg Issues 2020; 21:149-156. [PMID: 31958748 DOI: 10.1016/j.vhri.2019.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/03/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Escalating healthcare costs calls for the efficiency of health services, especially in the intensive care unit (ICU) where the bulk of resources are used. This study aims to identify the length of stay (LOS) and cost of care at ICUs, which are proxy indicators of efficiency and the factors determining them. METHODS A cross-sectional study of patients requiring ICU admissions in a teaching hospital in Malaysia from 2013 to 2015 was conducted. The cost at the ICU was estimated using the step down approach. Factors that determined the cost and LOS at the ICU were also explored by using multivariate regression analysis. RESULTS Each day of stay cost $427 (USD) at the pediatric intensive care unit and $1324 at the general intensive care unit. The mean LOS at the ICU was 5.7 days (standard deviation [SD]: 8.4) with a median of 4 days (95% confidence interval [CI] 1-16.7 days). Average cost of care at the ICU per episode of care was $5473 (SD $6499), and the median was $3463. ICU patients spent 29.3% of the total stay and 47.2% of the cost at ICU units. Upon multivariate regression analysis, severity, case base-group, and type of ICU that the patient was admitted to were associated with the cost and LOS at ICU. CONCLUSIONS Compared with critical care practices in hospitals from more developed nations, a Malaysian teaching hospital required a longer length of ICU stay. Hence, implementations of strategies that can reduce the length of stay and hospital costs without compromising healthcare quality are required.
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Affiliation(s)
- Yin Nwe Aung
- Department of Pathology and Community Medicine, Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Malaysia; International Center for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia, Bangi, Malaysia.
| | - Amrizal M Nur
- International Center for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | - Aniza Ismail
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | - Syed M Aljunid
- International Center for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia, Bangi, Malaysia; Department of Health Policy and Management, Faculty of Public Health, Kuwait University, Kywait City, Kuwait
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20
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Ruch R, Stoessel L, Stein P, Ganter MT, Button DA. Outcome, quality of life and direct costs after out-of-hospital cardiac arrest in an urban region of Switzerland. Scand J Trauma Resusc Emerg Med 2019; 27:106. [PMID: 31771619 PMCID: PMC6880486 DOI: 10.1186/s13049-019-0682-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/11/2019] [Indexed: 11/16/2022] Open
Abstract
Background Considering the significant morbidity and mortality of out-of-hospital cardiac arrest, only little data on survival or quality of life after successful resuscitation is available in Europe. Additionally, economic aspects of such events are poorly studied. The purpose of this study is to provide data for survival, quality of life and costs directly related to the cardiac arrest for a region of Switzerland served by one emergency medical service (EMS). Methods Eighty eight patients older than 18 years of age that were resuscitated by the EMS Winterthur in the year 2013 were included and retrospective analysis of EMS-protocols was performed. For patients alive at follow-up, 2 years after the event, a structured interview with quality of life questionnaires was conducted. This study was accepted by the local Ethics Committee. Results Thirty five percent (n = 31) of resuscitated patients were admitted alive to the hospital following out-of-hospital cardiac arrest. This incidence was as high as 60%, if the patients had a shockable rhythm as first rhythm. Survival to follow-up was 16% (n = 14). These patients had an excellent quality of life overall, with little to no limitations in daily life. There was no significant difference in survival for patients in outlying regions with comparatively longer timespans until arrival of EMS. Median EMS-costs for deceased patients were CHF 1731 (inter-quartile range 346), for survivors CHF 2′169 (inter-quartile range CHF 444) and median hospital-costs were CHF 27′707 (inter-quartile range CHF 62′783). Conclusion Quality of care for patients with out-of-hospital cardiac arrest in the region of Winterthur is high, including patients in outlying regions. The associated costs are similar to other European countries. Trial registration This trial was registered with www.clinicaltrials.gov under NCT02625883.
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Affiliation(s)
- Raphael Ruch
- Institute of Anesthesiology - Emergency Medical Service, Perioperative Medicine, Pain Therapy, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Switzerland
| | - Laura Stoessel
- Institute of Anesthesiology - Emergency Medical Service, Perioperative Medicine, Pain Therapy, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology - Emergency Medical Service, Perioperative Medicine, Pain Therapy, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Switzerland
| | - Michael Thomas Ganter
- Institute of Anesthesiology - Emergency Medical Service, Perioperative Medicine, Pain Therapy, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Switzerland.
| | - Daniel Anthony Button
- Institute of Anesthesiology - Emergency Medical Service, Perioperative Medicine, Pain Therapy, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Switzerland
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21
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Monk A, Patil S. Infrared pupillometry to help predict neurological outcome for patients achieving return of spontaneous circulation following cardiac arrest: a systematic review protocol. Syst Rev 2019; 8:286. [PMID: 31767023 PMCID: PMC6876106 DOI: 10.1186/s13643-019-1209-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy's predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy's results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome. METHODS The proposed study will test the hypothesis, "in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome". A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach. DISCUSSION IRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy's other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018118180.
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Affiliation(s)
- Alex Monk
- Emergency Department, Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London, SW10 9NH, England.
| | - Shashank Patil
- Emergency Department, Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London, SW10 9NH, England.,Kings College London, Room No 213, St Thomas' House, Westminster Bridge Road, London, SE1 7EH, England
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22
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Pareek N, Kordis P, Webb I, Noc M, MacCarthy P, Byrne J. Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions. Interv Cardiol 2019; 14:113-123. [PMID: 31867056 PMCID: PMC6918505 DOI: 10.15420/icr.2019.3.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.
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Affiliation(s)
- Nilesh Pareek
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | | | - Ian Webb
- King’s College Hospital NHS Foundation TrustLondon, UK
| | - Marko Noc
- University Medical CentreLjubljana, Slovenia
| | - Philip MacCarthy
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
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23
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Takura T. Current Trends in Medical Economics in the Circulatory Field - Socioeconomics Background and Research Issue. Circ Rep 2019; 1:342-346. [PMID: 33693160 PMCID: PMC7892485 DOI: 10.1253/circrep.cr-19-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Circulatory diseases now comprise a larger share of medical expenses, accounting for 19.7% (2016) of total national health expenditure. Medical economics is an area of study encompassing medical science and economics that deals with a wide variety of topics and issues related to the medical and health-care field. Methods and Results: In order to discuss the relationship between medical costs and research activities, this article conducted a correlation analysis of the ratio of national health expenditures to gross domestic product (GDP) and the number of medical economics articles in the circulatory field. A comparison of the ratios of national health expenditure and of the number of medical economics articles indicates that the number of articles increased as the ratio of the expenditure increased and vice versa with a slight time lag (r2=0.964, P<0.01). Medical economics will explore deeply the subjects related to the clinical and economy in the circulatory field in the future, with due consideration of these diverse backgrounds. Conclusions: Lively and in-depth future-oriented discussions of medical economics topics will facilitate the construction of valuable evidence that will help many personnel engaged in medical sites to gain new insights into clinical services, in addition to promoting the development of the healthcare system.
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Affiliation(s)
- Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo Tokyo Japan
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24
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von Vopelius-Feldt J, Powell J, Benger JR. Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model. BMJ Open 2019; 9:e028574. [PMID: 31345972 PMCID: PMC6661553 DOI: 10.1136/bmjopen-2018-028574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective? SETTING A single National Health Service ambulance service and a charity-funded prehospital critical care service in England. PARTICIPANTS The patient population is adult, non-traumatic OHCA. METHODS We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses. RESULTS Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%. CONCLUSION This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field. TRIAL REGISTRATION NUMBER ISRCTN18375201.
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Affiliation(s)
- Johannes von Vopelius-Feldt
- Faculty of Health and Applied Sciences, The University of the West of England, Bristol, UK
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jane Powell
- Centre for Public Health and Wellbeing, University of the West of England, Bristol, Bristol, UK
| | - Jonathan Richard Benger
- Faculty of Health and Applied Sciences, The University of the West of England, Bristol, UK
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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25
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Kawashima T, Uehara H, Miyagi N, Shimajiri M, Nakamura K, Chinen T, Hatano S, Nago C, Chiba S, Nakane H, Gima Y. Impact of first documented rhythm on cost-effectiveness of extracorporeal cardiopulmonary resuscitation. Resuscitation 2019; 140:74-80. [DOI: 10.1016/j.resuscitation.2019.05.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 04/21/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
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26
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Bougouin W, Piazza O, Dumas F, Baldi C, Cariou A, De Robertis E. Coronary angiogram after cardiac arrest? Reasonably and sensibly. Minerva Anestesiol 2019; 85:554-558. [DOI: 10.23736/s0375-9393.19.13425-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Dennis M, Zmudzki F, Burns B, Scott S, Gattas D, Reynolds C, Buscher H, Forrest P. Cost effectiveness and quality of life analysis of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Resuscitation 2019; 139:49-56. [PMID: 30922936 DOI: 10.1016/j.resuscitation.2019.03.021] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/20/2019] [Accepted: 03/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest (ECPR) has increased exponentially. ECPR is a resource intensive service and its cost effectiveness has yet to be demonstrated. We sought to complete a cost analysis with modelling of cost effectiveness and quality of life outcomes. We sought to complete a cost analysis with modelling of cost effectiveness and quality of life outcomes of patients who have undergone ECPR. METHODS Using data on all extracorporeal cardiopulmonary resuscitation (ECPR) patients at two ECMO centres in Sydney, Australia; we completed a costing analysis of ECPR patients. A Markov model of cost, quality of life and survival outcomes was developed to examine cost per QALY estimates and incremental cost effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) was completed to assess the probability of cost effectiveness for base case and variations. RESULTS Sixty-two consecutive ECPR patients were analysed; mean age of 51.9 ± 13.6 years, 38 (61%) were in hospital cardiac arrests (IHCA). Twenty-five patients (40%) survived to hospital discharge; all with a cerebral performance category (CPC) of 1 or 2. The mean cost per ECPR patient was AUD 75,165 (€50,535; ±AUD 75,737). Over 10 years ECPR was estimated to add a mean gain of 3.0 Quality Adjusted Life Years (QALYs) per patient with an incremental cost effectiveness ratio (ICER) of AUD 25,212 (€16,890) per QALY, increasing to 4.0 QALYs and an ICER of AUD 18,829 (€12,614) over a 15-year survival scenario. Mean cost per QALY did not differ significantly by OHCA or IHCA. CONCLUSIONS ECMO support for refractory cardiac arrests is cost effective and compares favourably to accepted cost effectiveness thresholds.
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Affiliation(s)
- Mark Dennis
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Fredrick Zmudzki
- Époque Consulting, Sydney, Australia; Social Policy Research Centre, University of New South Wales, Sydney, Australia.
| | - Brian Burns
- Sydney Medical School, University of Sydney, Sydney, Australia; Greater Sydney Area HEMS, NSW Ambulance Service, Australia.
| | - Sean Scott
- Department of Emergency Medicine, St. Vincent's Hospital, Sydney, Australia.
| | - David Gattas
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia.
| | - Claire Reynolds
- Department of Intensive Care, Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia.
| | - Hergen Buscher
- Department of Intensive Care, Centre for Applied Medical Research, St. Vincent's Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.
| | - Paul Forrest
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.
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28
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Souliotis K, Golna C, Mantzana V, Papaspyropoulos S, Koutsovasilis A, Sotiropoulos A. Clinical audit as a tool to optimize contracted private healthcare provision: Testing the waters in resource-deprived Greece. SAGE Open Med 2019; 7:2050312119838736. [PMID: 30911389 PMCID: PMC6425533 DOI: 10.1177/2050312119838736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/27/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Clinical audit is applied to optimize clinical practice and quality of healthcare services while controlling for money spent, critically in resource-deprived settings. This case study reports on the outcomes of a retrospective clinical audit on private hospitalizations, for which reimbursement had been pending by the Health Care Organization for Public Servants (OPAD) in Greece. This case study is the first effort by a social insurance organization in Greece to employ external clinical audit before settling contracted private healthcare charges. METHODS One thousand two hundred hospitalization records were reviewed retrospectively and a fully anonymized clinical audit summary report created for each one of them by a team of clinical audit experts, proposing evidence-based cuts in pending charges where medical services were deemed clinically unnecessary. These audit reports were then collated and analysed to test trends in overcharges among hospitalized insureds per reason for hospitalization. RESULTS The clinical audit report concluded that 17.4% of a total reimbursement claim of €12,387,702.18 should not be reimbursed, as it corresponded to unnecessary or not fully justifiable according to evidence-based, best practice, medical service provision. The majority of proposed cuts were related to charges for medical devices, which are borne directly by social insurance with no patient or private insurance co-payment. CONCLUSION Clinical audit of hospital practice may be a key tool to optimize care provision, address supplier-induced demand and effectively manage costs for national health insurance, especially in circumstances of budgetary constraints, such as in austerity-stricken settings or developing national healthcare systems.
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Affiliation(s)
- Kyriakos Souliotis
- Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece
- Health Policy Institute, Athens, Greece
| | | | - Vasiliki Mantzana
- Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece
| | | | | | - Alexios Sotiropoulos
- 3rd Internal Medicine Department & Diabetes Center, General Hospital of Nikaia, Athens, Greece
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Pekkarinen PT, Bäcklund M, Efendijev I, Raj R, Folger D, Litonius E, Laitio R, Bendel S, Hoppu S, Ala-Kokko T, Reinikainen M, Skrifvars MB. Association of extracerebral organ failure with 1-year survival and healthcare-associated costs after cardiac arrest: an observational database study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:67. [PMID: 30819234 PMCID: PMC6396453 DOI: 10.1186/s13054-019-2359-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/14/2019] [Indexed: 01/31/2023]
Abstract
Background Organ dysfunction is common after cardiac arrest and associated with worse short-term outcome, but its impact on long-term outcome and treatment costs is unknown. Methods We used nationwide registry data from the intensive care units (ICU) of the five Finnish university hospitals to evaluate the association of 24-h extracerebral Sequential Organ Failure Assessment (24h-EC-SOFA) score with 1-year survival and healthcare-associated costs after cardiac arrest. We included adult cardiac arrest patients treated in the participating ICUs between January 1, 2003, and December 31, 2013. We acquired the confirmed date of death from the Finnish Population Register Centre database and gross 1-year healthcare-associated costs from the hospital billing records and the database of the Finnish Social Insurance Institution. Results A total of 5814 patients were included in the study, and 2401 were alive 1 year after cardiac arrest. Median (interquartile range (IQR)) 24h-EC-SOFA score was 6 (5–8) in 1-year survivors and 7 (5–10) in non-survivors. In multivariate regression analysis, adjusting for age and prior independency in self-care, the 24h-EC-SOFA score had an odds ratio (OR) of 1.16 (95% confidence interval (CI) 1.14–1.18) per point for 1-year mortality. Median (IQR) healthcare-associated costs in the year after cardiac arrest were €47,000 (€28,000–75,000) in 1-year survivors and €12,000 (€6600–25,000) in non-survivors. In a multivariate linear regression model adjusting for age and prior independency in self-care, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €170 (95% CI €150–190) in the cost per day alive in the year after cardiac arrest. In the same model, an increase of one point in the 24h-EC-SOFA score was associated with an increase of €4400 (95% CI €3300–5500) in the total healthcare-associated costs in 1-year survivors. Conclusions Extracerebral organ dysfunction is associated with long-term outcome and gross healthcare-associated costs of ICU-treated cardiac arrest patients. It should be considered when assessing interventions to improve outcomes and optimize the use of resources in these patients. Electronic supplementary material The online version of this article (10.1186/s13054-019-2359-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pirkka T Pekkarinen
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, PB 340, 00029, Helsinki, HUS, Finland.
| | - Minna Bäcklund
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, PB 340, 00029, Helsinki, HUS, Finland
| | - Ilmar Efendijev
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, PB 340, 00029, Helsinki, HUS, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Daniel Folger
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, PB 340, 00029, Helsinki, HUS, Finland
| | - Erik Litonius
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, PB 340, 00029, Helsinki, HUS, Finland
| | - Ruut Laitio
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Stepani Bendel
- Division of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Sanna Hoppu
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Tero Ala-Kokko
- Department of Anaesthesiology, University of Oulu, Oulu, Finland.,Division of Intensive Care Medicine, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Matti Reinikainen
- University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lee TH, Juan IC, Hsu HY, Chen WL, Huang CC, Yang MC, Lei WY, Lin CM, Chou CC, Chang CF, Lin YR. Demographics of Pediatric OHCA Survivors With Postdischarge Diseases: A National Population-Based Follow-Up Study. Front Pediatr 2019; 7:537. [PMID: 32039107 PMCID: PMC6992593 DOI: 10.3389/fped.2019.00537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Postdischarge diseases (PDDs) have been reported for adult survivors of out-of-hospital cardiac arrest (OHCA). However, the detailed demographics of pediatric OHCA survivors with PDDs are not well-documented, and information regarding functional survivors is particularly limited. We aimed to report detailed information on the PDDs of survivors of traumatic and non-traumatic pediatric OHCA using a national healthcare database. Methods: We retrospectively obtained data from the Taiwan government healthcare database (2011-2015). Information on the demographics of traumatic and non-traumatic pediatric OHCA survivors (<20 years) was obtained and reported. The patients who survived to discharge (survivors) and those classified as functional survivors were followed up for 1 year for the analysis of newly diagnosed PDDs. The time from discharge to PDD diagnosis was also reported. Results: A total of 2,178 non-traumatic and 288 traumatic OHCA pediatric cases were included. Among the non-traumatic OHCA survivors (n = 374, survival rate = 17.2%), respiratory tract (n = 270, 72.2%), gastrointestinal (n = 187, 50.0%), and neurological diseases (n = 167, 49.1%) were the three most common PDD categories, and in these three categories, the majority of PDDs were atypical/influenza pneumonia, non-infective acute gastroenteritis, and generalized/status epilepsy, respectively. Among the traumatic OHCA survivors (n = 21, survival rate = 7.3%), respiratory tract diseases (n = 17, 81.0%) were the most common, followed by skin or soft tissue (n = 14, 66.7%) diseases. Most functional survivors still suffered from neurological and respiratory tract diseases. Most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge. Conclusions: Respiratory tract (pneumonia), neurological (epilepsy), and skin or soft tissue (dermatitis) diseases were very common among both non-traumatic and traumatic OHCA survivors. More importantly, most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge.
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Affiliation(s)
- Tsung-Han Lee
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - I-Cheng Juan
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Hsiu-Ying Hsu
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Nursing, Dayeh University, Changhua City, Taiwan.,Department of Nursing, Changhua Christian Hospital, Changhua City, Taiwan
| | - Wen-Liang Chen
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Cheng-Chieh Huang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Mei-Chueh Yang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Wei-Yuan Lei
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chih-Ming Lin
- Department of Neurology, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Social Work and Child Welfare, Providence University, Taichung City, Taiwan.,Department of Medicinal Botanicals and Health Applications, Dayeh University, Changhua City, Taiwan
| | - Chu-Chung Chou
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
| | - Chin-Fu Chang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yan-Ren Lin
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
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Irisawa T, Matsuyama T, Iwami T, Yamada T, Hayakawa K, Yoshiya K, Noguchi K, Nishimura T, Uejima T, Yagi Y, Kiguchi T, Kishimoto M, Matsuura M, Hayashi Y, Sogabe T, Morooka T, Kitamura T, Shimazu T. The effect of different target temperatures in targeted temperature management on neurologically favorable outcome after out-of-hospital cardiac arrest: A nationwide multicenter observational study in Japan (the JAAM-OHCA registry). Resuscitation 2018; 133:82-87. [PMID: 30316953 DOI: 10.1016/j.resuscitation.2018.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/30/2018] [Accepted: 10/07/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND It has been insufficiently investigated whether neurological function after out-of-hospital cardiac arrest (OHCA) would differ by 1 °C change in ordered target temperature of 33-36 °C among patients undergoing targeted temperature management (TTM) in the real-world setting. METHODS This nationwide hospital-based observational study (The Japanese Association for Acute Medicine-OHCA Registry) conducted between June 2014 and December 2015 in Japan included OHCA patients aged ≥18 years who were treated with TTM. The primary outcome was one-month survival with neurologically favorable outcomes defined by cerebral performance category 1 or 2. To investigate the effect of TTM by 1 °C change in ordered target temperature of 33-36 °C on each outcome, random effects logistic regression analyses were performed. RESULTS The final analysis included 738 patients. The proportion of patients with neurologically favorable outcome was 30.4% (7/23), 31.7% (175/552), 28.9% (11/38), and 30.4% (38/125) in the 33 °C, 34 °C, 35 °C, and 36 °C groups, respectively. In the multivariable logistic regression analysis, no group had a higher proportion of neurologically favorable outcome compared with the 34 °C group (vs. 33 °C group, adjusted odds ratio [AOR] 0.90; 95% confidence interval [CI] 0.25-3.12, vs. 35 °C group, AOR 1.17; 95% CI 0.44-3.13, vs. 36 °C group, AOR 1.26; 95% CI 0.78-2.02). CONCLUSIONS In this population, we evaluated the difference in outcomes after adult OHCA patients received TTM by 1 °C change in ordered target temperature of 33-36 °C and demonstrated that there was no statistically significant difference in neurologically favorable outcomes after OHCA irrespective of target temperature.
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Affiliation(s)
- Taro Irisawa
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taku Iwami
- Kyoto University Health Services, Kyoto, Japan
| | - Tomoki Yamada
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan; Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Koichi Hayakawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Takii Hospital, Moriguchi, Japan
| | | | - Kazuo Noguchi
- Department of Emergency Medicine, Tane General Hospital, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Critical Care Medicine, Osaka City University, Osaka, Japan
| | - Toshifumi Uejima
- Department of Emergency and Critical Care Medicine, Kinki University School of Medicine, Osaka-Sayama, Japan
| | - Yoshiki Yagi
- Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Takeyuki Kiguchi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan; Critical Care and Trauma Center, Osaka General Medical Center, Osaka, Japan
| | - Masafumi Kishimoto
- Osaka Prefectural Nakakawachi Medical Center of Acute Medicine, Higashi, Osaka, Japan
| | | | - Yasuyuki Hayashi
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Suita, Japan
| | - Taku Sogabe
- Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takaya Morooka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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Outcomes and healthcare-associated costs one year after intensive care-treated cardiac arrest. Resuscitation 2018; 131:128-134. [PMID: 29958958 DOI: 10.1016/j.resuscitation.2018.06.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite the significant socioeconomic burden associated with cardiac arrest (CA), data on CA patients' long-term outcome and healthcare-associated costs are limited. The aim of this study was to determine one-year survival, neurological outcome and healthcare-associated costs for ICU-treated CA patients. METHODS This is a single-centre retrospective study on adult CA patients treated in Finnish tertiary hospital's ICUs between 2005 and 2013. Patients' personal identification number was used to crosslink data between several nationwide databases in order to obtain data on one-year survival, neurological outcome, and healthcare-associated costs. Healthcare-associated costs were calculated for every patient stratified by cardiac arrest location (OHCA = out-of-hospital cardiac arrest, IHCA = all in-hospital cardiac arrest, ICU-CA = in-ICU cardiac arrest) and initial cardiac rhythm. Cost-effectiveness was estimated by dividing total healthcare-associated costs for all patients from the respective group by the number of survivors and survivors with favourable neurological outcome. RESULTS The study population included 1,024 ICU-treated CA patients. The sum of costs for all patients was €50,847,540. At one-year after CA, 58% of OHCAs, 44% of IHCAs, and 39% of ICU-CAs were alive. Of one-year survivors 97% of OHCAs, 88% of IHCAs, and 93% of ICU-CAs had favourable neurological outcome. Effective cost per one-year survivor was €76,212 for OHCAs, €144,168 for IHCAs, and €239,468 for ICU-CAs. Effective cost per one-year survivor with favourable neurological outcome was €81,196 for OHCAs, €164,442 for IHCAs, and €257,207 for ICU-CAs. CONCLUSIONS In-ICU CA patients had the lowest one-year survival with the effective cost per survivor three times higher than for OHCAs.
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Gatzoulis KA, Georgopoulos S, Antoniou CK, Anastasakis A, Dilaveris P, Arsenos P, Sideris S, Tsiachris D, Archontakis S, Sotiropoulos E, Theopistou A, Skiadas I, Kallikazaros I, Stefanadis C, Tousoulis D. Programmed ventricular stimulation predicts arrhythmic events and survival in hypertrophic cardiomyopathy. Int J Cardiol 2018; 254:175-181. [DOI: 10.1016/j.ijcard.2017.10.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/16/2017] [Accepted: 10/09/2017] [Indexed: 12/13/2022]
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Association of bystander interventions and hospital length of stay and admission to intensive care unit in out-of-hospital cardiac arrest survivors. Resuscitation 2017; 119:99-106. [DOI: 10.1016/j.resuscitation.2017.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/09/2017] [Accepted: 07/13/2017] [Indexed: 11/22/2022]
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Eveson L, Vizcaychipi M, Patil S. Role of bispectral index monitoring and burst suppression in prognostication following out-of-hospital cardiac arrest: a systematic review protocol. Syst Rev 2017; 6:191. [PMID: 28946920 PMCID: PMC5613623 DOI: 10.1186/s13643-017-0584-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is associated with significant mortality or may have a poor neurological outcome. Various community-training programmes have improved practices like bystander cardiopulmonary resuscitation (CPR) and early defibrillation using automated external defibrillator (AED). Post-resuscitation care has also changed significantly in the millennium. Interventions like targeted temperature management (TTM), avoidance of hyperoxia and emergency cardiac catheterisation have given patients a chance of a better neurological outcome. Despite these timely interventions, it is still very difficult to predict neurological outcome. The European Resuscitation Council and European Society of Intensive Care Medicine (ERC-ESICM) published guidance in 2015 with a strong recommendation to delay prognostication for at least 72 h and with an emphasis to adapt a multimodal approach, which includes neurological examination, biomarkers, electroencephalogram (EEG) and radiological tests. These interventions not only have cost attached to them, but the unpredictability has a significant emotional impact on family members. Bispectral index (BIS) monitoring device acts on the principle of EEG and converts the waveform into an absolute number and also measures the burst suppression. We hypothesize that patients who have a low BIS value and high burst suppression within 24 h of presentation will have a poor neurological outcome. The primary objective of this review is to look at BIS monitor as a tool, which could help bring forward the timing of prognostication. METHODS Electronic databases will be systematically searched for randomised controlled trials and prospective or retrospective cohort studies with no language restrictions. The search will be supplemented with grey literature searches of thesis, dissertations and hand searching of relevant journals. Two independent reviewers will screen, select and perform analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) method. The selected studies will be analysed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system. Meta-analysis will be performed if suitable. DISCUSSION This review will synthesize the evidence on the use of BIS monitors within 24 h of achieving return of spontaneous circulation (ROSC) and may help in early prognostication. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD 42016050224 .
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Affiliation(s)
- Leanne Eveson
- Emergency Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Marcela Vizcaychipi
- Anaesthesia & Intensive Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Shashank Patil
- Emergency Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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Fordyce CB. Reduced critical care utilization: Another victory for effective bystander interventions in cardiac arrest. Resuscitation 2017; 119:A4-A5. [PMID: 28818522 DOI: 10.1016/j.resuscitation.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
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Marti J, Hulme C, Ferreira Z, Nikolova S, Lall R, Kaye C, Smyth M, Kelly C, Quinn T, Gates S, Deakin CD, Perkins GD. The cost-effectiveness of a mechanical compression device in out-of-hospital cardiac arrest. Resuscitation 2017; 117:1-7. [DOI: 10.1016/j.resuscitation.2017.04.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/21/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
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Geri G, Fahrenbruch C, Meischke H, Painter I, White L, Rea TD, Weaver MR. Effects of bystander CPR following out-of-hospital cardiac arrest on hospital costs and long-term survival. Resuscitation 2017; 115:129-134. [DOI: 10.1016/j.resuscitation.2017.04.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/30/2017] [Accepted: 04/13/2017] [Indexed: 11/15/2022]
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Demographics and Clinical Features of Postresuscitation Comorbidities in Long-Term Survivors of Out-of-Hospital Cardiac Arrest: A National Follow-Up Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9259182. [PMID: 28286775 PMCID: PMC5327773 DOI: 10.1155/2017/9259182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/26/2016] [Accepted: 01/04/2017] [Indexed: 12/20/2022]
Abstract
The outcome of patients suffering from out-of-hospital cardiac arrest (OHCA) is very poor, and postresuscitation comorbidities increase long-term mortality. This study aims to analyze new-onset postresuscitation comorbidities in patients who survived from OHCA for over one year. The Taiwan National Health Insurance (NHI) Database was used in this study. Study and comparison groups were created to analyze the risk of suffering from new-onset postresuscitation comorbidities from 2011 to 2012 (until December 31, 2013). The study group included 1,346 long-term OHCA survivors; the comparison group consisted of 4,038 matched non-OHCA patients. Demographics, patient characteristics, and risk of suffering comorbidities (using Cox proportional hazards models) were analyzed. We found that urinary tract infections (n = 225, 16.72%), pneumonia (n = 206, 15.30%), septicemia (n = 184, 13.67%), heart failure (n = 111, 8.25%) gastrointestinal hemorrhage (n = 108, 8.02%), epilepsy or recurrent seizures (n = 98, 7.28%), and chronic kidney disease (n = 62, 4.61%) were the most common comorbidities. Furthermore, OHCA survivors were at much higher risk (than comparison patients) of experiencing epilepsy or recurrent seizures (HR = 20.83; 95% CI: 12.24-35.43), septicemia (HR = 8.98; 95% CI: 6.84-11.79), pneumonia (HR = 5.82; 95% CI: 4.66-7.26), and heart failure (HR = 4.88; 95% CI: 3.65-6.53). Most importantly, most comorbidities occurred within the first half year after OHCA.
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Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis. J Orthop Trauma 2017; 31:64-70. [PMID: 27984449 DOI: 10.1097/bot.0000000000000750] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fountain DM, Kolias AG, Laing RJ, Hutchinson PJ. The financial outcome of traumatic brain injury: a single centre study. Br J Neurosurg 2016; 31:350-355. [PMID: 27774811 DOI: 10.1080/02688697.2016.1244254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Severe traumatic brain injury (TBI) is a potentially devastating insult to the brain with high rates of fatality and neurological deficits. TBI can result in substantial costs to the centre providing care. We sought to present the experience of a Major Trauma Centre (MTC) and ascertain the financial implications of this healthcare provision, in particular detailed costs, reimbursement and the surplus or deficit accrued by the centre. DESIGN All cranial non-elective neurosurgical admissions with a TBI over 4.5 months (26 October 2014 to 15 March 2015) were analysed retrospectively, excluding cases of chronic subdural haematoma, at an MTC in England. Demographic data were collected alongside detailed cost and income data. RESULTS Ninety four patients were identified. The majority of patients presented with more than one diagnosis of cranial trauma. Average length of stay was 18.8 ± 21.6 days. Total deficits as a result of treating this cohort amounted to £558,034. There was a significant association between (i) more complex presentations and (ii) a longer length of stay and the deficit accrued by the centre. The major drivers of the financial outcome were costs associated with wards, medical staffing and overheads. CONCLUSION There was a substantial deficit accrued as a result of the management of patients with TBI at an MTC. The more complex the presentation, extensive the intervention, and lengthy the stay, the greater the deficit accrued by the centre. The current tariff payment system is not effectively reflecting the severity of injury or intensity of management of patients with TBI.
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Affiliation(s)
- Daniel M Fountain
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Rodney J Laing
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Peter J Hutchinson
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
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