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Buter R, van Schuppen H, Stieglis R, Koffijberg H, Demirtas D. Increasing cost-effectiveness of AEDs using algorithms to optimise location. Resuscitation 2024; 201:110300. [PMID: 38960067 DOI: 10.1016/j.resuscitation.2024.110300] [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: 04/10/2024] [Revised: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES Volunteer responder systems (VRSs) aim to decrease time to defibrillation by dispatching trained volunteers to automated external defibrillators (AEDs) and out-of-hospital cardiac arrest (OHCA) victims. AEDs are often underutilized due to poor placement. This study provides a cost-effectiveness analysis of adding AEDs at strategic locations to maximize quality-adjusted life years (QALYs). METHODS We simulated combined volunteer, police, firefighter, and emergency medical service response scenarios to OHCAs, and applied our methods to a case study of Amsterdam, the Netherlands. We compared the competing strategies of placing additional AEDs, using steps of 40 extra AEDs (0, 40, …, 1480), in addition to the existing 369 AEDs. Incremental cost-effectiveness ratios (ICERs) were calculated for each increase in additional AEDs, from a societal perspective. The effect of AED connection and time to connection on survival to hospital admission and neurological outcome at discharge was estimated using logistic regression, using OHCA data from Amsterdam from 2006 to 2018. Other model inputs were obtained from literature. RESULTS Purchasing up to 1120 additional AEDs (ICER €75,669/QALY) was cost-effective at a willingness-to-pay threshold of €80,000/QALY, when positioned strategically. Compared to current practice, adding 1120 AEDs resulted in a gain of 0.111 QALYs (95% CI 0.110-0.112) at an increased cost of €3792 per OHCA (95% CI €3778-€3807). Health benefits per AED diminished as more AEDs were added. CONCLUSIONS Our study identified cost-effective strategies to position AEDs at strategic locations in a VRS. The case study findings advocate for a substantial increase in the number of AEDs in Amsterdam.
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Affiliation(s)
- Robin Buter
- Center for Healthcare Operations Improvement and Research, University of Twente, Drienerlolaan 5, 7500 AE Enschede, The Netherlands; Industrial Engineering and Business Information Systems, University of Twente, Drienerlolaan 5, 7500 AE Enschede, The Netherlands.
| | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Remy Stieglis
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Hendrik Koffijberg
- Health Technology & Services Research, University of Twente, Drienerlolaan 5, 7500 AE, Enschede, The Netherlands.
| | - Derya Demirtas
- Center for Healthcare Operations Improvement and Research, University of Twente, Drienerlolaan 5, 7500 AE Enschede, The Netherlands; Industrial Engineering and Business Information Systems, University of Twente, Drienerlolaan 5, 7500 AE Enschede, The Netherlands.
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Khan KA, Petrou S, Smyth M, Perkins GD, Slowther AM, Brown T, Madan JJ. Comparative cost-effectiveness of termination of resuscitation rules for patients transported in cardiac arrest. Resuscitation 2024; 201:110274. [PMID: 38879073 DOI: 10.1016/j.resuscitation.2024.110274] [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: 02/13/2024] [Revised: 06/03/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024]
Abstract
AIM To compare the cost-effectiveness of termination-of-resuscitation (TOR) rules for patients transported in cardiac arrest. METHODS The economic analyses evaluated cost-effectiveness of alternative TOR rules for OHCA from a National Health Service (NHS) and personal social services (PSS) perspective over a lifetime horizon. A systematic review was used to identify the different TOR rules included in the analyses. Data from the OHCAO outcomes registry, trial data and published literature were used to compare outcomes for the different rules identified. The economic analyses estimated discounted NHS and PSS costs and quality-adjusted life-years (QALYs) for each TOR rule, based on which incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS The systematic review identified 33 TOR rules and the economic analyses assessed the performance of 29 of these TOR rules plus current practice. The most cost-effective strategies were the European Resuscitation Council (ERC) termination of resuscitation rule (ICER of £8,111), the Korean Cardiac Arrest Research Consortium 2 (KOC 2) termination of resuscitation rule (ICER of £17,548), and the universal Basic Life Support (BLS) termination of resuscitation rule (ICER of £19,498,216). The KOC 2 TOR rule was cost-effective at the established cost-effectiveness threshold of £20,000-£30,000 per QALY. CONCLUSION The KOC 2 rule is the most cost-effective at established cost-effectiveness thresholds used to inform health care decision-making in the UK. Further research on economic implications of TOR rules is warranted to support constructive discussion on implementing TOR rules.
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Affiliation(s)
- Kamran A Khan
- Warwick Medical School, University of Warwick, United Kingdom.
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - Michael Smyth
- Warwick Medical School, University of Warwick, United Kingdom
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, United Kingdom
| | | | - Terry Brown
- Warwick Medical School, University of Warwick, United Kingdom
| | - Jason J Madan
- Warwick Medical School, University of Warwick, United Kingdom
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Cruickshank M, Hudson J, Hernández R, Aceves-Martins M, Quinton R, Gillies K, Aucott LS, Kennedy C, Manson P, Oliver N, Wu F, Bhattacharya S, Dhillo WS, Jayasena CN, Brazzelli M. The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation. Health Technol Assess 2024; 28:1-210. [PMID: 39248210 PMCID: PMC11404359 DOI: 10.3310/jryt3981] [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] [Indexed: 09/10/2024] Open
Abstract
Background Low levels of testosterone cause male hypogonadism, which is associated with sexual dysfunction, tiredness and reduced muscle strength and quality of life. Testosterone replacement therapy is commonly used for ameliorating symptoms of male hypogonadism, but there is uncertainty about the magnitude of its effects and its cardiovascular and cerebrovascular safety. Aims of the research The primary aim was to evaluate the safety of testosterone replacement therapy. We also assessed the clinical and cost-effectiveness of testosterone replacement therapy for men with male hypogonadism, and the existing qualitative evidence on men's experience and acceptability of testosterone replacement therapy. Design Evidence synthesis and individual participant data meta-analysis of effectiveness and safety, qualitative evidence synthesis and model-based cost-utility analysis. Data sources Major electronic databases were searched from 1992 to February 2021 and were restricted to English-language publications. Methods We conducted a systematic review with meta-analysis of individual participant data according to current methodological standards. Evidence was considered from placebo-controlled randomised controlled trials assessing the effects of any formulation of testosterone replacement therapy in men with male hypogonadism. Primary outcomes were mortality and cardiovascular and cerebrovascular events. Data were extracted by one reviewer and cross-checked by a second reviewer. The risk of bias was assessed using the Cochrane Risk of Bias tool. We performed one-stage meta-analyses using the acquired individual participant data and two-stage meta-analyses to integrate the individual participant data with data extracted from eligible studies that did not provide individual participant data. A decision-analytic Markov model was developed to evaluate the cost per quality-adjusted life-years of the use of testosterone replacement therapy in cohorts of patients of different starting ages. Results We identified 35 trials (5601 randomised participants). Of these, 17 trials (3431 participants) provided individual participant data. There were too few deaths to assess mortality. There was no difference between the testosterone replacement therapy group (120/1601, 7.5%) and placebo group (110/1519, 7.2%) in the incidence of cardiovascular and/or cerebrovascular events (13 studies, odds ratio 1.07, 95% confidence interval 0.81 to 1.42; p = 0.62). Testosterone replacement therapy improved quality of life and sexual function in almost all patient subgroups. In the testosterone replacement therapy group, serum testosterone was higher while serum cholesterol, triglycerides, haemoglobin and haematocrit were all lower. We identified several themes from five qualitative studies showing how symptoms of low testosterone affect men's lives and their experience of treatment. The cost-effectiveness of testosterone replacement therapy was dependent on whether uncertain effects on all-cause mortality were included in the model, and on the approach used to estimate the health state utility increment associated with testosterone replacement therapy, which might have been driven by improvements in symptoms such as sexual dysfunction and low mood. Limitations A meaningful evaluation of mortality was hampered by the limited number of defined events. Definition and reporting of cardiovascular and cerebrovascular events and methods for testosterone measurement varied across trials. Conclusions Our findings do not support a relationship between testosterone replacement therapy and cardiovascular/cerebrovascular events in the short-to-medium term. Testosterone replacement therapy improves sexual function and quality of life without adverse effects on blood pressure, serum lipids or glycaemic markers. Future work Rigorous long-term evidence assessing the safety of testosterone replacement therapy and subgroups most benefiting from treatment is needed. Study registration The study is registered as PROSPERO CRD42018111005. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/68/01) and is published in full in Health Technology Assessment; Vol. 28, No. 43. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lorna S Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Frederick Wu
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Werner K, Hirner S, Offorjebe OA, Hosten E, Gordon J, Geduld H, Wallis LA, Risko N. A Systematic Review of Cost-Effectiveness of Treating Out of Hospital Cardiac Arrest: Implications for Resource-limited Health Systems. RESEARCH SQUARE 2024:rs.3.rs-4402626. [PMID: 38883781 PMCID: PMC11177998 DOI: 10.21203/rs.3.rs-4402626/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background Out-of-hospital cardiac arrest (OHCA) is a prevalent condition with high mortality and poor outcomes even in settings where extensive emergency care resources are available. Interventions to address OHCA have had limited success, with survival rates below 10% in national samples of high-income countries. In resource-limited settings, where scarcity requires careful priority setting, more data is needed to determine the optimal allocation of resources. Objective To establish the cost-effectiveness of OHCA care and assess the affordability of interventions across income settings. Methods The authors conducted a systematic review of economic evaluations on interventions to address OHCA. Included studies were (1) economic evaluations (beyond a simple costing exercise); and (2) assessed an intervention in the chain of survival for OHCA. Article quality was assessed using the CHEERs checklist and data summarised. Findings were reported by major themes identified by the reviewers. Based upon the results of the cost-effectiveness analyses we then conduct an analysis for the progressive realization of the OHCA chain of survival from the perspective of decision-makers facing resource constraints. Results 468 unique articles were screened, and 46 articles were included for final data abstraction. Studies predominantly used a healthcare sector perspective, modeled for all patients experiencing non-traumatic cardiac OHCA, were based in the US, and presented results in US Dollars. No studies reported results or used model inputs from low-income settings. Progressive realization of the chain of survival could likely begin with investments in TOR protocols, professional prehospital defibrillator use, and CPR training followed by distribution of AEDs in high-density public locations. Finally, other interventions such as indiscriminate defibrillator placement or adrenaline use, would be the lowest priority for early investment. Conclusion Our review found no high-quality evidence on the cost-effectiveness of treating OHCA in low-resource settings. Existing evidence can be utilized to develop a roadmap for the development of a cost-effective approach to OHCA care, however further economic evaluations using context-specific data are crucial to accurately inform prioritization of scarce resources within emergency care in these settings.
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Hernández R, de Silva NL, Hudson J, Cruickshank M, Quinton R, Manson P, Dhillo WS, Bhattacharya S, Brazzelli M, Jayasena CN. Cost-effectiveness of testosterone treatment utilising individual patient data from randomised controlled trials in men with low testosterone levels. Andrology 2024; 12:477-486. [PMID: 38233215 DOI: 10.1111/andr.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/05/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Testosterone is safe and highly effective in men with organic hypogonadism, but worldwide testosterone prescribing has recently shifted towards middle-aged and older men, mostly with low testosterone related to age, diabetes and obesity, for whom there is less established evidence of clinical safety and benefit. The value of testosterone treatment in middle-aged and older men with low testosterone is yet to be determined. We therefore evaluated the cost-effectiveness of testosterone treatment in such men with low testosterone compared with no treatment. METHODS A cost-utility analysis comparing testosterone with no treatment was conducted following best practices in decision modelling. A cohort Markov model incorporating relevant care pathways for individuals with hypogonadism was developed for a 10-year-time horizon. Clinical outcomes were obtained from an individual patient meta-analysis of placebo-controlled, double-blind randomised studies. Three starting age categories were defined: 40, 60 and 75 years. Cost utility (quality-adjusted life years) accrued and costs of testosterone treatment, monitoring and cardiovascular complications were compared to estimate incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for selected scenarios. RESULTS Ten-year excess treatment costs for testosterone compared with non-treatment ranged between £2306 and £3269 per patient. Quality-adjusted life years results depended on the instruments used to measure health utilities. Using Beck depression index-derived quality-adjusted life years data, testosterone was cost-effective (incremental cost-effectiveness ratio <£20,000) for men aged <75 years, regardless of morbidity and mortality sensitivity analyses. Testosterone was not cost-effective in men aged >75 years in models assuming increased morbidity and/or mortality. CONCLUSIONS AND FUTURE RESEARCH Our data suggest that testosterone is cost-effective in men <75 years when Beck depression index-derived quality-adjusted life years data are considered; cost-effectiveness in men >75 years is dependent on cardiovascular safety. However, more robust and longer-term cost-utility data are needed to verify our conclusion.
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Affiliation(s)
- Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Nipun Lakshitha de Silva
- Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Jemma Hudson
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Richard Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
- Translational & Clinical Research Institute, University of Newcastle upon Tyne, Newcastle Upon Tyne, UK
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Paul Manson
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Waljit S Dhillo
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
| | - Siladitya Bhattacharya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Miriam Brazzelli
- Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK
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Nilsson FN, Bie-Bogh S, Milling L, Hansen PM, Pedersen H, Christensen EF, Knudsen JS, Christensen HC, Folke F, Høen-Beck D, Væggemose U, Brøchner AC, Mikkelsen S. Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest. Sci Rep 2023; 13:20796. [PMID: 38012312 PMCID: PMC10682403 DOI: 10.1038/s41598-023-48350-8] [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: 06/12/2023] [Accepted: 11/25/2023] [Indexed: 11/29/2023] Open
Abstract
Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.
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Affiliation(s)
- Frederik Nancke Nilsson
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Søren Bie-Bogh
- OPEN, Open Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Louise Milling
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | - Peter Martin Hansen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- The Danish Air Ambulance, Aarhus, Denmark
| | - Helena Pedersen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Stubager Knudsen
- The Danish Air Ambulance, Aarhus, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Helle Collatz Christensen
- Prehospital Center, University of Copenhagen, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark
- Department of Cardiology, Herlev Gentofte University Hospital, Copenhagen, Denmark
| | - David Høen-Beck
- Department of Anaesthesiology, Denmark and Prehospital Center, Holbæk Hospital, HolbækRegion Zealand, Denmark
| | - Ulla Væggemose
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Craveiro Brøchner
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense C, Denmark.
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Perkins GD, Couper K. Improving vasopressor use in cardiac arrest. Crit Care 2023; 27:81. [PMID: 36864469 PMCID: PMC9979497 DOI: 10.1186/s13054-023-04301-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/04/2023] [Indexed: 03/04/2023] Open
Abstract
The Chain of Survival highlights the effectiveness of early recognition of cardiac arrest and call for help, early cardiopulmonary resuscitation and early defibrillation. Most patients, however, remain in cardiac arrest despite these interventions. Drug treatments, particularly the use of vasopressors, have been included in resuscitation algorithms since their inception. This narrative review describes the current evidence base for vasopressors and reports that adrenaline (1 mg) is highly effective at achieving return of spontaneous circulation (number needed to treat 4) but is less effective on long-term outcomes (survival to 30 days, number needed to treat 111) with uncertain effects on survival with a favourable neurological outcome. Randomised trials evaluating vasopressin, either as an alternative to or in addition to adrenaline, and high-dose adrenaline have failed to find evidence of improved long-term outcomes. There is a need for future trials to evaluate the interaction between steroids and vasopressin. Evidence for other vasopressors (e.g. noradrenaline, phenylephedrine) is insufficient to support or refute their use. The use of intravenous calcium chloride as a routine intervention in out of hospital cardiac arrest is not associated with benefit and may cause harm. The optimal route for vascular access between peripheral intravenous versus intraosseous routes is currently the subject of two large randomised trials. Intracardiac, endobronchial, and intramuscular routes are not recommended. Central venous administration should be limited to patients where an existing central venous catheter is in situ and patent.
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Keith Couper
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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9
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Ling X, Gabrio A, Mason A, Baio G. A Scoping Review of Item-Level Missing Data in Within-Trial Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1654-1662. [PMID: 35341690 DOI: 10.1016/j.jval.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 02/02/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Cost-effectiveness analysis (CEA) alongside randomized controlled trials often relies on self-reported multi-item questionnaires that are invariably prone to missing item-level data. The purpose of this study is to review how missing multi-item questionnaire data are handled in trial-based CEAs. METHODS We searched the National Institute for Health Research journals to identify within-trial CEAs published between January 2016 and April 2021 using multi-item instruments to collect costs and quality of life (QOL) data. Information on missing data handling and methods, with a focus on the level and type of imputation, was extracted. RESULTS A total of 87 trial-based CEAs were included in the review. Complete case analysis or available case analysis and multiple imputation (MI) were the most popular methods, selected by similar numbers of studies, to handle missing costs and QOL in base-case analysis. Nevertheless, complete case analysis or available case analysis dominated sensitivity analysis. Once imputation was chosen, missing costs were widely imputed at item-level via MI, whereas missing QOL was usually imputed at the more aggregated time point level during the follow-up via MI. CONCLUSIONS Missing costs and QOL tend to be imputed at different levels of missingness in current CEAs alongside randomized controlled trials. Given the limited information provided by included studies, the impact of applying different imputation methods at different levels of aggregation on CEA decision making remains unclear.
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Affiliation(s)
- Xiaoxiao Ling
- Department of Statistical Science, University College London, London, England, UK.
| | - Andrea Gabrio
- Department of Methodology and Statistics, Faculty of Health Medicine and Life Science, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Alexina Mason
- London School of Hygiene and Tropical Medicine, London, England, UK
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, England, UK
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10
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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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