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(Circulation. 2003;108:697.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Cost Effectiveness of Defibrillation by Targeted Responders in Public Settings

G. Nichol, MPH, MD; T. Valenzuela, MPH, MD; D. Roe, PhD; L. Clark, RN, MA; E. Huszti, MSc; G.A. Wells, PhD

From the Ottawa Health Research Institute (G.N., E.H., G.A.W.) and Department of Epidemiology and Community Medicine (G.N., G.A.W.), University of Ottawa, Ottawa, Canada; Department of Emergency Medicine (T.V., L.C.), University of Arizona, Tucson; and Division of Epidemiology and Biostatistics (D.R.), College of Public Health, University of Arizona, Tucson.

Correspondence to Dr Graham Nichol, F699 Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada.

Received July 9, 2002; de novo received December 23, 2002; revision received May 6, 2003; accepted May 7, 2003.

	Abstract

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

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

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

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

Key Words: heart arrest • defibrillation • cardiopulmonary resuscitation • death, sudden

	Introduction

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Out-of-hospital sudden cardiac arrest affects 350 000 to 450 000 Americans annually.^1–3 Survival after cardiac arrest is poor.^4,5 Public access defibrillation is a novel treatment for cardiac arrest that includes training and equipping targeted nontraditional responders to defibrillate.^6–8 Defibrillation by such responders has a high survival-to-discharge rate after cardiac arrest.⁹ It is unclear whether such programs are of sufficient value for the money expenditure to justify broad implementation.

Economic evaluation of an intervention assesses its effectiveness and costs so that decision makers can decide whether it is a good value for the money. Therefore, this analysis estimated the incremental cost effectiveness of defibrillation by targeted nontraditional responders.

	Methods

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Interventions
We considered treatment of cardiac arrest by emergency medical services (EMS) including first-responder defibrillation followed by advanced life support or by EMS supplemented by targeted nontraditional responders. The latter was evaluated in a cohort study in 65 gaming establishments.⁹ Participating security guards had current cardiopulmonary certification. Training in defibrillation was conducted by 2 instructors and lasted up to 6 hours. Casinos were encouraged to place sufficient defibrillators on scene to ensure that no more than 3 minutes elapsed from the time of collapse to the time of defibrillation.

Input Data
Survival to Discharge
Input data for the decision model were obtained from publicly available data (Table 1 and www.ohri.ca/coregroup/defib1 [Table 4]). The effectiveness of defibrillation was estimated by substituting observed response-time intervals⁹ into functions that estimated as a function of response time the probability that the initial rhythm would be ventricular fibrillation¹⁰ and the probability of survival to discharge after ventricular fibrillation.¹¹ Because there were no control data to estimate survival with EMS alone, time to CPR in the control group was based on that in the intervention group.

View this table: [in this window] [in a new window]   TABLE 1. Input Data for Short-Term Events

View this table: [in this window] [in a new window]   TABLE 4. Input Data for Long-Term Events (www.ohri.ca/coregroup/defib1)

Other Outcomes
Valuations of the quality of life of cardiac arrest survivors were derived from a cohort study.¹² Survival after insertion of an implantable cardioverter defibrillator was derived from a randomized trial.¹³ Chances of complications after insertion of an implantable cardioverter defibrillator were based on published estimates.¹⁴

Costs
The economic perspective was that of society. Costs were expressed in 2003 US dollars (Table 1). The cost of an automatic external defibrillator (AED) was depreciated over its anticipated life span (Medtronic Physio-Control Inc; lifespan as of May 31, 2002). This annual device cost was multiplied by the number of devices required and then divided by the annual incidence of arrest in each setting to account for the density of AEDs required and incidence of arrest in each public setting. For defibrillation in casinos, 320 devices were used to treat 148 cases of arrest during an average of 32 months of follow-up.⁹ For defibrillation in other settings, the numbers of devices and site incidence were based on published data.¹⁵

Costs of targeted nontraditional responder defibrillation included the wages of instructors for each class and number of classes required to train all responders, adjusted for the occupational life span of security guards relative to the duration of the cohort study (www.ohri.ca/coregroup/defib2 [Table 5]). Retraining costs were estimated by similar methods (www.ohri.ca/coregroup/defib3 [Table 6]). Costs of hospitalization were derived from a cohort of cardiac arrest patients treated at a single center, stratified by whether patients survived to discharge. All costs were adjusted for inflation by using the US Consumer Price Index (http://stats.bls.gov/cpi, accessed on March 30, 2003).

View this table: [in this window] [in a new window]   TABLE 5. Cost of Training Security Guards, per AED (www.ohri.ca/coregroup/defib2)

View this table: [in this window] [in a new window]   TABLE 6. Costs of Retraining Security Guards to Defibrillate, per AED (www.ohri.ca/defib3)

Structure of Decision Model
The analysis considered the lifetime horizon, as recommended.¹⁶ A state-transition Markov model compared costs and outcomes after cardiac arrest treated by each intervention. According to the model, patients either died before arriving at the hospital, died in the hospital, or lived to discharge (Figure 1). Neurologically impaired patients required long-term care; neurologically intact patients received an implantable cardioverter defibrillator (Figure 2). Such patients experienced benefits or complications of the device, with associated costs and effects.

View larger version (25K): [in this window] [in a new window]   Figure 1. Decision model for short-term events after out of hospital cardiac arrest.

View larger version (15K): [in this window] [in a new window]   Figure 2. Decision model for long-term events after implantable cardioverter defibrillator (ICD) insertion. Rx indicates treatment.

Decision analyses were performed with DATA Pro software (TreeAge Software, Inc) and Excel 2000 software (Microsoft Inc). Statistical analyses were performed with S Plus (Insightful Inc).

Assumptions
We made several assumptions about the costs of the defibrillation program because these costs are unknown. First, program implementation would not change the costs of treatment of cardiac arrest by EMS. Second, responders would not be compensated for time spent being trained. Because such training would occur during their regular duties, they would receive no additional wages. Third, there would be a 1-minute delay between EMS arrival on scene and defibrillation with standard EMS. Fourth, all neurologically intact (ie, cerebral performance category=1) survivors would receive implantable defibrillators. Although not all survivors of cardiac arrest receive implantable defibrillators,¹⁷ clinical trials have demonstrated that implantable defibrillators decrease mortality in such patients.^13,18–20 Finally, age-specific mortality due to unrelated causes was based on life tables.²¹

Uncertainty and Variability Analyses
The analysis distinguished between parameter uncertainty (ie, variation in costs and effects due to sampling and measurement error) and variability (ie, heterogeneity in costs and effects between groups of patients with systematic differences in cost or effects). Uncertainty was assessed by using probabilistic Monte Carlo simulation.^22,23 Empiric cost and time variables were assigned normal distributions. Empiric probability variables were assigned ß distributions.²² Variables without a known distributional form (ie, those with assumed values or those with values based on a range of published reports) were assigned triangular distributions.²⁴ Because there is no absolute cost-effectiveness criterion,²⁵ the cumulative distribution of the incremental cost effectiveness of security guard defibrillation was plotted by using cost-effectiveness acceptability curves.^26–28

Variability was assessed by using sensitivity analyses. We substituted the upper and lower limits of the value of each variable in the decision model while holding all other values constant (Table 1). ^29,30 For empirical variables, these limits were the 95% confidence limits for each variable. For assumed variables (eg, overall survival with standard EMS, cost of a defibrillator, cost of the defibrillator program, and discount rate), these limits were based on reasonable possible limits (ie, ±50%). Threshold analyses identified the value of each variable across its range, if any, at which one should be indifferent between standard EMS or public access defibrillation (ie, the incremental costs per quality-adjusted life year was $100 000).³⁰

Multiway sensitivity analyses were also performed. Because the effectiveness of both interventions may be correlated, we varied simultaneously the probability of survival to discharge with standard EMS, and relative risk of mortality with targeted nontraditional defibrillation. For the baseline analysis, these values correspond to 9.9% and 0.83 (ie, 74.4%/90.1%). Other sensitivity analyses considered defibrillation in public settings adjusted by incidence of arrest and number of defibrillators required because these factors are highly variable across public settings.¹⁵ Finally, sensitivity analyses considered the incremental cost effectiveness of targeted nontraditional responders when the responders are paid to be trained.

	Results

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Effectiveness of Standard EMS
In our cohort study of defibrillation by security guards in casinos, mean time from collapse to CPR was 2.9 minutes; mean time to EMS arrival was 9.8 minutes.⁹ If defibrillation were not performed by EMS until 10.8 minutes, the estimated survival to discharge with EMS was 9.9%.

Effectiveness of Public Access Defibrillation
In our cohort study, 148 patients had cardiac arrest in gaming establishments; 56 (37.8%) survived to discharge.⁹ Mean time to CPR was 2.9 minutes; mean time to defibrillation by security guards was 4.4 minutes. Therefore, the estimated survival to discharge was 25.6%.

Cost Effectiveness of Defibrillation by Targeted Nontraditional Responders
For cardiac arrest in casinos, standard EMS had a median of 0.47 (interquartile range [IQR]=0.32 to 0.69) discounted quality-adjusted life years and a median of $14 100 (IQR=$8600 to $21 900) in lifetime costs (Table 2). Defibrillation by targeted nontraditional responders had a median of 0.92 (IQR=0.70 to 1.19) discounted quality-adjusted life years and a median of $40 700 (IQR=$33 000 to $49 600) in lifetime costs. Compared with standard EMS, defibrillation by targeted nontraditional responders had an incremental cost per additional quality-adjusted life year of median $56 700 (IQR=$44 100 to $77 200). The incremental cost per additional quality-adjusted life year was less than $100 000 in 86% of Monte Carlo simulations (Figure 3).

View this table: [in this window] [in a new window]   TABLE 2. Potential Cost Effectiveness of Defibrillation by Security Guards in Casinos

View larger version (14K): [in this window] [in a new window]   Figure 3. Cumulative distribution of incremental cost effectiveness of defibrillation by security guards.

Variability Analyses
The incremental cost effectiveness of targeted nontraditional responders was sensitive to reasonable changes in values for time to defibrillation by EMS providers or by nontraditional responders. If EMS providers defibrillate within 6.9 minutes or if security guards do not defibrillate within 8.4 minutes, then EMS care is as good a value as defibrillation by targeted nontraditional responders (ie, incremental cost is less than $100 000 per quality-adjusted life year).

Public access defibrillation was not a good value for the money in settings with a low incidence of cardiac arrest relative to an annual site incidence of 85.3% (148 cases observed in 65 gaming establishments over 32 months=85% chance that an arrest will be observed annually [Table 3]).

View this table: [in this window] [in a new window]   TABLE 3. Potential Cost Effectiveness of Defibrillation in Various Public Settings

When the costs of paying wages to responders while being trained were included, defibrillation by targeted nontraditional responders cost more than $100 000 per additional quality-adjusted life year (details available from authors).

In summary, the results were sensitive to large changes in the time to defibrillation with standard EMS or nontraditional responders, decreases in the incidence of arrest, and whether responders are compensated for their time spent being trained.

	Discussion

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Our analysis shows that defibrillation by targeted nontraditional responders may be a good value for the money if cardiac arrest is frequent, devices and trained users are available, and time to treatment is short. However, it is unlikely to be a good value if cardiac arrest is infrequent or there is little difference in time to defibrillation between EMS providers and targeted responders. Therefore, decisions about implementation of a defibrillation program should consider the incidence of cardiac arrest, anticipated time to defibrillation with nontraditional responders, and survival achieved by the existing EMS system.

These results are consistent with previous analyses of cardiac arrest interventions.^31–33 However, the previous analyses considered the initial but not the future costs, considered improvements to existing EMS systems rather than introduction of enhanced defibrillation, underestimated the incremental costs of defibrillation by estimating lower costs of aftercare compared with the present analysis, underestimated long-term survival by not considering the benefits of implantable defibrillators in survivors of cardiac arrest, and overestimated survival to discharge by considering outcomes after ventricular fibrillation rather than after all cases of cardiac arrest.

The present results differ from those of a recent Scottish study that underestimated survival with lay responder defibrillation by assuming that it would be no greater than that obtained by early ambulance defibrillation.³⁴ The Scottish analysis estimated the predicted increase in survival from lay responder defibrillation as less than that achievable through expansion of first-responder defibrillation to include nonambulance personnel such as police or firefighters. However, these results are not generalizable because most North American emergency response systems already have first-responder defibrillation programs in place. Despite these limitations, the authors concluded that it was reasonable to place defibrillators in public places that were frequented by large numbers of susceptible people.

The results of this analysis should be interpreted cautiously. However, the incremental cost per quality-adjusted life year is similar to that of other common medical interventions.³⁵ If public access defibrillation is as efficacious and inexpensive as in this study, then it will be good value for money. The challenge will be to ensure that defibrillation can be achieved quickly in settings where cardiac arrest is less common and responders less vigilant than in casinos.

Our estimate of the effectiveness of public access defibrillation was derived from a study of defibrillation by security guards in gaming establishments. Casinos have unique characteristics that make them ideal settings for public access defibrillation programs, as follows: security officers are visible from any point in the casino, monitored security cameras scan public areas to detect unusual activity, and high levels of security staffing allow one officer to initiate CPR while a second officer retrieves a defibrillator from a nearby location. The high rate of survival observed with the defibrillation program in Chicago airports may also be unique because removal of an AED from its covered box activated the EMS response.³⁶ It remains unclear whether such benefits will be observed when public access defibrillation is implemented in settings where times to defibrillation are longer. Therefore, we underestimated survival to discharge in the intervention group to bias the results against the alternative hypothesis. Controlled studies are underway to demonstrate whether public access defibrillation is an effective and cost-effective treatment.³⁷

There are several limitations to this analysis. First, the cohort study of defibrillation in casinos observed a higher incidence of ventricular arrhythmia than reported in other recent studies.³⁸ Although this is likely attributable to the shorter response time interval observed in casinos than elsewhere, it is plausible that the experience observed with the selected cases and response program in casinos may not be applicable to other settings. If so, our analysis overestimates survival and underestimates the incremental cost of placing defibrillators in public settings.

Second, the input data were derived from several sources and may be confounded by information that was not incorporated into the model. For example, the effectiveness of resuscitation was not adjusted for the patient’s comorbid illness³⁹ or type of CPR performed at the scene.⁴⁰ Although individuals are less likely to survive cardiac arrest if they have comorbid illness or receive ineffective CPR, no data were available to define whether either was so in our study.

Third, most input data for this analysis were derived from cohort studies that are more susceptible to bias than experimental designs. Fourth, we assumed that EMS costs were constant, although implementation of public access defibrillation will increase EMS costs if the number of patients with circulation restored in the field increases.

Finally, it is unlikely that the relative benefit of defibrillation will be constant as the proportion of patients who survive with standard EMS increases. Therefore, as results from trials of enhanced defibrillation become available, our analysis should be revised to reflect better estimates of the true effectiveness and costs of the program.

	Conclusion

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Implementation of public access defibrillation in a setting with a high incidence of sudden cardiac arrest and vigilant responders is associated with an incremental cost-effectiveness ratio similar to those of other common medical interventions. Decision makers should consider the antici- pated frequency of cardiac arrest and time to defibrillation when selecting sites to implement public access defibrillation.

	Appendix

Top Abstract Introduction Methods Results Discussion Conclusion Appendix References

 
Tables 4 through 6 show input data for the decision model used in this study.

	Footnotes

 
Presented in part at the American Heart Association Scientific Sessions, Atlanta, Ga, November 1999; the Fifth Wolf Creek Conference, Palm Springs, Calif, June 2001; and the American Heart Association Scientific Sessions, Chicago, Ill, November 2002.

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				S. G. Priori, L. L. Bossaert, D. A. Chamberlain, C. Napolitano, H. R. Arntz, R. W. Koster, K. G. Monsieurs, A. Capucci, and H. J. Wellens ESC-ERC recommendations for the use of automated external defibrillators (AEDs) in Europe Eur. Heart J., March 1, 2004; 25(5): 437 - 445. [Full Text] [PDF]

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