Implantable Cardioverter Defibrillator: A Volkswagon or a Rolls Royce: How Much Will You Pay to Save a Life?
To the Editor:
I applaud Dr Zipes’ emphasis on the concept that a one-size implantable cardiac defibrillator does not fit all and that substantial cost savings may accrue by developing simple defibrillators for simple problems.1 However, I am uncomfortable with his statement that “making automated external defibrillators (AEDs) as common as fire extinguishers is a ‘no-brainer’ and offers an incredible return on the investment. . . .”
Dr Zipes may be confusing the high efficacy and low cost of the AED with the issue of cost-effectiveness. Although just one AED is used in a save, it is not just that particular AED’s cost ($3000) that must be applied to that save. Consider the following anecdotal example of the “ubiquitous” deployment of AEDs. Unpublished information from 200 AEDs installed outside of one formal emergency medical services (EMS) program shows 2 uses (zero saves!) over 2 years. Assuming a 5-year life span for defibrillators, this calculates to $120 000 per use. At a 20% survival rate, this comes to $600 000 per save. Costs for infrastructure and training are likely to exceed AED costs by several-fold.
The Public Access Defibrillation (PAD) trial, a National Heart, Lung, and Blood Institute study in 24 communities in North America, is investigating whether the installation of AEDs, with the development of infrastructure and training, as recommended by the American Heart Association, will increase survival and, if so, at what cost.2 Does having an AED available delay/inhibit a 911 call, cardiopulmonary resuscitation (CPR), or other activities of lay responders? Is it more cost-effective to invest in EMS infrastructure? Whatever the primary result of PAD, the study will identify infrastructure/training issues and their associated costs. Dr Zipes’ contention that this concept is a “no-brainer” may be correct. However, the empiric evidence to date is inconclusive.3
I think the PAD Trial will provide substantial information to inform public policy about AED deployment. I ask the leaders in cardiology and EMS to support the PAD trial by recognizing the need for effectiveness, cost-effectiveness, and process data. It is not a question of whether the AED is capable of defibrillating a patient in ventricular fibrillation. The AED is capable. The question is whether the “ubiquitous” AED will be used correctly by a lay responder often enough to justify the costs. I respectfully disagree with Dr Zipes that the answer is obvious.
Zipes DP. Implantable cardioverter defibrillator: a Volkswagon or a Rolls Royce: how much will you pay to save a life? Circulation. 2001; 103: 1372–1374.
Hallstrom AP. Public Access Defibrillation (PAD) Community Trial. Grant 1N01HC95177-000. 1999. Abstract. Available at http://commons.cit.nih.gov/crisp3/CRISP.Generate Ticket
I thank Dr Hallstrom for his comments on my editorial.1 Although the automated external defibrillator (AED) is expensive when used very infrequently, it must be relatively cheap in other situations. Because the pathophysiology of ventricular fibrillation is such that it can be terminated reliably in most instances by a shock delivered early after its onset—a “slam dunk” (will he agree with that, even if not with a “no brainer?”)—we now need to know where and how to deploy the AED. I made some suggestions in a recently published article on a neighborhood heart watch program that I call SAVE (Save A Victim Everywhere).2 Information from the Public Access Defibrillation (PAD) trial will be very helpful in this regard.