RESUMEN
STUDY OBJECTIVE: Our objective is to evaluate the incremental cost-effectiveness of use of cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) by lay responders (CPR+AED) versus CPR only for cardiac arrest during a multicenter randomized trial. METHODS: This was a prospective trial from July 2000 to September 2003 that randomly assigned 993 community units (eg, office buildings, public areas) in 24 sites to an emergency response system, using lay volunteers trained in CPR only or CPR+AED. Cost and quality of life data were collected with effectiveness data. The primary analysis evaluated the incremental cost-effectiveness of defibrillator use in public locations by using Markov modeling. RESULTS: CPR only had 14 survivors to discharge and CPR+AED had 29. CPR only had a mean of 0.58 (95% confidence interval [CI] 0.28 to 0.88) quality-adjusted life-years and a mean $42,400 (95% CI $22,100 to $62,600) costs. CPR+AED had mean 1.14 (95% CI 0.44 to 1.83) quality-adjusted life-years, mean $68,400 (95% CI $28,300 to $108,400) costs, and a long-term cost of mean $46,700 (95% CI $23,100 to $68,600) per quality-adjusted life-year. Results were sensitive to the effectiveness of the intervention, time horizon, location of arrest, and other factors. CONCLUSION: Training and equipping lay volunteers to defibrillate in public places may have an incremental cost-effectiveness that is similar to that of other common health interventions.
Asunto(s)
Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/educación , Desfibriladores/economía , Cardioversión Eléctrica/economía , Paro Cardíaco/terapia , Voluntarios/educación , Canadá , Análisis Costo-Beneficio , Cardioversión Eléctrica/instrumentación , Femenino , Paro Cardíaco/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Análisis de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVES: To evaluate the characteristics of volunteers responding to emergencies in the North American Public Access Defibrillation (PAD) Trial. METHODS: The PAD Trial was a prospective evaluation of cardiac arrest survival in community facilities randomized to cardiopulmonary resuscitation (CPR) or to CPR with automated external defibrillators (AEDs). The PAD volunteers' characteristics were analyzed using Poisson regression clustered on the facility and offset by the number of emergency episodes to which volunteers were exposed. RESULTS: A total of 19,320 volunteers in 1260 facilities were trained to provide emergency care. Of these, 8169 volunteers were participating actively at their facility during a time when one or more emergency episodes occurred. There were 1971 emergency episodes responded to by 1245 volunteers. The treatment arm (CPR-only versus CPR+AED) was not associated with the likelihood of volunteer participation in an episode. Likewise, the volunteers' age or sex did not affect response. Volunteers more likely to respond were supervisory/management or security personnel, non-minority participants, volunteers with previous CPR training, volunteers with previous experience in emergency care and those who passed the PAD CPR skills follow-up test. Volunteers who had a formal education beyond a high school level were less likely to respond. CONCLUSIONS: Volunteers with previous emergency training and positions of responsibility in their facility had a greater likelihood of participation in medical emergencies in the PAD Trial.
Asunto(s)
Desfibriladores , Paro Cardíaco/terapia , Sector Público , Voluntarios , Adulto , Canadá , Reanimación Cardiopulmonar/educación , Servicios de Salud Comunitaria , Evaluación Educacional , Cardioversión Eléctrica/instrumentación , Servicios Médicos de Urgencia/métodos , Femenino , Humanos , Masculino , Estudios Prospectivos , Estados Unidos , Voluntarios/educación , Voluntarios/psicologíaRESUMEN
BACKGROUND: Bystander CPR rates remain low. One reason may be that the thought of responding to an emergency is so stressful that it decreases the willingness of laypersons to respond. PURPOSE: The purpose of this study was to quantify the amount of stress experienced by lay responders to a medical emergency and to identify barriers that may have impeded their response to the event. METHODS: Responses from 1243 laypersons responding to an emergency during the Public Access Defibrillation Trial were analyzed in a mixed methods study. Stress related to the event was recorded using a 0 (none) to 5 (severe) scale. Qualitative responses to the question of "What was most difficult?" about the event were analyzed using content analysis. RESULTS: Reported stress levels were low overall (mean 1.2, median 1.0). Laypersons responding to an emergency presumed to be a cardiac arrest had higher stress than those involved in other events (median 2.0 versus 1.0). Stress levels were higher in residential than in public settings (mean 1.41, median 1.0 versus mean 1.13, median 1.0). Those who fit a certain profile (females, non-native English speakers) reported statistically higher stress levels than others. A total of 614 qualitative responses were studied and aggregated into four major categories of difficulty: practical issues; characteristics of the victim; interpersonal issues; thoughts and feelings of the lay responder. Most difficulties were in the category of practical issues. CONCLUSIONS: Among these study volunteer lay responders, low levels of stress were reported. Incorporating descriptions of the difficulties experienced by lay responders in CPR/AED training curricula may make courses more realistic and useful.
Asunto(s)
Reanimación Cardiopulmonar/psicología , Tratamiento de Urgencia/psicología , Paro Cardíaco/psicología , Estrés Psicológico/epidemiología , Voluntarios/psicología , Adulto , Femenino , Paro Cardíaco/terapia , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone. OBJECTIVES: To describe the types of facilities that participated in the trial and to report the incidence of CA and survival in these different types of facilities. METHODS: In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities and the numbers of presumed CAs, treatable CAs, and survivors are reported for each category of facilities. RESULTS: There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) and golf courses (4.8) and lowest in office complexes (0.7) and hotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), and fitness centers (0.4) and lowest in office complexes (0.1) and residential facilities (0.0). CONCLUSIONS: During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers and golf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, and fitness centers.
Asunto(s)
Desfibriladores/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Paro Cardíaco/epidemiología , Instalaciones Públicas/estadística & datos numéricos , Distribución por Edad , Anciano , Canadá/epidemiología , Humanos , Incidencia , Persona de Mediana Edad , Factores de Riesgo , Análisis de Supervivencia , Estados Unidos/epidemiología , Voluntarios/estadística & datos numéricosRESUMEN
BACKGROUND: Few data exist regarding the retention of cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills over time in relationship to characteristics of lay volunteer responders, training, or risk of exposure to victims. The purpose of this study was to describe the characteristics associated with adequate CPR and AED skill retention. METHODS AND RESULTS: Skill retention was tested 3 to 18 months (mean 6.9 +/- 3.5 months) after initial training. Instructors judged adequacy of performance of essential CPR or AED skills and provided an overall assessment (adequate/inadequate), which was used as the outcome. Data on 7261 laypersons trained in CPR (4358 also received AED training) in 24 sites across the United States and Canada were available from the Public Access Defibrillation (PAD) Trial. Characteristics of the volunteers, classes, and facilities were evaluated as predictors of performance adequacy. Adjusting for site, intervention assignment (CPR-only or CPR + AED), and time since initial training, volunteer characteristics associated with adequate CPR performance were age (OR 0.78 per 10-year increment), male sex (OR 1.44), minority (OR 0.62), married (OR 1.35), prior emergency experience (OR 1.66), prior CPR class (OR 1.68), prior advanced training (OR 1.59), and extracurricular CPR training (OR 1.91) (all P < .05). Characteristics associated with AED performance included age (OR 0.69), college education (OR 1.34), and native language other than English (OR 0.51) (all P < .05). CONCLUSIONS: Certain subgroups of lay volunteers may need targeted outreach programs in CPR and AED use, classes with longer training time, more practice, or more intense retraining to maintain their CPR and/or AED skills.
Asunto(s)
Reanimación Cardiopulmonar/educación , Competencia Clínica , Desfibriladores , Adulto , Femenino , Humanos , MasculinoRESUMEN
OBJECTIVE: Our objective is to describe the rationale and methods for the economic analysis of the PAD trial. The objective of this analysis is to assess whether automated external defibrillators (AEDs) use by lay responders is good value for money. METHODS: Design. This economic evaluation is being conducted concurrently with a randomized trial of (a) control--training to recognize arrest, access 911, and administer cardiopulmonary resuscitation (CPR) while awaiting arrival of emergency medical services providers versus (b) intervention--training to recognize arrest, access 911, administer CPR, and use an AED while awaiting emergency medical services providers. Lay responders in either group were trained to deliver the study intervention. Population. Participating sites identified distinct units with a population of at least 250 people aged > or = 50 years. Outcome. The primary economic outcome is the incremental cost-effectiveness ratio of intervention versus control. RESULTS: Nine hundred ninety-three units including 1260 public and residential locations were randomized. There were 30 survivors in the intervention group and 15 in the control group (P = .03). Sampling will identify program and health care costs. A societal perspective will be adopted. Incremental cost effectiveness will be estimated by using bootstrapping and decision analytic modeling. CONCLUSION: The study will demonstrate whether defibrillation by lay responders improves outcomes at reasonable cost. If so, then the thousands of lives will be improved annually. If not, then limited resources can be invested in other interventions. Our methods also provide a framework for economic evaluations of other interventions for acute cardiovascular events.
Asunto(s)
Reanimación Cardiopulmonar/economía , Desfibriladores/economía , Primeros Auxilios/instrumentación , Paro Cardíaco/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Adulto , Costo de Enfermedad , Análisis Costo-Beneficio , Costos y Análisis de Costo , Técnicas de Apoyo para la Decisión , Primeros Auxilios/economía , Recursos en Salud/economía , Paro Cardíaco/diagnóstico , Paro Cardíaco/economía , Paro Cardíaco/mortalidad , Paro Cardíaco/rehabilitación , Hospitalización/economía , Humanos , Institucionalización/economía , Estudios Prospectivos , Calidad de Vida , Proyectos de Investigación , Tamaño de la Muestra , Resultado del Tratamiento , VoluntariosRESUMEN
INTRODUCTION: Cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills competency can be tested using a checklist of component skills, individually graded "pass" or "fail." Scores are typically calculated as the percentage of skills passed, but may differ from an instructor's overall subjective assessment of simulated CPR or AED adequacy. OBJECTIVE: To identify and evaluate composite measures (methods for scoring checklists) that reflect instructors' subjective assessments of CPR or AED skills performance best. METHODS: Associations between instructor assessment and lay-volunteer skill performance were made using 6380 CPR and 3313 AED skill retention tests collected in the Public Access Defibrillation Trial. Checklists included CPR skills (e.g., calling 911, administering compressions) and AED skills (e.g., positioning electrodes, shocking within 90 s of AED arrival). The instructor's subjective overall assessment (adequate/inadequate) of CPR performance (perfusion) or AED competence (effective shock) was compared to composite measures. We evaluated the traditional composite measure (assigning equal weights to individual skills) and several nontraditional composite measures (assigning variable weights). Skills performed out of sequence were further weighted from 0% (no credit) to 100% (full credit). RESULTS: Composite measures providing full credit for skills performed out of sequence and down-weighting process skills (e.g., calling 911, clearing oneself from the AED) had the strongest association with the instructor's subjective assessment; the traditional CPR composite measure had the weakest association. CONCLUSION: Our findings suggest that instructors in public CPR and AED classes may tend to down-weight process skills and to excuse step sequencing errors when evaluating CPR and AED skills subjectively for overall proficiency. Testing methods that relate classroom performance to actual performance in the field and to clinical outcomes require further research.