RESUMEN
BACKGROUND: Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management. METHODS: Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated. RESULTS: A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR. CONCLUSION: The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.
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Reanimación Cardiopulmonar , Análisis Costo-Beneficio , Paro Cardíaco Extrahospitalario , Años de Vida Ajustados por Calidad de Vida , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/economía , Anciano , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/economía , Masculino , Femenino , Singapur/epidemiología , Servicios Médicos de Urgencia/economía , Servicios Médicos de Urgencia/métodos , Cadenas de Markov , Privación de Tratamiento/economía , Privación de Tratamiento/estadística & datos numéricos , Protocolos Clínicos , Persona de Mediana Edad , Anciano de 80 o más Años , Análisis de Costo-EfectividadRESUMEN
OBJECTIVES: To determine the actual cost and drivers of the cost of an extracorporeal cardiopulmonary resuscitation (E-CPR) care cycle. PERSPECTIVE: A time-driven activity-based costing study conducted from a healthcare provider perspective. SETTING: A quaternary care ICU providing around-the-clock E-CPR service for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in Australia. METHODS: The E-CPR care cycle was defined as the time from initiating E-CPR to hospital discharge or death of the patient. Detailed process maps with discrete steps and probabilistic decision nodes accounting for the complex trajectories of E-CPR patients were developed. Data about clinical and nonclinical resources and timing of activities was collected multiple times for each process . Total direct costs were calculated using the time estimates and unit costs per resource for all clinical and nonclinical resources. The total direct costs were combined with indirect costs to obtain the total cost of E-CPR. RESULTS: From 10 E-CPR care cycles observed during the study period, a minimum of 3 observations were obtained per process. The E-CPR care cycle's mean (95% CI) cost was $75,014 ($66,209-83,222). Initiation of extracorporeal membrane oxygenation (ECMO) and ECMO management constituted 18% of costs. The ICU management (35%) and surgical costs (20%) were the primary cost determinants. IHCA had a higher mean (95% CI) cost than OHCA ($87,940 [75,372-100,570] vs. 62,595 [53,994-71,890], p < 0.01), mainly because of the increased survival and ICU length of stay of patients with IHCA. The mean cost for each E-CPR survivor was $129,503 ($112,422-147,224). CONCLUSIONS: Significant costs are associated with E-CPR for refractory cardiac arrest. The cost of E-CPR for IHCA was higher compared with the cost of E-CPR for OHCA. The major determinants of the E-CPR costs were ICU and surgical costs. These data can inform the cost-effectiveness analysis of E-CPR in the future.
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Reanimación Cardiopulmonar , Oxigenación por Membrana Extracorpórea , Paro Cardíaco Extrahospitalario , Humanos , Reanimación Cardiopulmonar/economía , Oxigenación por Membrana Extracorpórea/economía , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/economía , Paro Cardíaco Extrahospitalario/mortalidad , Australia , Unidades de Cuidados Intensivos/economía , Factores de Tiempo , Masculino , Femenino , Persona de Mediana Edad , Paro Cardíaco/terapia , Paro Cardíaco/economía , Paro Cardíaco/mortalidad , Costos de la Atención en Salud/estadística & datos numéricos , Costos y Análisis de CostoRESUMEN
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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Algoritmos , Análisis Costo-Beneficio , Desfibriladores , Paro Cardíaco Extrahospitalario , Años de Vida Ajustados por Calidad de Vida , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/economía , Desfibriladores/economía , Desfibriladores/estadística & datos numéricos , Países Bajos , Masculino , Servicios Médicos de Urgencia/economía , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/economía , Femenino , Persona de Mediana Edad , Voluntarios/estadística & datos numéricos , Tiempo de TratamientoRESUMEN
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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Análisis Costo-Beneficio , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/economía , Años de Vida Ajustados por Calidad de Vida , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/métodos , Reino Unido , Órdenes de Resucitación , Medicina Estatal/economíaRESUMEN
AIMS: When out-of-hospital cardiac arrest (OHCA) becomes refractory, extracorporeal cardiopulmonary resuscitation (ECPR) is a potential option to restore circulation and improve the patient's outcome. However, ECPR requires specific materials and highly skilled personnel, and it is unclear whether increased survival and health-related quality of life (HRQOL) justify these costs. METHODS AND RESULTS: This cost-effectiveness study was part of the INCEPTION study, a multi-centre, pragmatic randomized trial comparing hospital-based ECPR to conventional CPR (CCPR) in patients with refractory OHCA in 10 cardiosurgical centres in the Netherlands. We analysed healthcare costs in the first year and measured HRQOL using the EQ-5D-5L at 1, 3, 6, and 12 months. Incremental cost-effectiveness ratios (ICERs), cost-effectiveness planes, and acceptability curves were calculated. Sensitivity analyses were performed for per-protocol and as-treated subgroups as well as imputed productivity loss in deceased patients. In total, 132 patients were enrolled: 62 in the CCPR and 70 in the ECPR group. The difference in mean costs after 1 year was 5109 (95% confidence interval -7264 to 15 764). Mean quality-adjusted life year (QALY) after 1 year was 0.15 in the ECPR group and 0.11 in the CCPR group, resulting in an ICER of 121 643 per additional QALY gained. The acceptability curve shows that at a willingness-to-pay threshold of 80.000, the probability of ECPR being cost-effective compared with CCPR is 36%. Sensitivity analysis showed increasing ICER in the per-protocol and as-treated groups and lower probabilities of acceptance. CONCLUSION: Hospital-based ECPR in refractory OHCA has a low probability of being cost-effective in a trial-based economic evaluation.
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Reanimación Cardiopulmonar , Análisis Costo-Beneficio , Paro Cardíaco Extrahospitalario , Calidad de Vida , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/métodos , Oxigenación por Membrana Extracorpórea/economía , Oxigenación por Membrana Extracorpórea/métodos , Países Bajos , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/economía , Años de Vida Ajustados por Calidad de Vida , Tasa de Supervivencia/tendenciasRESUMEN
OBJECTIVE: It remains unknown whether patient socioeconomic factors affect interventions and survival after out-of-hospital cardiac arrest (OHCA), and whether a socioeconomic effect on bystander interventions affects survival. Therefore, this study examined patient socioeconomic disparities in prehospital factors and survival. METHODS: From the Danish Cardiac Arrest Registry, patients with OHCA ≥30 years were identified, 2001-2014, and divided into quartiles of household income (highest, high, low, lowest). Associations between income and bystander cardiopulmonary resuscitation (CPR) and 30-day survival with bystander CPR as mediator were analysed by logistic regression and mediation analysis in private witnessed, public witnessed, private unwitnessed and public unwitnessed arrests, adjusted for confounders. RESULTS: We included 21 480 patients. Highest income patients were younger, had higher education and were less comorbid relative to lowest income patients. They had higher odds for bystander CPR with the biggest difference in private unwitnessed arrests (OR 1.74, 95% CI 1.47 to 2.05). For 30-day survival, the biggest differences were in public witnessed arrests with 26.0% (95% CI 22.4% to 29.7%) higher survival in highest income compared with lowest income patients. Had bystander CPR been the same for lowest income as for highest income patients, then survival would be 25.3% (95% CI 21.5% to 29.0%) higher in highest income compared with lowest income patients, resulting in elimination of 0.79% (95% CI 0.08% to 1.50%) of the income disparity in survival. Similar trends but smaller were observed in low and high-income patients, the other three subgroups and with education instead of income. From 2002 to 2014, increases were observed in both CPR and survival in all income groups. CONCLUSION: Overall, lower socioeconomic status was associated with poorer prehospital factors and survival after OHCA that was not explained by patient or cardiac arrest-related factors.
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Servicios Médicos de Urgencia/estadística & datos numéricos , Paro Cardíaco Extrahospitalario/economía , Sistema de Registros , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidad , Paro Cardíaco Extrahospitalario/terapia , Factores Socioeconómicos , Tasa de Supervivencia/tendencias , Factores de TiempoAsunto(s)
Reanimación Cardiopulmonar/economía , Infecciones por Coronavirus/prevención & control , Atención a la Salud/métodos , Recursos en Salud/economía , Paro Cardíaco/terapia , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Pandemias/prevención & control , Neumonía Viral/prevención & control , Aerosoles/efectos adversos , Betacoronavirus , COVID-19 , Reanimación Cardiopulmonar/efectos adversos , Infecciones por Coronavirus/epidemiología , Femenino , Humanos , Masculino , Salud Laboral/estadística & datos numéricos , Neumonía Viral/epidemiología , Pobreza/estadística & datos numéricos , Medición de Riesgo , SARS-CoV-2RESUMEN
BACKGROUND: This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment. METHODS: A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2-4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY). MEASUREMENTS AND MAIN RESULTS: Treating eligible patients with an ACCI below 2 points costs 8394 (95% CI: 4922-14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8825 (95% CI: 5192-15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5478-16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10,818 (95% CI: 6357-19,400) euro per extra QALY per IHCA patient. For WTP thresholds of 0-9500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most cost-effective strategy. CONCLUSIONS: Given that conventional WTP thresholds in Europe and North-America lie between 50,000-100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.
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Reanimación Cardiopulmonar/economía , Toma de Decisiones , Oxigenación por Membrana Extracorpórea/economía , Costos de la Atención en Salud , Paro Cardíaco Extrahospitalario/terapia , Sistema de Registros , Reanimación Cardiopulmonar/métodos , Análisis Costo-Beneficio , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/economía , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) initiated before medical help arrives saves lives. Hands-Only CPR keeps the blood flowing to the brain and other organs, increasing a person's chance of survival. METHODS: A literature review identified Hands-Only CPR as the preferred method of CPR performed in the community setting. Many states have passed legislation making CPR education a high school graduation requirement. RESULTS: School nurses can play a pivotal role as school districts address these new CPR requirements. The school nurse involvement in these newly mandated CPR training requirements can support student success and improve the health of communities. CONCLUSIONS: School nurses need to use these newly mandated CPR training requirements as an opportunity to showcase the profession of nursing to ensure the school nurse remains present in our schools.
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Reanimación Cardiopulmonar , Servicios de Salud Escolar/economía , Instituciones Académicas , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/educación , Humanos , Enfermeras y Enfermeros , Servicios de Enfermería Escolar/economía , Instituciones Académicas/economía , Instituciones Académicas/legislación & jurisprudencia , EstudiantesRESUMEN
OBJECTIVES: Recommendations for extracorporeal cardiopulmonary resuscitation (ECPR) state that appropriate patient selection is important for the sake of efficacy and cost-effectiveness of ECPR. It is not known whether first documented rhythm plays a prominent role in economic outcomes of patients with cardiac arrest who received ECPR. METHODS AND RESULTS: We reviewed the medical records of 120 consecutive patients who received extracorporeal membrane oxygenation (ECMO) assisted CPR due to refractory circulatory collapse between 2008 and 2016 in Urasoe General Hospital. The patients presented with ventricular fibrillation or pulseless ventricular tachycardia (VF/VT; n = 59, 49.2%) or with asystole or pulseless electric activity (ASY/PEA; n = 61, 50.8%) as the first documented rhythm. Multivariate logistic regression analysis identified shorter duration from collapse to ECMO initiation (odds ratio, 1.95 per 10 min; 95% confidence interval, 1.32-2.89, p = 0.001), bystander CPR (odds ratio, 5.53; 95% confidence interval, 1.36-22.5, p = 0.017), and first documented rhythm of VF/VT (odds ratio, 3.93; 95% confidence interval, 1.30-11.8, p = 0.015) as clinical predictors for neurologically intact survival. Total hospital cost per life saved by ECPR for ASY/PEA was approximately twice that for VF/VT ($213,656 vs. $101,669). ECPR yielded Quality adjusted life years (QALYs) of 3.32 at a mean total cost of $39,634 for VF/VT and QALYs of 1.17 at a mean cost of $35,609 for ASY/PEA. The cost per QALYs was $11,081 for VF/VT and $29,447 for ASY/PEA. The incremental cost-effectiveness ratio of ECPR vs. conventional CPR was estimated to be $ 16,246 per QALY gained. CONCLUSION: ECPR for patients presenting with VF/VT was found to be highly cost-effective and ECPR for patients presenting with ASY/PEA was borderline cost-effective.
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Reanimación Cardiopulmonar/métodos , Oxigenación por Membrana Extracorpórea/economía , Paro Cardíaco/terapia , Taquicardia Ventricular/terapia , Fibrilación Ventricular/terapia , Anciano , Reanimación Cardiopulmonar/economía , Análisis Costo-Beneficio , Femenino , Paro Cardíaco/mortalidad , Costos de Hospital , Humanos , Japón/epidemiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Taquicardia Ventricular/mortalidad , Fibrilación Ventricular/mortalidadRESUMEN
Cardiopulmonary resuscitation has become the default treatment for all patients who suffer cardiac arrest. The history of how this came to be suggests the clinical and ethical importance of establishing more humane and appropriate indications for extracorporeal membrane oxygenation and other aggressive therapies for patients at the end of life.
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Reanimación Cardiopulmonar/historia , Codificación Clínica/normas , Oxigenación por Membrana Extracorpórea/historia , Nivel de Atención/ética , Reanimación Cardiopulmonar/economía , Oxigenación por Membrana Extracorpórea/economía , Paro Cardíaco/terapia , Historia del Siglo XX , HumanosRESUMEN
BACKGROUND: Despite a consistent association with improved outcomes, public automated external defibrillators (AEDs) are rarely used in out-of-hospital cardiac arrest. One of the barriers towards increased use might be cost-effectiveness. METHODS: We compared the cost-effectiveness of public AEDs to no AEDs for out-of-hospital cardiac arrest in the United States over a life-time horizon. The analysis assumed a societal perspective and results are presented as costs per quality-adjusted life year (QALY). Model inputs were based on reviews of the literature. For the base case, we modelled an annual cardiac arrest incidence per AED of 20%. A probabilistic sensitivity analysis was conducted to account for joint parameter uncertainty. RESULTS: The no AED strategy resulted in 1.63 QALYs at a cost of $28,964. The AED strategy yielded an additional 0.26 QALYs for an incremental increase in cost of $13,793 per individual. The AED strategy yielded an incremental cost-effectiveness ratio of $53,797 per QALY gained. The yearly incidence of cardiac arrests occurring in the presence of an AED had minimal effect on the incremental cost-effectiveness ratio except at very low incidences. In several sensitivity analyses across a plausible range of health care and societal estimates, the AED strategy remained cost-effective. In the probabilistic sensitivity analysis, the AED strategy was cost-effective in 43%, 85%, and 91% of the scenarios at a willingness-to-pay threshold of $50,000, $100,000, and $150,000 per QALY gained, respectively. CONCLUSION: Public AEDs are a cost-effective public health intervention in the United States. These findings support widespread dissemination of public AEDs.
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Reanimación Cardiopulmonar/economía , Técnicas de Apoyo para la Decisión , Desfibriladores/economía , Servicios Médicos de Urgencia/economía , Paro Cardíaco Extrahospitalario/terapia , Salud Pública , Años de Vida Ajustados por Calidad de Vida , Reanimación Cardiopulmonar/métodos , Análisis Costo-Beneficio , Humanos , Paro Cardíaco Extrahospitalario/economía , Estudios Prospectivos , Estados UnidosRESUMEN
AIM: To systematically review studies comparing bystander automated external defibrillator (AED) use to no AED use in regard to clinical outcomes in out-of-hospital cardiac arrest (OHCA), and to provide a descriptive summary of studies on the cost-effectiveness of bystander AED use. METHODS: We searched Medline, Embase, the Web of Science, and the Cochrane Library for randomized trials and observational studies published before June 1, 2017. Meta-analyses were performed for patients with all rhythms, shockable rhythms, and non-shockable rhythms. RESULTS: Forty-four observational studies, 3 randomized trials, and 13 cost-effectiveness studies were included. Meta-analysis of 6 observational studies without critical risk of bias showed that bystander AED use was associated with survival to hospital discharge (all rhythms OR: 1.73 [95%CI: 1.36, 2.18], shockable rhythms OR: 1.66 [95%CI: 1.54, 1.79]) and favorable neurological outcome (all rhythms OR: 2.12 [95%CI: 1.36, 3.29], shockable rhythms OR: 2.37 [95%CI: 1.58, 3.57]). There was no association between bystander AED use and neurological outcome for non-shockable rhythms (OR: 0.76 [95%CI: 0.10, 5.87]). The Public-Access Defibrillation trial found higher survival rates when volunteers were equipped with AEDs. The other trials found no survival difference, although their study settings differed. The quality of evidence was low for randomized trials and very low for observational studies. AEDs were cost-effective in settings with high cardiac arrest incidence, with most studies reporting ratios < $100,000 per quality-adjusted life years. CONCLUSIONS: The evidence supports the association between bystander AED use and improved clinical outcomes, although the quality of evidence was low to very low.
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Reanimación Cardiopulmonar/economía , Desfibriladores/estadística & datos numéricos , Cardioversión Eléctrica/economía , Paro Cardíaco Extrahospitalario/terapia , Reanimación Cardiopulmonar/mortalidad , Estudios de Casos y Controles , Análisis Costo-Beneficio , Cardioversión Eléctrica/mortalidad , Servicios Médicos de Urgencia/economía , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Observacionales como Asunto , Paro Cardíaco Extrahospitalario/mortalidad , Años de Vida Ajustados por Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
AIM: To assess the cost-effectiveness of LUCAS-2, a mechanical device for cardiopulmonary resuscitation (CPR) as compared to manual chest compressions in adults with non-traumatic, out-of-hospital cardiac arrest. METHODS: We analysed patient-level data from a large, pragmatic, multi-centre trial linked to administrative secondary care data from the Hospital Episode Statistics (HES) to measure healthcare resource use, costs and outcomes in both arms. A within-trial analysis using quality adjusted life years derived from the EQ-5D-3L was conducted at 12-month follow-up and results were extrapolated to the lifetime horizon using a decision-analytic model. RESULTS: 4471 patients were enrolled in the trial (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group). At 12 months, 89 (5%) patients survived in the LUCAS-2 group and 175 (6%) survived in the manual CPR group. In the vast majority of analyses conducted, both within-trial and by extrapolation of the results over a lifetime horizon, manual CPR dominates LUCAS-2. In other words, patients in the LUCAS-2 group had poorer health outcomes (i.e. lower QALYs) and incurred higher health and social care costs. CONCLUSION: Our study demonstrates that the use of the mechanical chest compression device LUCAS-2 represents poor value for money when compared to standard manual chest compression in out-of-hospital cardiac arrest.
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Reanimación Cardiopulmonar/métodos , Masaje Cardíaco/instrumentación , Paro Cardíaco Extrahospitalario/terapia , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/mortalidad , Estudios de Casos y Controles , Análisis Costo-Beneficio , Servicios Médicos de Urgencia/economía , Femenino , Masaje Cardíaco/economía , Hospitalización/economía , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidad , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: Mechanical chest compression devices may help to maintain high-quality cardiopulmonary resuscitation (CPR), but little evidence exists for their effectiveness. We evaluated whether or not the introduction of Lund University Cardiopulmonary Assistance System-2 (LUCAS-2; Jolife AB, Lund, Sweden) mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest (OHCA). OBJECTIVE: Evaluation of the LUCAS-2 device as a routine ambulance service treatment for OHCA. DESIGN: Pragmatic, cluster randomised trial including adults with non-traumatic OHCA. Ambulance dispatch staff and those collecting the primary outcome were blind to treatment allocation. Blinding of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. We also conducted a health economic evaluation and a systematic review of all trials of out-of-hospital mechanical chest compression. SETTING: Four UK ambulance services (West Midlands, North East England, Wales and South Central), comprising 91 urban and semiurban ambulance stations. Clusters were ambulance service vehicles, which were randomly assigned (approximately 1 : 2) to the LUCAS-2 device or manual CPR. PARTICIPANTS: Patients were included if they were in cardiac arrest in the out-of-hospital environment. Exclusions were patients with cardiac arrest as a result of trauma, with known or clinically apparent pregnancy, or aged < 18 years. INTERVENTIONS: Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. MAIN OUTCOME MEASURES: Survival at 30 days following cardiac arrest; survival without significant neurological impairment [Cerebral Performance Category (CPC) score of 1 or 2]. RESULTS: We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 device and 2819 assigned to control) between 15 April 2010 and 10 June 2013. A total of 985 (60%) patients in the LUCAS-2 group received mechanical chest compression and 11 (< 1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30-day survival was similar in the LUCAS-2 (104/1652, 6.3%) and manual CPR groups [193/2819, 6.8%; adjusted odds ratio (OR) 0.86, 95% confidence interval (CI) 0.64 to 1.15]. Survival with a CPC score of 1 or 2 may have been worse in the LUCAS-2 group (adjusted OR 0.72, 95% CI 0.52 to 0.99). No serious adverse events were noted. The systematic review found no evidence of a survival advantage if mechanical chest compression was used. The health economic analysis showed that LUCAS-2 was dominated by manual chest compression. LIMITATIONS: There was substantial non-compliance in the LUCAS-2 arm. For 272 out of 1652 patients (16.5%), mechanical chest compression was not used for reasons that would not occur in clinical practice. We addressed this issue by using complier average causal effect analyses. We attempted to measure CPR quality during the resuscitation attempts of trial participants, but were unable to do so. CONCLUSIONS: There was no evidence of improvement in 30-day survival with LUCAS-2 compared with manual compressions. Our systematic review of recent randomised trials did not suggest that survival or survival without significant disability may be improved by the use of mechanical chest compression. FUTURE WORK: The use of mechanical chest compression for in-hospital cardiac arrest, and in specific circumstances (e.g. transport), has not yet been evaluated. TRIAI REGISTRATION: Current Controlled Trials ISRCTN08233942. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 11. See the NIHR Journals Library website for further project information.
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Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/instrumentación , Servicios Médicos de Urgencia/economía , Servicios Médicos de Urgencia/métodos , Paro Cardíaco Extrahospitalario/terapia , Anciano , Anciano de 80 o más Años , Ambulancias , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Salud Mental , Persona de Mediana Edad , Pruebas Neuropsicológicas , Paro Cardíaco Extrahospitalario/mortalidad , Método Simple Ciego , Medicina Estatal/economía , Análisis de Supervivencia , Reino UnidoRESUMEN
BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) is associated with a greater likelihood of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). However the long-term survival benefits in relationship to cost have not been well-studied. We evaluated bystander CPR, hospital-based costs, and long-term survival following OHCA in order to assess the potential cost-effectiveness of bystander CPR. PATIENTS AND METHODS: We conducted a retrospective cohort study of consecutive EMS-treated OHCA patients >=12years who arrested prior to EMS arrival and outside a nursing facility between 2001 and 2010 in greater King County, WA. Utstein-style information was obtained from the EMS registry, including 5-year survival. Costs from the OHCA hospitalization were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Cost effectiveness was based on hospital costs divided by quality-adjusted life years (QALYs) for a 5-year follow-up window. RESULTS: Of the 4448 eligible patients, 18.5% (n=824) were discharged alive from hospital and 12.1% (n=539) were alive at 5 years. Five-year survival was higher in patients who received bystander CPR (14.3% vs. 8.7%, p<0.001) translating to an average 0.09 QALYs associated with bystander CPR. The average (SD) total cost of the initial acute care hospitalization was USD 19,961 (40,498) for all admitted patients and USD 75,175 (52,276) for patients alive at year 5. The incremental cost-effectiveness ratio associated with bystander CPR was USD 48,044 per QALY. CONCLUSION: Based on this population-based investigation, bystander CPR was positively associated with long-term survival and appears cost-effective.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Paro Cardíaco Extrahospitalario , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/mortalidad , Análisis Costo-Beneficio , Servicios Médicos de Urgencia/economía , Femenino , Hospitalización/economía , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/economía , Paro Cardíaco Extrahospitalario/mortalidad , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Washingtón/epidemiologíaRESUMEN
OBJECTIVE: To understand perceived barriers to providing cardiopulmonary resuscitation (CPR) education, implementation processes, and practices in high schools. STUDY DESIGN: Iowa has required CPR as a graduation requirement since 2011 as an unfunded mandate. A cross-sectional study was performed through multiple choice surveys sent to Iowa high schools to collect data about school demographics, details of CPR programs, cost, logistics, and barriers to implementation, as well as automated external defibrillator training and availability. RESULTS: Eighty-four schools responded (26%), with the most frequently reported school size of 100-500 students and faculty size of 25-50. When the law took effect, 51% of schools had training programs already in place; at the time of the study, 96% had successfully implemented CPR training. Perceived barriers to implementation were staffing, time commitment, equipment availability, and cost. The average estimated startup cost was <$1000 US, and the yearly maintenance cost was <$500 with funds typically allocated from existing school resources. The facilitator was a school official or volunteer for 81% of schools. Average estimated training time commitment per student was <2 hours. Automated external defibrillators are available in 98% of schools, and 61% include automated external defibrillator training in their curriculum. CONCLUSIONS: Despite perceived barriers, school CPR training programs can be implemented with reasonable resource and time allocations.
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Reanimación Cardiopulmonar/educación , Reanimación Cardiopulmonar/economía , Análisis Costo-Beneficio , Estudios Transversales , Humanos , Iowa , Evaluación de Programas y Proyectos de Salud , Instituciones Académicas , Encuestas y CuestionariosRESUMEN
OBJECTIVES: This study sought to assess the impact of morbid obesity on outcomes in patients with in-hospital cardiac arrest (IHCA). BACKGROUND: Obesity is associated with increased risk of out-of-hospital cardiac arrest; however, little is known about survival of morbidly obese patients with IHCA. METHODS: Using the Nationwide Inpatient Sample database from 2001 to 2008, we identified adult patients undergoing resuscitation for IHCA, including those with morbid obesity (body mass index ≥40 kg/m2) by using International Classification of Diseases 9th edition codes and clinical outcomes. Outcomes including in-hospital mortality, length of stay, and discharge dispositions were identified. Logistic regression model was used to examine the independent association of morbid obesity with mortality. RESULTS: Of 1,293,071 IHCA cases, 27,469 cases (2.1%) were morbidly obese. The overall mortality was significantly higher for the morbidly obese group than for the nonobese group experiencing in-hospital non-ventricular fibrillation (non-VF) (77% vs. 73%, respectively; p = 0.006) or VF (65% vs. 58%, respectively; p = 0.01) arrest particularly if cardiac arrest happened late (>7 days) after hospitalization. Discharge to home was significantly lower in the morbidly obese group (21% vs. 31%, respectively; p = 0.04). After we adjusted for baseline variables, morbid obesity remained an independent predictor of increased mortality. Other independent predictors of mortality were age and severe sepsis for non-VF and VF group and venous thromboembolism, cirrhosis, stroke, malignancy, and rheumatologic conditions for non-VF group. CONCLUSIONS: The overall mortality of morbidly obese patients after IHCA is worse than that for nonobese patients, especially if IHCA occurs after 7 days of hospitalization and survivors are more likely to be transferred to a skilled nursing facility.
Asunto(s)
Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Obesidad Mórbida/complicaciones , Reanimación Cardiopulmonar/economía , Reanimación Cardiopulmonar/mortalidad , Femenino , Paro Cardíaco/economía , Paro Cardíaco/mortalidad , Costos de Hospital , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/economía , Obesidad Mórbida/mortalidad , Transferencia de Pacientes/economía , Transferencia de Pacientes/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos/epidemiología , Fibrilación Ventricular/complicaciones , Fibrilación Ventricular/economía , Fibrilación Ventricular/terapiaRESUMEN
BACKGROUND: Most studies on out-of-hospital cardiac arrest have focused on immediate survival. However, little is known about long-term outcomes and resource use among survivors. METHODS AND RESULTS: Within the national CARES registry, we identified 16 206 adults 65 years or older with an out-of-hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1-year mortality, cumulative readmission incidence, and follow-up inpatient costs differed according to patients' race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1-year mortality after hospital discharge was 31.8%. Among survivors, there were no long-term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58-1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient-years. Mean 1-year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1-year inpatient costs (P for all <0.05). CONCLUSION: Among elderly survivors of out-of-hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long-term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition.