RESUMO
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.
Assuntos
Algoritmos , Análise Custo-Benefício , Desfibriladores , Parada Cardíaca Extra-Hospitalar , Anos de Vida Ajustados por Qualidade de Vida , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/economia , Desfibriladores/economia , Desfibriladores/estatística & dados numéricos , Países Baixos , Masculino , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/economia , Feminino , Pessoa de Meia-Idade , Voluntários/estatística & dados numéricos , Tempo para o TratamentoRESUMO
INTRODUCTION: Wearable cardioverter-defibrillator (WCD) is recommended for patients with implantable cardioverter-defibrillator (ICD) removal. This study aimed to investigate the potential cost-effectiveness of WCD for patients with ICD explant in a high-income city of China. METHODS AND RESULTS: A 5-year decision-analytic model was developed to simulate outcomes of three strategies during the period between ICD explant and reimplantation: discharge-to-home without WCD (home group), discharge-to-home with WCD (WCD group), and stay-in-hospital (hospital group). Outcome measures were mortality rates (during the period between ICD explant and reimplantation), direct medical costs, quality-adjusted life years (QALYs), and incremental cost per QALY saved (ICER). Model inputs were derived from literature and public data. Base-case analysis was performed at four cost levels of WCD. Robustness of model results was examined by sensitivity analyses. In base-case analysis, the 8-week mortality rates of WCD, hospital, and home groups were 7.3%, 8.1%, and 9.4%, respectively. WCD group gained the highest QALYs (3.0990 QALYs), followed by hospital group (3.0553 QALYs) and home group (3.0132 QALYs). The WCD group was the cost-effective option with ICERs less than willingness-to-pay (WTP) threshold (57 315 USD/QALY) at WCD daily cost ≤USD48. In probabilistic sensitivity analysis, the WCD group at daily cost of USD24, USD48, USD72, and USD96 were cost-effective in 100%, 94.16%, 22.08%, and 0.16% of 10 000 Monte Carlo simulations, respectively. CONCLUSIONS: Use of WCD during the period between ICD explant and reimplantation is likely to save life and gain higher QALYs. Cost-effectiveness of WCD is highly subject to the daily cost of WCD in China.
Assuntos
Arritmias Cardíacas/economia , Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Desfibriladores/economia , Remoção de Dispositivo/economia , Cardioversão Elétrica/economia , Cardioversão Elétrica/instrumentação , Custos de Cuidados de Saúde , Dispositivos Eletrônicos Vestíveis/economia , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , China , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Cardioversão Elétrica/mortalidade , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Método de Monte Carlo , Alta do Paciente/economia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Resultado do TratamentoRESUMO
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.
Assuntos
Reanimação Cardiopulmonar/economia , Técnicas de Apoio para a Decisão , Desfibriladores/economia , Serviços Médicos de Emergência/economia , Parada Cardíaca Extra-Hospitalar/terapia , Saúde Pública , Anos de Vida Ajustados por Qualidade de Vida , Reanimação Cardiopulmonar/métodos , Análise Custo-Benefício , Humanos , Parada Cardíaca Extra-Hospitalar/economia , Estudos Prospectivos , Estados UnidosRESUMO
BACKGROUND: Early cardiopulmonary resuscitation (CPR) and defibrillation with an Automated External Defibrillator (AED) increase survival from out-of-hospital cardiac arrest (OHCA). Although international guidelines recommend the use of AED registries to increase AED use, little is known about implementation. The aim of this paper is to describe the development of a national AED registry, to analyse the coverage and barriers to register AEDs. METHODS: The Swedish AED Registry (SAEDREG) was initiated in 2009 with the purpose of gathering the data of all public AEDs in Sweden. Data on all AEDs between 2013 and 2016 were included in the study. Additionally, data of non-registered AEDs was collected in one region using a survey to AED owners focusing on AED functionality. RESULTS: The number of AEDs doubled between 2013-2016. A total of 6703 AEDs (30%) were removed due to unavailability of validation. At the end of 2016, AEDs were most frequently registered in offices and workplaces, 45% (nâ¯=â¯7241) followed by shops, 7% (nâ¯=â¯1200). In the Gotland region, 218 AEDs, 57% (nâ¯=â¯124) were registered in the SAEDREG. Of nâ¯=â¯94 Non-registered AED functionality was high, the main reason not to register was unawareness of the SAEDREG, 74.5%. Of those aware of the register but not having registered, 25% stated "hard to register" as cause. CONCLUSIONS: A national AED registry may gather information of AEDs on a national level. Although numbers have doubled between 2013-2016 in Sweden, a large proportion is still non-registered. More awareness of the registry and easier registration process is needed. General AED functionality seems high regardless of registered or non-registered AEDs. A key area for future research may be to use AED-registers to ascertain effectiveness of AED programs in terms of actual patient outcome.
Assuntos
Reanimação Cardiopulmonar , Desfibriladores/estatística & dados numéricos , Intervenção Médica Precoce , Cardioversão Elétrica/instrumentação , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar , Idoso , Reanimação Cardiopulmonar/instrumentação , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/estatística & dados numéricos , Desfibriladores/economia , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/organização & administração , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Sistema de Registros/estatística & dados numéricos , Suécia/epidemiologiaRESUMO
BACKGROUND: Mathematical optimisation models have recently been applied to identify ideal Automatic External Defibrillator (AED) locations that maximise coverage of Out of Hospital Cardiac Arrest (OHCA). However, these fixed location models cannot relocate existing AEDs in a flexible way, and have nearly exclusively been applied to urban regions. We developed a flexible location model for AEDs, compared its performance to existing fixed location and population models, and explored how these perform across urban and rural regions. METHODS: Optimisation techniques were applied to AED deployment and OHCA coverage was assessed. A total of 2802 geolocated OHCAs occurred in Canton Ticino, Switzerland, from January 1st 2005 to December 31st 2015. RESULTS: There were 719 AEDs in Canton Ticino. 635 (23%) OHCA events occurred within 100â¯m of an AED, with 306 (31%) in urban, and 329 (18%) in rural areas. Median distance from OHCA events to the nearest AED was 224â¯m (168â¯m urban vs. 269â¯m rural). Flexible location models performed better than fixed location and population models, with the cost to deploy 20 new AEDs instead relocating 171 existing AEDs to new locations, improving OHCA coverage to 38%, compared to 26% using fixed models, and 24% with the population based model. CONCLUSIONS: Optimisation models for AEDs placement are superior to population models and should be strongly considered by communities when selecting areas for AED deployment. Compared to other models, flexible location models increase overall OHCA coverage, and decreases the distance to nearby AEDs, even in rural areas, while saving significant financial resources.
Assuntos
Desfibriladores/provisão & distribuição , Parada Cardíaca Extra-Hospitalar/epidemiologia , Idoso , Desfibriladores/economia , Feminino , Acessibilidade aos Serviços de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/terapia , Sistema de Registros , Estudos Retrospectivos , Suíça/epidemiologiaRESUMO
OBJECTIVES: The aim of this study was to illustrate the contribution of stakeholder engagement to the impact of health technology assessment (HTA) using an Irish HTA of a national public access defibrillation (PAD) program. BACKGROUND: In response to draft legislation that proposed a PAD program, the Minister for Health requested that Health Information and Quality Authority undertake an HTA to inform the design and implementation of a national PAD program and the necessary underpinning legislation. The draft legislation outlined a program requiring widespread installation and maintenance of automatic external defibrillators in specified premises. METHODS: Stakeholder engagement to optimize the impact of the HTA included one-to-one interviews with politicians, engagement with an Expert Advisory Group, public and targeted consultation, and positive media management. RESULTS: The HTA quantified the clinical benefits of the proposed PAD program as modest, identified that substantial costs would fall on small/medium businesses at a time of economic recession, and that none of the programs modeled were cost-effective. The Senator who proposed the Bill actively publicized the HTA process and its findings and encouraged participation in the public consultation. Participation of key stakeholders was important for the quality and acceptability of the HTA findings and advice. Media management promoted public engagement and understanding. The Bill did not progress. CONCLUSIONS: The HTA informed the decision not to progress with legislation for a national PAD program. Engagement was tailored to ensure that key stakeholders including politicians and the public were informed of the HTA process, the findings, and the advice, thereby maximizing acceptance. Appropriate stakeholder engagement optimizes the impact of HTA.
Assuntos
Participação da Comunidade , Desfibriladores/provisão & distribuição , Avaliação da Tecnologia Biomédica/organização & administração , Análise Custo-Benefício , Tomada de Decisões , Desfibriladores/economia , Política de Saúde , Humanos , IrlandaRESUMO
The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach.
Assuntos
Arritmias Cardíacas/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Cardioversão Elétrica/instrumentação , Arritmias Cardíacas/economia , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Análise Custo-Benefício , Desfibriladores/economia , Difusão de Inovações , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/economia , Cardioversão Elétrica/mortalidade , Desenho de Equipamento , Custos de Cuidados de Saúde , Humanos , Cooperação do Paciente , Satisfação do Paciente , Fatores de Risco , Resultado do TratamentoRESUMO
This study aimed to describe the availability of advisory external defibrillators (AEDs) in Irish General Practice. The study utilised a computer generated random sample of Irish general practitioners and involved a postal questionnaire, with telephone follow up of non-responders. The cohort of GPs already known to possess an AED (via participation in the Merit Project) was excluded. 115 valid paper survey responses were received representing a response rate of 59%. 5 of the responding GPs identified themselves as Merit project participants and were excluded from data analysis. 74/110 GPs (67%) reported having one or more AED(s) available for use at their practice. 41/77 GPs (53%) who had not responded to the paper survey but were contactable by telephone had an AED available. When AED availability was examined by practice setting a higher proportion of rural and mixed settings had AEDs available than in urban and city areas. Cost was reported as the most common reason for not having an AED.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Medicina Geral , Clínicos Gerais , Atitude do Pessoal de Saúde , Desfibriladores/economia , Desfibriladores/estatística & dados numéricos , Desfibriladores/provisão & distribuição , Medicina Geral/economia , Medicina Geral/métodos , Medicina Geral/normas , Clínicos Gerais/psicologia , Clínicos Gerais/estatística & dados numéricos , Pesquisas sobre Atenção à Saúde , Humanos , Entrevistas como Assunto , Irlanda , Avaliação das Necessidades , Distribuição Aleatória , Inquéritos e Questionários , Fibrilação Ventricular/terapiaRESUMO
OBJECTIVE: Automated external defibrillators (AEDs) placed in public locations can save lives of cardiac arrest victims. In this paper, we try to estimate the cost-effectiveness of AED placement in Belgian schools. This would allow school policy makers to make an evidence-based decision about an on-site AED project. METHODS AND RESULTS: We developed a simple mathematical model containing literature data on the incidence of cardiac arrest with a shockable rhythm; the feasibility and effectiveness of defibrillation by on-site AEDs and the survival benefit. This was coupled to a rough estimation of the minimal costs to initiate an AED project. According to the model described above, AED projects in all Belgian schools may save 5 patients annually. A rough estimate of the minimal costs to initiate an AED project is 660 EUR per year. As there are about 6000 schools in Belgium, a national AED project in all schools would imply an annual cost of at least 3960 000 EUR, resulting in 5 lives saved. CONCLUSIONS: As our literature survey shows that AED use in schools is feasible and effective, the placement of these devices in all Belgian schools is undoubtedly to be considered. The major counter-arguments are the very low incidence and the high costs to set up a school-based AED programme. Our review may fuel the discussion about Whether or not school-based AED projects represent good value for money and should be preferred above other health care interventions.
Assuntos
Desfibriladores , Parada Cardíaca/terapia , Serviços de Saúde Escolar , Adolescente , Automação , Bélgica , Criança , Análise Custo-Benefício , Desfibriladores/economia , Estudos de Viabilidade , Humanos , Matemática , Modelos TeóricosRESUMO
BACKGROUND: Prevention of sudden cardiac arrest (SCA) after removal of an infected implantable cardioverter-defibrillator (ICD) is a challenging clinical dilemma. The cost-effectiveness of the wearable cardioverter-defibrillator (WCD) in this setting remains uncertain. OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of the WCD with discharge home, discharge to a skilled nursing facility, or inpatient monitoring for the prevention of SCA after infected ICD removal. METHODS: A decision model was developed to compare the cost-effectiveness of use of the WCD to several different strategies for patients who undergo ICD removal. One-way and 2-way sensitivity analyses were performed to account for uncertainties. RESULTS: In the base-case analysis, the incremental cost-effectiveness of the WCD strategy was $20,300 per life-year (LY) or $26,436 per quality-adjusted life-year (QALY) compared to discharge home without a WCD. Discharge to a skilled nursing facility and in-hospital monitoring resulted in higher costs and worse clinical outcomes. The incremental cost-effectiveness ratio was as low as $15,392/QALY if the WCD successfully terminated 95% of SCA events and exceeded the $50,000/QALY willingness-to-pay threshold if the efficacy was <69%.The WCD strategy remained cost-effective, assuming 5.6% 2-month SCA risk, as long as the time to reimplantation was at least 2 weeks. CONCLUSION: The WCD likely is cost-effective in protecting patients against SCA after infected ICD removal while waiting for ICD reimplantation compared to keeping patients in the hospital or discharging them home or to a skilled nursing facility.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Desfibriladores/economia , Remoção de Dispositivo , Alta do Paciente/economia , Infecções Relacionadas à Prótese/cirurgia , Análise Custo-Benefício , Morte Súbita Cardíaca/etiologia , Técnicas de Apoio para a Decisão , Desfibriladores Implantáveis/efeitos adversos , Desfibriladores Implantáveis/economia , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/economia , Remoção de Dispositivo/métodos , Remoção de Dispositivo/mortalidade , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde , Administração dos Cuidados ao Paciente/economia , Administração dos Cuidados ao Paciente/métodos , Infecções Relacionadas à Prótese/etiologia , Medição de Risco , Estados UnidosRESUMO
AIM: Proposed Irish legislation aimed at increasing survival from out-of-hospital-cardiac-arrest (OHCA) mandates the provision of automated external defibrillators (AEDs) in a comprehensive range of publicly accessible premises in urban and rural areas. This study estimated the clinical and cost effectiveness of the legislation, compared with alternative programme configurations involving more targeted AED placement. METHODS: We used a cost-utility analysis to estimate the costs and consequences of public access defibrillation (PAD) programmes from a societal perspective, based on AED deployment by building type. Comparator programmes ranged from those that only included building types with the highest incidence of OHCA, to the comprehensive programme outline in the proposed legislation. Data on OHCA incidence and outcomes were obtained from the Irish Out-of-Hospital-Cardiac-Arrest Register (OHCAR). Costs were obtained from the Irish health service, device suppliers and training providers. RESULTS: The incremental cost effectiveness ratio (ICER) for the most comprehensive PAD scheme was 928,450/QALY. The ICER for the most scaled-back programme involving AED placement in transport stations, medical practices, entertainment venues, schools (excluding primary) and fitness facilities was 95,640/QALY. A 40% increase in AED utilisation when OHCAs occur in a public area could potentially render this programme cost effective. CONCLUSION: National PAD programmes involving widespread deployment of static AEDs are unlikely to be cost-effective. To improve cost-effectiveness any prospective programmes should target locations with the highest incidence of OHCA and be supported by efforts to increase AED utilisation, such as improving public awareness, increasing CPR and AED training, and establishing an EMS-linked AED register.
Assuntos
Desfibriladores/provisão & distribuição , Cardioversão Elétrica/métodos , Acessibilidade aos Serviços de Saúde/economia , Parada Cardíaca Extra-Hospitalar/terapia , Idoso , Análise Custo-Benefício , Desfibriladores/economia , Cardioversão Elétrica/economia , Feminino , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Irlanda , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Taxa de SobrevidaRESUMO
Sudden Cardiac Death--SCD --is a major unmet health problem that needs urgent and prompt solution. AICDs are very expensive, risky and indicated for a small group of patients, at the highest risk. AEDs--Automatic External Defibrillators--are designed for public places and although safe, cannot enter the home-market due to their cost and need for constant, high-cost maintenance. We developed TED, a low-cost AED that derives its energy off the mains, designed for home-use, to save SCD victims' lives.
Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores , Cardioversão Elétrica/instrumentação , Serviços de Assistência Domiciliar , Fibrilação Ventricular/terapia , Animais , Morte Súbita Cardíaca/etiologia , Desfibriladores/economia , Cardioversão Elétrica/economia , Eletricidade , Desenho de Equipamento , Custos de Cuidados de Saúde , Humanos , Teste de Materiais , Modelos Animais , Ratos , Fatores de Risco , Suínos , Tempo para o Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/fisiopatologiaRESUMO
BACKGROUND: Automated external defibrillators (AEDs) have been used in the school setting to successfully resuscitate students, staff, and visitors. All public high schools in North Carolina have an AED. However, the number of North Carolina public middle schools with an AED is unknown. OBJECTIVE: The purpose of this study was to determine the presence of AEDs at public middle schools in North Carolina and to estimate the cost associated with providing an AED to all public middle schools currently without one. METHODS: All 547 middle schools in North Carolina's 117 public school systems were surveyed in 2009 via e-mail, fax, and, when necessary, telephone about whether an AED was present on site. For middle schools without AEDs, we estimated the cost of purchase and for 1 year of maintenance. RESULTS: A total 66.6% of public middle schools responded to 1 of 3 survey mailings. The remaining schools were contacted by telephone, so that 100% were included in data collection. At the time of the survey, at least 1 AED was present in 334 schools (61.1%). Of the 213 schools without AEDs, 57 (26.8%) were in school systems in which some middle schools had AEDs, and 156 (73.2%) were in systems in which no middle school had an AED. On the basis of a start-up cost of $1,200 per AED, the cost of providing an AED to each school without one is approximately $255,600. LIMITATIONS: These data are based on self-report, and we could not verify whether AEDs were functional. Cost estimates do not include charges for ongoing maintenance and staff training. CONCLUSIONS: Two hundred and thirteen North Carolina public middle schools (38.9%) do not have an AED on site.
Assuntos
Desfibriladores/estatística & dados numéricos , Instituições Acadêmicas , Adolescente , Criança , Desfibriladores/economia , Feminino , Humanos , Masculino , North Carolina , Inquéritos e QuestionáriosRESUMO
Patients who have a cardiac arrest in hospital should, if it is indicated, be defibrillated as quickly as possible--ideally within three minutes. Most hospital wards and other clinical areas have access to defibrillators with both advisory (semi-automated) and manual modes. The former enables first responders, including nurses without ECG interpretation skills, to defibrillate the patient while awaiting the arrival of the cardiac arrest team who can then select and use the manual mode. Most hospital nurses will be trained in advisory defibrillation, while a few will be trained in manual defibrillation. This article provides an overview of defibrillation in hospital, and looks at both advisory and manual defibrillation.