The cost-effectiveness of a mechanical compression device in out-of-hospital cardiac arrest.

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.

Prehospital randomised assessment of a mechanical compression device in out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised trial and economic evaluation.

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.

Investigación de factores de riesgo de enfermedad arterial ateromatosa: (Arteroesclerosis) en una población juvenil de Tacuarembó, Uruguay

Se entrevistaron al azar las madres de 195 niños y adolescentes con edades comprendidas entre los 4 y 16 años para un estudio posterior de factores considerados de riesgo de enfermedad vascular ateromatosa. Se estudiaron 114 niños con una edad media de 9 años ñ 3. Correspondieron a distintos niveles sociales, la mayoría con Graffar 3 (42,3 por ciento). Predominaron los de raza blanca (93,8 por ciento), los varones (58,8 por ciento) y los que tenían sobrepeso (48,7 por ciento con IMC por encima del percentil 90). El consumo promedio referido de colesterol fue de 396 mg/día, el de grasas totales de 34, 54 por ciento y el de grasas saturadas de 25,14 por ciento de las calorías totales ingeridas. Se encontraron antecedentes de enfermedad vascular en 24 progenitores (10,5 por ciento); el hallazgo más frecuente fue la hipertensión arterial (8,3 por ciento). Los valores medios de los lípidos séricos fueron, CT: 166 mg d/lñ25; c-LDL: 108,43 mg d/l ñ25; C-HDL:41 mg d/lñ8; y TG: 81,05mg d/lñ35. Al analizar los valores considerados de alto riesgo de enfermedad ateromatosa futura se comprobó que trece niños (11,4 por ciento) presentaron CT por encima de 200 mg d/l y veintiuno (18,4) presentaron C-LDL por encima de 130 mg/dl. Hubo 25 niños (20,2 por ciento) con triglicéridos por encima de 100 mg/dl y 26 (21,9 por ciento) con HDL por debajo de 35 mg d/l. La alta incidencia de sobrepeso, la dieta hipergrasa y los niveles lipídicos encontrados deben alertar sobre la presencia temprana de factores de aterogénesis en nuestro medio y deben llevar a planear acciones preventivas precoces