Public Defibrillators Deemed Not Cost Effective

Placing automatic external defibrillators (AEDs) in major transit hubs to revive people who go into cardiac arrest is excessively expensive in terms of the number of quality-adjusted life years (QALY) gained, Scottish investigators report. Moreover, reports a second group, equipping police and firefighters with AEDs does not substantively increase survival after cardiac arrest.

Locating automatic external defibrillators (AEDs) in major transit hubs to revive people who go into cardiac arrest is excessively expensive in terms of the number of quality-adjusted life years (QALY) gained, Scottish investigators report. Moreover, reports a second group, equipping police and firefighters with AEDs does not substantively increase survival after cardiac arrest. Dr. Jill P. Pell, with the Scottish Ambulance Service Headquarters in Edinburgh, and colleagues determined the economic efficiency of locating defibrillators in all major airports, railway stations, and bus stations in their country. They documented cardiac arrests and outcomes at these sites, then predicted the potential for public AEDs to improve survival by applying data from patients treated within 3 minutes by ambulance staff. Included were 17 sites, where 31 AEDs would be deployed altogether. Between 1991 and 1998, there were 38 cardiac arrests that actually occurred at these sites, translating to 5.4 annually. Their estimations, reported in the British Medical Journal, reveal that survival to hospital admission would increase by nearly 14 percent per year, but that survival to hospital discharge would increase by only 2 percent. The intervention would lead to gains of 5.7 life years per survivor and 4.5 QALYs per patient. The cost per life year gained was nearly US$50,000 (30,000 pounds). The cost per QALY was $69,000 (41,000 pounds). According to the authors, these exceed British and US standards for cost-effectiveness. Pell’s group suggests that other population-based interventions would be more effective, such as training first responders in AED use and installing AEDs on large commercial aircraft. However, findings of a team led by Dr. Anouk P. van Alem, at the Academic Medical Center in Amsterdam and reported in the same issue of BMJ, suggest that training first responders doesn’t live up to expectations. They conducted a trial, in which AEDs were randomly given to police and firefighters in four of eight participating regions in the Netherlands. In a comparison, or “control” group, ambulances only were supplied with manual defibrillators. Each region switched between the control and the experimental condition every 4 months for 24 months. A total of 243 cases of cardiac arrest occurred during experimental conditions and 226 during control conditions. The first shock was delivered in less than 5 minutes after the call was placed in 9 percent of patients in the experimental group and in 1 percent of the control group. Eighteen percent of patients survived to hospital discharge in the experimental group, versus 15 percent in the control group. “Delay in time to call, duration of call handling, and delay in dispatching severely reduce the potential benefit of dispatched first responders,” van Alem’s team maintains. An AED program “must focus on optimizing the civic response and the dispatch process.” However, both groups’ findings contrast significantly with previous reports on this topic. For example, one recent study showed that availability of public-access AEDs led to a 1-year survival rate of 56% after cardiac arrest. A second study found that AED deployment was associated with an annual cost of $30,000 per QALY. A third trial showed that survival rate increased from 9 percent to 17 percent when police were equipped with AEDs. Pell’s group cites the American Heart Association as recommending that AEDs not be deployed until cost-benefit analyses are completed. However, a spokesperson for the American Heart Association told Reuters Health that the AHA 2000 guidelines recommend AEDs be made accessible if “there is a reasonable probability of one AED use in 5 years.” The guidelines also recommend education in CPR and the use of an AED for responders, such as police and firefighters. Greater knowledge of the correct CPR technique was suggested to be in many cases just as effective.(Source:MEDLINE Plus, Reuters Health, British Medical Journal, Dec 2003.)