Cost-effectiveness of Automated External Defibrillator Deployment in Selected Public Locations

Peter Cram, MD, MBA, Sandeep Vijan, MD, MS, A. Mark Fendrick, MD

Disclosures

J Gen Intern Med. 2003;18(9) 

In This Article

Abstract and Introduction

Objective: The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates.
Design: Markov Decision Model employing a societal perspective.
Setting: Selected public locations in the United States.
Intervention: Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival.
Results: Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY.
Conclusions: AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.

It is estimated that 250,000 Americans die each year from out-of-hospital cardiac arrests.[1,2] Efforts to improve survival have been hampered by logistical difficulties involved in transporting specialized equipment and responders to the arrest victim.[3,4] In an effort to reduce time-to-shock intervals and ultimately improve survival, municipalities have increasingly turned to a decentralized first-responder system predicated upon public access to automated external defibrillators (AEDs).[5,6] While AEDs have been available for over 20 years as research instruments, only recently have reductions in their size and cost as well as improvements in their usability made public access defibrillation(PAD) a viable option.[7] Evidence is accumulating to support the assertion that public access to AEDs can improve survival compared with historical data.[8,9,10]

The American Heart Association has responded to these data by recommending that public access defibrillators be installed if "the frequency of cardiac arrest events is such that there is a reasonable probability of 1 AED use in 5 years."[1] More recently PAD received an endorsement from the United States Congress with the passage of the Community Access to Emergency Defibrillation Act of 2001 to increase federal funding for AED deployment.[11]

While PAD appears to be a convenient solution to the problem of out-of-hospital cardiac arrest, health authorities faced with limited resources must address the subtleties of deciding precisely which locations warrant deployment of AEDs. Several cost-effectiveness analyses examining AED deployment have been published, but provide limited guidance for policymakers attempting to make informed decisions regarding AED deployment.[12,13,14] A study by Jermyn examined the potential cost-effectiveness of equipping fire fighters with AEDs, but did not evaluate the cost-effectiveness of deploying defibrillators in specific public locations.[12] Foutz and Sayre demonstrated that AED deployment in nursing homes may be cost-effective, but did not extend their analysis to other public sites where AEDs might be placed.[13] Nichol et al. evaluated the cost-effectiveness of treating victims of out-of-hospital cardiac arrest with emergency medical services (EMS) compared to a strategy of EMS supplemented by AEDs deployed in public locations.[14] The investigators found the AED-based strategy to be cost-effective, but interpretation of their results is difficult because the analysis was based upon the assumption that AEDs were deployed in a manner "such that one device was available for each cardiac arrest that occurred in public."

Furthermore, none of these studies addressed the critical relationship between the probability of cardiac arrest at a given location (and by extension probability of AED use) and the overall cost-effectiveness of AED deployment. While precise data regarding cardiac arrest probabilities at public locations are certainly limited, there is a small body of literature providing estimates of annual arrest rates at several public locations.[10,15,16,17] In light of the rapid adoption of PAD across a range of geographic sites with varying cardiac arrest rates, it is critical to better define the relationship between the probability of cardiac arrest and the cost-effectiveness of AED deployment.

We constructed a Markov model to evaluate the cost-effectiveness of the American Heart Association guideline for AED deployment and to clarify the relationship between the probability of cardiac arrest at a given location and the cost-effectiveness of AED deployment. An additional objective was to use available data on cardiac arrest rates at public locations to provide physicians and other public health experts with a practical tool to use when contemplating AED deployment in the community.

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