Dr. Lars W. Andersen
Evaluating the cost-effectiveness of AEDs in the U.S.
May 24, 2019
It’s well known that public automated external defibrillators (AEDs) lead to better outcomes for cardiac arrest, but researchers based in Denmark set out to answer a more difficult question: are they actually cost effective?
By estimating costs in U.S. dollars per year of life adjusted for quality, the researchers looked at U.S. data on out-of-hospital cardiac arrest and determined public AED placement was indeed cost-effective and increased years of quality living. The findings were published in the May issue of the journal, Resuscitation.
HealthCare Business News spoke to one of the researchers, Lars Wiuff Andersen, M.D., M.P.H., Ph.D., D.M.Sc., from the Research Center for Emergency Medicine in Arhus, Denmark to learn more about the methods used in the study and what their findings should mean for AED access and utilization going forward.
HCB News: What prompted you to examine the cost-effectiveness of public AEDs?
Dr. Lars W. Andersen: There have been great a number of studies examining the association between the use of an AED and outcomes. We know from those studies that the use of an AED is associated with improved outcomes in patients who have a shockable rhythm (i.e., ventricular fibrillation or pulseless ventricular tachycardia).
Despite this, AEDs are still rarely used. One of the reasons for this low use might be a perception that AEDs are not cost-effective. Although there have been previous cost-effectiveness analyses, these have generally been conducted more than 10 years ago and did not account for a number of potentially relevant factors. Personally, I was also uncertain about the cost-effectiveness given the relative rarity of cardiac arrest at a given location. I therefore thought it would be interesting to examine this in a comprehensive analysis.
HCB News: AEDs are only used in about 10 percent of out of hospital cardiac arrests, what can we attribute that low number to?
LWA: There are basically two issues: 1) AEDs are not available and 2) AEDs that are available are not used. The first problem can only be addressed by putting up more AEDs in locations that are available to the public (i.e., available and unlocked 24/7). Who should put up these AEDs? That is a policy decision that is beyond my expertise. The second problem should be, and is being, addressed by education. One of the cool things that has happened in many countries (including Denmark, where I am from) is the introduction of CPR and AED training in primary school and as part of taking a driver’s license. This should ensure that as many as possible are being trained. This will make people more comfortable using an AED when a cardiac arrest occurs.
There is another potential complementary solution to this problem. If the AEDs are registered and the location is known, the 911-operator can guide the caller to the nearest AED. Alternatively, smart phone apps are being developed (and used in certain places) that can guide volunteers to the cardiac arrest and the AED. This is an exciting field.
HCB News: Your findings use “quality-adjusted life years” to illustrate the value of AEDs. What does that mean and how does it relate to a dollar amount?
LWA: Quality-adjusted life years, known as QALYs, are a combination of years lived and health-related quality of life (measured on a scale from 0 to 1). For example, a person in perfect health (i.e., a value of 1) who lives 10 years has 10 QALYs. A person who has only half the health-related quality of life (i.e., a value of 0.5) who lives 10 years will only have 5 QALYs. Using QALYs is the accepted standard for cost-effectiveness analyses. Health-related quality of life can be measured using standardized and validated questionnaires.
The final result of a cost-effectiveness analysis is cost per QALYs. For example, if the result is $50.000 / QALY this means that it costs $50 per QALY gained with the intervention. Whether this is cheap or expensive is a more philosophical/political discussion, but organizations like the American Heart Association and the World Health Organization consider any value less than $150.000 reasonably cost-effective in the USA.
HCB News: What do you think is the most important aspect of your research findings?
LWA: I think we have now determined, within the assumptions of the model, that public AEDs are cost-effective in countries like the U.S. This should encourage stakeholders to disseminate AEDs in public locations where cardiac arrests can occur. Our model also explores which factors will influence the cost-effectiveness.
HCB News: In what public spaces does AED access usually do the most good?
LWA: The more people in a certain location (especially older and sicker people), the more cardiac arrests and therefore, the more use of AEDs. This could be locations such as airports, shopping malls, sports and entertainment venues, etc. This could also be locations in and around hospitals, where there is a long response time for the hospital-based cardiac arrest team. One important aspect of our findings is that AEDs are cost-effective even in public locations where cardiac arrest is quite rare (e.g., one cardiac arrest every 20 years). As such, most public locations could probably benefit from AEDs.
HCB News: How can hospital professionals help spread awareness about the importance of public AEDs?
LWA: I think the most important thing is to encourage patients as well as friends and families to take a CPR and AED course. These are offered by multiple organizations and are usually free. If the hospital has acquired AEDs, these should be visible, unlocked, and available 24/7. Hopefully our findings will encourage dissemination of more AEDs in the public space. In the long run, this might help save some lives.
By estimating costs in U.S. dollars per year of life adjusted for quality, the researchers looked at U.S. data on out-of-hospital cardiac arrest and determined public AED placement was indeed cost-effective and increased years of quality living. The findings were published in the May issue of the journal, Resuscitation.
HealthCare Business News spoke to one of the researchers, Lars Wiuff Andersen, M.D., M.P.H., Ph.D., D.M.Sc., from the Research Center for Emergency Medicine in Arhus, Denmark to learn more about the methods used in the study and what their findings should mean for AED access and utilization going forward.
HCB News: What prompted you to examine the cost-effectiveness of public AEDs?
Dr. Lars W. Andersen: There have been great a number of studies examining the association between the use of an AED and outcomes. We know from those studies that the use of an AED is associated with improved outcomes in patients who have a shockable rhythm (i.e., ventricular fibrillation or pulseless ventricular tachycardia).
Despite this, AEDs are still rarely used. One of the reasons for this low use might be a perception that AEDs are not cost-effective. Although there have been previous cost-effectiveness analyses, these have generally been conducted more than 10 years ago and did not account for a number of potentially relevant factors. Personally, I was also uncertain about the cost-effectiveness given the relative rarity of cardiac arrest at a given location. I therefore thought it would be interesting to examine this in a comprehensive analysis.
HCB News: AEDs are only used in about 10 percent of out of hospital cardiac arrests, what can we attribute that low number to?
LWA: There are basically two issues: 1) AEDs are not available and 2) AEDs that are available are not used. The first problem can only be addressed by putting up more AEDs in locations that are available to the public (i.e., available and unlocked 24/7). Who should put up these AEDs? That is a policy decision that is beyond my expertise. The second problem should be, and is being, addressed by education. One of the cool things that has happened in many countries (including Denmark, where I am from) is the introduction of CPR and AED training in primary school and as part of taking a driver’s license. This should ensure that as many as possible are being trained. This will make people more comfortable using an AED when a cardiac arrest occurs.
There is another potential complementary solution to this problem. If the AEDs are registered and the location is known, the 911-operator can guide the caller to the nearest AED. Alternatively, smart phone apps are being developed (and used in certain places) that can guide volunteers to the cardiac arrest and the AED. This is an exciting field.
HCB News: Your findings use “quality-adjusted life years” to illustrate the value of AEDs. What does that mean and how does it relate to a dollar amount?
LWA: Quality-adjusted life years, known as QALYs, are a combination of years lived and health-related quality of life (measured on a scale from 0 to 1). For example, a person in perfect health (i.e., a value of 1) who lives 10 years has 10 QALYs. A person who has only half the health-related quality of life (i.e., a value of 0.5) who lives 10 years will only have 5 QALYs. Using QALYs is the accepted standard for cost-effectiveness analyses. Health-related quality of life can be measured using standardized and validated questionnaires.
The final result of a cost-effectiveness analysis is cost per QALYs. For example, if the result is $50.000 / QALY this means that it costs $50 per QALY gained with the intervention. Whether this is cheap or expensive is a more philosophical/political discussion, but organizations like the American Heart Association and the World Health Organization consider any value less than $150.000 reasonably cost-effective in the USA.
HCB News: What do you think is the most important aspect of your research findings?
LWA: I think we have now determined, within the assumptions of the model, that public AEDs are cost-effective in countries like the U.S. This should encourage stakeholders to disseminate AEDs in public locations where cardiac arrests can occur. Our model also explores which factors will influence the cost-effectiveness.
HCB News: In what public spaces does AED access usually do the most good?
LWA: The more people in a certain location (especially older and sicker people), the more cardiac arrests and therefore, the more use of AEDs. This could be locations such as airports, shopping malls, sports and entertainment venues, etc. This could also be locations in and around hospitals, where there is a long response time for the hospital-based cardiac arrest team. One important aspect of our findings is that AEDs are cost-effective even in public locations where cardiac arrest is quite rare (e.g., one cardiac arrest every 20 years). As such, most public locations could probably benefit from AEDs.
HCB News: How can hospital professionals help spread awareness about the importance of public AEDs?
LWA: I think the most important thing is to encourage patients as well as friends and families to take a CPR and AED course. These are offered by multiple organizations and are usually free. If the hospital has acquired AEDs, these should be visible, unlocked, and available 24/7. Hopefully our findings will encourage dissemination of more AEDs in the public space. In the long run, this might help save some lives.