COST-EFFECTIVENESS OF AEDS IN OFFICE SETTINGS Jeff HarrisKaileah McKellarRosanra YoonJohn MurphyRebecca Hancock-HowardPeter Coyte

CPHA– May 29, 2014

Background• 40,000 SCA per year in Canada.

• Survival of SCA is 5%.

• AED are effective at increasing survival.

• The cost-utility in office settings has yet to be examined.

What are AEDs?

Automated External Defibrillators

Are AEDs effective?• Survival rate from Sudden Cardiac Arrest (“SCA”) with

AED +CPR is approximately double compared to CPR alone.

• Citizen CPR and rapid defibrillation are the most important factors for survival.2-4

0 1 2 3 4 5 6 7 8 9 100%

20%

40%

60%

80%Survival Rates Based on Type and Time of Intervention

No interventionsCPR at 1 minuteAED at 2 minutesAED at 3 minutes

Time (minutes)

Su

rviv

al R

ate

(%

)

“Marketplace goes on the hunt”

“So having a cardiac arrest in a public place and not having an AED is a travesty,” 1

Policy Significance

• AEDs are currently not legislatively required in workplaces.

• Generally, the public thinks that AEDs are important to have in public and workplace settings.

• Federal government departments are exploring policies to make AEDs available in government office buildings.

Research Question

Are AEDs cost-effective in Canadian Federal Public Service office settings when

compared to employee CPR training?

Approach• Employer perspective

• Interventions:• CPR training (current practice).• AED installation and training.

• Setting / study population: • Population: 33488 workers.• Setting: Two federal government departments

• 657 buildings with >1 worker across Canada

Approach

• Cost-utility Analysis

• 8-year time period (two AED battery life cycles)

• Incremental costs per incremental unit of outcome associated with implementing AEDs together with CPR, compared to CPR training alone

• Sensitivity analysis: one-way and probabilistic (Monte Carlo simulation)

Data Collection• Setting/population: Data from two government

departments.

• Cost data: Environmental scan/web search.

• Outcomes data: Literature review.

Cost Data (Incremental Cost of AED)

Costs Specific Costs Value Notes Data Sources

Capital CostsInitial equipment

purchase (cost per unit x number of units

required)

$1,404,627 Based on 858 AED units

Levitt SafetyRescue 7

Acklands-Grainger, Federal gov’t data

Equipment installation costs (labour)

$4,375 Based on 858 AED units

Levitt SafetyRescue 7

Acklands-Grainger Federal gov’t data

Labour Canada

Development of AED program

$3,888 One-time event Federal gov’t data Citizen and

Immigration Canada

Maintenance Costs

Equipment maintenance /

replacement costs

$283,140 Based on 858 AED units

Levitt SafetyRescue 7

Acklands-Grainger Federal gov’t data

Outcomes DataEffect/Outcome  Value Data Source

Annual Incidence in the Population 59 per 100,000 Vaillancourt & Stiell (2004)5, OPAL

Percent in occupational settings 1.2% Vaillancourt & Stiell (2004)5, OPAL

Annual incidence of SCA at study setting 0.24 Calculation

Survival AED 0.35 Weisfeldt et al. (2010)8

Survival CPR 0.20 Weisfeldt et al. (2010)8

Survival EMS 0.05 Weisfeldt et al. (2010)8

Probability of receiving CPR (CPR arm) 0.67 Nichol et al. (2009)6

Probability of receiving AED (AED arm) 0.57 Weisfeldt et al. (2010)8, Nichol et al.

(2009)6, Calculation

Probability of receiving EMS 0.34 Nichol et al. (2009)6

Utility - AED 0.78 Nichol et al. (2009)6

Utility - CPR 0.78 Nichol et al. (2009)6

Life Expectancy of person 14.84 yearsSherrief &Kaulback (2007)2 calculation based on gender ratio in study population

Model Assumptions• Training costs excluded (AED / CPR offset one another).• Workplaces with only 1 worker excluded. • 1 AED unit per 100 workers per location.• Survival and incidence rates used are reflective of our

population. • Threshold ICER of $50,000

The Model

Results (Costs)  PROGRAM A

(CPR)PROGRAM B(AED +CPR)

Number of AEDs Required 0 858COSTSCapital InvestmentEquipment $- $1,404,627.51 AED cost per unit $- $1,632.00 Installation (labour) per unit $- $5.10 Development of AED program $- $3,888.00 Total capital cost $- $1,408,515.51 Maintenance CostReplacement parts cost per unit per year $- $283,140

Total maintenance cost per year $- $283,140TOTAL COSTS   $-     $1,691,655.51

Results (Effects)  PROGRAM A

(CPR)PROGRAM B(AED +CPR)

EFFECTS

Incidence

Incidence of OHCA SCA in population x/100000 59 59

Percent of OHCA in Office settings 1.20% 1.20%

Annual Incidence of SCA in Occupational Settings 0.00000708 0.00000708

Study population (n) 33488 33488

Incidence of SCA in study population annual 0.23709504 0.23709504

Incidence in Study Pop for 8 years 1.89676032 1.89676032

Survival

Survival to discharge with intervention activated 0.1993 0.345

Activated intervention 0.674 0.567

% CPR (AED Arm) - 0.144

Survival with EMS only (not activated intervention) 0.05 0.05

% Receive EMS 0.326 0.289

SURVIVAL WITH PROGRAM 0.1506282 0.2387642

QALYs

Life expectancy 14.84 14.84

Utility 0.78 0.78

QALYs gained per case 11.5752 11.5752

TOTAL EFFECTS 3.307099378 5.242158755

Results (ICER)

• Calculated ICER = $874,214 Cost/QALY

• The cost-effectiveness analysis exceeded the threshold ICER and due to the high cost/QALY would likely exceed the Federal government’s willingness to pay.

  PROGRAM A(CPR)

PROGRAM B(AED +CPR)

TOTAL COSTS $- $1,691,655.51TOTAL EFFECTS 3.307099378 5.242158755INCREMENTAL COST-EFFECTIVENESS RATIOIncremental Costs (B-A) $1,691,655.51Incremental Effects (B-A) 1.935059377ICER $874,214

One-Way Sensitivity Analysis

Probability of surviving to discharge

Length of program (4-20 years)

Unit Costs ($1632 - $3979)

QALYs gained per case (0.58-0.97)

Number of AED Units (657-1169)

Probability of receiving intervention

Incidence rates (50-78 per 100,000)

Maintenance Cost ($165-$509)

Utility different by intervention

Program Development Costs ($2390 - $5966)

Labour Per Unit ($9.75-$11.00)

$0 $500,000 $1,000,000 $1,500,000 $2,000,000 $2,500,000

Discussion

• The results are comparable to other office-based AED studies that calculated ICERs at $511,766 Cost/QALY on a 5 year cycle2.

• Other “public-based” studies have calculated ICERs in the range of $30, 000 $10,324,900 Cost/QALY (USD)7.

Strengths and Limitations• Strengths

• Actual population data provided more precise estimates• Model uses actual survival data from public locations rather than

assumptions based on time to intervention

• Limitations• No data available for the physical locations (e.g. number of floors)• Survival and likelihood data from all public settings vs. office only• Limited data on probability that AEDs will be used in office settings• Limited long-term SCA survival data based on the treatment they

received

Conclusions

• AED are not cost-effective in office settings

THANK YOU!

References1. Dr. Laurie Morrison, a medical researcher who specializes in emergency medicine. Cited by CBC,

http://www.cbc.ca/news/health/defibrillators-may-be- hard-to-find-in-emergencies-cbc-investigation-1.2443853

2. Sharieff W, Kaulback K. Assessing automated external defibrillators in preventing deaths from sudden cardiac arrest: An economic evaluation. International journal of technology assessment in health care 2007;23(03):362-7.

3. Cram P, Vijan S, Fendrick AM. Cost effectiveness of Automated External Defibrillator Deployment in Selected Public Locations. Journal of general internal medicine 2003;18(9):745-54.

4. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine 2000;343(17):1206-9.

5. Vaillancourt C, Stiell IG. Cardiac arrest care and emergency medical services in Canada. The Canadian journal of cardiology 2004;20(11):1081-90.

6. Nichol G, Huszti E, Birnbaum A, Mahoney B, Weisfeldt M, Travers A, et al. Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest. Annals of emergency medicine 2009;54(2):226-35.

7. Nichol G, Valenzuela T, Roe D, Clark L, Huszti E, Wells GA. Cost effectiveness of defibrillation by targeted responders in public settings. Circulation 2003;108(6):697-703.

8. Weisfeldt ML, Sitlani CM, Ornato JP, Rea T, Aufderheide TP, Davis D, et al. Survival After Application of Automatic External Defibrillators Before Arrival of the Emergency Medical SystemEvaluation in the Resuscitation Outcomes Consortium Population of 21 Million. Journal of the American College of Cardiology 2010;55(16):1713-20.

Age and Sex of Study Population

< 25 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 +0

500

1000

1500

2000

2500

3000

3500

4000

4500

MaleFemale

Age

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Chain of Survival

Review of Provincial and Federal AED Legislation and Guidance

Jurisdiction Regulated Requirements?

Nature of Requirements / Position Statement

Nature of Position

Alberta No. Position Statement Supports implementation of AEDs as part of the first aid program and emergency response plan. Guidelines are provided on the program requirements.(46;47)

British Columbia No.Workplace early defibrillation program withdrawn 2010.

Position Statement Supports implementation of AEDs as part of the first aid program and emergency response plan. Guidelines are provided on the program requirements.(48;49)

Manitoba No. None. Not applicable.(50)

New Brunswick No. None. Not applicable.(51)

Newfoundland / Labrador

No. None. Not applicable.(52)

Northwest Territories No. None. Not applicable.(53)

Nunavut No. None. Not applicable.(53)

Nova Scotia No. Position Statement Where employers install AEDs, the manufacturer’s specifications for operating, maintaining and training must be followed.(54;55)

Ontario No. None. Not applicable.(56)

Prince Edward Island No. None. Not applicable.(57)

Quebec No. Position Statement. If a first responder or ambulance technician isn’t present, any person who has received training that meets the standards set by the American Heart Association guidelines may use an AED.(58;59)

Saskatchewan No. None. Not applicable.(60)

Yukon No. None. Not applicable.(61)

Federal / National Joint Council

No. Position Statement. Departments to evaluate feasibility of purchasing AEDs when HS Committee makes such a recommendation.(26)(27)

American College of Occupational and Environmental Medicine’s Recommended AED Program Components

a) Development of a centralized management system for the AED program for managing the AED program and includes establishing roles and responsibilities of various workplace parties.

b) Medical direction and control of the workplace AED program by a qualified physician or health care provider

c) Compliance with local, provincial and federal legislation

d) Development of an AED program for each location where AEDs are to be deployed

e) Coordination with local emergency medical services

f) Integration of the AED program with established organizational emergency response plans

g) Selection technical consideration of AEDs to ensure they meet recognized standards and organizational needs.

h) Assessment of the proper number and placement of AEDs and supplies so to ensure AEDs and ancillary equipment are located within 5 minutes of a recognized SCA.

i) Scheduled maintenance and replacement of AEDs and ancillary equipment per manufacturers recommended service schedule.

j) Establishment of an AED QC/QA program, which should include medical review, record keeping and program evaluation. (29)

  PROGRAM A(CPR)

PROGRAM B(AED +CPR)

Number of AEDs Required 0 858

COSTS

Capital Investment

Equipment $- $1,404,627.51

AED cost per unit $- $1,632.00

Installation (labour) per unit $- $5.10

Development of AED program $- $3,888.00

Total capital cost $- $1,408,515.51

Maintenance Cost

Replacement parts cost per unit per year $- $283,140

Total maintenance cost per year $- $283,140

TOTAL COSTS $- $1,691,655.51

EFFECTS

Incidence

Incidence of OHCA SCA in population x/100000 59 59

Percent of OHCA in Office settings 1.20% 1.20%

Annual Incidence of SCA in Occupational Settings 0.00000708 0.00000708

Study population (n) 33488 33488

Incidence of SCA in study population annual 0.23709504 0.23709504

Incidence in Study Pop for 8 years 1.89676032 1.89676032

Survival

Survival to discharge with intervention activated 0.1993 0.345

Activated intervention 0.674 0.567

% CPR (AED Arm) - 0.144

Survival with EMS only (not activated intervention) 0.05 0.05

% Receive EMS 0.326 0.289

SURVIVAL WITH PROGRAM 0.1506282 0.2387642

QALYs

Life expectancy 14.84 14.84

Utility 0.78 0.78

QALYs gained per case 11.5752 11.5752

TOTAL EFFECTS 3.307099378 5.242158755

INCREMENTAL COST-EFFECTIVENESS RATIO

Incremental Costs (B-A) $1,691,655.51

Incremental Effects (B-A) 1.935059377

ICER $874,214