COST-EFFECTIVENESS
OF AEDS IN OFFICE
SETTINGS
Jeff Harris
Kaileah McKellar
Rosanra Yoon
John Murphy
Rebecca Hancock-Howard
Peter 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
Survival Rates Based on Type and Time of Intervention
80%
Survival Rate (%)
60%
No interventions
CPR at 1 minute
AED at 2 minutes
AED at 3 minutes
AED at 4 minutes
AED at 5 minutes
40%
20%
0%
0
1
2
3
4
5
6
Time (minutes)
7
8
9
10
“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
$1,404,627
Capital Costs
Initial equipment
purchase (cost per
unit x number of units
required)
Based on 858 AED
units
Levitt Safety
Rescue 7
Acklands-Grainger,
Federal gov’t data
Equipment installation
costs (labour)
$4,375
Based on 858 AED
units
Levitt Safety
Rescue 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
Equipment
maintenance /
replacement costs
$283,140
Based on 858 AED
units
Levitt Safety
Rescue 7
Acklands-Grainger
Federal gov’t data
Maintenance
Costs
Outcomes Data
Effect/Outcome
Value
Data Source
59 per 100,000
1.2%
Vaillancourt & Stiell (2004)5, OPAL
0.24
Calculation
0.35
0.20
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
Annual Incidence in the Population
Percent in occupational settings
Annual incidence of SCA at study
setting
Survival AED
Survival CPR
Survival EMS
Probability of receiving EMS
Utility - AED
Utility - CPR
Life Expectancy of person
0.34
0.78
0.78
14.84 years
Vaillancourt & Stiell (2004)5, OPAL
Weisfeldt et al. (2010)8
Weisfeldt et al. (2010)8
Nichol et al. (2009)6
Nichol et al. (2009)6
Nichol et al. (2009)6
Sherrief &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)
0
PROGRAM B
(AED +CPR)
858
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
Replacement parts cost per unit per
year
$-
$283,140
Total maintenance cost per year
$-
$283,140
TOTAL COSTS
$-
$1,691,655.51
Number of AEDs Required
COSTS
Capital Investment
Maintenance Cost
Results (Effects)
PROGRAM A
(CPR)
PROGRAM B
(AED +CPR)
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 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
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
EFFECTS
Incidence
Survival
QALYs
Results (ICER)
TOTAL COSTS
PROGRAM A
(CPR)
$-
PROGRAM B
(AED +CPR)
$1,691,655.51
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
• Calculated ICER =
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.
One-Way Sensitivity Analysis
$0
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)
$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
References
1.
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-cbcinvestigation-1.2443853
1.
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.
2.
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):74554.
3.
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.
4.
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. Costeffectiveness 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
4500
4000
Number of Employees
3500
3000
2500
Male
2000
Female
1500
1000
500
0
< 25
25 - 29
30 - 34
35 - 39
40 - 44
Age
45 - 49
50 - 54
55 - 59
60 +
Chain of Survival
Review of Provincial and Federal AED Legislation and Guidance
Nature of
Requirements /
Position Statement
Position Statement
Jurisdiction
Regulated
Requirements?
Alberta
No.
British Columbia
Position Statement
Manitoba
No.Workplace early
defibrillation program
withdrawn 2010.
No.
None.
Supports implementation of AEDs as part of the first aid
program and emergency response plan. Guidelines are
provided on the program requirements.(46;47)
Supports implementation of AEDs as part of the first aid
program and emergency response plan. Guidelines are
provided on the program requirements.(48;49)
Not applicable.(50)
New Brunswick
No.
None.
Not applicable.(51)
Newfoundland /
Labrador
Northwest Territories
No.
None.
Not applicable.(52)
No.
None.
Not applicable.(53)
Nunavut
No.
None.
Not applicable.(53)
Nova Scotia
No.
Position Statement
Ontario
No.
None.
Where employers install AEDs, the manufacturer’s
specifications for operating, maintaining and training must be
followed.(54;55)
Not applicable.(56)
Prince Edward Island
No.
None.
Not applicable.(57)
Quebec
No.
Position Statement.
Saskatchewan
No.
None.
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)
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)
Nature of Position
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)
0
858
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
Replacement parts cost per unit per
year
$-
$283,140
Total maintenance cost per year
$-
$283,140
TOTAL COSTS
$-
$1,691,655.51
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 to discharge with intervention
activated
0.1993
0.345
Activated intervention
0.674
0.567
Number of AEDs Required
COSTS
Capital Investment
Maintenance Cost
EFFECTS
Incidence
Survival