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{\info{\title EBM2}{\author Peter Green}{\operator Chris}{\creatim\yr2007\mo5\dy22\hr11\min37}{\revtim\yr2007\mo5\dy22\hr22\min43}{\version4}{\edmins4}{\nofpages3}{\nofwords791}{\nofchars4510}{\*\company Hambleton & Richmondshire PCT}{\nofcharsws0}
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\par }\pard \s16\qc \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs24 EBM2
\par Meta-analysis and Cost effectiveness
\par }\pard \s16\ql \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs24 
\par Please read reference material attached which constitutes part of a paper entitled \lquote Cost effectiveness and cost utility model of public place defibrillators in improving survival after pre-hospital cardiopulmonary arrest\rquote 
, and answer the questions given below.
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\f1 \~
\par }{\cs17\f1 1a) \~\~\~\~ Comment on the methodology described in this paper}{\f1 
\par \~
\par }{\cs17\f1 1b)\~\~\~\~\~ What is your interpretation of the admission, survival and quality of life results?}{\f1 
\par \~
\par }{\cs17\f1 1c) \~\~\~\~ What is your interpretation of the results expressed as costs?}{\f1 
\par \~
\par }{\cs17\f1 1d) \~\~\~\~ How might these data influence public health planning and policy?}{\f1 
\par 
\par 
\par }\pard \qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\page }{\b\f1 REFERENCE MATERIAL 
\par 
\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\b\f1 
\par Cost effectiveness and cost utility model of public place defibrillators in improving survival after pre-hospital cardiopulmonary arrest}{\cs17\f1 
\par }\pard\plain \s19\qj \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\cs17\b\f1 Economic model
\par }{\f1 We considered the status quo (no public place defibrillators)}{\f1\super  }{\f1 and the provision of defibrillators in all major airports and}{\f1\super  }{\f1 railway and bus stations. We compared costs and benefits from}{\f1\super  }{\f1 
a health service perspective. In clinical trials, outcome is}{\f1\super  }{\f1 usually measured as survival, though quality adjusted survival}{\f1\super  }{\f1 is also important to patients and decision makers. Therefore,}{\f1\super  }{\f1 
we undertook a cost effectiveness analysis using life years}{\f1\super  }{\f1 gained and a cost utility analysis using quality adjusted life}{\f1\super  }{\f1 years (QALY) gained.}{\f1\super  }{\f1 
\par During the period studied, there were no public place defibrillators}{\f1\super  }{\f1 in Scotland. All prehospital defibrillation was undertaken by}{\f1\super  }{\f1 ambulance staff (99%) or general practitioners (1%). We identified}{\f1\super  }{\f1 
all arrests that occurred in a major airport or railway or bus}{\f1\super  }{\f1 station over seven years from May 1991 and were due to cardiac}{\f1\super  }{\f1 disease and were not witnessed by ambulance staff. We determined}{\f1\super  }{\f1 
the observed survival to admission and discharge and predicted}{\f1\super  }{\f1 survival after location of defibrillators in these sites. A}{\f1\super  }{\f1 proportion of patients are unsuitable for defibrillation because}{\f1\super  }{\f1 
their initial arrthymia is asystole or pulseless electrical}{\f1\super  }{\f1 activity.
\par Therefore, we assumed that public place defibrillators}{\f1\super  }{\f1 could, at best, improve survival compared with that obtained}{\f1\super  }{\f1 by early attendance of ambulance staff. In the sites studied}{\f1\super  }{\f1 
we applied the observed survival among patients attended by}{\f1\super  }{\f1 ambulance staff within three minutes to those who waited longer}{\f1\super  }{\f1 to calculate predicted survival. We calculated current mean survival}{\f1\super  }{\f1 
after discharge from hospital and applied this to the additional}{\f1\super  }{\f1 patients who could be discharged alive. }{\f1\super 
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\f1 Results
\par }{\cs17\b\f1 Numbers of sites, arrests, and defibrillators
\par }\pard \qj \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\f1 \line Over the period studied, there were four major airports, nine}{\f1\super  }{\f1 major railway stations, and four major bus stations in Scotland,}{\f1\super  }{\f1 
equating to 17 eligible sites. Over seven years, 38 arrests}{\f1\super  }{\f1 occurred in these locations, equating to 5.4 a year. In the}{\f1\super  }{\f1 basic model, we assumed that four defibrillators would be located}{\f1\super  }{\f1 
in each airport, one in each bus station, two in each of the}{\f1\super  }{\f1 largest two railway stations, and one in each of the seven others}{\f1\super  }{\f1 (31 defibrillators altogether).}{\f1\super  }{\f1 
\par }\pard\plain \s19\ql \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\cs17\b\f1 \page Admission, survival, and quality of life
\par }\pard \s19\qj \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\f1 The observed survival to arrival at the accident and emergency}{\f1\super  }{\f1 
department, admission, and discharge was 52.9%, 26.4%, and 14.7%,}{\f1\super  }{\f1 respectively. If public place defibrillators were available,}{\f1\super  }{\f1 the predicted survival figures were 66.7%, 33.3%, and 16.7%,}{\f1\super  }{\f1 
respectively. Therefore, the marginal increases a year in the}{\f1\super  }{\f1 numbers surviving were 0.7 (13.8%), 0.4 (6.9%), and 0.1 (2.0%),}{\f1\super  }{\f1 respectively.}{\f1\super  }{\f1 
\par The mean length of stay after admission was 24 days among those}{\f1\super  }{\f1 discharged alive, 8 days among those who died, and 14 days overall.}{\f1\super  }{\f1 Application of these figures to the 5.4 eligible arrests a year}{\f1\super  }{\f1 
resulted in 0.7 additional patients attending accident and emergency}{\f1\super  }{\f1 and 5.6 additional inpatient days; 1.4 in coronary care and}{\f1\super  }{\f1 4.2 in general medicine or cardiology. Mean survival after discharge}{\f1\super  }{\f1 
alive from hospital was 6.2 years.}{\f1\super  }{\f1 
\par After discounting, we gained 5.7 life years per survivor\emdash that}{\f1\super  }{\f1 is, surviving to discharge from hospital. We applied the utility}{\f1\super  }{\f1 value of 0.72, calculated by Nichol et al, to estimate the}{\f1\super  }{\f1 
gain in QALYs. This meant that, on average, health related quality}{\f1\super  }{\f1 of life after arrest was 72% of normal. The gain in QALYs per}{\f1\super  }{\f1 survivor was, therefore, 4.5 undiscounted and 4.1 discounted.}{\f1\super  }{\f1 
\par }\pard \s19\ql \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\cs17\b\f1 Costs
\par }\pard \s19\qj \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\f1 The mean costs were \'a346 per accident and emergency attendance,}{\f1\super  }{\f1 \'a3612 per day in coronary care, and \'a3234 per day
}{\f1\super  }{\f1 in general medicine or cardiology. Each defibrillator cost}{\f1\super  }{\f1 \'a32500 to buy and maintain, which was converted into the}{\f1\super  }{\f1 capital charge that a health service budget holder would pay.}{\f1\super  }{\f1 
Training was calculated per site rather than per defibrillator.}{\f1\super  }{\f1 We applied the costs of the Scottish Ambulance Service training}{\f1\super  }{\f1 course, which was \'a352.40 a year (A Marsden, Scottish Ambulance}{\f1\super  }{\f1 
Service, personal communication). The life expectancy of a defibrillator}{\f1\super  }{\f1 was five years (A Marsden, Scottish Ambulance Service, personal}{\f1\super  }{\f1 communication).}{\f1\super  }{\f1 
\par The overall initial capital cost of the defibrillators was \'a377}{\f1\super  }{\f1 500. The capital charge over five years was \'a393 310 without}{\f1\super  }{\f1 discounting and \'a379 020 with discounting at 6%. Including}{\f1\super  }{\f1 
training, this equated to \'a316 554 a year. The incremental}{\f1\super  }{\f1 cost due to additional accident and emergency attendances and}{\f1\super  }{\f1 in hospital care was \'a31770 a year. Therefore, the total}{\f1\super  }{\f1 
direct cost combining capital and revenue was \'a318 325}{\f1\super  }{\f1 a year. The life year gain per year was 0.72, hence the discounted}{\f1\super  }{\f1 net cost per life year gained was \'a329 625. The QALY gain}{\f1\super  }{\f1 
a year was 0.44, producing a discounted net cost per QALY gained}{\f1\super  }{\f1 of \'a341 146.}{\f1\super  }{\f1 
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