1. COST-EFFECTIVENESS OF AEDS IN OFFICE SETTINGS Jeff Harris Kaileah McKellar Rosanra Yoon John Murphy Rebecca Hancock-Howard Peter Coyte CPHA– May 29, 2014

2. 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.

3. What are AEDs? Automated External Defibrillators

4. 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

5. “Marketplace goes on the hunt” “So having a cardiac arrest in a public place and not having an AED is a travesty,” 1

6. 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.

7. Research Question Are AEDs cost-effective in Canadian Federal Public Service office settings when compared to employee CPR training?

8. 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

9. 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)

10. Data Collection Setting/population: Data from two government departments. Cost data: Environmental scan/web search. Outcomes data: Literature review.

11. Cost Data (Incremental Cost of AED) CostsSpecific CostsValueNotesData Sources Capital Costs Initial equipment purchase (cost per unit x number of units required) $1,404,627Based on 858 AED units Levitt Safety Rescue 7 Acklands-Grainger, Federal gov’t data Equipment installation costs (labour) $4,375Based on 858 AED units Levitt Safety Rescue 7 Acklands-Grainger Federal gov’t data Labour Canada Development of AED program $3,888One-time eventFederal gov’t data Citizen and Immigration Canada Maintenance Costs Equipment maintenance / replacement costs $283,140Based on 858 AED units Levitt Safety Rescue 7 Acklands-Grainger Federal gov’t data

12. Outcomes Data Effect/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 years Sherrief &Kaulback (2007) 2 calculation based on gender ratio in study population

13. 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

14. The Model

15. Results (Costs) PROGRAM A (CPR) PROGRAM B (AED +CPR) Number of AEDs Required0858 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

16. Results (Effects) PROGRAM A (CPR) PROGRAM B (AED +CPR) EFFECTS Incidence Incidence of OHCA SCA in population x/10000059 Percent of OHCA in Office settings1.20% Annual Incidence of SCA in Occupational Settings0.00000708 Study population (n)33488 Incidence of SCA in study population annual0.23709504 Incidence in Study Pop for 8 years1.89676032 Survival Survival to discharge with intervention activated0.19930.345 Activated intervention0.6740.567 % CPR (AED Arm)-0.144 Survival with EMS only (not activated intervention)0.05 % Receive EMS0.3260.289 SURVIVAL WITH PROGRAM0.15062820.2387642 QALYs Life expectancy14.84 Utility0.78 QALYs gained per case11.5752 TOTAL EFFECTS3.3070993785.242158755

17. Results (ICER) PROGRAM A (CPR) PROGRAM B (AED +CPR) TOTAL COSTS $- $1,691,655.51 TOTAL EFFECTS3.3070993785.242158755 INCREMENTAL COST-EFFECTIVENESS RATIO Incremental Costs (B-A)$1,691,655.51 Incremental Effects (B-A)1.935059377 ICER$874,214

18. One-Way Sensitivity Analysis

20. Discussion The results are comparable to other office-based AED studies that calculated ICERs at $511,766 Cost/QALY on a 5 year cycle 2. Other “public-based” studies have calculated ICERs in the range of $30, 000 $10,324,900 Cost/QALY (USD) 7.

21. 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

22. Conclusions AED are not cost-effective in office settings

24. 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-cbc- investigation-1.2443853http://www.cbc.ca/news/health/defibrillators-may-be- 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):745- 54. 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. 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.

25. Age and Sex of Study Population

26. Chain of Survival

27. Review of Provincial and Federal AED Legislation and Guidance Jurisdiction Regulated Requirements? Nature of Requirements / Position Statement Nature of Position AlbertaNo.Position StatementSupports implementation of AEDs as part of the first aid program and emergency response plan. Guidelines are provided on the program requirements.(46;47) British ColumbiaNo.Workplace early defibrillation program withdrawn 2010. Position StatementSupports implementation of AEDs as part of the first aid program and emergency response plan. Guidelines are provided on the program requirements.(48;49) ManitobaNo.None.Not applicable.(50) New BrunswickNo.None.Not applicable.(51) Newfoundland / Labrador No.None.Not applicable.(52) Northwest TerritoriesNo.None.Not applicable.(53) NunavutNo.None.Not applicable.(53) Nova ScotiaNo.Position StatementWhere employers install AEDs, the manufacturer’s specifications for operating, maintaining and training must be followed.(54;55) OntarioNo.None.Not applicable.(56) Prince Edward IslandNo.None.Not applicable.(57) QuebecNo.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) SaskatchewanNo.None.Not applicable.(60) YukonNo.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)

28. 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)

29. PROGRAM A (CPR) PROGRAM B (AED +CPR) Number of AEDs Required0858 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 Percent of OHCA in Office settings1.20% Annual Incidence of SCA in Occupational Settings 0.00000708 Study population (n)33488 Incidence of SCA in study population annual 0.23709504 Incidence in Study Pop for 8 years1.89676032 Survival Survival to discharge with intervention activated 0.19930.345 Activated intervention0.6740.567 % CPR (AED Arm)-0.144 Survival with EMS only (not activated intervention) 0.05 % Receive EMS0.3260.289 SURVIVAL WITH PROGRAM0.15062820.2387642 QALYs Life expectancy14.84 Utility0.78 QALYs gained per case11.5752 TOTAL EFFECTS3.3070993785.242158755 INCREMENTAL COST-EFFECTIVENESS RATIO Incremental Costs (B-A)$1,691,655.51 Incremental Effects (B-A)1.935059377 ICER$874,214