Cost-Effectiveness of Therapeutic Hypothermia After Cardiac Arrest

Background—Therapeutic hypothermia can improve survival and neurological outcomes in cardiac arrest survivors, but its cost-effectiveness is uncertain. We sought to evaluate the cost-effectiveness of treating comatose cardiac arrest survivors with therapeutic hypothermia. Methods and Results—A decision model was developed to capture costs and outcomes for patients with witnessed out-of-hospital ventricular fibrillation arrest who received conventional care or therapeutic hypothermia. The Hypothermia After Cardiac Arrest (HACA) trial inclusion criteria were assumed. Model inputs were determined from published data, cooling device companies, and consultation with resuscitation experts. Sensitivity analyses and Monte Carlo simulations were performed to identify influential variables and uncertainty in cost-effectiveness estimates. The main outcome measures were quality-adjusted survival after cardiac arrest, cost of hypothermia implementation, cost of posthospital discharge care, and incremental cost-effectiveness ratios. In our model, postarrest patients receiving therapeutic hypothermia gained an average of 0.66 quality-adjusted life years compared with conventional care, at an incremental cost of $31 254. This yielded an incremental cost-effectiveness ratio of $47 168 per quality-adjusted life year. Sensitivity analyses demonstrated that poor neurological outcome postcooling and costs associated with posthypothermia care (in-hospital and long term) were the most influential variables in the model. Even at extreme estimates for costs, the cost-effectiveness of hypothermia remained less than $100 000 per quality-adjusted life year. In 91% of 10 000 Monte Carlo simulations, the incremental cost-effectiveness ratio was less than $100 000 per quality-adjusted life year. Conclusions—In cardiac arrest survivors who meet HACA criteria, therapeutic hypothermia with a cooling blanket improves clinical outcomes with cost-effectiveness that is comparable to many economically acceptable health care interventions in the United States.

[1]  Kevin L. Thomas,et al.  Systematic review of the incidence of sudden cardiac death in the United States. , 2011, Journal of the American College of Cardiology.

[2]  M. Shuster,et al.  Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[3]  R. Neumar,et al.  Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2010, Circulation.

[4]  Claudia Stöllberger,et al.  Guidelines for device-based therapy of cardiac rhythm abnormalities. , 2009, Heart rhythm.

[5]  G. Rubenfeld,et al.  Cost Savings Attributable to Reductions in Intensive Care Unit Length of Stay for Mechanically Ventilated Patients , 2008, Medical care.

[6]  C. Callaway,et al.  Neurological and functional status following cardiac arrest: method and tool utility. , 2008, Resuscitation.

[7]  J. Schefold,et al.  Mild therapeutic hypothermia shortens intensive care unit stay of survivors after out-of-hospital cardiac arrest compared to historical controls , 2008, Critical care.

[8]  Harlan M Krumholz,et al.  ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemaker , 2008, Journal of the American College of Cardiology.

[9]  Harlan M Krumholz,et al.  ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemaker , 2008, Circulation.

[10]  R. Silbergleit,et al.  Public health impact of full implementation of therapeutic hypothermia after cardiac arrest. , 2008, Resuscitation.

[11]  M. Roberts,et al.  What Does the Value of Modern Medicine Say About the $50,000 per Quality-Adjusted Life-Year Decision Rule? , 2008, Medical care.

[12]  A. Ruhparwar.  Spotlight: Arjang Ruhparwar, MD. Interview by Richard Hoey. , 2008, Circulation.

[13]  K. Furie,et al.  Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. , 2007, Circulation.

[14]  J. Nolan,et al.  Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database * , 2007, Anaesthesia.

[15]  Harald Herkner,et al.  Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine. , 2007, Resuscitation.

[16]  Benjamin S. Abella,et al.  Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest* , 2006, Critical care medicine.

[17]  Franklin Dexter,et al.  A Markov computer simulation model of the economics of neuromuscular blockade in patients with acute respiratory distress syndrome , 2006, BMC Medical Informatics Decis. Mak..

[18]  K. Kirchhoff,et al.  American Association of Critical-Care Nurses' national survey of facilities and units providing critical care. , 2006, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[19]  Subcommittees.  2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2005 .

[20]  M. Copass,et al.  Pilot Study of Rapid Infusion of 2 L of 4°C Normal Saline for Induction of Mild Hypothermia in Hospitalized, Comatose Survivors of Out-of-Hospital Cardiac Arrest , 2005, Circulation.

[21]  I. Kakadiaris,et al.  Images in cardiovascular medicine. Detection of luminal-intimal border and coronary wall enhancement in intravascular ultrasound imaging after injection of microbubbles and simultaneous sonication with transthoracic echocardiography. , 2005, Circulation.

[22]  Benjamin S Abella,et al.  Induced hypothermia is underused after resuscitation from cardiac arrest: a current practice survey. , 2005, Resuscitation.

[23]  M. Holzer,et al.  Hypothermia for neuroprotection after cardiac arrest: Systematic review and individual patient data meta-analysis , 2005, Critical care medicine.

[24]  Douglas K Owens,et al.  Cost-effectiveness of training unselected laypersons in cardiopulmonary resuscitation and defibrillation. , 2005, The American journal of medicine.

[25]  P. Name.  2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. , 2005, Circulation.

[26]  S. Saba,et al.  Utilization of implantable cardioverter-defibrillators in survivors of cardiac arrest in the United States from 1996 to 2001. , 2004, Journal of the American College of Cardiology.

[27]  J. Grotta,et al.  A prospective, multicenter pilot study to evaluate the feasibility and safety of using the CoolGard System and Icy catheter following cardiac arrest. , 2004, Resuscitation.

[28]  George Tomlinson,et al.  Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. , 2004, JAMA.

[29]  I. Stiell,et al.  Health-Related Quality of Life Is Better for Cardiac Arrest Survivors Who Received Citizen Cardiopulmonary Resuscitation , 2003, Circulation.

[30]  T. Rea,et al.  Temporal Patterns in Long-Term Survival After Resuscitation From Out-of-Hospital Cardiac Arrest , 2003, Circulation.

[31]  T Valenzuela,et al.  Cost Effectiveness of Defibrillation by Targeted Responders in Public Settings , 2003, Circulation.

[32]  Peter A Ubel,et al.  What is the price of life and why doesn't it increase at the rate of inflation? , 2003, Archives of internal medicine.

[33]  D. Berwick.  Disseminating innovations in health care. , 2003, JAMA.

[34]  S. Bernard,et al.  Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report. , 2003, Resuscitation.

[35]  Alan D. Lopez,et al.  Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. , 2002, The New England journal of medicine.

[36]  Karen Smith,et al.  Treatment of Comatose Survivors of Out-of-hospital Cardiac Arrest With Induced Hypothermia , 2003 .

[37]  G. Lamas,et al.  Outcome and Cost-Effectiveness of Cardiopulmonary Resuscitation after In-Hospital Cardiac Arrest in Octogenarians , 2002, Cardiology.

[38]  Michael Holzer,et al.  Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest , 2002 .

[39]  S. Bernard,et al.  Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. , 2002, The New England journal of medicine.

[40]  Vincent,et al.  Intensive care medicine , 2002, Springer New York.

[41]  George A. Mensah,et al.  Sudden Cardiac Death in the United States, 1989 to 1998 , 2001, Circulation.

[42]  G. Sanders,et al.  Cost-effectiveness of automated external defibrillators on airlines. , 2001, JAMA.

[43]  R. Virmani,et al.  Sudden cardiac death. , 1987, Human pathology.

[44]  A. Laupacis,et al.  A cumulative meta-analysis of the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest. , 1999, Annals of emergency medicine.

[45]  David J. Pasta,et al.  Probabilistic Sensitivity Analysis Incorporating the Bootstrap , 1999, Medical decision making : an international journal of the Society for Medical Decision Making.

[46]  B. Lindqvist,et al.  Modeling the occurrence of cardiac arrest as a poisson process. , 1999, Annals of emergency medicine.

[47]  C. Stoutenbeek,et al.  Systematic review of early prediction of poor outcome in anoxicischaemic coma , 1998, The Lancet.

[48]  J P Ornato,et al.  Potential cost-effectiveness of public access defibrillation in the United States. , 1998, Circulation.

[49]  G. Sanders,et al.  Cost-Effectiveness of Implantable Cardioverter Defibrillators Relative to Amiodarone for Prevention of Sudden Cardiac Death , 1997, Annals of Internal Medicine.

[50]  M. Gold.  Cost-effectiveness in health and medicine , 2016 .

[51]  D K Owens,et al.  The effect of stroke and stroke prophylaxis with aspirin or warfarin on quality of life. , 1996, Archives of internal medicine.

[52]  Multi-Society Task Force on Pvs.  Medical aspects of the persistent vegetative state (2). , 1994, The New England journal of medicine.

[53]  Multi-Society Task Force on Pvs.  Medical aspects of the persistent vegetative state (1). , 1994, The New England journal of medicine.

[54]  R. Klein,et al.  The Beaver Dam Health Outcomes study , 1993, Medical decision making : an international journal of the Society for Medical Decision Making.

[55]  Andrew M. Johanos.  A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. , 1991, The New England journal of medicine.

[56]  B. McNeil,et al.  Probabilistic Sensitivity Analysis Using Monte Carlo Simulation , 1985, Medical decision making : an international journal of the Society for Medical Decision Making.

[57]  A Hallstrom,et al.  Long-term survival after out-of-hospital cardiac arrest. , 1982, The New England journal of medicine.

[58]  J J Heger,et al.  Sudden cardiac death. , 1998, Circulation.

[59]  B. Jennett,et al.  ASSESSMENT OF OUTCOME AFTER SEVERE BRAIN DAMAGE A Practical Scale , 1975, The Lancet.

[60]  B Jennett,et al.  Assessment of outcome after severe brain damage. , 1975, Lancet.