cost-effectiveness of defibrillation by emergency medical technicians

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Page 1: Cost-effectiveness of defibrillation by emergency medical technicians

Cost-Effectiveness of Defibrillation by Emergency Medical Technicians

JOSEPH P. ORNATO, MD,* EDWARD J. CRAREN, MA,t EDGAR R. GONZALEZ, PharmD,* A. RANDOLPH GARNETT, MD,* BARBARA K. McCLUNG, RN, BSN,* MARY M. NEWMAN, BS*

Effective emergency systems using emergency medical techni- cians (EMTs) trained to defibrillate or paramedics can save more lives fmm out-of-hospital cardiac arrest due to ventricular fibrii- iation than can emergency systems staffed with basic EMTs who cannot defibrillate. This article focuses on the cost-effectiveness of systems staffed with each type of EMT. Data were collected from ail 50 states and from the District of Columbia to determine the number of hours and estimated cost of initial training for the three types of EMTs in the United States in 1986. The median initial training hours for basic EMTs, EMTs trained in defibriiia- tion, and paramedics were 110, 129, and 700, respectively. Me- dian costs for initial training at each EMT level were $123, $150, and $1580/student. According to published survival data for emergency medical systems staffed with EMTs at each level, the total initial training personnel and equipment cost per life saved from ventricular fibrillation was $7687, $2126, and $2289 for systems staffed by the respective EMTs. The initial cost per life saved from ventricular fibrillation is more than three times greater in systems staffed by basic EMTs than in systems staffed by EMTs trained in defibrillation or paramedics. From a medical and a cost-effective standpoint, ail communities served by basic EMTs should consider upgrading them to at least the defibriiia- tion-trained EMT level. (Am J Emerg Med 1988;6:108-112)

Rapid electrical countershock of patients in ventric- ular fibrillation by emergency medical technicians (EMTs) trained to defibrillate can save lives in urban,’ suburban,* and rural settings.3 The cost-effectiveness of systems served by basic EMTs who cannot deti- brillate has not been compared with that of systems served by EMTs trained to defibrillate or paramedics.

From the ‘Section of Emergency Medical Services, Department

of Internal Medicine, Medical College of Virginia, Richmond, Virginia, and the tDivision of Emergency Medical Services, Ne- braska State Department of Health, Lincoln, Nebraska.

Manuscript received 11 February 1987; revision accepted 10

June 1987.

Address reprint requests to Dr. Ornato: Medical College of Vir- ginia, Box 525, Richmond, VA 23298.

Key Words: Cost-effectiveness analysis, defibrillation, emer- gency medical system, emergency medical technician, para- medics, ventricular fibrillation.

0 1988 W.B. Saunders Company

0735-8757188 $0.00 + .25

108

This article compares the average time and cost needed initially to train a basic EMT, an EMT trained to defibrillate, and a paramedic and compares the cost- effectiveness of each of these providers to the com- munity in terms of dollars spent per life saved from out-of-hospital cardiac arrest due to ventricular fibril- lation.

METHODS

The number of training hours and the cost of training EMTs were determined by a mail survey sent to the director of the state division of emergency medical services in all 50 states and the District of Columbia. Telephone follow-up was done when we received no response to the initial questionnaire or when we had questions about the answers provided on the question- naire .

Median values for EMT initial training hours and cost for the United States were determined. Using data from published studies,‘” the average survival to

hospital discharge in systems staffed with each of the three types of EMTs was used to predict how many lives (out of 100 out-of-hospital cardiac arrests due to ventricular fibrillation) would be saved by rescue teams at each of the three levels of training. Survival from out-of-hospital cardiac arrest due to ventricular fibrillation treated by the three types of EMTs was estimated to be 6%,3*536 25%,le3 and 28%,’ respective-

ly. The relative training cost for each prehospital pro-

vider per life saved was defined as the training cost (in dollars) for each provider divided by the number of lives saved out of 100 out-of-hospital cardiac arrests. In states that had different hours of training or differ- ent costs within each category of service, an average number of training hours and an average cost were determined by weighting the sum for the number of EMTs trained in each category in that state. If the training costs could not be accurately estimated by the Division of Emergency Medical Services in a state be- cause no figures were available, training costs for that state were listed as “not available” and that state was not included in the cost analysis.

Emergency medical technicians trained to “intermediate” levels other than to defibrillate were

Page 2: Cost-effectiveness of defibrillation by emergency medical technicians

ORNATO ET AL n COST-EFFECTIVENESS OF EMT-DEFIBRILLATION

not included in the analysis, because there was no con- sistent pattern to the training from state to state and because many states have multiple “intermediate” EMT categories.

Initial equipment cost was defined as the equipment that a prehospital provider needs to care for and trans- port a patient in cardiac arrest. Items included in the analysis were an ambulance, radio equipment, and miscellaneous medical equipment (stretcher, oxygen, first aid supplies) for all categories of EMTs. For EMTs trained to defibrillate and paramedics, a de- fibrillator monitor was included. A UHF radio with telemetry and a cardiac drug box were added to the equipment cost for paramedics only. Initial equipment cost was estimated from 1986 prices of standard am- bulance equipment items obtained from nationwide distributors. The total initial training and equipment cost for each prehospital provider per life saved was defined as the sum of the training cost (in dollars) for each provider plus the equipment cost for that provid- er to function divided by the number of lives saved out of 100 out-of-hospital cardiac arrests.

Because the distributions of training hours and train- ing cost were skewed, calculations were made with the median rather than the mean values. The nonparamet- ric Kruskal-Wallis test was used for statistical analysis.’ A p value of ~0.05 was considered to be statistically significant.

RESULTS

Initial training and cost data for basic EMTs were obtained for all 50 states and the District of Columbia (Table 1). Comparable data for EMTs trained to de% brillate were obtained for the 29 states that have at least one such program.

Median initial training time for EMTs trained to de- fibrillate was 19 hours more than the median initial training time for basic EMTs (Table 2). The median initial training time for paramedics was five to six times greater than the median initial training time for the other two categories of EMTs. The number of ini- tial training hours for paramedics was significantly higher (p < 0.0001) than the number of training hours for the other EMTs.

The median cost of initial training was only $27 higher for EMTs trained to defibrillate than for basic EMTs. The median initial training cost for paramedics was almost 10 to 13 times greater than the initial train- ing cost for basic or defibrillation-trained EMTs. It costs significantly more @ < 0.0001) to train paramed- ics than to train the other two groups of EMTs.

Because complete initial training hour and initial cost data for all three categories of EMT service could be obtained from only 12 states, the analysis was re- peated for only these states. The results were not sig-

niticantly different from those of the aggregate analy- sis for all states. In the 12 states, median initial training hours for basic EMTs, EMTs trained to defibrillate, and paramedics were 110, 127, and 563, respectively; median initial training costs were $110, $145, and $1585, respectively.

With either form of analysis, the conclusion was the same: the initial cost per life saved from out- of-hospital cardiac arrest due to ventricular fibrillation is highest for a system using basic EMTs. Such sys- tems have more than triple the initial setup cost per life saved than systems staffed by EMTs trained to defi- brillate or paramedics.

DISCUSSION

An analysis of the influence of the EMT provider level on cost-effectiveness for treating out-of-hospital ventricular fibrillation is appropriate because survival from this condition is most influenced by provi- sion of advanced life support in the field.’ For initial startup costs, systems using EMTs trained to defibril- late and paramedics are of comparable economic value to the community in treating patients with out- of-hospital cardiac arrest due to ventricular fibrilla- tion. Basic life support systems staffed with basic EMTs save few lives from out-of-hospital cardiac ar- rest. A basic EMT system requires a major investment in equipment and training without providing the res- cuer with the single most effective life-saving treat- ment for out-of-hospital cardiac arrest: electrical coun- tershock.

Wages and fringe benefits for EMTs, dispatch costs, and vehicle maintenance costs were not included in this analysis because of the extreme diversity in each of these variables between volunteer systems and sys- tems staffed by full-time paid providers. It is likely that for each system, wages and fringe benefits will in- crease minimally from basic EMTs to EMTs trained to defibrillate, with a larger increase to the paramedic level. Dispatch and vehicle maintenance costs are rel- atively independent of the level of training of the EMT staffing the vehicles. If these assumptions are correct, the system using EMTs trained to defibrillate may be the most cost-effective of the three in paid provider systems, strictly in terms of cost per lives saved from ventricular fibrillation.

Although current salary information is unavailable for a nationwide comparison, one system has com- pared operational costs between basic EMT and para- medic service. Urban and coworkers’ estimated that it cost $42,358/1ife saved from out-of-hospital cardiac ar- rest in King County, Washington, in 1981 to upgrade its basic life support system to an advanced life sup- port system staffed by paramedics. The analysis in- cluded direct and indirect costs of operating an ad-

109

Page 3: Cost-effectiveness of defibrillation by emergency medical technicians

AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 6, Number 2 I March 1988

TABLE 1. Training Hours and Cost by State for Emergency Medical Technicians (EMT)

Training Hours Training Costs ($)

EMT-A EMT-D

Alabama 140

Alaska 110

Arizona 110

Arkansas 120 California 104

Colorado 110

Connecticut 120

Delaware 110

Dist. Columbia 110

Florida 110

Georgia 150 Hawaii 315 Idaho 105

Illinois 126

Indiana 110

Iowa 120

Kansas 120

Kentucky 103

Louisiana 110

Maine 110

Maryland 110

Massachusetts 110

Michigan 115

Minnesota 81

Mississippi 90

Montana 110

Missouri 138 N. Carolina 110

N. Dakota 110

Nebraska 81 Nevada 110

New Hampshire 110

New Jersey 120

New Mexico 105

New York 109

Ohio 90

Oklahoma 124

Oregon 110

Pennsylvania 126

Rhode Island 110

S. Carolina 109

S. Dakota 110 Tennessee 130

Texas 130

Utah 118 Vermont 120

Virginia 210 W. Virginia 109

Washington 81 Wisconsin 110 Wyoming 120

NA 570 122 1110 114 784 NA 720 NA 916

126 910 132 560 126 910 NA 400 NA 710 NA 700 NA 1530 121 825 141 456 NA 1210

136 480 146 1000 NA 603 NA 1070 146 510

118 410 130 1360 125 515

105 1281 NA 890 NA 610 NA 763 NA 528 128 1110

97 496 140 1010

134 1910 NA 920 NA 925 124 494

130 590

140 364 126 536 NA 926 122 340 129 533 NA 610 NA 630 NA 520 134 703 137 1280 NA 663 NA 441 96 881

130 860 130 520

EMT-P -

EMT-A EMT-D EMT-P

NA 223

2585 100 NA 175 NA

45

400 NA

NA 1704

NA NA

115 NA NA

75 140 160 NA

315 NA 200 NA NA

140 NA

90 65

123 105 NA NA 115 NA

90 180

1260 200 NA

80 100 150 NA NA NA NA 120 NA

80

NA

253

NA NA

NA

NA

NA

60

NA

NA

NA

NA

NA NA

NA

NA

NA

NA

NA

184

NA

NA

NA

NA

NA

NA

NA

NA 105 140 135 195 NA NA

135

NA

NA

212

NA

212

NA

NA

NA NA NA

NA

NA NA

150 NA

115

NA NA

26585 1200 NA

1925 NA

4210

7000 NA NA 8294 NA NA

1315 NA NA

800 1190 1360 NA

4215 NA

1950 NA NA

820 NA 1590 2565 1923

10105 NA NA

690 NA

240

795 9260

650 NA 1580

800 1150 NA NA NA NA 2120 NA 1580

ABBREVIATIONS: EMT-A, basic EMT; EMT-D, EMT trained to defibrillate; EMT-P, paramedic

vanced life support system, including paramedic sala- ries, benefits, vehicle dispatch, and vehicle maintenance.

Survival statistics from out-of-hospital cardiac ar- rest are specific to each system. The published surviv-

al figures used for our analysis may be higher than comparable figures noted in other communities, be- cause the published figures come from systems partic- ularly noted for their excellence. The relative cost per life saved among the different levels of service is likely

110

Page 4: Cost-effectiveness of defibrillation by emergency medical technicians

ORNATO ET AL n COST-EFFECTIVENESS OF EMT-DEFIBRILLATION

TABLE 2. Cost-Effectiveness of Emergency Medical Technician (EMT) Services in Treating Cardiac Arrest Due to Ventricular

Fibrillation (VF)

Median initial training hours EMT per

Median initial training cost EMT ($) per

Equipment costs ($)

Ambulance

Medical equipment

VHF radio with HEAR capability UHF radio with telemetry, no repeater

Defibrillator/monitor Drug box and supplies

Total equipment costs Total initial costs

Lives saved 100 VF arrests per

Total initial costs life saved (9) per

EMT-A EMT-D EMT-P

110 129 700 123 150 1580

40,000 40,000 40,000

3000 3000 3000

3000 3000 3000 NA NA 9000

NA 7000 7000 NA NA 500

48,000 53,000 62,500 46,123 53,150 64,080

6 25 28

7687 2126 2289

to be insensitive to local variation in the survival rate, because there is generally a severalfold relative im- provement in survival when basic life support systems are compared with systems that can at least provide rapid defibrillation.

On the basis of this analysis, a strong argument can be made that all rescue vehicles responsible for initial care of patients in cardiac arrest should be staffed with providers who can defibrillate. Economic consider- ations (the cost of training and a defibrillator) strongly favor providing the skill. More lives can be saved from out-of-hospital ventricular fibrillation in an effective system using EMTs trained to defibrillate than in an effective system using basic EMTs.~*~ There is negli- gible risk of harm, provided that there is adequate medical control.“’ Even in systems that have a low frequency of calls, in which a potential continuing ed- ucation problem exists in maintaining EMT defibrilla- tion skills, safety and effectiveness can be ensured by using an automatic defibrillator.“5

Cardiac arrest due to ventricular fibrillation and ma- jor trauma account for the majority of potentially pre- ventable deaths in most emergency medical systems. Adding the skill of defibrillation to a promptly dis- patched basic life support system that serves an edu- cated public will improve survival from ventricular fi- brillation. From a medical and a cost-effective stand- point, all communities served by basic EMTs should consider upgrading to at least the defibrillation-trained EMT level. As a first priority, communities should concentrate on adding the skill of defibrillation for 1) basic EMT units that function without advanced life support backup, and 2) primary-response basic EMT units serving in geographic areas of two-tiered services where the response times of advanced life support units are prolonged.

Communities served by units that provide only basic life support care should strongly consider upgrading to the defibrillation-trained EMT or paramedic levels.

Published data suggest that more lives may be saved with a paramedic system than with a system using EMTs trained to defibrillate, but paramedic systems require more initial training time and setup cost. On- going personnel costs and continuing education re- quirements are greater in paramedic systems than in systems using defibrillation-trained EMTs. From a practical standpoint, some volunteers may not be able to dedicate hundreds of hours or more for paramedic training. Although not considered in this analysis, the paramedic’s additional training and skills in areas other than emergency cardiac care are relevant to the community’s choice of upgraded service. The optimal system from the standpoint of both service and cost- effectiveness must be determined by the unique needs and characteristics of each community.

REFERENCES

1. Weaver WD, Copass MK, Bufi D, et al: Improved neurologic

recovery and survival after early defibrillation. Circulation 1984;69:943-948

2. Eisenberg MS, Copass MK, Hallstrom AP, et al: Treatment of

out-of-hospital cardiac arrests with rapid defibrillation by

emergency medical technicians. N Engl J Med 1980;302:1379-1383

3. Stults KR, Brown DD, Schug VL, et al: Prehospital defibril-

lation performed by emergency medical technicians in ru- ral communities. N Engl J Med 1984;310:219-223

4. Eisenberg M, Bergner L, Hallstrom A: Paramedic programs

and out-of-hospital cardiac arrest: I. Factors associated

with successful resuscitation. Am J Public Health 1979;69:3&38

5. Eisenberg MS, Copass MK, Hallstrom A, et al: Management of out-of-hospital cardiac arrest: failure of basic emer- gency medical technician services. JAMA 1980;243:1049- 1051

6. Wilson BH, Severance HW, Raney MP, et al: Management of

out-of-hospital cardiac arrest by basic emergency medi- cal technician services. Am J Cardiol 1984;53:68-70

7. SAS User’s Guide: Statistics, version 5. Cary, NC, SAS Insti-

tute, 1985, pp 433-506

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AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 6, Number 2 n March 1988

8. Urban N, Bergner L, Eisenberg MS: The costs of a suburban paramedic program in reducing deaths due to cardiac

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10. Rozkovec A, Crossley J, Walesby R, et al: Safety and effec-

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ment. Circulation 1986:73:701-709