Correspondence
Public Use of Automated External Defibrillators
N Engl J Med 2003; 348:755-756February 20, 2003
- Article
To the Editor:
The results of the study by Caffrey et al. of the use of publicly available defibrillators in three Chicago airports (Oct. 17 issue)1 are encouraging, but several issues warrant further discussion. First, although the estimated cost of $7,000 per life saved is interesting, it fails to take into account the downstream costs associated with the deployment of automated external defibrillators. Using estimates from the medical literature, we calculated a cost–utility ratio of approximately $33,000 per quality-adjusted year of life gained2-4 (Table 1Table 1
Key Variables in the Cost-Effectiveness Model for the Deployment of Automated External Defibrillators in Public Places.). This finding supports the authors' conclusions regarding the cost effectiveness of their program.Second, the article and the accompanying Perspective5 do not specifically address the relation between the probability that automated external defibrillators will be used and the cost effectiveness of their deployment. Deployment of these devices at O'Hare International Airport is cost effective because this airport is densely populated, virtually 24 hours per day, with persons at moderate risk. In contrast, Meigs Field Airport appears to be sparsely and infrequently populated. These differences highlight the importance of evaluating population density, population risk profiles, and hours of occupancy when deciding which locations warrant the installation of an automated external defibrillator.
Finally, as indications for implantable cardiac defibrillators continue to expand and increasing numbers of high-risk persons receive these devices, any benefit that the deployment of automated external defibrillators may offer is paradoxically reduced.6
6 ReferencesPeter Cram, M.D., M.B.A.
University of Iowa Hospitals and Clinics, Iowa City, IA 52242
peter-cram@uiowa.edu A. Mark Fendrick, M.D.
University of Michigan Medical Center, Ann Arbor, MI 48109Sandeep Vijan, M.D.
Ann Arbor Veterans Affairs Hospital, Ann Arbor, MI 481091
Caffrey SL ,Willoughby PJ ,Pepe PE ,Becker LB . Public use of automated external defibrillators. N Engl J Med 2002;347:1242-1247
Full Text | Web of Science | Medline2
Groeneveld PW ,Kwong JL ,Liu Y , et al. Cost-effectiveness of automated external defibrillators on airlines. JAMA 2001;286:1482-1489
CrossRef | Web of Science | Medline3
The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators
Full Text | Web of Science | Medline4
Nichol G ,Hallstrom AP ,Ornato JP , et al. Potential cost-effectiveness of public access defibrillation in the United States. Circulation 1998;97:1315-1320
Web of Science | Medline5
Weaver WD ,Peberdy MA . Defibrillators in public places -- one step closer to home. N Engl J Med 2002;347:1223-1224
Full Text | Web of Science | Medline6
Gregoratos G ,Abrams J ,Epstein AE , et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation 2002;106:2145-2161
CrossRef | Medline
To the Editor:
Optimal public-access defibrillation programs critically depend on a thorough understanding of the effectiveness of automated external defibrillators, particularly in the hands of untrained laypersons. In their insightful study, Caffrey et al. conclude that “lack of . . . training should not constrain attempts to use a defibrillator in emergencies.” Their data, however, indicate that 15 or 16 of 18 defibrillation attempts were made by persons trained in the use of the defibrillators or by health professionals. (The occupation of one untrained rescuer is not specified.) The authors do not indicate whether these health professionals had experience with cardiac resuscitation or conventional defibrillation, yet at a minimum they would be expected to respond to medical emergencies more appropriately than untrained persons.
Although untrained persons can successfully operate an automated external defibrillator in simulated emergencies,1 it remains unclear how adequately such persons would perform in actual emergencies and how the lack of rescuer training affects patient outcomes. The best outcomes in public-access defibrillation programs have been observed in settings where a network of trained rescuers responded rapidly and appropriately to cardiac arrests.2,3 Creating and enhancing such networks, rather than carrying out public-education campaigns encouraging the use of automated external defibrillators without training, may be the more prudent public health policy.
3 ReferencesPeter W. Groeneveld, M.D.
Stanford University Center for Primary Care and Outcomes Research, Stanford, CA 94305-6019
petegro@healthpolicy.stanford. edu 1
Gundry JW ,Comess KS ,DeRook FA ,Jorgenson D ,Bardy GH . Comparison of naive sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation 1999;100:1703-1707
Web of Science | Medline2
Page RL ,Joglar JA ,Kowal RC , et al. Use of automated external defibrillators by a U.S. airline. N Engl J Med 2000;343:1210-1216
Full Text | Web of Science | Medline3
Valenzuela TD ,Roe DJ ,Nichol G ,Clark LL ,Spaite DW ,Hardman RG . Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206-1209
Full Text | Web of Science | Medline
Author/Editor Response
Although we stand by our opinion that a lack of training “should not constrain attempts to use a defibrillator in emergencies,” we agree with Dr. Groeneveld's comments. Optimally, we should always have trained rescuers responding to cardiac arrests. We stress in our article that all persons (i.e., all potential bystanders) should be trained in basic cardiopulmonary resuscitation (CPR), which today includes training in the use of automated external defibrillators. The principal public policy that we strongly endorse, on the basis of past successes in many communities, is the required training of all schoolchildren (e.g., children in the 9th or 10th grade) in CPR techniques, including the use of automated defibrillators.1 Therefore, we emphasize that automated external defibrillators should always be considered only one aspect of CPR. As pointed out in our article, all the survivors in the study did indeed receive other traditional CPR procedures (chest compressions and rescue breathing), even if only for a very brief period.
Nevertheless, although we take the firm position that all persons should be formally trained in CPR and the use of automated defibrillators, we still encourage bystanders, trained or otherwise, to act quickly in situations involving a cardiac arrest. We also encourage bystanders to attempt to use accessible defibrillators, particularly considering their ease of use and remarkable safety record.
We agree with Dr. Cram and colleagues that, regardless of the cost-analysis method used, the deployment of automated external defibrillators at airports appears to be cost effective. We also believe, as stated in our article, that the airport defibrillator program has “unique advantages.” We do note in the article that it is not known whether our results can be generalized to other public places. Nevertheless, more than 4000 Americans will die this week from out-of-hospital ventricular fibrillation, long before they are evaluated for an implantable device — simply because a defibrillator was not nearby. If we can train our citizens in CPR and in the use of automated external defibrillators, and if we can develop devices that are substantially less expensive than those being deployed today, the cost-effectiveness issue may become relatively moot.2 More important, defibrillation by bystanders will probably become the standard of care.
2 ReferencesSherry Caffrey-Villari, E.M.T.-P.
City of Chicago Department of Aviation, Chicago, IL 60666
sherord@aol.com Paul E. Pepe, M.D., M.P.H.
University of Texas Southwestern Medical Center, Dallas, Dallas, TX 752351
Pepe PE . CPR in schools. Dallas Med J 2001;87:290-2932
Weaver WD ,Peberdy MA . Defibrillators in public places -- one step closer to home. N Engl J Med 2002;347:1223-1224
Full Text | Web of Science | Medline
