Tuesday, June 24, 2008

AED's - The Barriers to Entry

Melinda Beck of the Wall Street Jounal, did a nice piece on the need for automatic external defibrillators (AEDs) in public spaces today and started to address some of the issues of why these amazing gizmo's aren't available more widely:
Some states now require AEDs in schools; some require them in health clubs, shopping malls and golf courses. There's little uniformity; despite their foolproof nature, some businesses oppose them out of fear of being sued if something goes awry with an on-site AED. "I predict that 10 years from now, people will say, 'I'm not going to work in a building or stay in a hotel or eat in a restaurant that doesn't have an AED," says San Diego city-council member Jim Madaffer, who helped place nearly 5,000 AEDs in public facilities since 2001. They've saved 49 lives.

Schools have been a tough sell, too, largely because of cost. Some parents are raising money for AEDs themselves, often after a tragedy. Evelyn and Larry Pontbriant have donated 32 AEDs to Norwich, Conn., schools since last summer, when their 15-year-old son, an athlete with no known heart problems, suffered a fatal cardiac arrest during a running event in the local park. An AED arrived on the scene too late. "It's a good investment to have on hand in your school," says Mrs. Pontbriant. "It benefits not just the athletes, but also the teachers, coaches, referees, grandparents and siblings."
As electrophysiologists, we often get to see the "saves" made by these devices: the young boy playing baseball, struck in the chest by a fast ball ("commodio cordis") that fibrillates his heart and the police officer who responds with the AED in the trunk of his squad car to save the boy's life; or the father who collapses just outside the fire department and is rescued by their defibrillator. These event happen every day, but unfortunately as experienced in the Tim Russert case, many more are not so fortunate.

So why aren't these devices more readily available?

First and foremost: is cost. These devices are still expensive: the cheapest quoted goes for about $1300. But there are other costs not commonly discussed: like the cost of new batteries every 2-7 years (depending on the cost of the model) that can set folks back at least a $100 for each device. And what about those defibrillator patches placed on the chest? They contain a gel that improves the conductivity of the patches on the chest, making the devices more reliable at correcting the normal heart rhythm. That gel degrades and the patches must be replaced every two to seven years, too - to the tune of about $100 a set, too. These are the unspoken issues with AEDs that are never written about and schools and institutions must understand these additional costs and maintenance requirements if they are to assure the proper functioning of these devices.

Next, is the location consideration: where will these devices be used? Will they be in the office setting, car trunk, or placed next to the baseball field? Humidity, motion, and other environmental issues might require a more expensive device to be deployed without the bargain-basement price. Certainly, in the NIH-sponsored trial "Home Automated External Defibrillator Trial (HAT)," home use has not been found to be more effective than a conventional call to 911: in part because of the low incidence of events that occur in the home when a responder is present (58 patients out of 7001 studied, and only 32 had AEDs used and only 4 survived to hospital discharge).

But the cost and efficacy considerations might be offset if more defibrillators were deployed in public spaces where more responders were present and events occurred - thereby driving down the costs. I suppose it would be utopia if these devices could be deployed and maintained within 3 minutes of whereever a person traveled. But the path to implementation, especially with staffing and budget shortfalls, is a lengthy one. As a case in point: many doctors' offices, dialysis centers, and rehab units still do not have these devices and instead rely on calling 911 for a response in emergencies.

Sad, but true.

-Wes

10 comments:

Jay said...

Wes,

I agree completely and have been an AED advocate for years. It's been interesting to watch as AED awareness has overtaken ICD awareness. I even heard one person refer to an ICD as an AED implanted in the chest.

What's troubling about the column is the way AEDs are contrasted with ICDs with the former implied to be a better, rather that complementary treatment strategy.

To quote the columnist:
"...ICD's cost as much as $55,000 and have had a history of recalls. What's more, roughly 75% of people who have one never require a shock, and 70% of people who do have a sudden cardiac arrest don't fit the criteria to receive an ICD."

Using the numbers cited in this very column you can see that AED saves are quite a bit less common than ICD saves (49 saves for 5000 ICDs for one community in San Diego). This, in effect, means that only a small minority of the AEDs are "needed."

One also need not look hard to find multiple instances of AED recalls: http://www.fda.gov/oc/po/firmrecalls/heartsine03_05.html, http://www.medscape.com/viewarticle/536868 among others.

Let's not forget that wealth of research showing the efficacy and cost effectiveness of ICDs at saving lives. As the column itself points out, such data is lacking with AEDs.

ICDs continue to be beat up in the media, and this bad press has real impact on the public health. Every reluctant patient becomes a potential life lost.

Jay

david said...

i am an architect. .. and the majority of our projects are theaters- since i had my pacemaker put in a few years ago i have been specifying them for all of our projects. so far i think we have put 11 in use. i do not think any of them have been used yet, but i shoudl probably go back to my clients and make sure that they are being properly maintained. thanks for the awareness article.

Patrick said...

Zoll will replace the pads for free, in exchange for the data from the event. It's called PEER (Post-Event Electrode Replacement). And uses consumer-replaceable batteries.

DrWes said...

jay-

Great comments. I concur w/that the article sounded negative toward implantable defibrillators (ICDs), but the relative "save-rate" for ICD's far exceeds that for AEDs - probably because of the pre-selected high-risk population that receive implanted defibrillators.

And while $55,000 per implantable device is high, the article quoted that San Diego, CA has installed about 5000 of these devices since 2001 to save 49 lives - a conservative price estimate for that installation is $6.5 million ($132,653 per life saved) - an even bigger number.

david-

Glad it helped.


patrick -

Great info. Thanks. BTW, are you aware of any patient privacy implications when that information is turned over to Zoll in exchange for the pads? Just asking.

Patrick said...

The AED doesn't know who the patient is, and the only data given over (on the phone to the rep who enrolls you for the free pad exchange) is age & gender of the patient. Since these are mostly PADs (public access defibs), not much HIPAA data is available.

Anonymous said...

This article may be of interest:
http://www.ncbi.nlm.nih.gov/pubmed/18241970

An Austrian audit which compared use of newly installed AEDs to historical survival data. In a two year period following 1,865 AEDs being installed in public places, 73 defibrillations were performed with 15 patients surviving with good neurological status. As you note, the cost effectiveness is questionable.

emmy said...

I used to be a big fan of AED's in public places, especially schools, because my daughter and I have LQTS. Our experience with them has been underwelming. At my daughter's school the gym coach decided that the fact he had one available made it OK for him to have my daughter run the stairs in a timed gym test. He told me that when I called to ream him over the coals for ignoring my instructions and causing a syncopal episode. The Fortune 500 company that I work for decided that the best place to put the AED is in my cube. That's good, but the people I work with will call the OHS Nurse if I ever need it and it will take her longer than 6 minutes to get to my cube. I'm not sure that anyone at the Airport here in Atlanta would think to run get the AED off the wall if they saw someone faint either. I'm not sure if they'd know that they can use it.

Nice boat, but it doesn't float.

Patrick said...

Emmy,
It's all about how it's presented and what AED is purchased. Unfortunately, some of the older ones (older than 2-3 years old) can't have their software updated to keep up with the changing CPR standards. Zoll, for instance, is compatible with "hands only CPR" that is all the rage in public access CPR and defibrillation now. And most AEDs that are made for public access situations assume the rescuer doesn't know anything.

Pete said...

On a lighter note, an MD friend strongly suggested to me that if I'm going to go into VF or VT, hope that it happens at a barber shop, so they can shave my chest...otherwise, they'll zap me and I'll probably burst into flames....we had a good laugh about that, but it highlights the problem of presenting a seemingly simple solution which has many variables. Should my time come, I hope the fire extinguisher will accompany the AED.

Elliot Fisch said...

Batteries range in cost from $65/$75 (Zoll - Duracell 123 Lithium) to over $300 (Cardiac Science proprietary).

Pads need to be replaced every two years and run from $38 (Defibtech) to $149 (Zoll, which has a special CPR feedback device built into the pads - and has a 5 year shelf life).

On the comment about AEDs being not cost efficient; tell that to the families of the 15 survivors. Check out the cost of all the fire prevention equipment; 5,000 people a year die from fires, while 1,000 people a day suffer from cardiac arrest.

One of the problems that exists is that publicly placed AEDs are seldom used because they are not seen by the first responder (they are not in immediate sight, but could be in the vicinity) and the 9-1-1 dispatcher is unaware that one may be nearby.

A system called AED Link (www.aedlink.com) can close that information gap by supplying the dispatcher with the location of the nearest AED.