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Resuscitation 86 (2015) 54–61

Contents lists available at ScienceDirect

Resuscitation

j ourna l ho me pa g e: www.elsev ier .com/ locate / resusc i ta t ion

linical paper

ost–utility analysis of treating out of hospital cardiac arrestsn Jerusalem

ary M. Ginsberga,∗, Jeremy D. Karkb, Sharon Einavc

Department of Technology Assessment, Israel Ministry of Health, Jerusalem, IsraelHebrew University-Hadassah School of Public Health and Community Medicine, Jerusalem, IsraelIntensive Care Unit, Shaare Zedek Medical Centre and Hebrew University, School of Medicine, Jerusalem, Israel

r t i c l e i n f o

rticle history:eceived 19 May 2014eceived in revised form 2 October 2014ccepted 26 October 2014

eywords:ardiopulmonary resuscitationeart arrestost–utility analysis

a b s t r a c t

Background: Out-of-hospital cardiac arrest (OHCA) initiates a chain of responses including emergencymedical service mobilization and medical treatment, transfer and admission first to a hospital EmergencyDepartment (ED) and then usually to an intensive care unit and ward. Costly pre- and in-hospital care maybe followed by prolonged post discharge expenditure on treatment of patients with severe neurologicalsequelae. We assessed the cost-effectiveness of treatment of OHCA by calculating the cost per DisabilityAdjusted Life Year (DALY) averted.Methods and results: We studied 3355 consecutive non-traumatic OHCAs (2005–2010) in Jerusalem,Israel, supplemented by hospital utilization data extracted from patient files (n = 570) and post-dischargefollow-up (n = 196). Demographic, utilization and economic data were incorporated into a spreadsheetmodel to calculate the cost-utility ratio.

Advanced life support was administered to 2264 of the 3355 OHCAs (67.5%) and 1048 (45.6%) patientswere transferred to the ED. Of 676 (20.1%) patients who survived the ED and were admitted, therewere 206 (6.1%) survivors to discharge, among them only 113 (3.4%) neurologically intact. Total cost

($39,100,000) per DALY averted (1353) was $28,864.Conclusions: The current package of OHCA interventions in Jerusalem appears to be very cost-effective asthe cost per averted DALY of $28,864 is less than the Gross Domestic Product per capita ($33,261). Thispaper provides a basis for studying the effects of potential interventions that can be evaluated in termsof their incremental costs per averted DALY for treatment of OHCA.

© 2014 Elsevier Ireland Ltd. All rights reserved.

Provision of cardiopulmonary resuscitation (i.e. first basic thendvanced life support) has become almost the default procedureor treating out of hospital cardiac arrest (OHCA). However, basicnd advanced life support remain medical interventions, not ritesf passage. As a result there is increasing conflict between the ide-listic approach of egalitarianism (supporting aggressive treatmentfforts for all arrested patients) and a more realistic approach whichows to the realization that limited medical resources demand

more utilitarian approach to these medical procedures 1. Thatasic and advanced life support efforts are intended to restoreardiac function should not render these treatments immune to

∗ Corresponding author at: Medical Technology Assessment Division, Room 329,inistry of Health, Yirmiahu 39, Jerusalem 9446724, Israel. Fax: +792 26474852.

E-mail addresses: gary.ginsberg@moh.health.gov.il, gmginsberg@gmail.comG.M. Ginsberg).

ttp://dx.doi.org/10.1016/j.resuscitation.2014.10.024300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.

cost-effectiveness analysis. Both basic and advanced life supportshould be assessed using the same tools employed for other med-ical interventions and should be provided only when medicallyindicated.

We carried out a cost–utility analysis of CPR in Jerusalem, Israel,in order to quantify the cost of the considerable resources thatare spent on this care process as well as to estimate the DisabilityAdjusted Life Years (DALY) losses averted by the intervention.

1. Methods

1.1. Study design

The study design is a cost–utility analysis of the current treat-ment mode for OHCA, based on health service utilization and healthoutcome data that were prospectively collected at an individuallevel.

G.M. Ginsberg et al. / Resuscit

Table 1Annual ED costs (USD at 2011 price levels) (excluding pharmaceutical, laboratorytests, imaging and other procedures).

Standard procedures 651,501 58.5%Manpower 213,801 19.2%Hospital overheads 129,210 11.6%Machinery 33,205 3.0%Cleaning 32,998 3.0%Building maintenance 24,067 2.2%Utilities 12,521 1.1%Building 11,375 1.0%Laundry 2402 0.2%Furniture 3518 0.3%

$1114,599Bed days per year 731

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transfer the deceased to the funeral parlor. Due to their fewer num-

Cost per bed day $1526Cost per hour ER $63.58

.1.1. Clinical settingOut of hospital CPR in the Jerusalem district is performed by

he teams of the Magen David Adom (MDA) emergency medicalervices (EMS) 2. The MDA is the officially recognized national aidociety of Israel and is a member of the International Federationf Red Cross and Red Crescent Societies. Basic life support (BLS)s provided by first and second tier teams (volunteers and BLSmbulances). Advanced life support (ALS) is provided by third tiereams (Mobile Intensive Care Unit ambulances) who are requiredo attend all cases of cardiac arrest regardless of whether they wererst on location. Patients who achieve ROSC are transported tone of the four university-affiliated hospitals in the district. Twoniversity-affiliated hospital Institutional Review Boards autho-ized the study. Informed consent was waved for all patients excepthose interviewed after hospital discharge, who signed informedonsent forms as required. All hospital, chronic care and rehabilita-ion center directors and the MDA medical director approved dataollection in their respective institutions/organizations.

.2. Study population

The study prospectively included all patients aged over 18 yearsith non-traumatic cardiac arrest in the Jerusalem district with

MS documented (by a paramedic or physician) pulselessnessccompanied by a non-perfusing rhythm [i.e. asystole, pulselesslectrical activity, ventricular fibrillation or ventricular tachycar-ia] at any time during prehospital treatment (1 st April 2005–31stecember 2010).

.3. Intervention

The “treatment bundle” provided to patients suffering cardiacrrest (listed in Table 1), including basic and advanced life supporty the MDA, transfer to an Emergency Medicine Department (ED),reatment in the ED and throughout the hospital admission andppropriate post hospital discharge care (including cardiac reha-ilitation, home care, nursing care and mechanical ventilation) isenceforth referred to as the “intervention”.

.4. Data collection and analysis

Resource utilization and survival data were collected on ROSCatients from their ED and hospital files and from structured

nterviews. Use of imaging, laboratory tests, pharmaceuticals androcedures undertaken in the ED, ICU or other hospital depart-

ents were extracted from the files of patients transferred after

OSC to the Shaare Zedek Medical Center (n = 570), one of the fourerusalem hospitals receiving patients after cardiac arrests. Costsf care at Shaare Zedek Medical Center are representative to those

ation 86 (2015) 54–61 55

of the other three hospitals for the following reasons: (a) staffingratios are governed by the same Ministry of Health ordinances and(b) re-imbursements are made by the same four Health InsuranceProviders who universally insure the Israeli population in accor-dance with Ministry of Health Tariffs. Hospital utilization data weremultiplied by unit costs obtained from the Ministry of Health andinternal hospital costing tariffs in order to provide individual esti-mates of ED and hospital resource consumption.

1.5. Cost–utility criteria

A model, using Microsoft Excel spreadsheets (Microsoft OfficeExcel 2006, Microsoft Corporation) was constructed incorporat-ing epidemiological, demographic, health service utilization andeconomic data.

The basic formulae used for calculating the cost per avertedDALY loss is:

Cost per averted DALY loss = Cost of interventionAverted DALY losses

where Averted DALY losses = Increase in DALY losses due to mor-bidity of persons who arrived alive at the ED + Averted DALY lossesas a result of decreases in mortality.

In Israel there are no governmental policy marker’s for definingwhether or not a health intervention is cost-effective. Affordabil-ity of interventions is clearly a function of the amount of resourcesavailable in a country as proxied by its Gross Domestic Product(GDP) per capita. Therefore, we relied on WHO guidelines whichdefine an intervention as being very cost-effective 3 if the costper DALY averted is less than the GDP per capita (being $33,261in Israel) 4 and just cost-effective if the cost per DALY averted liesbetween one and three times the Gross Domestic Product (GDP) percapita (being between $33,261 to $99,784 in Israel). If the inter-vention supplies DALYS at a cost of more than three times theGDP (being >$99,784), the intervention is not cost-effective. Allcosts are presented from a social perspective, in US dollars at 2011price levels (at 3.578 New Israeli Shekels to the US Dollar) 5. Theseinclude costs incurred by health and welfare services as well aswork absences. All costs and DALYs were discounted at a 3% annualrate, as is the current practice in Israel 6.

1.6. Measurement of costs

1.6.1. VolunteersCosts of first-response volunteers were obtained from a major

volunteer organization 7. These included costs of insurance andmaintenance of vehicles, defibrillation and resuscitation equip-ment, as well as an imputation of volunteers’ time (conservativelybased on 1 h per call at minimum wage levels) and fuel costs.

1.6.2. Basic life support (BLS) ambulancesAround 62% of calls were attended by a BLS ambulance costing

$334 per callout (including CPR costs) mainly reflecting their lowermanpower usage compared to a more expensive mobile intensivecare unit (MICU).

1.6.3. Mobile intensive care unit (MICU)According to the methodology shown in Appendix I, the cost per

MICU call in Israel was estimated to either $586 or $548 (includingCPR costs), depending on whether the MICU continued to a hospi-tal or returned directly to the depot leaving a regular ambulance to

bers and wider dispersion, MICU travelled an average of 6.4 km tothe location of cardiac arrest compared to 4.9 km by basic ambu-lances. Costs took into account OHCA where more than one vehicleattended (whether MICU or basic ambulances).

56 G.M. Ginsberg et al. / Resuscit

Table 2Annual ICU costs (USD at 2011 price levels) (excluding pharmaceutical, laboratorytests, imaging and other procedures).

Manpower 1150,750 52.2%Cleaning 290,093 13.1%Building maintenance 211,578 9.6%Building 120,000 5.4%Utilities 110,078 5.0%Hospital overheads 100,727 4.6%Machinery 84,769 3.8%Furniture 69,108 3.1%Thermal cooling 37,151 1.7%Food 24,855 1.1%Laundry 7045 0.3%

$2206,154Bed days per year 2143Cost per bed day $1029

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.6.4. Department of emergency medicine (ED) (Table 2)During the study period the Shaare Zedek Medical center’s

hock-trauma ED, which also deals with OHCA cases, operated withour beds at a 50% occupancy rate admitting 5498 patients annu-lly. Patients admitted after ROSC were in the ED for an averageime of 3.2 h per patient; 2.3 h for those who died and 3.9 h forurvivors transferred to a hospital ward. Patients dying in the EDsed an average of $145 of ED resources, plus an additional $560er person due to imaging, pharmaceuticals, procedures and lab-ratory tests. Hospitalized patients used $246 of ED resources inddition to imaging, pharmaceuticals, procedures and laboratoryosts, that were recorded together with their hospitalization costssee Appendix II). Table 2.

.6.5. Hospitalization in coronary intensive care unit (ICU)Table 3]

The cardiac ICU operated with seven beds at an 83.8% occupancyate. Cost per patient day (excluding pharmaceuticals, laboratoryests, imaging and other procedures) was $1029 (see Appendix III).able 3.

.6.6. Hospitalization in non-ICU departmentsFor the minority of patients that were admitted directly to non-

CU departments, the average cost per day was $459 8, which wasdjusted downwards by 25% (based on the hospitals budget) tovoid double counting with the costs of imaging, laboratory tests,harmaceuticals and procedures, which were recorded separately

n the utilization study.

.6.7. Imaging, laboratory, pharmaceutical and proceduresIndividual patient utilization data extracted from patient files

ere multiplied by unit costs at 2011 price levels 8 and were addedo department-specific hospitalization costs in order to obtain indi-idual cost data for all hospitalized patients.

.6.8. Post-hospitalization costsThe costing methodology is described in detail in Appendix

V according to sub-groups with mild neurological sequelae andevere neurological sequelae (with and without mechanical venti-ation).

.6.9. Lost productivity

A sub-sample of 54 survivors who were intensively investigated

n order to provide an estimate of lost work days per survivor.ost work days were multiplied by the average employment costser day of $138 5 to obtain estimates of resource losses from lostroductivity.

ation 86 (2015) 54–61

1.7. Measurement of DALY gains

The disability-adjusted-life-year (DALY) is a time-based mea-sure which combines years of life lost due to premature mortalityand years of life lost due to time lived in states of less than fullhealth. The DALY metric was developed for and is currently usedto assess the burden of disease consistently across diseases, riskfactors and regions 9.

In the absence of intervention, it was assumed that all thepatients would have died on the spot, incurring no resource costs.

1.7.1. Potential years of life lost (PYLL) with no interventionAge-, gender- and population specific life expectances were cal-

culated from life tables of the Central Bureau of Statistics 5. Thesewere used to calculate the potential years of life lost (PYLL) bythe cohort had there not been any medical intervention (the “null”scenario).

We calculated the discounted DALYs gained as a result of theintervention as explained in the following sections:

1.7.2. DALY gains as a result of the interventionAge- and gender-specific disability weights (DW) used by the

Ministry of Health, were applied to these life expectancies (adjustedby the DWs shown below) in order to calculate each individual’sadditional Healthy Adjusted Life Expectancy.

1.7.2.1. Due to surviving after discharge. This large category con-sisted of the following three groups, who were assigned DWaccording to the WHO valuation 10:

1.7.2.1.1. Without neurological sequelae. The average lifeexpectancy for this sub-cohort was 21.8 years, similar to that foundin the Framingham study 11.

Cerebral performance category 1 (CPC1): 22 and 24 persons hadmild (DW = 0.037) or moderate heart failure (DW = 0.07), respec-tively, for an average of 6 months. Five persons with moderate heartfailure suffered from severe weakness for an average of four months(DW = 0.292; proxied by moderate musculoskeletal generalizeddisorders), two had lifelong short-term memory loss (DW = 0.082;proxied by mild dementia) and one received home oxygen therapy(DW = 0.192; proxied by moderate chronic obstructive pulmonarydisease).

CPC2: This group had disabilities that were best proxied by mildand moderate motor and cognitive impairments (DW = 0.138).After two years one person improved and was re-assigned as CPC1.

1.7.2.2. With neurological sequelae. The average life expectancy forthis sub-cohort was assumed to be 3.0 years 12.

CPC3: This group had disabilities that were best proxied bysevere motor and cognitive impairments (DW = 0.425).

CPC4: This group had disabilities that were best proxied bypersons who had untreated spinal cord lesions at their neck(DW = 0.673).

1.7.2.3. Due to acute morbidity in survivors during their hospitalstay. A DW for persons not neurologically impaired of 0.422 wasapplied to the first two days hospitalization 10, with half the weightbeing applied for the rest of the hospitalization. For CPC3 and CPC4survivors an additional DW of 0.599 was given to reflect theirneurological impairments, giving a combined DW of 0.768 (i.e.1 − [(1 − 0.422) × (1 − 0.599)]).

1.7.2.4. Due to acute morbidity in deceased persons. This very smalladjustment takes into account the extra hours or days of stayingalive achieved by persons who died in the ED or in a hospital ward.The DW for persons in this situation was assumed to be 0.9. The

G.M. Ginsberg et al. / Resuscitation 86 (2015) 54–61 57

Table 3Discounted costs (USD at 2011 price levels) of cardiac resuscitation services.

Persons Unit cost USD Days or visits Total cost

USD %

Numbers calling MDA 3355Volunteers attended 551 617 339,764 0.9BLS ambulances attended 2080 334 695,577 1.8MICU attended of which 3355 586 1965,469 5.0Received care in ED 1048 –Numbers receiving CPR in ED 348 52 18,238 0.05Died in ED 372 706 262,801 0.65Hospitalised of which 676 13,386 9046,314 23.1Died in hospital 469 –Discharged alive of which 206 –No or mild neurological sequelae of which 113Discharged home 50 –Discharged home with cardiac rehab 27 214 384 72,279 0.19Discharged home with 24 h help 4 142 619 375,342 0.96Received home non-cardiac rehab 4 37 39 6066 0.02Received rehab in day hospital 5 189 365 12,155 0.03Transferred to rehabilitation ward 11 504 26 137,972 0.35Transferred to convalescent home 7 72 30 16,130 0.04Transferred to another hospital 4 975 4171 0.01Home Ventilation costs of which 4 76 619 198,125 0.51Neurological sequelae of which 93Home with 24 h home help 2 151 1562 503,136 1.3Home with 24 h nursing care 4 594 1562 3967,774 10.2Transferred to rehabilitation ward 14 504 26 179,364 0.5Regular nursing home 3 72 1562 359,900 0.9Nursing home after rehab ward 14 72 1536 1534,025 3.9Complex nursing facility 19 177 1562 5334,729 13.7Geriatric ventilation department 46 392 284 3152,555 8.1Transferred to another hospital 4 –Post ventilation costs* 46 76 335 1167,972 3.0Employment losses –No or mild neurological sequelae 113 138 240 6877,503 17.6Neurological sequelae 93 138 84 2856,509 7.3

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esultant gain in averted DALYs was again adjusted by the age andender specific DW.

. Results

.1. Survival (Fig. 1)

OHCA patients (n = 3355, 56.6% male) were aged 73.8 ± 16.1ears (median 78, range 18–108). Asystole was common (76.3%),T/VF rare (8.9%) and bystander CPR was delivered in only 15% of

he cases. Despite this in 2264 patients ALS was provided by MDAeams (67.5%) and 1048 (46.3%) of these achieved ROSC and wereransported to hospitals. In the ED 348 re-arrested and underwentdditional ALS and 35.5% died (372/1048). Of the remaining 676atients, only 206 (9.1% of those receiving ALS by MDA teams)urvived to hospital discharge. 113 (5.0% of ALS recipients, and.4% of all OHCAs) were classified as CPC1 (n = 77) or CPC2 (n = 36).round half of the 93 survivors who had severe neurological seque-

ae, CPC3 (n = 28) or CPC4 (n = 65), required mechanical ventilationMV) (n = 46). Fig. 1.

.2. Total care costs (Table 1 and Fig. 2)

These amounted to $29.3 million or $8471 per OCHA patient, ofhich $26.3 million were treatment costs. Post-hospital care costs

in complex nursing facilities, rehabilitation hospitals and mechan-cal ventilation departments) of the 93 persons who survived witheurological sequelae accounted for $16.2 million (55.2% of totalare costs) or $174,120 per person. Fig. 2.

39,068,008

dmissions, outpatients visits and transport costs. (Appendix Ref. 7).

In contrast, post-hospital care costs of the 113 survivors withmild or no neurological sequelae amounted to only $824,000 (2.8%of total care costs) or $7275 each.

The 676 persons who were initially hospitalized after their car-diac arrest used $9.04 million of hospitalization and ED resources(30.8% of total care costs). The 372 people who died in the ED usedonly 0.9% of total care costs. Initial response costs accounted for theremaining $3.0 million (10.2%).

2.3. Employment losses (Table 1)

Extrapolation from a sub-sample of 54 survivors who wereintensively investigated 13 showed that OHCA led to an averageof 133 lost work days per survivor. Employment losses amountedto an additional $9.7 million, of which 70.7% was attributable to theCPC1 or CPC2 groups (averaging 240 lost days per survivor), due totheir far longer life expectancy than persons with severe neurolog-ical sequelae (who averaged 84 lost days per survivor). Thereforetotal costs, from both treatment and productivity losses, amountedto $39.1million.

2.4. DALY losses averted

Of the 2752 PYLL that were averted in the whole cohort, 2473(89.9%) were averted in persons in CPC1 or CPC2. In total, 1353discounted DALY (Table 4) losses were averted due to the inter-

vention (cf: zero life years under the null scenario). Around 1267DALYs (93.6%) were averted in the 113 CPC1 and CPC2 survivors,whilst only 82 DALYs (6.1%) were averted in the 93 survivors withneurological sequelae. The remaining 3.5 averted DALYs (0.3% of

58 G.M. Ginsberg et al. / Resuscitation 86 (2015) 54–61

Fig. 1. Numbers treated by stage of treatment & disability level on discharge. Legend: ALS: advanced life support; MICU: mobile intensive care unit; ROSC: return of spontaneouscombustion; ED: emergency department; CPC: cerebral performance category.

Table 4Discounted DALYs gained by persons who arrived alive at the ED.

No. (1-DW) Years DALYS DALYS

Due to surviving after dischargeCPC1 77 21.8 908CPC2 36 21.8 359CPC3 28 3.0 35CPC4 65 3.0 47

1350

Due to acute morbidity in hospitalized survivorsCPC1 & CPC2 first two days 113 0.44 0.0055 0.27CPC1 & CPC2 remainder of hospitalization 113 0.60 0.0139 0.95CPC3 & CPC4 93 0.18 0.0643 1.07

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Due to acute morbidity in deceased personsDying in ER 372 0.1 0.0003 0.01Dying during hospitalization 469 0.1 0.0263 1.23

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G.M. Ginsberg et al. / Resuscitation 86 (2015) 54–61 59

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otal DALYs) were averted due to persons living for a few hours inhe ED or a few extra days in hospital and also with acute morbidityuring the hospitalization phase for survivors.

.5. Cost–utility analysis

The 1353 discounted DALYs were averted due to the basic inter-ention of caring for OHCA at a total cost of $39.1 million. Theost per DALY averted was $28,864 rendering the intervention veryost-effective according to the cost-utility criteria explained in Sec-ion 1.

.6. Sensitivity analysis

Assuming our cost data (or DW) were over and underestimatedy 10% would change the cost per DALY of the baseline scenario to26,241 and $31,751, respectively, still rendering the interventionery cost-effective.

. Discussion

The package of interventions currently being used for OHCA inerusalem is very cost-effective. This finding is striking in light ofhe adverse underlying OHCA characteristics of the Jerusalem dis-rict population and the high survival rates. Our patients are 10ears older than most OHCA populations reported in the literaturend is reminiscent of the OHCA population of Japan 14. There is aow rate of bystander chest compression [15% compared with 33%,1.3% and 44.9% in the US 12, Japan 15 and Denmark 16, respec-ively] and a very low proportion of presentation with ventricularbrillation or ventricular tachycardia (9% compared with 20–40%

n the United States and Europe 17). Yet reluctance to withhold orithdraw treatment resulted in a remarkably high rate of return

f spontaneous circulation compared to that described elsewhere8 and one third of the patients who actually survived to hospitalischarge had severe neurological sequelae.

We found no other study which incorporated real data ontility with a degree of detail such as ours. An early cost-utilitynalysis in the United States of both in- and out-of-hospitalesuscitation extending from pre-hospital services to post-hospital

erebral performance category; ED: emergency department.

discharge provided a preliminary estimate of the cost-effectivenessof CPR programs for all 6-month survivors of $225,892 per quality-adjusted-life-year 19, clearly not cost-effective compared with thethreefold GNP per capita threshold of $87,450 in 1995 20.

The only recent paper addressing in-hospital cost-effectivenessof resuscitation was restricted to targeted temperature man-agement in patients with witnessed out-of-hospital ventricularfibrillation arrest (i.e. those patients with the best prognosis a-priori) and reported a very cost-effective incremental ratio of$47,168 per quality-adjusted life year 21, since US per capita GNPwas $49,350 in 2008 20.

A pure costing study from Japan showed that patients dis-charged after OHCA either to home or to another destination aresignificantly costlier ($28,097 and $31,161 respectively) than thosedeclared dead at the time of arrival to hospital ($434),dying on theday of admission ($1735),or dying more than 2 days after admission($4869) 22. Higher age was associated with lower costs even afteradjustment for positive survival status, longer hospital stay andreceipt of specific treatments 22. A recent assessment of the averagecost of in- hospital ALS found that patients undergoing more thanone resuscitation attempt were much more costly ($4485 versus$3581 per hospital day) 23. However, this cost assessment nei-ther included post-admission expenditures nor assessed patient’sutility.

Decreases in ED and hospital case-fatality rates, while increas-ing DALYs also increase the absolute costs due to their being moresurvivors (both with and without sequelae).

One of our most striking findings is the number of patientssurviving to hospital discharge despite the presence of severeneurological sequelae. These patients consume a disproportionateamount of resources. We estimate that the annual national expen-diture on neurologically impaired survivors is equivalent to around43% of the $84 million dollars allotted annually for the introductionof new drugs and medical technologies in the Israeli basket of healthservices.

A similar situation is likely being encountered in other regions

and countries where there is greater reluctance towards with-holding and withdrawing life support. In Europe and the UnitedStates, guidelines for the Termination of Resuscitation (TOR) aremore widely accepted resulting in a lower 15% rate of CPC3 or

6 suscit

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PC4 survivorship 24–26. Adherence to these TOR guidelines likelyignificantly limits costly treatment of patients with preventableebilitating disabilities 13. This considerable change in the propor-ion of neurologically intact survivors would be accompanied by

slight fall in DALYS averted from the much smaller CPC3 andPC 4 group, with a consequent substantial fall in the cost perALY ratio. Unfortunately, many clinicians do not accept the prog-ostic accuracy provided by current tools. Our findings provide

strong incentive for directing attention and resources towardsevelopment of better prognostic tools and determining the pre-ise indications for basic and advanced life support and continuedost-resuscitation care.

Our study has several limitations; firstly, the cost per DALYatio is over-estimated (making it appear as less cost-effectivehat what it really is) to the extent that we were unable tottribute any value to decreased care-giver and mourner burdens a result of the intervention (causing underestimation of avertedALYS).

Second, our cost per DALY ratio is underestimated (making itppear as more cost-effective that what it really is) because thege-specific DW already contained an allowance for the prevalencef cardiac ailments in the general population resulting in the DW ofurvivors being biased downwards. Third, additional cost per DALYnderestimation arises because we did not include the (discounted)verted costs of premature burials in our model. Fourth, our coster DALY ratio is likely to be lower relative to other countries ashe Israeli medical system is significantly understaffed (comparedo Europe or the US) in general and has slightly lower staffing ratiosor CPR in particular.

Finally, if (as we suspect) Israel provides too few rehabilitationervices, expenses on survivors would be underestimated but thisay be balanced out by there being greater residual damage, which

ould be more expensive in the long run.Lacking data on length of basic life support efforts or conver-

ion to a shockable rhythm during these efforts we were unable toetermine whether the Jerusalem EMS adhered to the recommen-ations to terminate treatment after 20 min for a non-shockablehythm 27.

An equivalent violation of guidelines for withholding or termi-ation of resuscitation of patients in pre-hospital traumatic cardiacrrest resulted in six patients surviving to hospital dischargeith a Glasgow Coma Score of six at a cost of $3852,446 while

dherence would have resulted in no loss of neurologically intacturvivors 28.

Regardless, the data in this paper on costs and utilities ofPR provides a basis for studying the effects of further potential

nterventions that can be evaluated in terms of their incremen-al costs per averted DALY. These interventions include programsf CPR training 29, adjusting local guidelines to avoid redundantnd overly-zealous life support efforts among patients unlikely tochieve good neurological outcomes (e.g. no bystander chest com-ression, prolonged arrival times, asystolic) 30.

Targeted CPR education at schools 31 and during mandatory mil-tary service 32 would likely promote early symptom recognitionnd bystander chest compression. The time to defibrillation coulde reduced through greater ambulance availability, provision ofome automated external defibrillators to persons at high-risk forudden cardiac death 33, deploying these in selected high-risk pub-ic locations 34 and equipping police 35 or fire services personnel 36

ith defibrillators to act as first responders.In addition, in-hospital treatment modifications should be con-

idered including application of standard treatment protocols 37

nd increasing the current use of therapeutic hypothermia 38. Thisould obviously depend on increasing the proportion of patientsith presenting rhythms of ventricular tachycardia/ventricular fib-

illation.

1

ation 86 (2015) 54–61

4. Conclusion

Anecdotal and poorly researched reports of success in seem-ingly futile situations, reluctance to admit defeat in the face of anextremely challenging medical situation, a culture of death denial39,40, and contention that basic and advanced life support should beviewed in light of considerations other than those of the patient 41

have resulted in little in-depth research into the economic impli-cations of cardiopulmonary resuscitation. Our study shows thecurrent package of interventions for OHCA is very cost-effective,since the cost per averted DALY is less than the GNP per capitafigure. Nonetheless, improved cost-effectiveness may be achievedby modifying the current intervention package, particularly by act-ing to decrease the percentage of people who survive with severeneurological disorders.

Sources of funding

This study was funded by a research grant from the IsraelNational Institute for Health Policy Research (no. 2008/90/a).

Conflict of interest statement

None.

Acknowledgments

We would like to extend our thanks to our research nursesDaniel Ziv and Nehama Kaufman for their assistance in data col-lection. To Israel Cohen, Ilan Gur Ari and their directors at the MDA,Israeli National EMS for allowing us to access OHCA case data. Wewould also like to thank Shifra Shif, Chair of the Department ofInformation Technology and her team, Amir Shemesh, Chief hospi-tal economist for providing data on in-hospital resource utilization,Todd Zalut, Director of the ED and Jonathan Balkin, Director of theCoronary Care Unit all at the SZMC for their patient responses toour multiple queries and harassments.

Appendix A. Supplementary data

Supplementary data associated with this article can be found,in the online version, at http://dx.doi.org/10.1016/j.resuscitation.2014.10.024

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