|
February
1997
Cardiopulmonary
resuscitation: What cost to cheat death?
Lee KH, Angus DC, Abramson NS;
Crit Care Med 1996; 24:2046-2052
[ see abstract below ]
"CPR: What cost to cheat death?" This timely and apposite question is posed
by Lee et al. in the December issue of Critical Care Medicine. They attempt
to answer it not by metanalysis but by evaluation of outcome data on CPR
from contemporary studies. In this they distinguished the resources required
for in-hospital arrest ("Code Team") from out-of-hospital arrest (EMS, physician
"on-line", ER).
In their review, the authors reaffirm that CPR is adversely affected by
the following factors:
- advanced age
- EMD or asystole
(survival 1-6% as opposed to 25% with VF or VT - and VF or VT occur
more commonly in younger patients)
- delay in BCLS and
ACLS (mortality has been calculated to increase 3% for each minute until
CPR is begun!)
- inadequate coronary
perfusion pressure (aortic - right atrial pressure gradient < 15 mmHg
during the relaxation phase of CPR)
- low end-tidal CO2
(indicative of poor pulmonary blood flow)
- failure to restore
spontaneous circulation in the field (almost 100% mortality)
Outcome after out-of-hospital
resuscitation is very dependent on time to CPR and subsequent EMS skills,
transport etc. However, despite prompt access to CPR and ACLS, in-hospital
resuscitation occurs in patients with a wide variety of underlying medical
disorders, so that the outcomes are no better. Most studies show a range
of 2-20% survival to hospital discharge.
Once patients leave hospital their survival is quite good - about 70%
at one year, and with about a 20% incidence of severe neurologic deficit.
Unfortunately, there are no reliable prognostic indices of long term outcome
after CPR.
In their discussion on cost analysis, the authors describe the limitations
of the various models used, pointing out that the cost depends not only
on the site and method by which CPR is delivered but also on the duration
and intensity of care provided after immediate resuscitation. They suggest
that the cost per 6-month survivor is about $400,000, and the cost per
quality-adjusted life years is about $225,000.
Although withholding of CPR - especially out-of-hospital CPR - poses too
great a moral and ethical dilemma to be addressed at present, they suggest
that we are leaving an era of saving at all costs "hearts too young to
die", and entering one where the question is posed: "What cost to cheat
death?"
Return to the Current Literature Review Front
Page, or read the abstract:
ABSTRACT
Objectives:
To review the various outcomes from cardiopulmonary resuscitation (CPR),
the factors that influence these outcomes, the costs associated with CPR,
and the application of cost analyses to CPR.
Data Sources:
Data used to prepare this article were drawn from published articles and
work in progress.
Study Selection:
Articles were selected for their relevance to the subjects of CPR and
cost-analysis by MEDLINE keyword search.
Data Extraction:
The authors extracted al applicable
data from the English literature.
Data Synthesis:
Cost-analysis studies of CPR programs are limited by the high variation
in resources consumed and attribution of cost to these resources. Furthermore,
cost projections have not been adjusted in reflect patient-dependent variation
in outcome. Variation in the patient's underlying condition, presenting
cardiac rhythm, time to provision of definitive CPR, and effective perfusion
all influence final outcome and, consequently, influence the cost-effectiveness
of CPR programs.
Based on the cost data from previous studies, preliminary estimates of the
cost-effectiveness of CPR programs for all 6-moth survivors of a large international
multicenter collaborative trial are $405,606.00 per life saved (range $344,314.00
to $966,759.00), and $225,882.00 per quality-adjusted-life-year (range $191,288.00
to $537,088.00).
Conclusions:
Reported outcome from CPR has varied from reasonable
rates of good recovery, including return to full employment to 100% mortality.
Appropriate CPR is encouraged, but continued widespread application appears
extremely expensive.
|
