Context

Octogenarians are the fastest growing segment of the population and little is known about the results of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest in this population.

Objective

We sought to investigate the clinical benefit and cost-effectiveness of CPR after in-hospital cardiac arrest in octogenarians.

Main outcome measure

Years of life saved.

Design

Effectiveness data were obtained from a review of 91,372 hospital discharges from January 1st, 1993 until June 30th, 1996. Cardiac arrest was reported in 956 patients. The study group consisted of 474 patients > or = 80 years old. CPR costs included equipment and training, physician and nursing time and medications. Post-CPR expenses included in-hospital true cost, repeat hospitalizations, physician office visits, nursing home, rehabilitation, and chronic care hospital costs. Life expectancy of the patients who were still alive at the end of the study was estimated from census data. A utility of 0.8 was used to calculate quality-adjusted-life years saved (QALYS). We used a societal perspective for analysis.

Results

The study population was 86 +/- 4.8 years old (range 80-103), and 42% were male. Fifty-four patients (11%) were discharged alive, 35 to a chronic care facility and 19 to their home. Assuming that a cardiac arrest without CPR has 100% mortality, 12 octogenarians required treatment with CPR in order to save one life to hospital discharge. Similarly, 29 octogenarian patients with cardiac arrest have to be treated with CPR to net one long-term survivor (mean survival 21 months, with a range from 9 to 48 months). The cost-effectiveness ratio, after estimating the life expectancy of octogenarian survivors, was USD 50,412 per year of life saved, and USD 63,015 per QALYS. However, a utility of 0.5 yielded a cost of USD 100,825 per QALYS.

Conclusion

In comparison with other life-saving strategies, CPR in octogenarians is effective. The favorable cost-effectiveness ratio is highly dependent on the patients' preference for quality rather than quantity of life, as expressed by the utility assumptions.

Background

Health value or utility is the abstracted magnitude of a person's preference for quality and quantity of life. It reflects how much lifetime with the patient's current health condition a patient is willing to exchange for a life in excellent health. Health values are used in cost-effectiveness analysis as a means of calculating quality-adjusted years of life.

Objective

This study assessed the health values of elderly patients before and after pacemaker implantation.

Methods

We prospectively examined 398 patients from the Pacemaker Selection in the Elderly study, in which patients were randomized to either VVIR or DDDR mode. Health values were estimated with the time tradeoff method before implantation and at 3, 9, and 18 months after implantation.

Results

The mean age of patients was 76 +/- 6 years; 234 patients (59%) were male. At baseline, patients were, on average, willing to exchange 5 years of current health for approximately 4 years in perfect health (value 0.76 +/- 0.06). There was no difference in baseline health values with implant diagnosis (sinus node dysfunction n = 172, 0.72, atrioventricular block n = 227, 0.75, other diagnoses n = 39, 0.78, P = not significant). The overall improvement in health values at 3 months after pacemaker implantation was 0.165 +/- 0.4 (P =.0001). The improvement in health values was independent of pacing mode (P =.6). The time tradeoff score was modestly correlated with other measurements of health-related quality of life. The change in time tradeoff score with time was not influenced by demographic characteristics such as age and sex, diagnoses, pacing mode, employment status, or history of angina. Patients with a lower functional class at enrollment (III or IV on the Specific Activity Scale) demonstrated an absolute improvement of 23% in their health values, whereas patients in class I or II improved only by 12%, (P =.03).

Conclusions

Permanent pacemaker implantation for standard indications improves health values and descriptive health status measures. The values reported here may be used as a means of calculating the cost-effectiveness of different pacing modalities.