CORRESPONDENCE

ity of CRP in s c r e e n i n g for m e n ingitis.

Steven M Green, MD Steven G Rothrock, MD Riverside General Hospital Loma Linda University Medical Center Riverside and Loma Linda, California 1. 8ystat @ 5.0 statistical software, Evanston, Illinois. 2. Berry DA: Multiple comparisons, multiple tests, and data dredging: A Bayesian perspective, in: Bernardo JM, DeGroot MH, Lindley DV, et aI (eds]: Bayesian Statistics 3. Oxford, Oxford University Press, 1988, p 79-94. 3. Woolson RF: Statistical Methods .for the Analysis of Biomedical Data. New York, John Wiley and Sons, 1987, p 82-85.

'Economic Malpractice': Inappropriate Use of Cost Analysis To the Editor." T h e article, " C o s t - E f f e c t i v e n e s s A n a l y s i s of P a r a m e d i c E m e r g e n c y Medical Services in the Treatment of P r e h o s p i t a l C a r d i o p u l m o n a r y Arrest" by Valenzuela et al [December 1990;19:1407-1411] has a n u m b e r of p r o b l e m s . T h e q u e s t i o n p o s e d is w r o n g , a n d t h e c o s t a n a l y s i s is wrong. About 1.5 million Americans have heart attacks each year; 300,000 die before reaching the hospital. An excellent study by Eisenberg et al, "Survival Rates F r o m O u t - o f - H o s p i t a l Cardiac Arrest: R e c o m m e n d a t i o n s for Uniform Definitions and Data to R e p o r t " [ N o v e m b e r 1990;19:12491257], found the highest average survival rates (defined as survival to hospital discharge) from cardiac arrest from ventricular fibrillation in e m e r g e n c y m e d i c a l services (EMS) systems employing the highest trained individuals, ie, EMT-Ds plus paramedics. Yet it is invalid to define the cost of treating sudden cardiac death in the prehospital environment as "the additional cost of operating a paramedic level EMS system versus an Intermediate EMT level system" with vastly different response times. The Valenzuela cost analysis is inappropriate. Costs have two basic categories: fixed and variable (marginal). 1 The authors cannot count the fixed cost items in their analysis that 20:8 August 1991

m u s t exist if a basic EMS system is to exist. Is the only reason to have an advanced paramedic s y s t e m just to treat one condition - cardiac arrest? No. The appropriate cost analysis is a marginal cost analysis 2 of the variable costs for each ambulance run in the care of a cardiac arrest victim. This m a r g i n a l cost should be estimated by taking the total overhead operating costs of the paramedic run system (including education training costs3), multiplied by the fraction of runs made for cardiac arrest, added to the special equipment and medication costs for each cardiac arrest run (intubation, IV therapy, and monitor/ defibrillators). A l t h o u g h Eisenberg et al defined survivors of out-of-hospital cardiac arrest as those surviving to hospital discharge (including those with neurologic deficits and patients disc h a r g e d to n u r s i n g homes), m o r e r e f i n e m e n t is n e e d e d in o u t c o m e measures to be able to define "effectiveness." Comparing costs per year of life saved for such disparate disease processes as cardiac arrest, acute leukemia, and diseases treated with heart, liver, and bone marrow transplantation is like comparing apples to artichokes to argula - they're not in the same category even if they are all life-threatening (or edible). We believe that the cardiac arrest p a t i e n t p o p u l a t i o n in Valenzuela's study should exclude pediatric arrest, poisonings, and k n o w n terminal illness as well as traumatic cardiac arrest. It would be more valid and more intriguing to c o m p a r e age-adjusted s u r v i v a l rates f r o m v a r i o u s treatments as measured by years of life in which patients are discharged able to resume their previous functional level of activity.

Janet A Eastaugh, MD, FACEP Steven R Eastaugh, ScD George Washington University Washington, DC 1. Eastaugh SR: Medical Economics and Health Fi nance. Westport, Connecticut, Greenwood Press, 1981, p 340. 2. Eastaugh SR: Financing Health Care: Economic Efficiency and Equit]z Westport, Connecticut, Greenwood Press, 1987, p 720. 3. Eastaugh SR: Financing the rate of growth of medical technology. Quarterly Review of Economics and Busi ~ hess 1990~30:92-98.

Annals of Emergency Medicine

In Reply: I am grateful for the careful attention paid by the Drs Eastaugh to our article on cost-effectiveness analysis of p a r a m e d i c EMS. U n f o r t u n a t e l y , their observations are in error, likely because of an unfamiliarity with prehospital care in general and the treatm e n t of out-of-hospital cardiopulmonary arrest in particular. It is entirely valid to compare costs in a paramedic EMS system with rigorous response time standards (four minutes basic life support response; eight minutes advanced life support response) to an I n t e r m e d i a t e EMT system with response times that do not meet that standard. The former is capable of consistent successful resuscitation of out-of-hospital arrest; the latter is not.t Therefore, the additional resources required are legitimately the marginal costs of a serious effort to address this problem. Ask any EMS medical director. Interestingly, Drs Eastaugh seem unaware that modern paramedic EMS s y s t e m s were, in fact, established primarily to treat the problem of prehospital cardiac arrest. I am well aware that paramedic EMS syst e m s treat other conditions; however, quantifying the benefits (lives saved) in conditions other than cardiac arrest is, at present, not possible. Our analysis, therefore, determined a m i n i m u m cost-effectiveness for paramedic EMS. To the extent that these benefits exist, as clearly stated in the article, paramedic cost-effectiveness was underestimated. Drs E a s t a u g h prefer t h e i r o w n method of calculating marginal cost; this is entirely understandable. Our methods arc not, therefore, rendered "inappropriate." I direct Annals readers to Dr Eisenberg's book, Sudden Cardiac Death in the Community, z w h i c h c o n t a i n s a cost-effectiveness analysis of alternative EMS system configurations using methods very similar to ours. Readers will decide for themselves whether the suggestions of Drs Eastaugh are more appropriate or useful. I, too, am interested in the course of o u t - o f - h o s p i t a l arrest survivors and am currently studying it. However, the end points (lives saved and 944/169

'Economic malpractice': inappropriate use of cost analysis.

CORRESPONDENCE ity of CRP in s c r e e n i n g for m e n ingitis. Steven M Green, MD Steven G Rothrock, MD Riverside General Hospital Loma Linda Uni...
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