To conduct an economic analysis of the implementation of the Ottawa Knee Rule.
The decision analysis compared usual practice based on physician judgment with practice based on a clinical decision rule, which allows more selective use of radiography. The study participants were all adults with blunt knee trauma. The likelihood and cost of radiography, missed fracture, lost productivity, and medicolegal actions were defined by published data and an expert panel. Separate analyses considered US Medicare and Canadian hospital costs. Sensitivity analyses considered a range of values for each variable in the model, including costs in a US fee-for-service setting. The study outcome was the mean cost per patient.
The mean cost savings associated with practice based on the Ottawa Knee Rule was $31 (95% confidence interval 22 to 44) to $34 (95% confidence interval 24 to 47) per patient. These results were robust to reasonable changes in the values of variables in the model.
Implementation of the Ottawa Knee Rule would be associated with meaningful reductions in societal health care costs both in the United States and Canada without a reduction in quality of care.
Comment In: Ann Emerg Med. 1999 Oct;34(4 Pt 1):535-710499954
To measure the incremental cost-effectiveness of various improvements to emergency medical services (EMS) systems aimed at increasing survival after out-of-hospital cardiac arrest.
We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the various EMS systems, (2) costing of each component of EMS systems, (3) modeling of the relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteristics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components.
The incremental cost-effectiveness ratio for a 48-second improvement in mean response time in a one-tier EMS system yielded by the addition of more EMS providers was $368,000 per quality-adjusted life year (QALY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53,000 per QALY with pump vehicles or $159,000 per QALY with ambulances. Change from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40,000. Change from one-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94,000.
The most attractive options in terms of incremental cost-effectiveness were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time.
The Ottawa Knee Rule is a previously validated clinical decision rule that was developed to allow physicians to be more selective and efficient in their use of plain radiography for patients with acute knee injuries.
To assess the impact on clinical practice of implementing the Ottawa Knee Rule.
Controlled clinical trial with before-after and concurrent controls.
Emergency departments of 2 teaching and 2 community hospitals.
All 3907 consecutive eligible adults seen with acute knee injuries during two 12-month periods before and after the intervention.
During the after period in the 2 intervention hospitals, the Ottawa Knee Rule was taught to all house staff and attending physicians who were encouraged to order knee radiography according to the rule.
Referral for knee radiography, accuracy and reliability of the rule, mean time in emergency department, and mean charges.
There was a relative reduction of 26.4% in the proportion of patients referred for knee radiography in the intervention group (77.6% vs 57.1 %; P
Comment In: JAMA. 1997 Dec 17;278(23):2108-99403428
The Ontario Prehospital Advanced Life Support (OPALS) Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period (1994-2002). The current article, Part II, describes in detail the rationale and methodology for major trauma and respiratory distress patients and for an economic evaluation of Advanced Life Support (ALS) programs in the OPALS Study. The OPALS Study, using a rigorous controlled methodology and a large sample size, should clearly indicate the benefit in trauma and respiratory distress patient survival and morbidity that results from the widespread introduction of prehospital ALS programs to communities of many different sizes. [Stiell IG, Wells GA, Spaite DW, Nichol G, O'Brien B, Munkley DP, Field BJ, Lyver MB, Luinstra LG, Dagnone E, Campeau T, Ward R, Anderson S, for the OPALS Study Group: The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients.
To evaluate the quality of life of survivors of in-hospital and out-of-hospital cardiac arrest, and to correlate quality of life with clinically important parameters.
Cohort followed at least six months after hospital discharge. Eligible patients had survived to hospital discharge after sudden cardiac arrest in 1) EDs, wards, and intensive care units of five university hospitals and 2) all locations outside hospitals in two midsized cities. Of 126 patients discharged alive, 30 died before they could be interviewed. Of the 96 patients remaining, 86 (90% of available patients, 68% of survivors to discharge) completed the interview. Quality of life was assessed with the Health Utilities Index Mark 3, which describes health as a utility score on a scale from perfect health (equal to 1.0) to death (equal to 0.)
Mean age (+/- SD) of interviewed survivors was 65 +/- 14 years, and 47 (55%) were male; mean time between collapse and initiation of CPR was 2.2 +/- 2.6 minutes. Mean utility was 0.72 (+/- 0.22). Utilities were significantly higher among patients who had a shorter duration of resuscitation (mean = 0.81 for those who received less than 2 minutes of CPR, 0.76 for those who received 3 to 10 minutes, and 0.65 for others, p = 0.05, r2 = 0.07). Mean utilities of survivors were worse than those of the general population (mean = 0.85 +/- 0.16, p