Real-world cost-effectiveness of targeted temperature management in out-of-hospital cardiac arrest survivors: results from an academic medical center

doi:10.5847/wjem.j.1920-8642.2025.012

Abstract

Abstract:

BACKGROUND Targeted temperature management (TTM) is a common therapeutic intervention, yet its cost-effectiveness remains uncertain. This study aimed to evaluate the real-world cost-effectiveness of TTM compared with that of conventional care in adult out-of-hospital cardiac arrest (OHCA) survivors using clinical patient-level data.

METHODS: We conducted a retrospective cohort study at an academic medical center in the USA to assess the cost-effectiveness of TTM in adult non-traumatic OHCA survivors between 1 January, 2019 and 30 June, 2023. The primary outcome was survival to hospital discharge. Incremental cost-effectiveness ratios (ICERs) were calculated and compared with various decision makers’ willingness to pay. Cost-effectiveness acceptability curves were utilized to evaluate the economic attractiveness of TTM. Uncertainty about the incremental cost and effect was explored with a 95% confidence ellipse.

RESULTS: Among 925 non-traumatic OHCA survivors, only 30 (3%) received TTM. After adjusting for potential confounders, the TTM group did not demonstrate a significantly lower cost (delta cost -\$5,141, 95% confidence interval [95% CI]: \$-35,347 to $25,065, P=0.79) and higher survival to hospital discharge (delta effect 6%, 95% CI: -11% to 23%, P=0.41). Additionally, a 95% confidence ellipse indicated uncertainty reflected by evidence that the true value of the ICER could be in any of the quadrants of the cost-effectiveness plane.

CONCLUSION: Although TTM did not demonstrate a clear survival benefit in this study, its potential cost-effectiveness warrants further investigation with larger sample sizes. These findings highlight the need for additional research to optimize TTM use in OHCA care and inform resource allocation decisions.

Key words: Out-of-hospital cardiac arrest, Targeted temperature management, Cost-effectiveness, Survival, Real-world data

Wachira Wongtanasarasin, Daniel K. Nishijima, Wanrudee Isaranuwatchai, Jeffrey S. Hoch. Real-world cost-effectiveness of targeted temperature management in out-of-hospital cardiac arrest survivors: results from an academic medical center[J]. World Journal of Emergency Medicine, 2025, 16(1): 28-34.

Figures/Tables 4

Figure 1.

Table 1.

Characteristics and demographics of the included participants

Variables	Total (n=925)	TTM (n=30)	Non-TTM (n=895)	P-value
Age, years, mean±SD	61.4±16.3	59.6±12.6	61.4±16.4	0.54^a
Age categories, n (%)				0.46^b
18-49 years	200 (22)	8 (27)	192 (22)
50-69 years	420 (45)	15 (50)	405 (45)
≥70 years	305 (33)	7 (23)	298 (33)
Male, n (%)	573 (62)	17 (57)	556 (62)	0.55^b
Race, n (%)				0.01^c
White	398 (44)	10 (35)	388 (45)
African American	147 (16)	2 (7)	145 (17)
Asian	103 (12)	1 (4)	102 (12)
Native Hawaii/Pacific islanders	19 (2)	3 (10)	16 (2)
American Indian/Alaskan Native	4 (1)	0 (0)	4 (1)
Others/Preferred not to state	226 (25)	13 (45)	213 (25)
Ethnicity, n (%)				0.02^b
Hispanic	156 (17)	10 (35)	146 (17)
Non-Hispanic	758 (83)	19 (66)	739 (84)
Day of the event, n (%)				0.29^b
Weekday	695 (75)	20 (67)	675 (75)
Weekend	230 (25)	10 (33)	220 (25)
Comorbidities, n (%)
Diabetes	269 (29)	5 (17)	264 (30)	0.15^c
Malignancy	155 (17)	1 (3)	154 (17)	0.05^c
Hypertension	197 (21)	9 (30)	188 (21)	0.24^b
Chronic kidney disease	284 (31)	7 (23)	277 (31)	0.37^b
Hyperlipidemia	255 (28)	5 (17)	250 (28)	0.22^c
Stroke	92 (10)	4 (13)	88 (10)	0.53^c
Chronic pulmonary disease	215 (23)	8 (27)	207 (23)	0.65^b
Myocardial infarction	338 (37)	11 (37)	327 (37)	0.99^b
Chronic heart failure	411 (44)	13 (43)	398 (44)	0.90^b
Peripheral vascular disease	57 (6)	1 (3)	56 (6)	1.00^c
Dementia	64 (7)	1 (3)	63 (7)	0.72^c
Chronic liver disease	121 (13)	2 (7)	119 (13)	0.41^c
Charlson Comorbidity Index, mean±SD	5.3±3.2	3.7±2.1	5.3±3.2	0.007^a
Co-interventions, n (%)
Extracorporeal cardiopulmonary resuscitation	8 (1)	0 (0)	8 (1)	1.00^c
Percutaneous coronary intervention	53 (6)	2 (7)	51 (6)	0.69^c
Hospital length of stay, d, median (IQR)	7 (2-16)	7 (4-14)	7 (2-16)	0.21^d
Total costs, $, median (IQR)	61,556 (30,052-134,985)	70,921 (50,580-114,166)	61,080 (29,552-136,790)	0.26^d
Direct costs, $, median (IQR)	38,253 (18,849-84,633)	45,320 (29,849-73,679)	37,529 (18,414-85,842)	0.25^d
Administrative costs, $, median (IQR)	24,086 (10,984-52,507)	27,690 (20,731-45,975)	23,969 (10,876-53,306)	0.30^d

Table 1.

Figure 2.

Figure 3.

References 27

1	Wong CX, Brown A, Lau DH, Chugh SS, Albert CM, Kalman JM, et al. Epidemiology of sudden cardiac death: global and regional perspectives. Heart Lung Circ. 2019; 28(1):6-14. doi: S1443-9506(18)31905-X pmid: 30482683
2	Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care. 2020; 24(1):61.
3	Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017; 135(10):e146-603.
4	Chai J, Fordyce CB, Guan M, Humphries K, Hutton J, Christenson J, et al. The association of duration of resuscitation and long-term survival and functional outcomes after out-of-hospital cardiac arrest. Resuscitation. 2023; 182:109654.
5	Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med. 2021; 47(12):1393-414. doi: 10.1007/s00134-021-06548-2 pmid: 34705079
6	Merchant RM, Becker LB, Abella BS, Asch DA, Groeneveld PW. Cost-effectiveness of therapeutic hypothermia after cardiac arrest. Circ Cardiovasc Qual Outcomes. 2009; 2(5):421-8.
7	Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullén S, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med. 2021; 384(24):2283-94.
8	Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management at 33 °C versus 36 °C after cardiac arrest. N Engl J Med. 2013;369(23):2197-206.
9	Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, et al. 2023 American Heart Association focused update on adult advanced cardiovascular life support: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2024; 149(5):e254-73.
10	Bakhsh A, Alotaibi H, Alothman S, Alothman A, Alothman R, Alsulami A, et al. Opinions and attitudes toward targeted temperature management in the emergency department and intensive care unit in a developing country: a survey study. World J Emerg Med. 2023; 14(2):138-42. doi: 10.5847/wjem.j.1920-8642.2023.030 pmid: 36911059
11	Lüsebrink E, Binzenhöfer L, Kellnar A, Scherer C, Schier J, Kleeberger J, et al. Targeted temperature management in postresuscitation care after incorporating results of the TTM2 Trial. J Am Heart Assoc. 2022;11(21):e026539.
12	Bisht A, Gopinath A, Cheema AH, Chaludiya K, Khalid M, Nwosu M, et al. Targeted temperature management after cardiac arrest: a systematic review. Cureus. 2022; 14(9):e29016.
13	Javanbakht M, Mashayekhi A, Hemami MR, Branagan-Harris M, Keeble TR, Yaghoubi M. Cost-effectiveness analysis of intravascular targeted temperature management after cardiac arrest in England. Pharmacoecon Open. 2022; 6(4):549-62. doi: 10.1007/s41669-022-00333-7 pmid: 35503202
14	Guo GQ, Ma YN, Xu S, Zhang HR, Sun P. Effect of post-rewarming fever after targeted temperature management in cardiac arrest patients: a systematic review and meta-analysis. World J Emerg Med. 2023; 14(3):217-23.
15	Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Ann Intern Med. 2007; 147:573-7. doi: 10.7326/0003-4819-147-8-200710160-00010 pmid: 17938396
16	Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: updated reporting guidance for health economic evaluations. Pharmacoeconomics. 2022; 40(6):601-9.
17	Hoch JS, Briggs AH, Willan AR. Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis. Health Econ. 2002; 11(5):415-30. doi: 10.1002/hec.678 pmid: 12112491
18	Hoch JS, Rockx MA, Krahn AD. Using the net benefit regression framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of “community acquired” syncope. BMC Health Serv Res. 2006; 6(1):68.
19	Donnino MW, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, et al. Temperature management after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Circulation. 2015; 132(25):2448-56. doi: 10.1161/CIR.0000000000000313 pmid: 26434495
20	Toma A, Bensimon CM, Dainty KN, Rubenfeld GD, Morrison LJ, Brooks SC. Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: a qualitative study of emergency department and critical care workers. Crit Care Med. 2010; 38(2):504-9. doi: 10.1097/CCM.0b013e3181cb0a02 pmid: 20016377
21	Bigham BL, Dainty KN, Scales DC, Morrison LJ, Brooks SC. Predictors of adopting therapeutic hypothermia for postcardiac arrest patients among Canadian emergency and critical care physicians. Resuscitation. 2010; 81(1):20-4. doi: 10.1016/j.resuscitation.2009.09.022 pmid: 19913981
22	Matilla-García M, Ubeda Molla P, Sánchez Martínez F, Ariza-Solé A, Gómez-López R, López de Sá E, et al. Economic burden of cardiac arrest in Spain: analyzing healthcare costs drivers and treatment strategies cost-effectiveness. BMC Health Serv Res. 2023; 23(1):1220. doi: 10.1186/s12913-023-10274-4 pmid: 37936221
23	Punniyakotty B, Ong XL, Ahmad M, Kirresh A. Improving mortality in pediatric out-of-hospital cardiac arrest events requires a multifactorial approach. JACC Asia. 2023; 3(1):166. doi: 10.1016/j.jacasi.2022.11.011 pmid: 36873764
24	Nguyen DD, Spertus JA, Uzendu AI, Kennedy KF, McNally BF, Chan PS. Alignment of targeted temperature management treatment with patients’ mortality risk for out-of-hospital cardiac arrest. Resuscitation. 2022; 181:110-8. doi: 10.1016/j.resuscitation.2022.10.024 pmid: 36336197
25	Damluji AA, Al-Damluji MS, Pomenti S, Zhang TJ, Cohen MG, Mitrani RD, et al. Health care costs after cardiac arrest in the United States. Circ Arrhythm Electrophysiol. 2018; 11(4):e005689.
26	Geri G, Scales DC, Koh M, Wijeysundera HC, Lin S, Feldman M, et al. Healthcare costs and resource utilization associated with treatment of out-of-hospital cardiac arrest. Resuscitation. 2020; 153:234-42. doi: S0300-9572(20)30170-2 pmid: 32422247
27	Wang H, Zhao H. Estimating incremental cost-effectiveness ratios and their confidence intervals with differentially censored data. Biometrics. 2006; 62(2):570-5. pmid: 16918922

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