The impact of including passive benefits in cost-effectiveness analysis: The case of automated external defibrillators on commercial aircraft

Objective: Traditional cost-utility analysis assumes that all benefits from health-related interventions are captured by the quality-adjusted life-years (QALYs) gained by the few individuals whose outcome is improved by the intervention. However, it is possible that many individuals who do not directly benefit from an intervention receive utility, and therefore QALYs, because of the passive benefit (aka sense of security) provided by the existence of the intervention. The objective of this study was to evaluate the impact that varying quantities of passive benefit have on the cost-effectiveness of airline defibrillator programs. Methods: A decision analytic model with Markov processes was constructed to evaluate the cost-effectiveness of defibrillator deployment on domestic commercial passenger aircraft over 1 year. Airline passengers were assigned small incremental utility gains (.001-.01) during an estimated 3-hour flight to evaluate the impact of passive benefit on overall cost-effectiveness. Results: In the base case analysis with no allowance for passive benefit, the cost-effectiveness of airline automated external defibrillator deployment was $34,000 per QALY gained. If 1% of all passengers received utility gain of .01, the cost-effectiveness declined to $30,000. Cost-effectiveness was enhanced when the quantity of passive benefit was raised or the percentage of individuals receiving passive benefit increased. Conclusions: Automated external defibrillator deployment on passenger aircraft is likely to be cost-effective. If a small percentage of airline passengers receive incremental utility gains from passive benefit of automated external defibrillator availability, the impact on overall cost-effectiveness may be substantial. Further research should attempt to clarify the magnitude and percentage of patients who receive passive benefit.