IntraVenous vs IntraOsseous access in Cardiac Arrest: the omitted economic question (IVOCA study)

Aims : Intraosseous (IO) access is increasingly used during out-of-hospital cardiac arrest (OHCA) despite higher device costs and no proven clinical superiority over peripheral intravenous (IV) access. We conducted a cost-minimization analysis to estimate device-related costs under observed current practice and hypothetical alternative IV/IO strategies. Methods : Retrospective cohort study using regional data from the French national OHCA registry (RéAC), 2013–2024 (Seine-Saint-Denis, France). Patients receiving adrenaline (epinephrine) via IV or IO were included. Unit costs were €0.6 per IV catheter and €109 per IO needle. Scenario modelling was used to estimate device costs for alternative strategies (first-line IO versus stepwise IV-to-IO), using cumulative IV success rates (65% after one attempt to 99% after four), assuming 100% IO success, and applied to median annual registry volumes. Results : Among 10,737 OHCAs, 5,350 (50%) patients were included (median age 62 years; 30% women). Access was IV only in 4,128 (77%), IO only in 1,092 (20%), and both in 130 (2%). Annual IO device costs increased from €5,450 in 2013 to a peak of €16,350 in 2022, totaling €133,198 versus €2,555 for IV. Return of spontaneous circulation (ROSC) occurred in 31% of cases (−0.3% annual decline); 30-day survival was 2.8% (−0.08% annual decline). Scenario modelling indicated that systematic first-line IO would correspond to €349 per ROSC and €3,974 per survivor in device costs, whereas a strategy without IO would correspond to €2 per ROSC and €22 per survivor. Conclusion Over the study period, IO use increased and generated substantially higher device costs. In the absence of proven clinical superiority, an IV-first strategy with selective IO use appears economically preferable.