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Cited by 170Cardiovascular Syncope and Autonomic DisordersHealth Systems, Economic Evaluations, Quality of LifeHealthcare cost, quality, practices

Cost implications of testing strategy in patients with syncope

Open access
Krahn, Andrew D, Klein, George J, Yee, Raymond, Hoch, Jeffrey S, Skanes, Allan C·2003·Journal of the American College of Cardiology
DOI 10.1016/s0735-1097(03)00659-4
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Abstract

Objectives We sought to assess the cost implications of two investigation strategies in patients with unexplained syncope.Background Establishing a diagnosis in patients with unexplained syncope is complicated by infrequent and unpredictable events. The cost-effectiveness of immediate, prolonged monitoring as an alternative to conventional diagnostic strategies has not been studied.Methods Sixty patients (age 66 +/- 14 years; 33 males) with unexplained syncope and LV ejection fraction >35% were randomized to conventional testing with an external loop recorder, tilt and electrophysiologic (EP) testing, or prolonged monitoring with an implantable loop recorder with one-year monitoring. If patients remained undiagnosed after their assigned strategy, they were offered a crossover to the alternate strategy. Cost analysis of the two testing strategies was performed.Results Fourteen of 30 patients who were being monitored were diagnosed at a cost of 2,731 Canadian dollars +/- 285 Canadian dollars per patient and 5,852 Canadian dollars +/- 610 Canadian dollars per diagnosis. In contrast, only six of 30 conventional patients were diagnosed (20% vs. 47%, p = 0.029), at a cost of 1,683 Canadian dollars +/- 505 Canadian dollars per patient (p < 0.0001) and 8,414 Canadian dollars +/- 2,527 Canadian dollars per diagnosis (p < 0.0001). After crossover, a diagnosis was obtained in 1 of 5 patients undergoing conventional testing, compared with 8 of 21 patients who completed monitoring (20% vs. 38%, p = 0.44). Overall, a strategy of monitoring followed by tilt and EP testing was associated with a diagnostic yield of 50%, at a cost of 2,937 Canadian dollars +/- 579 Canadian dollars per patient and 5,875 Canadian dollars +/- 1,159 Canadian dollars per diagnosis. Conventional testing followed by monitoring was associated with a diagnostic yield of 47%, at a greater cost of 3,683 Canadian dollars +/- 1,490 Canadian dollars per patient (p = 0.013) and a greater cost per diagnosis (7,891 Canadian dollars +/- 3,193 Canadian dollars, p = 0.002).Conclusions A strategy of primary monitoring is more cost-effective than conventional testing in establishing a diagnosis in recurrent unexplained syncope.

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  • Randomized controlled trials of implantable loop recorder clinical effectiveness consistently show that for older patients with unexplained syncope, recorders should be used earlier rather than later in the investigation.

    “It is important to note that there have been randomized controlled trials of the devices’ clinical effectiveness, and the results consistently show that for older patients with unexplained syncope, recorders should be used earlier in the investigation rather than later.102–104”

    From 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope (2015) · cites this paper as [103]

    The Patients and Discussion sections describe a randomized comparison and report that using an implantable loop recorder as the primary monitoring strategy yielded more diagnoses than conventional testing in patients with unexplained syncope. But this paper reports one trial, not consistent results across multiple trials; it also advises trying an external loop recorder first when the patient can use one and cautions against generalizing its findings to all patients with syncope. (LLM, conf=0.86)

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  • Mean costs per diagnostic result were high in an outpatient specialty clinic for unexplained recurrent syncope ($19,900).

    “Finally, mean costs per diagnostic result were also high in an outpatient ($19,900) specialty clinic for unexplained recurrent syncope (163).”

    From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [163]

    The Cost of Testing in Syncope section reports costs per diagnosis for patients with unexplained syncope, but its overall figures are $5,875 for monitoring-first testing and $7,891 for conventional-first testing. The Patients section describes referrals to an arrhythmia service; our copy does not report a $19,900 mean cost per diagnostic result for an outpatient specialty clinic. (LLM, conf=0.82)

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Research works printed but not linked: 1

  1. [21]21. Sutton R, Bloomfield DM. Indications, methodology, and classifica- tion of results of tilt-table testing. Am J Cardiol 1999;84:10 -9Q.

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Authors
Krahn, A. D., Klein, G. J., Yee, R., Hoch, J. S., & Skanes, A. C.
Affiliations
Western University (CA)
Corresponding author
Krahn, Andrew D
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2003-08
Volume
42
Issue
3
Pages
495-501
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/s0735-1097(03)00659-4
OpenAlex
W2130890027
Semantic Scholar
fb515b0e264326bf89e06d61086adca7e71aabcd
Cited by
170
References
34
Citations by year
2026: 3 · 2025: 4 · 2024: 1 · 2023: 1 · 2022: 5 · 2021: 6 · 2020: 3 · 2019: 1 · 2018: 4 · 2017: 12 · 2016: 17 · 2015: 14 · 2014: 13 · 2013: 14 · 2012: 9
FWCI
7.67
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
Funders
Heart and Stroke Foundation of Canada
Topics
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
  • Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
Keywords
unexplained syncope, cost-effectiveness, implantable loop recorder, prolonged cardiac monitoring, tilt table test, electrophysiologic testing, diagnostic yield, recurrent syncope, diagnostic approach, elderly patients, crossover design, United States comparison, United Kingdom comparison
MeSH terms
Aged, Costs and Cost Analysis, Electrodes, Implanted, Female, Humans, Male, Middle Aged, Prospective Studies, Recurrence, Syncope, Electrocardiography, Ambulatory

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