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Cost implications of testing strategy in patients with syncope
Open accessAbstract
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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“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]
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“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]
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Metadata
- Authors
- Krahn, A. D., Klein, G. J., Yee, R., Hoch, J. S., & Skanes, A. C.
- Affiliations
- Western University (CA)
- Corresponding author
- Krahn, Andrew D
- 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)
- 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
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Heart and Stroke Foundation of Canada
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › 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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