Krahn Andrew D, Klein George J, Yee Raymond, Hoch Jeffrey S, Skanes Allan C
Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.
J Am Coll Cardiol. 2003 Aug 6;42(3):495-501. doi: 10.1016/s0735-1097(03)00659-4.
We sought to assess the cost implications of two investigation strategies in patients with unexplained syncope.
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.
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.
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).
A strategy of primary monitoring is more cost-effective than conventional testing in establishing a diagnosis in recurrent unexplained syncope.
我们试图评估两种检查策略对不明原因晕厥患者的成本影响。
不明原因晕厥患者的诊断因发作不频繁且不可预测而变得复杂。作为传统诊断策略的替代方法，立即进行长时间监测的成本效益尚未得到研究。
60例不明原因晕厥且左室射血分数>35%的患者（年龄66±14岁；男性33例）被随机分为接受外置式循环记录仪、倾斜试验和电生理（EP）检查的传统检测组，或接受植入式循环记录仪进行一年监测的长时间监测组。如果患者在其指定策略后仍未确诊，则为他们提供交叉至另一种策略的机会。对两种检测策略进行成本分析。
接受监测的30例患者中有14例被诊断，每位患者的成本为2731加元±285加元，每次诊断的成本为5852加元±610加元。相比之下，30例接受传统检查的患者中只有6例被诊断（20%对47%，p = 0.029），每位患者的成本为1683加元±505加元（p < 0.0001），每次诊断的成本为8414加元±2527加元（p < 0.0001）。交叉后，接受传统检查的5例患者中有1例得到诊断，而完成监测的21例患者中有8例得到诊断（20%对38%，p = 0.44）。总体而言，先进行监测然后进行倾斜试验和EP检查的策略诊断率为50%，每位患者的成本为2937加元±579加元，每次诊断的成本为5875加元±1159加元。先进行传统检查然后进行监测的诊断率为47%，每位患者的成本更高，为3683加元±1490加元（p = 0.013），每次诊断的成本更高（7891加元±3193加元，p = 0.002）。
在复发性不明原因晕厥的诊断中，以监测为主的策略比传统检查更具成本效益。
