The high cost of syncope: Cost implications of a new insertable loop recorder in the investigation of recurrent syncope

Background Patients with recurrent syncope frequently undergo extensive inv estigations that consume significant health care resources. Recent advances in long-term monitoring techniques have enhanced diagnostic yield in patie nts with infrequent symptoms. There is little information on the relative c ost-effective profile of the investigative tools used in patients with sync ope. Methods Two methods to determine health core costs in patients with syncope were used. In the first, health care resource utilization was determined i n 24 patients with recurrent unexplained syncope and negative investigation s who underwent insertion of the implantable loop recorder (IIR) during a p ilot study of the feasibility of the device. The costs of investigations be fore,during, and after 1LR implantation in each patient were calculated on the basis of median charges for an index investigation and a regression ana lysis of 1018 US Medicare hospital claims For syncope From 1993. Charges we re converted to costs using a cost-to-charge ratio of 0.64. The second meth od was based on estimated costs per diagnosis and published diagnostic yiel ds of 6 commonly applied tests in patients with syncope. A cohort simulatio n using theoretic models of 100 patients undergoing investigation for synco pe was created to compare the diagnostic yield and cost per diagnosis of va rious diagnostic cascades. Results In the pilot study, the cost of investigation of syncope in the 2 y ears before IIR insertion was $7584 per patient. After the 1LR was inserted ,a diagnosis was obtained in 21 of 24 patients -(diagnostic yield 88%). The cost of therapy was $2452; followed by a reduction in cost of care to $596 over 30 +/- 10 months of follow-up. In the second method, the diagnostic y ield of individual tests ranged from 3% for echocardiography to 88% For the 1LR. The cost per diagnosis obtained ranged from $529 for the external loo p recorder to $73,260 for-electrophysiologic testing in patients without st ructural heart disease. An approach to syncope similar to that of the IIR p ilot study resulted in a cost per diagnosis of $3193 and a diagnostic yield of 98%. Performance of echocardiography in half of the patients and electr ophysiologic testing only in the presence of structural heart disease reduc ed the cost to $2494 and retained a diagnostic yield of 98%. Conclusions The cost of investigation of syncope is high. The IIR may reduc e health care resource utilization by providing a diagnosis permitting defi nitive therapy. The cost per diagnosis profile of current diagnostic tests commonly used in patients with syncope is highly variable. A cost-effective approach to diagnosing this disorder can retain a high diagnostic yield wi th a reduction in resource utilization compared with a conventional approac h.