title: Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial.
abstract: OBJECTIVE
  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.
authors.affiliation: Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada. akrahn@uwo.ca
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Krahn
authors.forename: George J
authors.initials: GJ
authors.lastname: Klein
authors.forename: Raymond
authors.initials: R
authors.lastname: Yee
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.forename: Allan C
authors.initials: AC
authors.lastname: Skanes
mesh_terms: D000368:Aged; D003365:Costs and Cost Analysis; D015716:Electrocardiography, Ambulatory / Q000191:economics* / Q000379:methods*; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D013575:Syncope / Q000175:diagnosis* / Q000209:etiology