Syncope - Costly, Low-Yield Tests to Avoid

Written by Clay Smith

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The higher cost, lower yield tests to consider avoiding for patients ≥60 with syncope were: EEG, head CT, MRA, cardiac stress test, and EP study.

Why does this matter?
Syncope is a target diagnosis for Medicare to retrospectively audit and decide an admission was "unnecessary."  Given that in this cohort alone the serious 30-day adverse event rate was 25.1%, including such things as MI, stroke, major hemorrhage, SAH, etc, it seems a bit "armchair quarterback-ish" for Medicare to do this.  Regardless, there are some low-yield diagnostic tests that may be targets for cost reduction.

DFO (done fell out) workup
This was a prospective multicenter study of 3686 patients ≥60 with syncope or presyncope.  The goal was to observe the variability, frequency, yield, and cost of the workup.  All patients had a standardized H&P + ECG.  Ironically, the second lowest yield test was ECG, with only 1.9% of tests abnormal, just behind troponin at 1.3%.  Coronary angiography was infrequently done but had the highest overall proportion of abnormal results at 42%.  The most commonly ordered test was troponin in 88%.  The most widely variable from hospital to hospital was carotid ultrasound.  The most expensive when considering cost per abnormal test was electrophysiology (EP) study at $39,703 per abnormal test.  The highest total expense was echocardiogram at $672,648.  Of the top 5 tests ordered, echo had the highest proportion of abnormal results at 22%.  The biggest outliers in cost per abnormal result were cardiac stress tests, coronary angiogram, EEG, MRA, and EP study.  The higher cost, lower yield tests to consider avoiding without a compelling indication were: EEG, head CT, MRA, cardiac stress test, and EP study. Here is a table sorted by percent with an abnormal finding from lowest to highest.

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Variation in diagnostic testing for older patients with syncope in the emergency department.  Am J Emerg Med. 2018 Jul 23. pii: S0735-6757(18)30623-5. doi: 10.1016/j.ajem.2018.07.043. [Epub ahead of print]
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Reviewed by Thomas Davis

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