Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal

BMC Cardiovascular Disorders

Stelios Tsintzos⁷  Simon Eggington⁷  Sara Farinha⁴  Vitor Sanfins⁵  Luís Elvas¹  Hipólito Reis³  Carlos Morais²  Rui Candeias⁶  Rui Providência⁸ 

[1] Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra, Portugal;Hospital Prof. Doutor Fernando da Fonseca EPE, Amadora, Portugal;Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal;Medtronic, Lisboa, Portugal;Hospital de Guimarães, Centro Hospitalar do Alto Ave EPE, Guimarães, Portugal;Hospital de Faro EPE, Faro, Portugal;Medtronic, Tolochenaz, Switzerland;Serviço de Cardiologia, Hospital Geral do, Centro Hospital e Universitário de Coimbra, Quinta dos Vales, 3041-801 S. Martinho do Bispo, Coimbra, Portugal

关键词: Budget impact analysis;    Emergency department;    Implantable loop recorder;    Syncope;   

Others  :  855072
DOI  :  10.1186/1471-2261-14-63

 received in 2013-08-30, accepted in 2014-04-28,  发布年份 2014

【 摘 要 】

Background

To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS).

Methods

A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons.

Results

The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP).

Conclusion

The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

【 授权许可】

   
2014 Providência et al.; licensee BioMed Central Ltd.

【 图 表 】

【 参考文献 】

• [1]Ammirati F, Colivicchi F, Santini M: Diagnosing syncope in clinical practice. Implementation of a simplified diagnostic algorithm in a multicentre prospective trial - the OESIL 2 study (Osservatorio Epidemiologico della Sincope nel Lazio). Eur Heart J 2000, 21(11):935-940.
• [2]Blanc J, L’Her C, Touiza A, Garo B, L’Her E, Mansourati J: Prospective evaluation and outcome of patients admitted for syncope over a 1 year period. Eur Heart J 2002, 23(10):815-820.
• [3]Blanc J, L’her C, Gosselin G, Cornily J, Fatemi M: Prospective evaluation of an educational programme for physicians involved in the management of syncope. Europace 2005, 7(4):400-406.
• [4]Brignole M, Menozzi C, Bartoletti A, Giada F, Lagi A, Ungar A, Ponassi I, Mussi C, Maggi R, Re G, Furlan R, Rovelli G, Ponzi P, Scivales A: A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 2006, 27(1):76-82.
• [5]Crane S: Risk stratification of patients with syncope in an accident and emergency department. Emerg Med J 2002, 19(1):23-27.
• [6]Sarasin F, Louis-Simonet M, Carballo D, Slama S, Rajeswaran A, Metzger J, Lovis C, Unger PF, Junod AF: Prospective evaluation of patients with syncope: a population-based study. Am J Med 2001, 111(3):177-184.
• [7]Baron-Esquivias G, Matínez-Alday J, Matín A, Moya A, García-Rivera R, López-Chicharro MP, Martín-Mendez M, del Arco C, Laguna P: Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loss of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study. Europace 2010, 12:869-876.
• [8]Brignole M, Disertori M, Menozzi C, Raviele A, Alboni P, Pitzalis M, Delise P, Puggioni E, Del Greco M, Malavasi V, Lunati M, Pepe M, Fabrizi D: Management of syncope referred urgently to general hospitals with and without syncope units. Europace 2003, 5(3):293-298.
• [9]Krahn A, Klein G, Yee R, Manda V: The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart J 1999, 137(5):870-877.
• [10]Maisel W, Stevenson W: Syncope: getting to the heart of the matter. N Engl J Med 2002, 347(12):931-933.
• [11]Soteriades E, Evans J, Larson M, Chen M, Chen L, Benjamin EJ, Levy D: Incidence and prognosis of syncope. N Engl J Med 2002, 347(12):878-885.
• [12]Krahn A, Klein G, Yee R, Skanes A: Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy. Circulation 2001, 104(1):46-51.
• [13]Brignole M, Ungar A, Bartoletti A, Ponassi I, Lagi A, Mussi C, Ribani MA, Tava G, Disertori M, Quartieri F, Alboni P, Raviele A, Ammirati F, Scivales A, De Santo T: Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace 2006, 8(8):644-650.
• [14]Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm J, Task Force for the Diagnosis and Management of Syncope: Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009, 30(21):2631-2671.
• [15]Krahn A, Klein G, Yee R, Hoch J, Skanes A: Cost implications of testing strategy in patients with syncope: randomized assessment of syncope trial. J Am Coll Cardiol 2003, 42(3):495-501.
• [16]Farwell D, Freemantle N, Sulke A: Use of implantable loop recorders in the diagnosis and management of syncope. Eur Heart J 2004, 25(14):1257-1263.
• [17]Brignole M, Vardas P, Hoffman E, Huikuri H, Moya A, Ricci R, Sulke N, Wieling W, Auricchio A, Lip GY, Almendral J, Kirchhof P, Aliot E, Gasparini M, Braunschweig F, EHRA Scientific Documents Committee: Indications for the use of diagnostic implantable and external ECG loop recorders. Europace 2009, 11(5):671-687.
• [18]Instituto Nacional de Estatística (Statistics Portugal): Tabelas de Mortalidade (2008–2010). [Online]: Instituto Nacional de Estatística. cited 2012 January 20. Available from: [http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=107454430&DESTAQUESmodo=2 webcite]
• [19]Farwell D, Freemantle N, Sulke N: The clinical impact of implantable loop recorders in patients with syncope. Eur Heart J 2006, 27(3):351-356.
• [20]Brignole M, Bellardine Black C, Thomsen P, Sutton R, Moya A, Stadler R, Cao J, Messier M, Huikuri HV: Improved arrhythmia detection in implantable loop recorders. J Cardiovasc Electrophysiol 2008, 19(9):928-934.
• [21]Edvardsson N, Frykman V, van Mechelen R, Mitro P, Mohii-Oskarsson A, Pasquié J, Ramanna H, Schwertfeger F, Ventura R, Voulgaraki D, Garutti C, Stolt P, Linker NJ: Use of an implantable loop recorder to increase the diagnostic yield in unexplained syncope: results from the PICTURE registry. Europace 2011, 13(2):262-269.
• [22]Administração Central do Sistema de Saúde (Central Administration of the Health System): Relatório Nacional de Retorno 2006. [Online]. cited 2012 January 20. Available from: [http://www.acss.min-saude.pt/ÁreaseUnidades/FinanciamentoeContratualização/CodificaçãoClínica/tabid/358/language/pt-PT/Default.aspx webcite]
• [23]van Dijk N, Boer K, Colman N, Bakker A, Stam J, van Grieken J, Wilde AA, Linzer M, Reitsma JB, Wieling W: High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment Study. J Cardiovasc Electrophysiol 2008, 19(1):48-55.
• [24]Sousa P, Marques N, Faria R, Trigo J, Chin J, Amado J, Pereira S, Candeias R, de Jesus I: Syncope unit: experience of a center using diagnostic flowcharts for syncope of uncertain etiology after initial assessment. Rev Port Cardiol 2013. Epub ahead of print
• [25]Diário da República‒ 1: ª série — N.° 80 — 24 de abril de 2013. Portaria 163/2013.
• [26]Bartoletti A, Fabiani P, Bagnoli L, Cappelletti C, Cappellini M, Nappini G, Gianni R, Lavacchi A, Santoro GM: Physical injuries caused by a transient loss of consciousness: main clinical characteristics of patients and diagnostic contribution of carotid sinus massage. Eur Heart J 2008, 29(5):618-624.
• [27]Davis S, Westby M, Pitcher D, Petkar S: Implantable loop recorders are cost-effective when used to investigate transient loss of consciousness which is either suspected to be arrhythmic or remains unexplained. Europace 2012, 14(3):402-409.
• [28]Davis S, Westby M, Petkar S, Pitcher D: Tilt testing is more cost-effective than implantable loop recorder monitoring as a means of directing pacing therapy in people with recurrent episodes of suspected vasovagal syncope that affect their quality of life of life or present a high risk of injury. Heart 2013, 99(11):805-810.
• [29]da Silva EA, Pinto CG, Sampaio C, Pereira JA, Drummond M, Trindade R, INFARMED: Orientações Metodológicas para estudos de avaliação económica de medicamentos. [Online]. 1998. cited 2012 April 5. Available from: [http://www.infarmed.pt/portal/page/portal/INFARMED/MEDICAMENTOS_USO_HUMANO/AVALIACAO_ECONOMICA_E_COMPARTICIPACAO/MEDICAMENTOS_USO_AMBULATORIO/AVALIACAO_DE_COMPARTICIPACAO/Orien_Metodologicas_EAEM.pdf webcite]
• [30]Furukawa T, Maggi R, Bertolone C, Fontana D, Brignole M: Additional diagnostic value of very prolonged observation by implantable loop recorder in patients with unexplained syncope. J Cardiovasc Electrophysiol 2012, 23(1):67-71.
• [31]Vitale E, Ungar A, Maggi R, Francese M, Lunati M, Colaceci R, Del Rosso A, Castro A, Santini M, Giuli S, Belgini L, Casagranda I, Brignole M: Discrepancy between clinical practice and standardized indications for an implantable loop recorder in patients with unexplained syncope. Europace 2010, 12(10):1475-1479.
• [32]Auricchio A, Kuck KH, Hatala R, Arribas F: The Current Status of Cardiac Electrophysiology in ESC Member Countries. The EHRA White Book 2012. France: European Heart Rhythm Association; 2012.
• [33]EHRA White Book [Online] cited 2012 January 20. Available from: [http://www.escardio.org/communities/EHRA/publications/Pages/white-book-project.aspx webcite]
• [34]Kabra R, Gopinathannair R, Sandesara C, Messinger C, Olshansky B: The dual role of implantable loop recorder in patients with potentially arrhythmic symptoms: a retrospective single-center study. Pacing Clin Electrophysiol 2009, 32(7):908-912.
• [35]Kenny D, Chakrabarti S, Ranasinghe A, Chambers A, Martin R, Stuart G: Single-centre use of implantable loop recorders in patients with congenital heart disease. Europace 2009, 11(3):303-307.
• [36]Haeusler K, Koch L, Ueberreiter J, Coban N, Safak E, Kunze C, Villringer K, Endres M, Schultheiss HP, Fiebach JB, Schirdewan A: Safety and reliability of the insertable reveal XT recorder in patients undergoing 3 tesla brain magnetic resonance imaging. Heart Rhythm 2011, 8(3):373-376.
• [37]Morris S, Ridley S, Lecky F, Munro V, Christensen M: Determinants of hospital costs associated with traumatic brain injury in England and Wales. Anaesthesia 2008, 63:499-508.