NEW YORK (Reuters Health) – Of all the tests commonly used to diagnose syncopal episodes in older patients, postural blood pressure testing is the one most likely to affect diagnosis and management, new research indicates. However, some of the most expensive, but least helpful, are the ones that tend to be ordered the most.
“Perhaps the finding in this study that causes the most concern is the extent to which unhelpful, and presumably unnecessary, testing in the evaluation of syncope continues to be performed despite the compelling evidence against the practice dating back 20 years,” Dr. Mary E. Tinetti and her group assert in the Archives of Internal Medicine for July 27.
The research team at Yale University School of Medicine in New Haven, Connecticut determined the diagnostic yield and costs of tests among patients age 65 years or older who presented to the emergency department with syncope between 2002 and 2006. Included were 1920 patients with a total admission count of 2106.
The most frequent tests — used for more than 90% of patients — were electrocardiogram, telemetry, and cardiac enzymes test. Echocardiography was ordered for 63% for the patients.
Postural blood pressure recording was performed in 38% of patients, although only 24% had recordings obtained while changing from a lying to a standing position. This test – costing less than $20 — was the one most frequently reported to have helped determine etiology of the syncopal episode.
Those least likely to affect diagnosis or management were computed tomography imaging of the head, carotid ultrasound, electroencephalography, and cardiac enzyme testing.
The most expensive tests were also the ones that helped determine the etiology of the fainting spell less than 2% of the time.
“Extrapolating our results nationally, assuming approximately 460,000 hospitalizations per year for syncope, yearly costs associated with the most commonly obtained tests may be nearly $6 billion,” Dr. Tinetti and associates write.
They recommend use of the San Francisco Syncope Rule for identifying patients likely to benefit from cardiac testing.
“Because almost one quarter of older patients who experience a syncopal episode experience serious injuries, such as a hip fracture, during the episode, another goal is to identify non-life-threatening, but treatable, etiologies such as postural hypotension,” Dr. Dinette’s group reports.
“Our study suggests that inexpensive postural blood pressure testing is greatly underutilized, resulting in many missed opportunities to institute effective treatment strategies such as medication reduction.”
In a related editorial, Dr. Paul A Heidenreich of Palo Alto VA Health Care System, California, predicts that studies such as this will help guide future appropriateness criteria for tests used in the evaluation of syncope.
Until then, he adds “we should be realistic in our communication with patients regarding our uncertainty, both in the etiology of syncope and in the value of testing.”
Reference:
Arch Intern Med 2009;169:1262-1264,1299-1305.
