Mallika Mendu

Date of Award

9-21-2009

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

First Advisor

Mary Tinetti

Abstract

ABSTRACT: YIELD OF DIAGNOSTIC TESTS IN THE EVALUATION OF SYNCOPAL EPISODES IN OLDER PATIENTS Mallika L. Mendu, Gail McAvay, Rachel Lampert, Jonathan Stoehr, Mary E. Tinetti, Department of Internal Medicine, Department of Epidemiology and Public Health Yale University, School of Medicine, New Haven, CT Syncopal episodes are common among older adults; etiologies range from benign to life-threatening. We determined the frequency, yield, and costs of tests obtained to evaluate older persons with syncope. We also calculated the cost per test yield and determined whether the San Francisco Syncope Rule (SFSR) improved test yield. Review of 2,106 consecutive patients 65 years and older admitted following a syncopal episode. Electrocardiograms (99%), telemetry (95%), cardiac enzymes (95%), and head computed tomography (CT) (63%) were the most frequently obtained tests. Cardiac enzymes, CTs, echocardiograms, carotid ultrasounds, and electroencephalography all affected diagnosis or management in <5% of cases and helped determine etiology of syncope < 2% of the time. Postural blood pressure, performed in only 38% of episodes, had the highest yield with respect to affecting diagnosis (18-26%) or management (25-30%) and determining etiology of the syncopal episode (15-21%). The cost per test affecting diagnosis or management was highest for electroencephalography ($32,973), CT ($24,881), and cardiac enzymes ($22,397) and lowest for postural blood pressure ($17-$20). The yields and costs for cardiac tests were better among patients meeting, than not meeting, SFSR. For example, the cost per cardiac enzymes affecting diagnosis or management was $10,331 in those meeting, versus $111,518 in those not meeting, the SFSR. Many unnecessary tests are obtained to evaluate syncope. Selecting tests based on history and examination and prioritizing less expensive and higher yield tests would ensure a more informed and cost-effective approach to evaluating older patients with syncope.

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This is an Open Access Thesis.

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