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January 23, 1995

Ambulatory Electrocardiography: A Cost per Management Decision Analysis

Author Affiliations

From the Division of Cardiology, Department of Medicine, University of Miami (Fla) School of Medicine, and the Cardiology Section, Medical Service, Department of Veterans Affairs Medical Center, Miami, Fla.

Arch Intern Med. 1995;155(2):165-169. doi:10.1001/archinte.1995.00430020052006

Background:  This study evaluated the current clinical use and costs of ambulatory electrocardiographic (AECG) monitoring for arrhythmia detection based on a cost per management decision analysis.

Methods:  Consecutive inpatient and outpatient 24-hour AECGs (n=650) performed during the calendar year 1991 were retrospectively reviewed for clinical indication, arrhythmia detection, diary information, and whether a management decision that might alter patient outcome was derived from the data. The cost per management decision (based on a representative reimbursement of $550 per AECG) and the cost index (CI) (all tests divided by useful tests) were calculated.

Results:  Although arrhythmias were identified in 91% of the patients, management decisions were indicated in only 18% (cost per decision, $2974; CI=5.4). Management decisions were most often derived from the data in patients being evaluated for arrhythmia therapy (37 of 37 patients; cost per decision, $550; CI=1). Symptoms and arrhythmias were correlated in only 11 patients (2%) More often typical clinical symptoms were present (26 patients) in the absence of an arrhythmia. Of 101 AECGs following a cerebrovascular event, four had unsuspected atrial fibrillation (cost per decision, $13 888; CI=25.0). Dizziness or lightheadednessassociated with other cardiac symptoms was more likely to lead to a management decision than the same symptoms in isolation (29% vs 7%; P<.05). No patient had central nervous system symptoms correlated with an arrhythmia during the recording period or unsuspected ventricular tachycardia.

Conclusion:  Ambulatory electrocardiography has a highly variable and indication-dependent effectiveness and cost. The results suggest a strategy for improving the use of AECG based on knowing what testing indications are more likely to lead to useful clinical information.(Arch Intern Med. 1995;155:165-169)