Abstract 9778: Insertable Cardiac Monitoring in Unexplained Syncope Patients is Cost-Saving Compared to External ECG Monitoring Followed by Insertable Cardiac Monitor

Abstract

Background: Insertable cardiac monitors (ICMs) are recommended early in the evaluation of unexplained syncope patients after a non-diagnostic initial evaluation, and have been demonstrated as cost-effective for arrhythmia detection in this population. However, pathways frequently include short-term external cardiac monitors (ECM) prior to ICM. Objective: We aimed to evaluate the cost-effectiveness of immediate ICM versus a delayed ICM approach (30-day ECM followed by ICM in patients remaining undiagnosed), in unexplained syncope patients in the U.S. Methods: A discrete state Markov model assessed the cost-effectiveness of immediate vs. delayed ICM, from a U.S. payer perspective. Cohort characteristics were informed using the 2008-2016 Optum ® Clinformatics ® U.S. claims database. Syncope recurrence was modeled based on the EasyAs trial, with risks of mortality, injury, and quality of life consequences identified from the literature. ICM data capture was based on data for Reveal LINQ™ ICM. Diagnostic success with ECM was simulated based on the likelihood of monitoring occurring simultaneously to syncopal recurrence and patient adherence. Cost inputs were derived from claims and national average payment data. All diagnostic and arrhythmia-related treatment costs and benefits were modeled over a lifetime horizon, and future costs/effects were discounted at 3% per annum. Results: Immediate ICM was associated with lower lifetime per-patient costs compared to delayed ICM ($36,348 vs.$36,826), and a gain of 0.013 quality-adjusted life-years. This was largely driven by the cost of ECMs in the delayed ICM strategy, totaling $616,600 per 1,000 patients but with a small diagnostic yield such that 92.8%of patients required an ICM. The immediate ICM approach remained the dominant strategy when the assumed patient adherence to prescribed ECM was increased to 100%, and regardless of the choice of initial ECM (1, 2, 14, or 30-day monitor). Cost savings with immediate ICM increased further in scenarios assuming some delayed ICM patients are loss to follow-up after the initial ECM. Conclusions: A strategy of immediate ICM was cost-saving compared to delayed ICM, due to the cost and low diagnostic yield of ECM and the delay in arrhythmia detection and treatment.