Friday, September 4, 2009

Did you pass out? Felt dizzy? What you don't say can cost you.

A recent article in the Archives of Internal Medicine titled, "Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients" found that patients 65 years and older are often given unnecessary tests to determine episodes of syncope which is defined as "sudden, transient loss of consciousness with spontaneous recovery". Researchers found that although the vast majority of patients received EKGs (99 percent) , were admitted to hospital beds with continuous heart monitoring (95 percent), and a significant number (63 percent) received CT scans of the head, these tools only provided doctors to the correct diagnosis 2% of the time. The results of these tests only changed their medical decisions about 5% of the time.

A far better tool was simply checking the patient's postural blood pressure. This means checking the blood pressure of a person laying down and standing up and noticing if there is a difference between the heart rates and blood pressures. This simple procedure which can be performed by doctors, nurses, or medical assistants resulted in diagnosing the correct cause of the syncope in 15% to 21% of cases, which is up to 10 times better than the fancy expensive tests listed previously. This simple procedure changed what doctors did in 18 to 26% of the time, which is 5 times better.

Unfortunately, this relatively simple and inexpensive procedure was only done 38% of the time.

What is particularly disturbing isn't these findings, but rather the fact that this is been known for 20 years. As the authors note:

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. The current study complements earlier work by showing the high costs associated with this unnecessary testing. 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. Investigators have shown that easy availability of low-risk testing contributes to the overuse of resources. The frequency of syncope and wide availability of low-risk testing make its an important source of revenue for hospitals. Unnecessary testing is a substantial contributor to rising health care costs and has been proposed as a target for cost savings.

So what other tools might doctors use if the expensive tests don't provide clues in the vast majority of cases? It's the secret that good doctors know. It's the secret that medical students are taught even today. It's something you should know.

Getting a good history and doing a good physical exam is far better in determining which tests are the right tests to get to the right diagnosis.

Therefore in the case of syncope, be sure to try to provide your doctors all of the information you can think of. Provide them the FOUR W's, which are reviewed in my book. In brief, they are the what, the where, the when, and the why. If you don't, then it is very likely you'll have lots of tests, told that they are all normal, and you won't get an answer of what is wrong. With increasing out of pocket costs, can you afford to pay for unnecessary expensive tests especially if they don't get you the right answer in 98% of cases?

As this study shows and what good doctors know are that what you say about your symptoms are far more helpful to get the right diagnosis and right treatment than ordering a battery of tests.

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