The High Cost of Fainting

In the old days, women (and occasionally men) swooned and recovered with the aid of smelling salts and a glass of water (or something stronger). When I was in medical school in UK, emergency patients who’d fainted had their blood pressure taken and a quick clinical (neurological & cardiovascular) exam, and were usually sent home to the care of their family doctor. Now, if I’m taken to the ER after ‘passing out’ I’ll be lucky to get away with a battery of tests and exams that run into thousands of dollars. This is brought home by a study reported in the Archives of Internal Medicine.

Fainting, or syncope, is defined as the sudden, transient loss of consciousness with spontaneous recovery. The causes of syncope in the elderly are more wide ranging than in younger folk, and may be benign or life-threatening. Yale researchers, therefore, decided to investigate over 2,000 consecutive patients aged 65 or older who were admitted following a fainting episode, to see which tests affected the diagnosis or management, and the approximate costs of each management-changing test result.

The most frequently performed tests included electrocardiography (ECG), heart serum-enzyme levels, CT scan of the head, were not efficient in providing management-changing information. Although some of these were done in over 90% of patients, they were only ‘diagnostic’ in less than 5% of cases, and ‘effective’ in helping change the management of the patient in less than 2% of cases. Each positive result with one of these tests averaged costs of about $25,000.

One of the commonest causes of syncope is a sudden fall in blood pressure, often related to posture or to a strong emotional stimulus – this is called a vaso-vagal attack. It can be detected in most cases by a postural blood pressure test. The blood pressure is taken first lying, and then immediately after standing; a fall in systolic or diastolic pressure of 20 or 10 mm Hg, respectively, is a positive result.

Postural blood pressure measurement, although performed in only about a third of the cases in the study, was the most effective and cost-effective test. Results affected diagnosis or management about 25% of the time, and cost $17 to $20 per management-changing test.

My summary here can only give a rough idea of the study results. However, syncope seems a good example (and maybe one target area) for President Obama’s proposal to try to eliminate unnecessary tests, even in older patients.