Ambulatory Electrocardiography

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Abstract
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)

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