Table .1 Characteristics of the costing studies of AECG Study ID Country Population Intervention Derivation of costs Cost findings Conclusions Unexplained syncope Providencia (2014) Portugal Healthcare system (PNHS) Patients with unexplained, recurrent syncope (N=197). Early referral for ILR vs conventional diagnostic pathway (CDP). Data on the frequency of use of a range of diagnostic tests came from the published literature and was used to estimate the average cost of syncope episode admissions, using costs from the PNHS prices table (2013).a Two DRG tariffs were used as a proxy for the (inpatient) cost of trauma/injury in recurrent syncope. ILR device cost (2,000€) was based on the price of Reveal DX loop recorder in Portugal. A Markov model was developed to estimate the expected number of hospital admissions due to unexplained syncope and its respective financial impact in patients implanted with ILR vs CDP. Time horizon: 3 yrs and lifetime. Costs discounted at 5% per yr. Average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Lifetime horizon costs (discounted) of hospital admissions and syncope diagnosis for the entire cohort were 23% lower among patients in the ILR group compared with the CDP group (1,204,621€ for ILR vs 1,571,332€ for CDP). This translates to a saving of 1,861€ per patient. ILR led to an earlier diagnosis and consequently to a lower number of syncope hospital admissions, allowing important hospital offsets, with savings of between 307,872€ and 973,429€ for the entire cohort (1,563€ to 4,941€ per patient) over a lifetime horizon. Over a 3-year horizon, costs were higher in the ILR group, due to the upfront cost of the device and implantation. The utilisation of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. ILR appears to be significantly cost saving over a lifetime horizon under every scenario considered. sensitivity analyses failed to identify any plausible scenario under which ILR use does not result in significant cost savings, prompting us to believe that ILRs should be offered to indicated patients.
Table A-.2 AMSTAR scores of included systematic reviews Author, Year Overall AMSTAR score a (1) Provided study design (2) Duplicate study selection (3) Broad literature search (4) Considered status of publication (5) List of studies (6) Provided study (7) Assessed scientific quality (8) Considered quality in report (9) Methods to combine appropriate (10) Assessed publication bias (11) Stated conflict of interest Afzal (2015) 6/11 0 1 1 0 0 1 1 1 1 0 0 AHRQ (2007) 7/11 0 CA 1 1 1 1 1 1 1 0 0 Bell (2000) 0/10 0 CA 0 0 0 0 0 0 NA 0 0 Harris (2012) 2/10 0 CA 1 0 0 1 0 0 NA 0 0 Hoefman (2010) 5/11 0 1 1 0 0 1 CAb 1 1 0 0 Kishore (2014) 7/11 0 1 1 1 1 1 0 0 1 1 0 Liao (2007) 4/11 0 1 1 0 0 1 0 0 1 0 0 (2013) 1/10 0 CA 1 0 0 0 0 0 NA 0 0 MSAC (2003) 7/10 0 1 1 1 1 1 1 1 NA 0 0 NICE (2012) Update of Westby 2010 2/10 CA CA 1 CA 0 1 0 0 NA 0 0 Parry (2010) 1/10 0 CA 1 0 0 0 0 0 NA 0 0 Sposato (2015) 8/11 1 1 1 0 0 1 1 1 1 1 0 Westby (2010) 9/11 1 1 1 1 1 1 1 1 1 0 0 Abbreviations: AHRQ, Agency for Healthcare Research and Quality; AMSTAR, Assessment of Multiple Systematic Reviews; CA, can’t answer; HTA, health technology assessment; MSAC, Medical Services Advisory Committee; NA, not applicable; NICE, National Institute for Health and Care Excellence. a 1 = Yes, 0 = No; maximum possible score is 11. Details of AMSTAR Score are described in Shea et al (2007). b Jadad used but quality assessment was not shown.