Cost of initial therapy in the electrophysiological study versus ECG monitoring trial (ESVEM)

Background: patients randomized to either serial electrophysiological testing (EPS) or serial Holter monitoring (HM) to guide antiarrhythmic therapy for life-threatening ventricular arrhythmias had equivalent rates of mortality and arrhythmia recurrence in the ESVEM study. This report analyzes the effects of EPS, HM, and clinical factors on the charges for initial evaluation and management of patients with life-threatening ventricular arrhythmias. Methods and Results: Ten of 14 clinical centers participating in ESVEM provided bills from the initial hospitalization for randomized patients. Predictors of charges (1991 dollars) were analyzed by linear regression after logarithmic transformation. Initial hospital charge data were obtained for 286 patients randomized in ESVEM (88% of patients eligible for this substudy, 59% of all ESVEM patients). Patients with charge data were somewhat more likely to be older, to be female, and to have failed previous antiarrhythmic drug therapy at study entry and were less likely to have a drug predicted effective after randomization. Mean overall hospital charges were $35 986 (SD, $32 628) with a median of $24 532 (interquartile range, $16 126 to $43 593). Prerandomization patient characteristics generally had insignificant effects on charges, with the exception of presentation with resuscitated sudden death (28% increase in charges, P=.01) and heart failure (26% increase in charges, P=.02). Patients randomized to EPS had higher mean charges for evaluation ($42 002 versus $29 970, P=.0015) as well as more drug trials (3.0 versus 2.1, P=.0001) and a longer hospital stay (19.6 versus 13.9 days, P=.0007). In a multivariate regression model, failure to find an effective drug (P=.0001), the number of drug trials (P=.0001), and resuscitated sudden death as the presenting arrhythmia (P=.0001) were the only independent predictors of higher initial charges. Conclusions: (1) Initial hospital charges are significantly higher for EPS-guided than HM- guided therapy. (2) The higher charges for EPS-guided therapy were due to a greater number of drug trials and a lower probability of finding an effective drug. (3) Failure to find an effective drug, a larger number of drag trials, and a history of resuscitated sudden death independently predict higher charges.