A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department

JACC: CLINICAL ELECTROPHYSIOLOGY

VOL.

ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

-, NO. -, 2017

ISSN 2405-500X/$36.00

PUBLISHED BY ELSEVIER

https://doi.org/10.1016/j.jacep.2017.09.003

A Population-based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department Roopinder K. Sandhu, MD, MPH,a Dat T. Tran, MPH,b,c Robert S. Sheldon, MD, PHD,d Padma Kaul, PHDb,c

ABSTRACT OBJECTIVES This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). BACKGROUND ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. METHODS A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. RESULTS Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 (Cohort 1: $75.3 million; $29,519/patient, Cohort 2:$138.1 million; $42.042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). CONCLUSIONS Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts. (J Am Coll Cardiol EP 2017;-:-–-) © 2017 by the American College of Cardiology Foundation.

S

yncope is common, representing 1% to 3% of all

are discharged without a clear diagnosis (7,8). Despite

emergency department (ED) visits (1,2). Diag-

efforts to improve ED diagnostic evaluation and risk

prognosis

stratification (9–11), a 10-year analysis from the United

mainly drive the high proportion of patients, ranging

nostic

uncertainty

and

unclear

States found no significant downward trend in the

from 12% to 83%, who are admitted (3,4). Evaluating

rates of syncope ED visits, admissions, or hospital

an underlying etiology for syncope is challenging and

discharge diagnosis of syncope while the use of

often results in numerous and expensive testing (5,6)

advanced imaging rose significantly (12).

yet these efforts have limited clinical utility and anywhere from a third to a half of patients with syncope

Single-center studies from multiple

countries

consistently report high costs of a hospital evaluation

From the aDivision of Cardiology, University of Alberta, Edmonton, Canada; bSchool of Public Health, University of Alberta, Edmonton, Canada; cCanadian VIGOUR Centre, University of Alberta, Edmonton, Canada; and the dDivision of Cardiology, University of Calgary, Calgary, Canada. Funded by the University Hospital Foundation of the University of Alberta and the Cardiac Arrhythmia Network of Canada. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received July 31, 2017; revised manuscript received August 30, 2017, accepted September 7, 2017.

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ABBREVIATIONS

for syncope (13–15). The 2000 Cost and Utili-

STUDY POPULATION AND VARIABLE ELEMENTS. The

AND ACRONYMS

zation Project National Inpatient Sample

study population included all patients 20 years or

provides the only national cost estimate of

older who presented to the ED from April 2006 to

syncope-related hospitalizations based on

March 2014 with a primary diagnosis of syncope (In-

discharge diagnosis of $2.4 billion U.S. dol-

ternational Classification of Diseases-10th revision:

lars per annum (16). There are currently no

R55 [22]). Patients were divided into 3 cohorts based

data on contemporary costs of syncope and none that

on their ED discharge status: Cohort 1 consisted of

incorporate costs beyond the hospital setting.

patients who were hospitalized within 24 h of ED visit

CT = computed tomography ED = emergency department EP = electrophysiology

Data evaluating the effect of acute health care

and discharged with a primary diagnosis of syncope;

visits on outcomes also remain sparse. A meta-

Cohort 2 consisted of patients who were hospitalized

analysis (17) of patients presenting to the ED with

within 24 hours of ED visit and discharged with a

syncope found that 1.6% died within 30 days

primary diagnosis other than syncope; and Cohort 3

(n ¼ 3,214) and 8.4% died at 1 year (n ¼ 4,879).

consisted of patients who were discharged home from

Among patients hospitalized for syncope, 1-year

the ED. Patients were followed from the index ED

mortality rates have been shown to vary between

presentation until death or being censored by March

1.9% and 14.7% depending on comorbidity burden

31, 2014.

(18–20). No large study has evaluated patient char-

Comorbidities based on previously validated In-

acteristics and outcomes of unselected patients with

ternational Classification of Diseases codes were

syncope in various clinical settings (emergency vs.

considered to be present if they were recorded for the

nonemergency) in 1 health care system. A better

index visit or hospitalization, within 24 h of ED

understanding of how outcomes and costs differ

discharge (if it occurred), and for all other contacts

among patients with syncope based on ED triage

with the health care system in the 4 years preceding

decisions and hospital course could help to develop

the index visit using the ambulatory care and hospi-

care pathways and provide baseline data against

talization databases (23). A Charlson Comorbidity In-

which the effectiveness of these interventions can

dex was calculated for each patient and categorized

be benchmarked.

into as 0, 1 to 2, 3 to 4, or $5 (24). Canadian Classifi-

Accordingly, we performed a population-based

cation of Health Interventions codes were used to

study of consecutive patients presenting to the ED

track pacemakers (1.HZ.53 ending in NM, NK, NL, NN,

with a primary diagnosis of syncope and evaluated

FR), implantable cardioverter defibrillator (1.HZ.53

comorbidities and short- and long-term outcomes for

ending in FS) implants, and advanced imaging

3 syncope cohorts: 1) those admitted to hospital and

(computer tomography [CT] of the head [3.ER.20,

discharged with a diagnosis of syncope; 2) those

3.AN.20] and brain magnetic resonance imaging

admitted to hospital and discharged with a diagnosis

[3.AN.40]). The imaging codes search was restricted

other than syncope; and 3) those discharged from the

to ED index data before April 1, 2013, for 1-year of

ED. We also compared resource utilization (inpatient,

follow-up (n ¼ 47,886) and all ED visits within a year

outpatient, physician, drugs) and costs among the

was queried where syncope was the primary diag-

3 cohorts.

nosis.

Invasive

electrophysiology

(EP)

testing

(2.HZ.24.GP-XJ, KJ, KL) was also queried after index

METHODS

ED visit performed in all ambulatory care visits and hospitalizations within 1 year.

DATA SOURCES. Data were obtained by linking the

Syncope costs were obtained from the Alberta

following 5 databases maintained by Ministry of

Interactive Health Data Application (25) and calcu-

Health and Wellness, in Alberta, Canada (20): 1) the

lated using Comprehensive Ambulatory Classification

Ambulatory Care Classification

database

System, which provides average costs for an ED or

tracks all visits to the 101 EDs in the province and was

outpatient visit; Case Mix Groups, similar in function

used to identify the study cohort; 2) the Discharge

to Diagnostic Related Groups, which provide average

Abstract Database records all admissions to acute care

costs incurred in the direct care of patients admitted

hospitals; 3) the Practitioners Claims database tracks

to hospital; and physician billing claims, which pro-

all physician claims for outpatient services; 4) the

vide physician costs. Drug prices were extracted from

Alberta Health Care Insurance Registry includes

the Alberta Drug Benefit List (26) from 2008 only and

demographic and vital statistics data for all residents

if a drug was not listed, we used the market price at

of the province; and 5) the Pharmaceutical Informa-

Canada Drugs (27). Drug costs were derived by

tion Network database records information on drugs

multiplying the price of a dispensed unit by the

dispensed for prescribed medications (21).

number of units dispensed. We calculated total costs

System

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and per patient costs of 1-year follow-up from the time of the index ED visit. Cost analysis was restricted

F I G U R E 1 Discharge Status Among Patient Presenting to the ED With a Primary

Diagnosis of Syncope, 2006 to 2014

to those with ED visits from 2006 to 2011 because Comprehensive Ambulatory Classification System and Case Mix Groups codes were only available during fiscal years of 2006 to 2012. All costs were converted to 2016 Canadian dollars using Bank of Canada inflation calculator (28). MAIN OUTCOMES. The primary outcomes were 30-day

revisits to the ED and rehospitalizations for a primary diagnosis of syncope and 30-day and 1-year mortality. Secondary outcomes included 1-year revisits to the ED and rehospitalizations for a primary diagnosis of syncope; 30-day and 1-year readmissions to the ED and hospital for any cause; in-hospital mortality; and annual costs including the distribution of inpatient, outpatient, physician, and drug costs for the 3 syncope cohorts. STATISTICAL ANALYSIS. We summarized patient

characteristics using means ( SD), medians (interquartile ranges), counts, and percentages, as appro-

Cohort 1, hospitalized and discharged with a primary diagnosis of syncope (red). Cohort 2,

priate. Values were compared across cohorts using

hospitalized with a primary diagnosis of syncope and discharged with another diagnosis

chi-square test for categorical variables and the

(blue). Cohort 3, discharged from the ED (green). ED ¼ emergency department.

Kruskal-Wallis test for continuous variables. Cumulative mortality and readmission to ED and hospital were calculated using Kaplan-Meier curve. Patients who died during the index ED visit (for Cohort 3) and who died during the index hospital episode (for Cohorts 1 and 2) were excluded from the readmission analyses. All analyses were performed using Stata version 14 (Stata Corporation, College Station, Texas). Two-sided p values <0.05 were considered statisti-

urban residence with a higher median household income compared with patients with syncope who were hospitalized (Cohorts 1 and 2) (Table 1). Hospitalized patients had a higher comorbidity burden with more than a third having a Charlson comorbidity score of $3, whereas almost two-thirds of patients discharged from the ED had a score of 0.

cally significant. The study was reviewed and

OUTCOMES. A 30-day ED revisit for a primary diag-

approved by the ethics board at the University of

nosis of syncope occurred in 2.4% of patients in

Alberta.

Cohort 1, in 1.2% of patients in Cohort 2, and in 1.7% of patients in Cohort 3 (Figure 2) (p < 0.001). The rate of

RESULTS

hospitalization at 30 days was low, ranging from 0.3% (Cohort 3) to 0.9% (Cohort 1; p < 0.001). At 1 year,

BASELINE

CHARACTERISTICS. There

were 51,831

8.6% in Cohort 1, a total of 5.2% in Cohort 2, and 4.8%

patients who had an ED visit for a primary diagnosis

in Cohort 3 had repeat visit to the ED for a primary

of syncope during the 8-year study period. Of these,

diagnosis of syncope (Figure 2) (p < 0.001). Compared

6.6% were hospitalized and discharged with a pri-

with Cohort 3, the rate of a rehospitalization was

mary diagnosis of syncope (Cohort 1), 8.7% were

2-fold higher in Cohort 2 and 4-fold higher in Cohort 1

hospitalized and discharged with a primary diagnosis

(p < 0.001).

other than syncope (Cohort 2), and 84.7% were dis-

After discharge, 19.8% of patients in Cohort 1, a

charged home with a syncope diagnosis (Cohort 3).

total of 24% in Cohort 2, and 15.6% in Cohort 3 had a

The number of syncope presentations remained sta-

30-day ED revisit for any cause (Online Figure 1)

ble from 2006 to 2010 (6,170 to 6,199) but increased

(p < 0.001). The rates of hospitalization for these

subsequently (p < 0.001) (Figure 1), primarily as a

patients differed significantly among the cohorts,

result of an increase in patients in Cohort 3 (14.7%

ranging from 4.0% (Cohort 3) to 13.1% (Cohort 2)

increase).

(p < 0.001). Syncope was the most common primary

Patients discharged from the ED (Cohort 3) were

reason for rehospitalization for Cohort 1 (9.7%) and

younger, more likely to be female, and live in an

Cohort 3 (6.9%), whereas heart failure (6.8%) was the

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T A B L E 1 Baseline Characteristics of Patients With Syncope According to Emergency

Department Discharge Status

1.3% of Cohort 2, and 3.5% and 0.3% of Cohort 3 were implanted with pacemaker and implantable cardioverter defibrillators, respectively.

Cohort 1 (n ¼ 3,419)

Cohort 2 (n ¼ 4,500)

Cohort 3 (n ¼ 43,912)

p Value

A total of 7,393 (15.4%) CT head scans were ordered for patients seen in the ED for a primary diagnosis of

Demographic characteristics 75 (60–83)

76 (63–84)

51 (32–71)

<0.001

syncope. Of these, 25.1% occurred in Cohort 1, 23.9%

1,812 (53)

2,412 (53.6)

19,962 (45.5)

<0.001

for Cohort 2, and 13.7% for Cohort 3 (p < 0.001). Few

2,561 (74.9)

3,407 (75.7)

35,183 (80.1)

<0.001

brain magnetic resonance images were ordered for

Myocardial infarct

654 (19.1)

967 (21.5)

2,836 (6.5)

<0.001

Congestive heart failure

617 (18.1)

1,093 (24.3)

2,327 (5.3)

<0.001

Peripheral vascular disease

358 (10.5)

574 (12.8)

1,525 (3.5)

<0.001

Cerebrovascular disease

696 (20.4)

1,061 (23.6)

3,689 (8.4)

<0.001

Dementia

346 (10.1)

578 (12.8)

1,539 (3.5)

<0.001

Chronic pulmonary disease

830 (24.3)

1,295 (28.8)

6,572 (15)

<0.001

Rheumatoid disease

118 (3.5)

178 (4)

742 (1.7)

<0.001

Peptic ulcer disease

189 (5.5)

317 (7)

1,291 (2.9)

<0.001

Age, yrs Male Urban residence Comorbidities

the entire population (n ¼ 47). The rate of invasive EP procedures was 0.2% (78 of 44,855) and occurred in 20 patients in Cohort 1, in 14 patients in Cohort 2, and in 44 patients in Cohort 3 (p < 0.001). COSTS. The total cost of syncope presentations to the

ED from 2006 to 2011 was $530.6 million (2016 Canadian Dollars) (Table 2). Of this, Cohort 1 accounted for

92 (2.7)

160 (3.6)

764 (1.7)

<0.001

$75.3 million ($29,519/patient), Cohort 2 accounted

803 (23.5)

1,275 (28.3)

5,015 (11.4)

<0.001

for $138.1 million ($42,042/patient), and Cohort 3

77 (2.3)

136 (3)

516 (1.2)

<0.001

accounted

Renal disease

389 (11.4)

624 (14.9)

1,578 (3.6)

<0.001

p < 0.001). Across the 3 cohorts, the distribution of

Cancer

costs

Mild liver disease Diabetes Hemiplegia or paraplegia

416 (12.2)

716 (15.9)

2,557 (5.8)

<0.001

Moderate/severe liver disease

18 (0.5)

61 (1.4)

139 (0.3)

<0.001

Metastatic solid tumor

92 (2.7)

266 (5.9)

673 (1.5)

<0.001

AIDS

4 (0.1)

5 (0.1)

41 (0.1)

0.864

Charlson Score <0.001

for

(inpatient,

$317.3

million

outpatient,

($9,963/patient;

physician,

drugs)

remained similar for each year. The highest proportion of annual costs was because of hospitalizations (Cohort 1, 69%; Cohort 2, 74%; Cohort 3, 48%) for all cohorts (Figure 4). Compared with the other cohorts,

0

1,023 (29.9)

988 (22)

26,994 (61.5)

1–2

1,154 (33.8)

1,450 (32.2)

11,032 (25.1)

the proportion of outpatient visits and physician

3–4

624 (18.3)

856 (19)

3,023 (6.9)

claims was highest for Cohort 3.

$5

618 (18.1)

1,206 (26.8)

2,863 (6.5)

DISCUSSION

Values are median (interquartile range) or n (%). IQR ¼ interquartile range.

In this population-based study evaluating postmost common reason for Cohort 2. At 1 year, the rates of ED revisits for any cause was high for all cohorts (Cohort 1, 59.9%; Cohort 2, 64.9%; Cohort 3, 48.9%; p < 0.001) (Online Figure 1) and subsequent hospitalizations ranged from 20.2% in Cohort 3 to 43.7% in Cohort 2 (p < 0.001). The most common primary discharge diagnosis from hospital continued to be syncope for Cohort 1 (9.0%) and heart failure for Cohort 2 (8.0%) and care involving use of rehabilitation procedures for Cohort 3 (4.9%). In-hospital mortality was 9 times higher for Cohort 2 (6.1%) compared with Cohort 1 (0.7%). Figure 3

discharge outcomes and costs of 51,831 patients presenting to the ED with a primary diagnosis of syncope, we report the following findings: 1) most patients were considered low risk and discharged home; 2) short- and long-term outcomes for hospitalized and discharged patients with syncope are related to comorbidity burden; and 3) the most health care costs are incurred by patients with syncope discharged from the ED, whereas per patient cost is highest among patients hospitalized with syncope but discharged with a primary diagnosis other than syncope.

shows the cumulative mortality rates according to

IMPACT OF HEALTH CARE VISITS ON OUTCOMES.

discharge status. Short- and long-term mortality rates

Although syncope is a frequent presentation, limited

were highest for Cohort 2 and lowest for Cohort 3

data exist evaluating whether ED visits and, in

(30-day mortality: Cohort 1, 1.2%; Cohort 2, 5.2%;

particular, hospitalization influence outcomes of

Cohort 3, 0.4%; p < 0.001) (1-year mortality: Cohort 1,

syncope (19). In a meta-analysis of consecutive pa-

9.2%; Cohort 2, 17.7%; Cohort 3, 3.0%; p < 0.001).

tients presenting to the ED, mortality rates were 1.6%

Among those hospitalized after the index ED visit,

and 8.4% at 30 days and 1 year, respectively (17).

3.4% and 0.4% of Cohort 1 and 10% and 0.6% of

However,

Cohort 2 underwent pacemaker and implantable car-

included patients both discharged or admitted from

dioverter

respectively.

the ED. An Italian study of 675 patients with syncope

Within 1 year, 6.6% and 0.9% of Cohort 1, 12% and

found 1-year mortality rates based on ED disposition

defibrillator

implantation,

many

of

these

observational

studies

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F I G U R E 2 30-Day and 1-Year Readmission Rates to the ED and Hospitalizations for Syncope According to Discharge Status

Cohort 1, hospitalized and discharged with a primary diagnosis of syncope. Cohort 2, hospitalized with a primary diagnosis of syncope and discharged with another diagnosis. Cohort 3, discharged from the ED. Abbreviation as in Figure 1.

and found 1.8% of the patients who were discharged

(15.3%) compared with studies from the United States

from the ED died compared with 14.7% who were

and Europe (35% to 83%) (1,4,12), further reductions

admitted (19). Almost one-half of admitted patients

in the admission rates are needed, particularly

were 65 years or older and had significantly higher

because

burden of cardiovascular comorbidity compared with

mately

hospitalizations 70%

of

costs

accounted of

patients

for

approxi-

hospitalized

those patients discharged from the ED. We found similar differences in mortality among patients discharged versus admitted from the ED. Short- and

F I G U R E 3 Mortality Rates According to Discharge Status

long-term mortality rates among patients with syncope discharged from the ED were very low (30 day, 0.4%; 1 year, 3.0%). Among admitted patients, mortality rates were 4 times higher at 30 day and almost 2 times higher at 1 year among patients in whom an underlying etiology was established (Cohort 2) than among those who were discharged with a diagnosis of syncope.

Significant

differences

in

comorbidity

burden are likely to explain a large portion of the differences in mortality outcomes among the 3 cohorts of patients. Patients with syncope discharged home from the ED were younger and had significantly lower rates of comorbidities and mortality than admitted patients, suggesting appropriate triage was occurring in the ED. Both the short- and long-term mortality was highest among Cohort 2 who were sicker than the other cohorts. These data suggest ED visits or hospitalization does not seem to modify long-term prognosis.

Cohort 1, hospitalized and discharged with a primary diagnosis of syncope. Cohort 2, hospitalized with a primary diagnosis of syncope and discharged with another diagnosis.

STRATEGIES TO REDUCE HOSPITALIZATIONS. Although

our study demonstrated a low rate of hospitalizations

Cohort 3, discharged from the ED. Abbreviation as in Figure 1.

5

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T A B L E 2 Annual Costs for Patients With Syncope According to Discharge

Status, 2006 to 2011

unit improved diagnostic yield and reduced hospitalizations and costs without adversely impacting outcomes compared with admission to an inpatient

Cost Type (Million $)

2006

2007

2008

2009

2010

2011

Total

All patients

78.6

80.6

93.3

95.6

90.1

92.5

530.6

Cohort 1

service in patients with intermediate risk factors ($50 years, cardiac history, concerning electrocardiogram

Hospitalization

8.5

8.5

9.1

9.3

8.5

7.9

51.8

findings, family history of sudden cardiac disease,

Outpatient

1.5

2.1

1.9

2.1

2.5

2.4

12.6

symptoms not suggestive of reflex syncope). The Falls

Claim

1.2

1.3

1.3

1.5

1.7

1.7

8.7

and Syncope Service in England had also shown an

0.5

0.5

0.6

0.6

2.2

initial detailed assessment by a physician syncope expert using evidence-based algorithms to advise

Drug Total

11.2

12

12.8

13.4

13.3

12.6

75.3

16.3

14.8

19.8

18.2

16.9

15.6

101.5

Outpatient

2.8

2.6

3.2

3.1

3.0

3.2

17.9

Claim

2.3

2.1

15.1

Cohort 2

admission, investigations, and referrals resulted in

Hospitalization

2.4

2.7

2.8

2.8

0.8

0.8

1.0

0.9

diagnosis reduced admission and implementation of good clinical practices (32). Before widespread use of

3.5

these approaches consensus on factors for classifying

21.4

19.5

26.2

24.8

23.7

22.4

138.1

low, intermediate, and high risk is needed, and addi-

Hospitalization

25.4

27.5

27.0

26.0

23.2

24.0

153.1

Outpatient

12.0

12.8

14.0

14.9

14.6

16.4

84.6

8.6

8.9

9.2

10.1

10.6

12.1

59.5

COST-SAVING ED MEASURES. Multiple and expen-

4.1

6.3

4.8

4.9

20.1

sive testing is often used in the ED to determine an

54.3

57.4

53.1

57.5

317.3

underlying cause for syncope (5,6). A prospective,

Drug Total

tional large, clinical studies evaluating outcomes and

Cohort 3

Claim Drug Total

45.9

49.1

cost-effectiveness in different countries.

multicenter, observational study found a median Costs reported in Canadian 2016 dollar values. Total costs may not be exactly equal to sum of individual costs because of rounding.

number of 13 tests were performed per patient with unexplained syncope and almost half had advanced imaging (33). A similar finding was reported from a

(Cohorts 1 and 2) and 50% of costs for patients

10-year analysis of ED visits for syncope where

discharged from the ED (Cohort 3). A promising strat-

CT/magnetic resonance imaging scan rates increased

egy to reduce hospitalizations for any country may be

from 21% to 45% in recent years, and we also found

ED-based syncope units, which consist of time-limited

CT head scans frequently ordered (12). Studies

observation with telemetry, a multidisciplinary team,

(1,34,35) have shown that advanced imaging in the

and expedited access to cardiac testing (29). Two

absence of clinical suspicion affects diagnosis and

small, randomized clinical trials (30,31) in the United

management in very few patients (2%) yet is costly

States demonstrated a protocol-driven ED syncope

($24,881 U.S. dollars) (6). The Choosing Wisely

F I G U R E 4 Distribution of 1-Year Costs According to Discharge Status

Cohort 1, hospitalized and discharged with a primary diagnosis of syncope. Cohort 2, hospitalized with a primary diagnosis of syncope and discharged with another diagnosis. Cohort 3, discharged from the ED. Annual Costs: inpatient (blue), outpatient (orange), physician claims (gray), and drugs (yellow). Abbreviation as in Figure 1.

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campaign is a program that encourages clinicians and

appropriate (39). Readmission rates significantly

patients to engage in conversation regarding unnec-

decreased after evaluation in Rapid Access Blackouts

essary tests, treatments, and procedures. In Canada,

Triage Clinic from 46.2% to 6.8% with no difference

the Choosing Wisely campaign in partnership with

across risk strata. An outpatient syncope clinic may

the Canadian Medical Association has targeted ED

not be feasible in all health care systems; however,

physicians in reducing unnecessary CT head scans in

identifying physicians who have an interest in syn-

adult patients with syncope in the absence of defined

cope evaluation and management in a geographic

high-risk predictors. This program exists in 20 coun-

area may allow for scheduled follow-up appoint-

tries and 5 continents and provides a unique platform

ments to be integrated into discharge planning (40).

to initiate similar campaigns globally. Evaluating

Patients stop fainting after assessment in the absence

practice changes with the Choosing Wisely campaign

of specific therapy, although reasons for this are un-

is needed. Similarly, appropriate use of expensive

clear (41). This may, in part, be caused by getting a

testing during a syncope work-up, such as invasive

diagnosis, education, and reassurance.

EP testing, is needed. Although our data demonstrate a low rate, an observational study in 10 European countries and Israel found invasive EP testing occurred in 25% of patients with recurrent unexplained syncope before implantable loop recorder insertion and was the highest cost per test (33,36). An implantable loop recorder–guided strategy has been shown to have high diagnostic yield (36) and is costeffective compared with a conventional testing strategy including invasive EP testing (37). A key quality indicator for syncope management is 30-day revisits to the ED. We found short-term revisits for syncope, ranging from 1.2% (Cohort 2) to 2.4% (Cohort 1) and 1-year revisits for syncope, ranging from 4.8% (Cohort 3) and 8.6% (Cohort 1). The rate of 30-day revisits was much higher in our study without a pre-defined syncope management algorithm than reported in the Evaluation of Guidelines in SYncope Study 2 (EGSYS 2) study (n ¼ 380) (38). Italian patients managed according to the European Society of Cardiology syncope guidelines had a syncope relapse at 30 days of 0.3% after a first

STUDY

LIMITATIONS. Our

study

has

several

strengths and some limitations. Our study provides population-based estimates of admission/discharge rates, outcomes, and costs, in a contemporary cohort of patients presenting with syncope to the ED in a geographically

defined

province

with

universal

health care access. However, these data may not be generalizable to other provinces or other countries. We were unable to determine the type and frequency of tests and specialist consultations performed in the evaluation of syncope in inpatient and outpatient settings. These data may further aid in cost-saving measures. The study relies on administrative codes for the diagnosis of syncope. Although these codes have been validated in the ED and hospital settings (22), their accuracy in the outpatient clinic setting has not been established, and may have led to misclassifications and underestimation of costs. However,

we

were

consistent

in

our

use

of

the

administrative code and focused on a primary diagnosis of syncope.

ED presentation. Application of novel evidence-based algorithms has also been shown to reduce 1-year ED

CONCLUSIONS

visits. Readmission rates decreased from 12% to 0% after implementation of algorithms by the Falls and

In this population-based study, we found most

Syncope Service (32). The recently published 2017

patients presenting to the ED with a primary diag-

American

Heart

nosis of syncope were discharged home and had

Association/Heart Rhythm Society guidelines on

favorable prognosis relative to patients admitted to

syncope evaluation and management provides simple

the hospital. Regardless of ED discharge status, the

algorithms that may be incorporated into clinical

high health care utilization and costs suggests further

pathways to improve diagnosis, use of diagnostic

research is needed on syncope models of care in

testing, and assist with triage decisions but needs

different health care settings that evaluate outcomes

further research (29).

and cost-effectiveness of multidisciplinary syncope

College

of

Cardiology/American

Improved discharge planning from the ED to an outpatient syncope clinic may also reduce read-

teams, evidence-based care pathways, discharge planning, and patient education.

mission rates. A multidisciplinary, specialist nursein

ADDRESS FOR CORRESPONDENCE: Dr. Roopinder K.

Manchester provided risk stratification, comprehen-

Sandhu, Division of Cardiology, University of Alberta,

sive assessment using evidence-based algorithms,

8440-112 Street, 2C2 WMC, Edmonton, Alberta T6G

direct

2B7, Canada. E-mail: [email protected].

led

Rapid

Access

treatment,

Blackouts

or

Triage

specialist

Clinic

referral

where

7

8

Sandhu et al.

JACC: CLINICAL ELECTROPHYSIOLOGY VOL.

-, NO. -, 2017 - 2017:-–-

Health Care Utilization of Syncope Visits to the ED

PERSPECTIVES COMPETENCY IN MEDICAL KNOWLEDGE: Decisions

patients with high-risk features requiring urgent assess-

made at the first point of care, (i.e., the ED) have major

ment and low-risk patients with a benign condition

implications on outcomes and costs of patients present-

requiring minimal evaluation and reassurance.

ing with syncope. In this population-based study, most patients with syncope are discharged home. Short- and

TRANSLATIONAL OUTLOOK 2: Further research is

long-term mortality is low; however, overall health care

needed on syncope care models evaluating outcomes and

costs are high compared with patients hospitalized.

cost-effectiveness of a multidisciplinary syncope team, use of evidence-based algorithms, and discharge planning

TRANSLATIONAL OUTLOOK 1: Improved risk

strategies in different countries.

stratification is needed for correct classification of

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A PP END IX For a supplemental figure, please see the online version of this article.

KEY WORDS costs, emergency department, hospitalization, outcomes,

9