Variation in diagnostic testing for older patients with syncope in the emergency department

the Syncope Risk Stratification Study Group

Research output: Contribution to journalArticle

Abstract

Background: Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. Methods: We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit. Results: While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. Conclusion: Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.

Original languageEnglish (US)
JournalAmerican Journal of Emergency Medicine
DOIs
StateAccepted/In press - Jan 1 2018

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Syncope
Hospital Emergency Service
Costs and Cost Analysis
Routine Diagnostic Tests
Troponin
Medicare
Coronary Angiography
Observational Studies
Electrocardiography
Cohort Studies
Thorax
History
Head
X-Rays

Keywords

  • Cost
  • Diagnostic testing
  • Emergency department
  • Near syncope
  • Syncope
  • Variation
  • Yield

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Variation in diagnostic testing for older patients with syncope in the emergency department. / the Syncope Risk Stratification Study Group.

In: American Journal of Emergency Medicine, 01.01.2018.

Research output: Contribution to journalArticle

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title = "Variation in diagnostic testing for older patients with syncope in the emergency department",
abstract = "Background: Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. Methods: We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit. Results: While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5{\%}, range 1.1{\%} to 49.3{\%}). The most frequently-obtained diagnostic tests were initial troponin (88.6{\%}), chest x-ray (75.1{\%}), head CT (42.5{\%}) and echocardiogram (35.5{\%}). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9{\%} (electrocardiogram) to 42.0{\%} (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1{\%}. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. Conclusion: Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.",
keywords = "Cost, Diagnostic testing, Emergency department, Near syncope, Syncope, Variation, Yield",
author = "{the Syncope Risk Stratification Study Group} and Baugh, {Christopher W.} and Sun, {Benjamin C.} and Erica Su and Nicks, {Bret A.} and Shah, {Manish N.} and Adler, {David H.} and Aveh Bastani and Caterino, {Jeffrey M.} and Clark, {Carol L.} and Diercks, {Deborah B.} and Hollander, {Judd E.} and Malveau, {Susan E.} and Nishijima, {Daniel K.} and Stiffler, {Kirk A.} and Storrow, {Alan B.} and Wilber, {Scott T.} and Yagapen, {Annick N.} and Weiss, {Robert E.} and Gibson, {Thomas A.}",
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AU - Baugh, Christopher W.

AU - Sun, Benjamin C.

AU - Su, Erica

AU - Nicks, Bret A.

AU - Shah, Manish N.

AU - Adler, David H.

AU - Bastani, Aveh

AU - Caterino, Jeffrey M.

AU - Clark, Carol L.

AU - Diercks, Deborah B.

AU - Hollander, Judd E.

AU - Malveau, Susan E.

AU - Nishijima, Daniel K.

AU - Stiffler, Kirk A.

AU - Storrow, Alan B.

AU - Wilber, Scott T.

AU - Yagapen, Annick N.

AU - Weiss, Robert E.

AU - Gibson, Thomas A.

PY - 2018/1/1

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N2 - Background: Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. Methods: We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit. Results: While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. Conclusion: Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.

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