Trends of hospitalizations for syncope/collapse in the United States from 2004 to 2013-An analysis of national inpatient sample

Comparison of syncope risk scores in predicting the prognosis of patients presenting to the emergency department with syncope

BACKGROUND

Various scores have been derived for the assessment of syncope patients in the emergency department (ED).

AIM

We aimed to compare the effectiveness of Canadian Syncope Risk Scores (CSRS), San Francisco Syncope Rules (SFSR), and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores in predicting the risk of major adverse cardiac events (MACE) and mortality among syncope patients within 30 days of the initial ED visit.

METHODS

We performed a prospective, observational case series study of adults (≥ 18 years) with unexplained syncope/near-syncope who presented to ED. Demographic characteristics of the patients and clinical and laboratory data were recorded in the standard data collection form of the study. Our primary outcome was a 30-day mortality.

RESULTS

A total of 421 patients (mean age 50.9 ± 20.8, 51.5% male) were enrolled. The rate of MACE development in the 30-day follow-up of the patients was 12.8% (n = 54). While 20.2% (n = 85) of the patients were hospitalized, two of the patients died in the emergency room and the 30-day mortality was 5.5% (n = 23). CSRS was found to have the highest predictive power of mortality (AUC: 0.869, 95% CI 0.799-0.939, p < 0.001). If the cut-off value of CSRS was 0.5, the sensitivity was found to be 82.6% and the specificity was 81.9%. Also CSRS (OR: 1.402, 95% CI: 1.053-1.867, p = 0.021) was found to be an independent predictor of the 30-day mortality.

CONCLUSION

The CSRS may be used as a safety risk score for a 30-day risk of MACE and mortality after discharge from the emergency department.

Novel Machine Learning Approach to Predict and Personalize Length of Stay for Patients Admitted with Syncope from the Emergency Department

Background: Syncope, a common problem encountered in the emergency department (ED), has a multitude of causes ranging from benign to life-threatening. Hospitalization may be required, but the management can vary substantially depending on specific clinical characteristics. Models predicting admission and hospitalization length of stay (LoS) are lacking. The purpose of this study was to design an effective, exploratory model using machine learning (ML) technology to predict LoS for patients presenting with syncope. Methods: This was a retrospective analysis using over 4 million patients from the National Emergency Department Sample (NEDS) database presenting to the ED with syncope between 2016−2019. A multilayer perceptron neural network with one hidden layer was trained and validated on this data set. Results: Receiver Operator Characteristics (ROC) were determined for each of the five ANN models with varying cutoffs for LoS. A fair area under the curve (AUC of 0.78) to good (AUC of 0.88) prediction performance was achieved based on sequential analysis at different cutoff points, starting from the same day discharge and ending at the longest analyzed cutoff LoS ≤7 days versus >7 days, accordingly. The ML algorithm showed significant sensitivity and specificity in predicting short (≤48 h) versus long (>48 h) LoS, with an AUC of 0.81. Conclusions: Using variables available to triaging ED clinicians, ML shows promise in predicting hospital LoS with fair to good performance for patients presenting with syncope.

Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope

STUDY PURPOSE

Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary.

STUDY DESIGN

We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients.

RESULTS

Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028).

CONCLUSION

In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.

Ambulatory ECG monitoring for syncope and collapse in United States, Europe, and Japan: The patients' viewpoint

BACKGROUND

Practice guidelines provide clinicians direction for the selection of ambulatory ECG (AECG) monitors in the evaluation of syncope/collapse. However, whether patients' understand differences among AECG systems is unknown.

METHODS AND RESULTS

A survey was conducted of USA (n = 99), United Kingdom (UK)/Germany (D) (n = 75) and Japan (n = 40) syncope/collapse patients who underwent diagnostic AECG monitoring. Responses were quantitated using a Likert-like 7-point scale (mean ± SD) or percent of patients indicating a Top 2 box (T2B) for a particular AECG attribute. Patient ages and diagnosed etiologies of syncope/collapse were similar across geographies. Patients were queried on AECG attributes including the ability to detect arrhythmic/cardiac causes of collapse, instructions received, ease of use, and cost. Patient perception of the diagnostic capabilities and ease of use did not differ significantly among the AECG technologies; however, USA patients had a more favorable overall view of ICM/ILRs (T2B: 42.4%) than did UK/D (T2B: 28%) or Japan (T2B: 17.5%) patients. Similarly, US patient rankings for education received regarding device choice and operation tended to be higher than UK/D or Japan patients; nevertheless, at their best, the Likert scores were low (approximately 4.7-6.0) suggesting need for education improvement. Finally, both US and UK/D patients were similarly concerned with ICM costs (T2B, 31% vs 20% for Japan).

CONCLUSIONS

Patients across several geographies have a similar but imperfect understanding of AECG technologies. Given more detailed education the patient is likely to be a more effective partner with the clinician in establishing a potential symptom-arrhythmia correlation.

Regional variation in outcomes and healthcare resources utilization in, emergency department visits for syncope

BACKGROUND

Management of patients with syncope lacks standardization. We sought to assess regional variation in hospitalization rates and resource utilization of patients with syncope.

METHODS

We identified adults with syncope using the Nationwide Emergency Department Sample from years 2006 to 2014. Demographics and comorbidity characteristics were compared across geographic regions in the US. Multiple regression was conducted to compare outcomes.

RESULTS

9,132,176 adults presented with syncope. Syncope in the Northeast (n = 1,831,889) accounted for 20.1% of visits; 22.6% in the Midwest (n = 2,060,940), 38.5% in the South (n = 3,527,814) and 18.7% in the West (n = 1,711,533). Mean age was 56 years with 57.7% being female. The Northeast had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, OR_adj 0.58; 95% CI 0.52-0.65, p < 0.001), the Midwest (17.2%, OR_adj 0.51; 95% CI 0.46-0.58, p < 0.001) and West (15.8%, OR_adj 0.45; 95% CI 0.39-0.51, p < 0.001). Risk-adjusted rates of syncope hospitalizations significantly declined from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (P_trend < 0.001). The Northeast had the lowest risk-adjusted ED (Emergency Department) service charges per visit ($3320) followed by the Midwest ($4675, IRR_adj 1.41; 95% CI 1.30-1.52, p < 0.001), the West ($4814, IRR_adj 1.45; 95% CI 1.31-1.60, p < 0.001) and South ($4969, IRR_adj 1.50; 95% CI 1.38-1.62, p < 0.001). Service charges increased from $3047/visit (95% CI $2912-$3182) in 2006 to $6267/visit (95% CI $5947-$6586) in 2014 (P_trend < 0.001).

CONCLUSIONS

Significant regional variability in hospitalization rates and ED service charges exist among patients with syncope. Standardizing practices may be needed to reduce variability.

Trends in use of echocardiography in hospitalized patients with syncope

PURPOSE

We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database.

METHODS

Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18 years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained.

RESULTS

A total of 3 174 619 patients with a primary discharge diagnosis of syncope were identified, of which 184 167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [P_trend  = 0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR = 0.827, P = 0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P < 0.001).

CONCLUSIONS

The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope.

Causes and Predictors of 30-Day Readmission in Patients With Syncope/Collapse: A Nationwide Cohort Study

Background Syncope accounts for 0.6% to 1.5% of hospitalizations in the United States. We sought to determine the causes and predictors of 30-day readmission in patients with syncope. Methods and Results We identified 323 250 encounters with a primary diagnosis of syncope/collapse in the 2013-2014 Nationwide Readmissions Database. We excluded patients younger than 18 years, those discharged in December, those who died during hospitalization, hospital transfers, and those whose length of stay was missing. We used multivariable logistic regression analysis to evaluate the association between baseline characteristics and 30-day readmission. A total of 282 311 syncope admissions were included. The median age was 72 years (interquartile range, 58-83), 53.9% were women, and 9.3% had 30-day readmission. The most common cause of 30-day readmissions was syncope/collapse, followed by cardiac, neurological, and infectious causes. Characteristics associated with 30-day readmissions were age 65 years and older (odds ratio [OR], 0.7; 95% confidence interval [ CI ], 0.6-0.7), female sex (OR, 0.9; 95% CI, 0.8-0.9), congestive heart failure (OR, 1.5; 95% CI, 1.2-1.9), atrial fibrillation/flutter (OR, 1.3; 95% CI, 1.3-1.4), diabetes mellitus (OR, 1.2; 95% CI, 1.2-1.3), coronary artery disease (OR, 1.2; 95% CI, 1.2-1.3), anemia (OR, 1.4; 95% CI, 1.4-1.5), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.3-1.4), home with home healthcare disposition (OR, 1.5; 95% CI, 1.5-1.6), leaving against medical advice (OR, 1.7; 95% CI, 1.6-1.9), length of stay of 3 to 5 days (OR, 1.5; 95% CI, 1.4-1.6) or >5 days (OR, 2; 95% CI, 1.8-2), and having private insurance (OR, 0.6; 95% CI, 0.6-0.7). Conclusions The 30-day readmission rate after syncope/collapse was 9.3%. We identified causes and risk factors associated with readmission. Future prospective studies are needed to derive risk-stratification models to reduce the high burden of readmissions.