Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations

Abstract

Study objective: Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data.

Methods: We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation.

Results: Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81).

Conclusion: In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.

Figure 1:

Flow Diagram of Canadian Emergency Department Syncope Patients included in the Very Low-Risk Cohort (Phase 1)

Figure 2:. Variability in Hospitalization Rates Across Hospitals for the Very Low-Risk Syncope Cohort in the 2019 NEDS Dataset, n=722*.

NEDS: Nationwide Emergency Department Sample. Each dot represents one hospital. The horizontal lines forming the boxes represents that 75^th percentile, the median, and the 25^th percentile (from top to bottom). *Figure excludes the 265 of 989 hospitals in the sample that do not report any hospitalizations, as well as two outlier sites with extremely high reporting of ED observation stays for syncope with a total hospitalization rate of 100%.