Appropriate Utilization of Echocardiography in Syncope

From the 2019 HVPAA National Conference

Dr. Gina Hurng (Drexel University College of Medicine), Dr. Willis Ko (Drexel University College of Medicine), Dr. Kevin Gu (Drexel University College of Medicine), Dr. Kevin D’mello (Drexel University College of Medicine), Dr. Naitik Patel (Drexel University College of Medicine)

Background

Syncope is a sudden and transient loss of consciousness followed by complete and spontaneous recovery of neurological function.  It accounts for over 740,000 emergency department visits annually, resulting in significant admission rates.  The subsequent medical costs of inpatient evaluation of syncope exceeds $2.4 billion in the United States.  Syncope is classified by the following etiologies: orthostatic, vasovagal, cardiac, and neurologic.  Depending on the etiology, echocardiograms may not be recommended as part of the routine syncope workup.  However, it is common practice to order echocardiograms regardless of patient presentation and etiology resulting in a high burden on the healthcare system.

Objective

To improve appropriate utilization of echocardiograms in the management of patients admitted for syncope and to reduce the burden of healthcare cost.

Methods

A pre-intervention phase set between 10/16/2016 and 12/30/2016 when retrospective chart review of patients admitted with the diagnosis of syncope was performed. Baseline patient demographics, data on patient presentation, and objective findings were collected.

An intervention phase set between 3/1/2018 and 4/01/2018 where house staff received education on a simplified algorithm that was created using the American College of Cardiology guidelines for appropriate utilization of echocardiogram.

A post-intervention phase was set between 4/20/2018 and 7/21/2018 in which retrospective chart review of patients and data collection was performed in a method similar to the pre-intervention phase.   Statistical analysis was then performed.

Inclusion criteria consists of patients with the diagnosis of syncope.  Exclusion criteria consists of patients admitted for trauma and were on non-internal medicine services.

Results

In the pre-intervention group, 38 patients were hospitalized for syncope and 24 echocardiograms were subsequently performed. Of the 24 echocardiograms performed, 12 met criteria and 12 did not.  Only 14 patients did not receive echocardiograms and 0 of those 14 patients met appropriate utilization criteria.  Of the 12 patients who met criteria, 3 patients had positive echocardiograms that may explain the syncopal event.   All echocardiograms ordered that did not meet indication were unremarkable.

In the post-intervention group, 46 patients were hospitalized for syncope and only 12 echocardiograms were subsequently performed.   Of the 12 echocardiograms performed, 9 met criteria and only 3 did not.  34 patients did not receive echocardiograms and 0 of those 34 patients met appropriate utilization criteria.   Of the 9 patients who met criteria, 2 patients had positive echocardiograms that may explain the syncopal event.  All echocardiograms ordered that did not meet indication were unremarkable.

Conclusions

Our intervention decreased the percentage of echocardiograms ordered from 63% to 25.5% while increasing appropriate utilization criteria from 50% to 75%.  The echocardiogram results between the pre-intervention and post-intervention groups were not significantly different.  Thus, we successfully decrease the number of echocardiograms ordered without compromising patient care.

Clinical Implications

The estimated cost of an echocardiogram is $2000 and appropriate utilization of echocardiograms in syncope workup over time will decrease overall wasteful spending, healthcare costs, and healthcare burden.