SYNCOPE
Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals
1 Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Via don Bobbio 24, 16033 Lavagna, Italy; 2 Department of Geriatrics, Ospedale Careggi, University of Firenze, Firenze, Italy; 3 Department of Cardiology, Nuovo Osp.S.Giovanni di Dio, Firenze, Italy; 4 Department of Emergency Medicine, Ospedale S Martino, Genova, Italy; 5 Department of Emergency Medicine, Ospedale S.Maria Nuova, Firenze, Italy; 6 Department of Geriatrics, University of Modena and Reggio Emilia, Modena, Italy; 7 Department of Emergency Medicine, Policlinico S Orsola Malpighi and Ospedale Bellaria University of Bologna, Bologna, Italy; 8 Department of Geriatrics, Ospedale S Chiara, Trento, Italy; 9 Department of Cardiology, Ospedale S Chiara, Trento, Italy; 10 Department of Cardiology, Ospedale S Maria Nuova, Reggio Emilia, Italy; 11 Department of Cardiology, Ospedale Civile, Cento, Italy; 12 Department of Cardiology, Ospedale Umberto I, Mestre, Italy; 13 Department of Cardiology, Ospedale S Filippo, Roma, Italy; 14 Fondazione Medtronic, Milano, Italy
Aims The study hypothesis was that a decision-making approach improves diagnostic yield and reduces resource consumption for patients with syncope who present as emergencies at general hospitals.
Methods and results This was a prospective, controlled, multi-centre study. Patients referred from 5 November to 7 December 2001 were managed according to usual practice, whereas those referred from 4 October to 5 November 2004 were managed according to a standardized-care pathway in strict adherence to the recommendations of the guidelines of the European Society of Cardiology. In order to maximize its application, a decision-making guideline-based software was used and trained core medical personnel were designated—both locally in each hospital and centrally—to verify adherence to the diagnostic pathway and give advice on its correct application. The ‘usual-care’ group comprised 929 patients and the ‘standardized-care’ group 745 patients. The baseline characteristics of the two study populations were similar. At the end of the evaluation, the standardized-care group was seen to have a lower hospitalization rate (39 vs. 47%, P=0.001), shorter in-hospital stay (7.2±5.7 vs. 8.1±5.9 days, P=0.04), and fewer tests performed per patient (median 2.6 vs. 3.4, P=0.001) than the usual-care group. More standardized-care patients had a diagnosis of neurally mediated (65 vs. 46%, P=0.001) and orthostatic syncope (10 vs. 6%, P=0.002), whereas fewer had a diagnosis of pseudo-syncope (6 vs. 13%, P=0.001) or unexplained syncope (5 vs. 20%, P=0.001). The mean cost per patient and the mean cost per diagnosis were 19 and 29% lower in the standardized-care group (P=0.001).
Conclusion A standardized-care pathway significantly improved diagnostic yield and reduced hospital admissions, resource consumption, and overall costs.
Key Words: Syncope, Diagnosis, Interactive decision-making
* Corresponding author. Tel: +39 0185 329569; fax: +39 0185 306506. E-mail address: mbrignole{at}asl4.liguria.it
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