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Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis.

ABSTRACT: STUDY OBJECTIVE:Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days. METHODS:We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (?60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days. RESULTS:We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%). CONCLUSION:In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.

SUBMITTER: Probst MA

PROVIDER: S-EPMC6650347 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Project description:ObjectivesClinical prediction models for risk stratification of older adults with syncope or near syncope may improve resource utilization and management. Predictors considered for inclusion into such models must be reliable. Our primary objective was to evaluate the inter-rater agreement of historical, physical examination, and electrocardiogram (ECG) findings in older adults undergoing emergency department (ED) evaluation for syncope or near syncope. Our secondary objective was to assess the level of agreement between clinicians on the patient's overall risk for death or serious cardiac outcomes.MethodsWe conducted a cross-sectional study at 11 EDs in adults 60 years of age or older who presented with unexplained syncope or near syncope. We excluded patients with a presumptive cause of syncope (e.g., seizure) or if they were unable or unwilling to follow-up. Evaluations of the patient's past medical history and current medication use were completed by treating provider and trained research associate pairs. Evaluations of the patient's physical examination and ECG interpretation were completed by attending/resident, attending/advanced practice provider, or attending/attending pairs. All evaluations were blinded to the responses from the other rater. We calculated the percent agreement and kappa statistic for binary variables. Inter-rater agreement was considered acceptable if the kappa statistic was 0.6 or higher.ResultsWe obtained paired observations from 255 patients; mean (±SD) age was 73 (±9) years, 137 (54%) were male, and 204 (80%) were admitted to the hospital. Acceptable agreement was achieved in 18 of the 21 (86%) past medical history and current medication findings, none of the 10 physical examination variables, and three of the 13 (23%) ECG interpretation variables. There was moderate agreement (Spearman correlation coefficient, r = 0.40) between clinicians on the patient's probability of 30-day death or serious cardiac outcome, although as the probability increased, there was less agreement.ConclusionsAcceptable agreement between raters was more commonly achieved with historical rather than physical examination or ECG interpretation variables. Clinicians had moderate agreement in assessing the patient's overall risk for a serious outcome at 30 days. Future development of clinical prediction models in older adults with syncope should account for variability of assessments between raters and consider the use of objective clinical variables.

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Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis.

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