Skip to main content

Advertisement

Log in

Practice Variation and Resource Use in the Evaluation of Pediatric Vasovagal Syncope: Are Pediatric Cardiologists Over-Testing?

  • Original Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

Syncope is a common problem in children and adolescents. Usually vasovagal in etiology, this benign problem often results in considerable testing and expense. We sought to define the current practice, practice variation, and resource utilization as well as evaluate a screening strategy for syncope at an academic tertiary care center. We reviewed the medical records of all patients age 8 to 19 years who presented with syncope between January 1994 and January 2012 and collected data regarding demographics, history, physical examination, and diagnostic tests. Practice variation was evaluated based on provider experience and subspecialty. The sensitivity and specificity of history, physical examination, and electrocardiogram (ECG) to identify a cardiac cause for syncope were calculated. Of the 617 patients studied, a cardiac cause for syncope was found in 15 (2 %). A screening strategy consisting of history, physical examination, and ECG was 100 % sensitive and 55 % specific for diagnosing a cardiac cause for syncope. Despite having a negative screen, 314 (54 %) patients had a total of 334 additional tests at an average charge of $983/patient. Although practice variation existed, it was not explained by provider experience or electrophysiology training. Factors associated with increased testing included greater number of clinic visits and increased frequency of events, whereas those associated with decreased testing included increased number of syncopal episodes and history of psychiatric medication use. A more standardized approach to syncope is needed to decrease resource use and cost while maintaining quality of care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J et al (2012) PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff–Parkinson–White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 9:1006–1024

    Article  PubMed  Google Scholar 

  2. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC (1997) Syncope in children and adolescents. J Am Coll Cardiol 29:1039–1045

    Article  CAS  PubMed  Google Scholar 

  3. Friedman KG, Kane DA, Rathod RH, Renaud A, Farias M, Geggel R et al (2011) Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics 128:239–245

    Article  PubMed  Google Scholar 

  4. Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W (2003) Prevalence and triggers of syncope in medical students. Am J Cardiol 91(1006–1008):A1008

    Google Scholar 

  5. Goldenberg I, Moss AJ, Peterson DR, McNitt S, Zareba W, Andrews ML et al (2008) Risk factors for aborted cardiac arrest and sudden cardiac death in children with the congenital long-QT syndrome. Circulation 117:2184–2191

    Article  PubMed Central  PubMed  Google Scholar 

  6. Katz DA, Williams GC, Brown RL, Aufderheide TP, Bogner M, Rahko PS et al (2005) Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med 46:525–533

    Article  PubMed  Google Scholar 

  7. Lamb LE, Green HC, Combs JJ, Cheeseman SA, Hammond J (1960) Incidence of loss of consciousness in 1,980 Air Force personnel. Aerospace Med 31:973–988

    CAS  PubMed  Google Scholar 

  8. Lewis DA, Dhala A (1999) Syncope in the pediatric patient. The cardiologist’s perspective. Pediatr Clin North Am 46:205–219

    Article  CAS  PubMed  Google Scholar 

  9. Massin MM, Malekzadeh-Milani S, Benatar A (2007) Cardiac syncope in pediatric patients. Clin Cardiol 30:81–85

    Article  PubMed  Google Scholar 

  10. Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB et al (2009) Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 30:2631–2671

    Article  PubMed Central  PubMed  Google Scholar 

  11. Murdoch BD (1980) Loss of consciousness in healthy South African men: incidence, causes and relationship to EEG abnormality. South Afr Med J 57:771–774

    CAS  Google Scholar 

  12. Ritter S, Tani LY, Etheridge SP, Williams RV, Craig JE, Minich LL (2000) What is the yield of screening echocardiography in pediatric syncope? Pediatrics 105:E58

    Article  CAS  PubMed  Google Scholar 

  13. Steinberg LA, Knilans TK (2005) Syncope in children: diagnostic tests have a high cost and low yield. J Pediatr 146:355–358

    Article  PubMed  Google Scholar 

  14. Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA et al (2006) AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, the Quality of Care and Outcomes Research Interdisciplinary Working Group, and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. Circulation 113:316–327

    Article  PubMed  Google Scholar 

  15. Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K et al (2005) Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 293:2609–2617

    Article  CAS  PubMed  Google Scholar 

  16. Wieling W, Ganzeboom KS, Saul JP (2004) Reflex syncope in children and adolescents. Heart 90:1094–1100

    Article  PubMed Central  PubMed  Google Scholar 

  17. Zhang Q, Du J, Wang C, Du Z, Wang L, Tang C (2009) The diagnostic protocol in children and adolescents with syncope: a multi-centre prospective study. Acta Paediatr 98:879–884

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This investigation was supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Resear4ch Resources and the National Center for Advancing Translational sciences, National Institutes of Health, through Grant No. 8UL1TR000105 (formerly UL1RR025764).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Shaji C. Menon.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Johnson, E.R., Etheridge, S.P., Minich, L.L. et al. Practice Variation and Resource Use in the Evaluation of Pediatric Vasovagal Syncope: Are Pediatric Cardiologists Over-Testing?. Pediatr Cardiol 35, 753–758 (2014). https://doi.org/10.1007/s00246-013-0848-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-013-0848-4

Keywords

Navigation