Syncope in children: Diagnostic tests have a high cost and low yield

doi:10.1016/j.jpeds.2004.10.039

The Journal of Pediatrics

Volume 146, Issue 3, March 2005, Pages 355-358

https://doi.org/10.1016/j.jpeds.2004.10.039 Get rights and content

Objectives

To assess the use, yield, and cost-effectiveness of diagnostic tests used in the evaluation of syncope in children.

Study design

A retrospective review of 169 pediatric patients presenting to a tertiary care center with new onset syncope was undertaken. Test results were considered diagnostic when an abnormal result correlated with the clinical diagnosis or a normal result was obtained during a syncopal episode. Costs were based on the hospital cost of testing for fiscal year 1999, using a relative value unit–based costing methodology and did not include professional fees or costs of hospitalization.

Results

A total of 663 tests were performed at a cost of $180,128. Only 26 tests (3.9%) were diagnostic in 24 patients (14.2%). The average cost per patient was $1055, and the cost per diagnostic result was $6928. Echocardiograms, chest radiographs, cardiac catheterizations, electrophysiology studies, and serum evaluations were not diagnostic.

Conclusions

The evaluation of pediatric syncope remains expensive, and testing has a low diagnostic yield. An approach that focuses on the use of testing to verify findings from the history and physical examination or exclude life-threatening causes is justified.

Section snippets

Methods

Patients presenting to the hospital or clinics for evaluation of syncope between January 1, 1998, and December 31, 1999, were identified from hospital billing records. Subjects between 4 and 18 years of age were included if they underwent an initial evaluation for episodes characterized by transient loss of consciousness associated with loss of postural tone. Patients were excluded if their presenting episode was diagnosed as a seizure at the initial visit or if the episode was characteristic

Patients

Patients who met the inclusion criteria (n = 169; 99 female) ranged in age from 4.5 to 18.7 years (mean, 13.2 ± 3.6). The follow-up period ranged from 122 to 768 days (mean, 312 ± 129).

Several patients had preexisting conditions that may have affected their evaluation. Three patients had congenital heart disease, and 1 patient had a family history of hypertrophic cardiomyopathy. Preexisting neurologic disorders were present in 9 patients, including 3 patients with a history of seizures.

Discussion

Multiple studies have documented the limited utility of laboratory testing in adult populations with syncope, particularly when not guided by the history and physical examination.4, 5, 6 Limited data are available in children, but other small studies have reported a high cost and low yield.3, 7 Our study confirms this finding, as demonstrated in Figure 2. The disparity in the numbers of each test performed is displayed in the denominator of the fraction above each test. The cost per diagnostic

Limitations

This study is subject to several limitations. The group may not be representative of patients evaluated in a primary care setting or other tertiary care centers. The costs of individual tests may be different at other centers and the yield of tests may differ. Also, the study does not account for the validity of the clinical impression. In some patients, test results were abnormal but no diagnosis was established. Since the effectiveness of each test was judged against each patient's diagnosis,

Conclusions

The evaluation of syncope remains costly, and the majority of tests demonstrate a low diagnostic yield. Often, a diagnosis can be established without a positively correlating test result. Since most tests are unlikely to produce diagnostic results, an approach that focuses on the use of testing primarily to corroborate findings from the history and physical examination and to identify life-threatening diseases may be warranted. The results of this study are consistent with previous findings in

References (21)

W.N. Kapoor et al.
Syncope of unknown origin: the need for a more cost-effective approach to its diagnosis evaluation
JAMA
(1982)
H. Calkins et al.
The economic burden of unrecognized vasodepressor syncope
Am J Med
(1993)
T.A. Gordon et al.
A retrospective analysis of the cost-effective workup of syncope in children
Cleve Clin J Med
(1987)
W.N. Kapoor
Evaluation and outcome of patients with syncope
Medicine (Baltimore)
(1990)
S.C. Day et al.
Evaluation and outcome of emergency room patients with transient loss of consciousness
Am J Med
(1982)
K.A. Eagle et al.
The impact of diagnostic tests in evaluating patients with syncope
Yale J Biol Med
(1983)
T. Lerman-Sagie et al.
A prospective evaluation of pediatric patients with syncope
Clin Pediatr (Phila)
(1994)
M. Linzer et al.
Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope
Am J Cardiol
(1990)
S.R. Cumbee et al.
Cardiac loop ECG recording: a new noninvasive diagnostic test in recurrent syncope
South Med J
(1990)
A.P. Brown et al.
Detection of arrhythmias: use of a patient-activated ambulatory electrocardiogram device with a solid-state memory loop
Br Heart J
(1987)

There are more references available in the full text version of this article.

Cited by (89)

Evaluation of changes in physician behavior after introduction of pediatric syncope approach protocol in the emergency department
2022, American Journal of Emergency Medicine
Syncope is a common presenting symptom in the pediatric emergency department (PED). The etiology of pediatric syncope is generally benign. However, differentiating cardiac and other serious causes from benign causes of syncope are crucial. The aim of this study was to evaluate the change of physicians' behavior after introduction of an institutional protocol designed to act as a guide in the assessment and management of syncope patients in the PED.
This was a retrospective study, conducted at the PED of our University Children's Hospital. A “pediatric syncope approach protocol” was introduced on March 1, 2019 for quality improvement purposes. Documented information in the medical records, laboratory investigations and the patients' final diagnoses during the six-month periods before and after the protocol introduction were compared.
268 patients were included in the study (131 pre-protocol, 137 post-protocol patients). When compared with the pre-protocol group, there was a significant improvement in the documentation of syncope characteristics (prodromal findings, predisposing factors, association with exercise), cardiac, neurological and electrocardiographic (ECG) warning signs and ordering of cardiac markers in the post-protocol group.
The introduction of the syncope approach protocol in PED has enabled an evidence-based and systematic evaluation and management of syncope patients, and reduced the rates of low-yield investigations. Sustained implementation of this protocol can have long-term benefits in the care of children with syncope at the emergency department.
Utilization of the electrocardiogram in the pediatric emergency department
2021, American Journal of Emergency Medicine
Review pediatric electrocardiogram (ECG) result severity classification and describe the utilization of ECG testing, and rate of clinically significant results, in the pediatric emergency department (PED).
This was a review of patients ≤18 years who had an ECG performed in a tertiary children's hospital PED 2005–2017. Using established guidelines and expert consultation, ECG results were categorized: Class 0 = normal, Class I = mild abnormality (no cardiology follow-up), Class II = moderate abnormality (cardiology follow-up), Class III = severe abnormality (immediate intervention). Chi-square tests were used to examine differences between patients with clinically insignificant (Class 0/I) and clinically significant (Class II/III) results. Multivariable regression was used to examine factors associated with clinically significant results.
16,147 unique PED encounters with ECG performed were included for analysis. The most common ECG indications were chest pain (32.5%), syncope (22.0%), arrhythmia (11.8%), toxicology/ingestion (9.4%), and seizure (5.7%). Overall, 12.7% (n = 2056) of ECGs had clinically significant (Class II/III) results, and only 2.0% (n = 325) had severe abnormality (Class III) that would require immediate intervention or cardiologist input. Factors associated with increased odds of clinically significant ECG were age ≤ 1 year (OR = 1.20, 95% CI: 1.02–1.41), male (OR = 1.33, 95% CI: 1.20–1.46), and indications of arrhythmia (OR = 1.84, 95% CI: 1.59–2.13), cardiac (OR = 2.57, 95% CI: 1.99–3.31), blank indication (OR = 1.52, 95% CI: 1.17–1.98), and electrolyte abnormality (OR = 1.42, 95% CI: 1.03–1.95).
In this study, we provided a valuable review of ECG result severity classification in the pediatric population. We found that chest pain and syncope represented over half of all ECGs performed. We found that clinically significant results are rare in the pediatric population at 12.7% of all ECGs performed, and very few (2.0%) have severe abnormalities that would require immediate intervention. Those with increased odds of a clinically significant ECG include young patients ≤1 year of age, male patients, and certain ECG indications.
Comparison of Initial Pediatric Outpatient Echocardiogram Indications between Community and Academic Practice
2019, Journal of Pediatrics
To compare the appropriateness and diagnostic yield of initial outpatient transthoracic echocardiography (TTE) between a community pediatric cardiology practice and an academic children's hospital.
Initial outpatient pediatric TTE ordered by pediatric cardiologists between January and March 2014 at a community practice (Packard Children's Health Alliance [PCHA]; n = 238) and an academic tertiary center (Lucile Packard Children's Hospital [LPCH]; n = 76) were evaluated based on appropriate use criteria (AUC) released in December 2014. Multivariate logistic regression was used to identify predictors of “rarely appropriate” indications and abnormal TTE findings.
Of 314 TTEs, 165 (52.5%) were classified as “appropriate,” 40 (12.7%) were classified as “may be appropriate,” 100 (31.9%) were classified as “rarely appropriate,” and 9 (2.9%) were unclassifiable. The proportion of abnormal findings did not differ between the 2 practice settings (5.3% for LPCH vs 7.6% for PCHA; P = .61). TTEs performed at PCHA were significantly more likely to be “rarely appropriate” (OR, 2.57; 95% CI, 1.28-5.15; P = .008). Children aged <1 year (OR, 1.90; 95% CI, 1.03-3.50; P = .04) and ordering providers with <10 years since the completion of their fellowship (OR, 2.15; 95% CI, 1.20-3.87; P = .01) were associated with “rarely appropriate” indications. “Appropriate” TTEs were associated with abnormal findings (OR, 8.69; 95% CI, 1.77-42.68; P = .008).
The community practice was independently associated with greater inappropriate ordering of initial outpatient pediatric TTEs compared with the academic practice. The assessment of practice patterns following AUC release should account for physician and practice-related factors that could influence differences in TTE ordering patterns.
Pediatric Appropriate Use Criteria for Outpatient Echocardiography: Practice Variations among Pediatric Cardiologists, Noncardiologist Subspecialists, and Primary Care Providers
2017, Journal of the American Society of Echocardiography
Citation Excerpt :
Our cohort provides further insight into the diagnostic yield of specific indications that were commonly used. Prior publications have illustrated diagnostic value of routine TTE for general pediatric referrals that varies from 20% to 32% for heart murmur20-23 to <5% for chest pain24 and syncope.25,26 When focusing on the individual A or M referrals within the indication table, we uncovered cardiac pathology in 40% of referrals for pathologic murmur and in 15% for exertional chest pain.
The first pediatric appropriate use criteria (AUC) address the use of initial transthoracic echocardiography in outpatients by all ordering providers. The aim of this study was to appraise the performance of the AUC across pediatric cardiologists, noncardiologist subspecialists, and primary care providers (PCPs). A further aim was to describe the variations in ordering patterns of different groups of practitioners, which could serve as the basis for targeted quality improvement activities.
Electronic health records for Seattle Children's Hospital and its four regional sites were retrospectively reviewed for initial transthoracic echocardiographic studies performed on patients aged ≤18 years. A sample of 1,000 consecutive studies and a sample of 1,514 studies in which studies ordered by noncardiologists were enriched were reviewed. The ordering provider type, study indication, and findings (normal, incidental, or abnormal) were classified. Indications mapped to three categories: appropriate (A), may be appropriate (M), and rarely appropriate (R). If multiple indications were documented, the highest level of appropriateness was used.
In the consecutive sample, pediatric cardiologists ordered 81%, noncardiologist subspecialists 13%, and PCPs 5% of the total studies. In the enriched sample, only 4% were unclassifiable by the AUC. Abnormal findings were identified in 23% of A, 13% of M, and 9% of R studies (P = .03). Appropriateness varied among the three groups of providers (P < .001). For pediatric cardiologists, 67% of studies were indication category A, 13% M, and 14% R. Noncardiologist subspecialists ordered the highest percentage of A studies (88%) and the lowest percentage of R studies (1%). PCPs had the highest percentage of R indications (18%), and 23% could not be fully classified, because of insufficient order information. Yield of abnormal findings was highest for subspecialists (23%), intermediate for cardiologists (19%), and lowest for PCPs (15%; P = .03).
The AUC performed well across all provider types, as measured by the low percentage of unclassifiable indications and the observed relationship between greater appropriateness and higher yield of abnormal findings. The three provider types differed in appropriateness rates and had distinct ordering patterns, which could form the basis for future targeted quality improvement efforts.
The Use of Echocardiography for Pediatric Patients Presenting with Syncope
2017, Journal of Pediatrics
To assess the frequency, yield, and cost of echocardiograms meeting “rarely appropriate” criteria.
Retrospective, single-center study of pediatric patients presenting with syncope. Patients were categorized according to the appropriate use criteria and based upon location of care (emergency department only, primary care setting only, or referred to a pediatric cardiologist). Multivariable regression was used to determine factors associated with performance of a “rarely appropriate” echocardiogram. Costs were calculated using fair market values from the Healthcare Bluebook.
The cohort included 637 patients presenting with syncope during the 1-year study. Echocardiograms were ordered for 127 of 637 (20.1%) including 0 of 328 emergency department patients, 1 of 66 (1.5%) primary care setting patients, and 127 of 243 (52.3%) patients evaluated by a pediatric cardiologist. Use of echocardiography by pediatric cardiologists was categorized as “appropriate” in 92 of 127 (72.4%), “maybe appropriate” in 6 of 127 (4.7%), and “rarely appropriate” in 29 of 127 (22.8%). Abnormal findings were seen in 6 of 127 (4.7%) echocardiograms but in none of the “rarely appropriate” studies. In multivariable analysis, female sex and younger age were the only factors associated with performance of a “rarely appropriate” echocardiogram. “Rarely appropriate” echocardiograms cost an estimated $16 704.00 ($576.00 per patient) in the 1-year study.
“Rarely appropriate” echocardiograms performed for syncope do not contribute management changing diagnostic information. However, they burden patients with additional cost and perhaps contribute to increased need for follow-up.
Appropriateness of Outpatient Echocardiograms Ordered by Pediatric Cardiologists or Other Clinicians
2017, Journal of Pediatrics
To assess the appropriateness and diagnostic yield of TTEs ordered by various pediatric providers according to the pediatric appropriate use criteria (AUC) for outpatient transthoracic echocardiography (TTE) before its release.
Clinic notes of patients aged ≤18 years who underwent initial outpatient TTE between April and September 2014 were reviewed to determine the AUC indication, and appropriateness was assigned based on the AUC document. Ordering physicians were categorized into cardiologists, primary care physicians (PCPs; including pediatricians and family practitioners [FPs]), and noncardiology subspecialists.
Of the 1921 TTEs ordered during the study period, 84.6% were by cardiologists, 9.2% by pediatricians, 3.4% by FPs, and 2.8% by noncardiology subspecialists. The appropriateness rate for cardiologists was higher than that for PCPs (86% vs 64%; P < .001) but not noncardiology subspecialist (86% vs 87%; P = .80). PCPs had a significantly higher proportion of studies that could not be classified compared with cardiologists (35% vs 5%; P < .001) and noncardiology subspecialists (35% vs 11%; P < .001), owing primarily to a lack of adequate clinical information. The likelihood of an abnormal finding was higher in TTEs ordered by a cardiologist vs those ordered by a noncardiologist (OR, 4.8; 95% CI, 2.1-10.9; P < .001).
Compared with PCPs, cardiologists ordered more TTEs, had the highest yield of abnormal findings, and had greater appropriateness of TTE orders. A large proportion of TTEs ordered by PCPs were unclassifiable owing to insufficient information. This study lays a framework for provider education and improvement in the TTE order intake process.

View all citing articles on Scopus

View full text

Original ArticleSyncope in children: Diagnostic tests have a high cost and low yield

Objectives

Study design

Results

Conclusions

Section snippets

Methods

Patients

Discussion

Limitations

Conclusions

Syncope of unknown origin: the need for a more cost-effective approach to its diagnosis evaluation

JAMA

The economic burden of unrecognized vasodepressor syncope

Am J Med

A retrospective analysis of the cost-effective workup of syncope in children

Cleve Clin J Med

Evaluation and outcome of patients with syncope

Medicine (Baltimore)

Evaluation and outcome of emergency room patients with transient loss of consciousness

Am J Med

The impact of diagnostic tests in evaluating patients with syncope

Yale J Biol Med

A prospective evaluation of pediatric patients with syncope

Clin Pediatr (Phila)

Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope

Am J Cardiol

Cardiac loop ECG recording: a new noninvasive diagnostic test in recurrent syncope

South Med J

Detection of arrhythmias: use of a patient-activated ambulatory electrocardiogram device with a solid-state memory loop

Br Heart J

Original Article
Syncope in children: Diagnostic tests have a high cost and low yield