Objective To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. Methods Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty‐day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30‐day SAE and disposition status from ED. Results Two hundred and eighty‐three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty‐day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3–94.9%), specificity 72.8% (95% CI 67.1–77.9%) for a threshold score of 1 or higher. Conclusion Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30‐day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS.
Study questionOur primary objective is to validate the utility and safety of the Canadian Syncope Risk Score (CSRS) as a clinical decision rule when assessing patients who present with syncope to Australian emergency departments (EDs). Our secondary objective is to evaluate the economic benefits of diverting patients who are at low risk of serious adverse events from admission to hospital. TimetablePhase one of the study will be conducted during March 2018 -March 2019 at the ED of Redcliffe Hospital, an outer metropolitan hospital near Brisbane, which receives 65 000 ED presentations each year. MethodsThis protocol describes phase one of a two-phase validation study. Phase one is an observational prospective validation study. Patients aged 18 or more who present to the ED with syncope, defined as a transient loss of consciousness followed by prompt recovery within the preceding 24 hours, will be recruited as participants. Patients are excluded if they have prolonged syncope (longer than 5 minutes) or persistent reduction in Glasgow Coma Scale (GCS) score, an obvious seizure, intoxication, inability to communicate in English, or major trauma requiring hospitalisation. The study is designed to not influence patient management, with the decision regarding ultimate patient disposition remaining at the discretion of the treating clinician. Demographic and clinical information required to satisfy the domains of the CSRS will be prospectively recorded by the treating clinician, and the CSRS will be calculated retrospectively. Patients will be contacted by telephone 30 days after their initial presentation to the ED for information about any subsequent adverse events.We will undertake a cost-effectiveness analysis from the health care perspective, comparing usual care and applying the CSRS to identify patients at low risk of adverse events who can be safely discharged from the ED instead of being admitted to hospital for further evaluation. Health care costs, including those associated with inpatient stay and admission-related resource use, will be collected from routine administrative databases. Statistical analysisAs phase one is an observational validation study, no formal sample size calculation is required, but we aim to recruit about 500 eligible patients over the one-year period. Data will be summarised as means with standard deviations, medians with interquartile ranges, or frequencies and percentages as appropriate. The diagnostic utility of the CSRS will be assessed by estimating its specificity, sensitivity, positive and negative predictive values, and the area under the receiver operating characteristic (ROC) curve.Parameters included in the economic model will be informed by the collected study data. The outcome of interest is the number of inpatient admissions avoided, with results being presented as costs saved per avoided admission. Health care costs will be included in the economic model and analysed with previously published methods. The results of the economic analysis will be presented as incremental ...
Objective To evaluate the Canadian Syncope Risk Score (CSRS) in syncope patients presenting to the ED from an economic perspective, using very‐low and low‐risk patients (CSRS −3 to 0) as a threshold for avoiding hospital admissions. Methods A decision‐analytic model, specifically a decision‐tree, was developed to evaluate application of the CSRS. A hypothetical cohort of 1000 patients was modelled based on characteristics and outcome of patients enrolled in a clinical validation study performed alongside this evaluation. Several analytic based approaches were used to handle model outputs and uncertainties. Results For a cohort of 1000 patients, applying the CSRS was associated with 169 less inpatient admissions from the ED, when compared to usual care. There was also a cost‐saving of $8255 per admitted patient, when the CSRS was applied, compared to usual care. Adopting the CSRS was the optimal approach in all scenario analyses and was robust to changes in model parameters. More than three‐quarters (78.6%) of all model simulations showed that applying the CSRS is a cost‐saving approach to managing syncope. There was high confidence in all results, with the approach using the CSRS reducing the costs and number of syncope‐related hospital admissions. Conclusions Compared to usual care, applying the CSRS appeared as a cost‐effective strategy. This new evidence will help decision‐makers choose cost‐effective approaches for the management of patients presenting to the ED with syncope, as they search for efficient ways to maximise health gain from a finite budget.
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