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

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.

Appropriate Use Criteria for paediatric echocardiography in an outpatient practice: a validation study

“…11 Because the assigned severity of an abnormal echocardiographic result in our study was related to whether an intervention occurred within two years, our reported yields are not entirely comparable to other studies that used different or no follow up periods. 11,14,16,18 Still, our yield for indications related to chest pain or syncope are similar to other reported yields when considering that only those findings thought to be causing the presenting symptoms resulted in an intervention in our study (Table 1). The 4% yield for syncope and 1.1% for chest pain that resulted in treatment were related to findings such as anomalous origin of the right coronary artery and severe non-compaction.…”

“…This pattern and diagnostic yield for abnormal results motiving treatment correlates with that seen in recent literature discussing echocardiograms for syncope and chest pain. 11,16,17 Our yield for the indication of murmur was also similar to other studies; however, our yield for any abnormal result for the indications of chest pain and syncope was higher. 11 Because the assigned severity of an abnormal echocardiographic result in our study was related to whether an intervention occurred within two years, our reported yields are not entirely comparable to other studies that used different or no follow up periods.…”

Regional Implementation of a Pediatric Cardiology Syncope Algorithm Using Standardized Clinical Assessment and Management Plans (SCAMPS) Methodology

“…Both are rare, both are classically associated with at least peri‐exertional if not midexertional symptoms,31, 32 and hence, in this clinical pathway, should be detected with proscribed testing. All diagnostic testing carries with it the risk of incidental findings, false positive/false negative results, and ineffective interpretation (whether a technical or provider issue).…”

“…Experienced clinicians rapidly identify precise details of the history that shift their thinking toward more serious diagnoses 5, 32, 33. Given the low incidence of serious disease, this experience has a limited role in refining that algorithm.…”

Fifteen-minute consultation on limiting investigations in the fainting child

“…Studies have confirmed that the sensitivity of screening using history, examination and 12-lead ECG findings can be 100% sensitive for the cardiac causes of syncope 1 5…”