Regional variation in outcomes and healthcare resources utilization in, emergency department visits for syncope.

BACKGROUND: Management of patients with syncope lacks standardization. We sought to assess regional variation in hospitalization rates and resource utilization of patients with syncope. METHODS: We identified adults with syncope using the Nationwide Emergency Department Sample from years 2006 to 2014. Demographics and comorbidity characteristics were compared across geographic regions in the US. Multiple regression was conducted to compare outcomes. RESULTS: 9,132,176 adults presented with syncope. Syncope in the Northeast (n = 1,831,889) accounted for 20.1% of visits; 22.6% in the Midwest (n = 2,060,940), 38.5% in the South (n = 3,527,814) and 18.7% in the West (n = 1,711,533). Mean age was 56 years with 57.7% being female. The Northeast had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, ORadj 0.58; 95% CI 0.52-0.65, p < 0.001), the Midwest (17.2%, ORadj 0.51; 95% CI 0.46-0.58, p < 0.001) and West (15.8%, ORadj 0.45; 95% CI 0.39-0.51, p < 0.001). Risk-adjusted rates of syncope hospitalizations significantly declined from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (Ptrend < 0.001). The Northeast had the lowest risk-adjusted ED (Emergency Department) service charges per visit ($3320) followed by the Midwest ($4675, IRRadj 1.41; 95% CI 1.30-1.52, p < 0.001), the West ($4814, IRRadj 1.45; 95% CI 1.31-1.60, p < 0.001) and South ($4969, IRRadj 1.50; 95% CI 1.38-1.62, p < 0.001). Service charges increased from $3047/visit (95% CI $2912-$3182) in 2006 to $6267/visit (95% CI $5947-$6586) in 2014 (Ptrend < 0.001). CONCLUSIONS: Significant regional variability in hospitalization rates and ED service charges exist among patients with syncope. Standardizing practices may be needed to reduce variability.

Stakeholder Perspectives on an Inpatient Hypoglycemia Informatics Alert: Mixed Methods Study.

BACKGROUND: Iatrogenic hypoglycemia is a common occurrence among hospitalized patients and is associated with poor clinical outcomes and increased mortality. Clinical decision support systems can be used to reduce the incidence of this potentially avoidable adverse event. OBJECTIVE: This study aims to determine the desired features and functionality of a real-time informatics alert to prevent iatrogenic hypoglycemia in a hospital setting. METHODS: Using the Agency for Healthcare Research and Quality Five Rights of Effective Clinical Decision Support Framework, we conducted a mixed methods study using an electronic survey and focus group sessions of hospital-based providers. The goal was to elicit stakeholder input to inform the future development of a real-time informatics alert to target iatrogenic hypoglycemia. In addition to perceptions about the importance of the problem and existing barriers, we sought input regarding the content, format, channel, timing, and recipient for the alert (ie, the Five Rights). Thematic analysis of focus group sessions was conducted using deductive and inductive approaches. RESULTS: A 21-item electronic survey was completed by 102 inpatient-based providers, followed by 2 focus group sessions (6 providers per session). Respondents universally agreed or strongly agreed that inpatient iatrogenic hypoglycemia is an important problem that can be addressed with an informatics alert. Stakeholders expressed a preference for an alert that is nonintrusive, accurate, communicated in near real time to the ordering provider, and provides actionable treatment recommendations. Several electronic medical record tools, including alert indicators in the patient header, glucose management report, and laboratory results section, were deemed acceptable formats for consideration. Concerns regarding alert fatigue were prevalent among both survey respondents and focus group participants. CONCLUSIONS: The design preferences identified in this study will provide the framework needed for an informatics team to develop a prototype alert for pilot testing and evaluation. This alert will help meet the needs of hospital-based clinicians caring for patients with diabetes who are at a high risk of treatment-related hypoglycemia.