Does Hospital Admission/Observation for Chest Pain Improve Patient Outcomes after Emergency Department Evaluation for Suspected Acute Coronary Syndrome?

BACKGROUND: Chest pain is the top reason for hospitalization/observation in the USA, but it is unclear if this strategy improves patient outcomes. OBJECTIVE: The objective of this study was to compare 30-day outcomes for patients admitted versus discharged after a negative emergency department (ED) evaluation for suspected acute coronary syndrome. DESIGN: A retrospective, multi-site, cohort study of adult encounters with chest pain presenting to one of 13 Kaiser Permanente Southern California EDs between January 1, 2015, and December 1, 2017. Instrumental variable analysis was used to mitigate potential confounding by unobserved factors. PATIENTS: All adult patients presenting to an ED with chest pain, in whom an acute myocardial infarction was not diagnosed in the ED, were included. MAIN MEASURES: The primary outcome was 30-day acute myocardial infarction or all-cause mortality, and secondary outcomes included 30-day revascularization and major adverse cardiac events. KEY RESULTS: In total, 77,652 patient encounters were included in the study (n=11,026 admitted, 14.2%). Three hundred twenty-two (0.4%) had an acute myocardial infarction (n=193, 0.2%) or death (n=137, 0.2%) within 30 days of ED visit (1.5% hospitalized versus 0.2% discharged). Very few (0.3%) patients underwent coronary revascularization within 30 days (0.7% hospitalized versus 0.2% discharged). Instrumental variable analysis found no adjusted differences in 30-day patient outcomes between the hospitalized cohort and those discharged (risk reduction 0.002, 95% CI -0.002 to 0.007). Similarly, there were no differences in coronary revascularization (risk reduction 0.003, 95% CI -0.002 to 0.007). CONCLUSION: Among ED patients with chest pain not diagnosed with an acute myocardial infarction, risk of major adverse cardiac events is quite low, and there does not appear to be any benefit in 30-day outcomes for those admitted or observed in the hospital compared to those discharged with outpatient follow-up.

Automated abstraction of myocardial perfusion imaging reports using natural language processing.

BACKGROUND: Findings and interpretations of myocardial perfusion imaging (MPI) studies are documented in free-text MPI reports. MPI results are essential for research, but manual review is prohibitively time consuming. This study aimed to develop and validate an automated method to abstract MPI reports. METHODS: We developed a natural language processing (NLP) algorithm to abstract MPI reports. Randomly selected reports were double-blindly reviewed by two cardiologists to validate the NLP algorithm. Secondary analyses were performed to describe patient outcomes based on abstracted-MPI results on 16,957 MPI tests from adult patients evaluated for suspected ACS. RESULTS: The NLP algorithm achieved high sensitivity (96.7%) and specificity (98.9%) on the MPI categorical results and had a similar degree of agreement compared to the physician reviewers. Patients with abnormal MPI results had higher rates of 30-day acute myocardial infarction or death compared to patients with normal results. We identified issues related to the quality of the reports that not only affect communication with referring physicians but also challenges for automated abstraction. CONCLUSION: NLP is an accurate and efficient strategy to abstract results from the free-text MPI reports. Our findings will facilitate future research to understand the benefits of MPI studies but requires validation in other settings.

Evaluating Sex Disparities in the Emergency Department Management of Patients With Suspected Acute Coronary Syndrome.

STUDY OBJECTIVE: We compare clinical management and outcomes of emergency department (ED) encounters by sex after implementation of a clinical care pathway in 15 community EDs that standardized recommendations based on patient risk, using the History, ECG, Age, Risk Factors, and Troponin (HEART) score. METHODS: This was a retrospective analysis of adult ED encounters evaluated for suspected acute coronary syndrome with a documented HEART score from May 20, 2016, to December 1, 2017. The primary outcomes were hospitalization or 30-day stress testing. Secondary outcomes included 30-day acute myocardial infarction or all-cause death (major adverse cardiac event). A generalized estimating equation regression model was used to compare the odds of hospitalization or stress testing by sex; we report HEART scores (0 to 10) stratified by sex and describing major adverse cardiac events. RESULTS: A total of 34,715 adult ED encounters met the inclusion criteria (56.0% women). A higher proportion of women were classified as low risk (60.5% versus 52.4%; odds ratio [OR] 1.39; 95% confidence interval [CI] 1.33 to 1.45). Women were hospitalized or received stress testing less frequently than men for low HEART scores (18.8% versus 22.8%; OR 0.79; 95% CI 0.73 to 0.84) and intermediate ones (46.7% versus 49.7%; OR 0.88; 95% CI 0.83 to 0.95), but similarly for high-risk ones (74.1% versus 74.4%; OR 0.99; 95% CI 0.77 to 1.28). Women had 18% lower odds of hospitalization or noninvasive cardiac testing (OR 0.82; 95% CI 0.78 to 0.86), even after adjusting for HEART score and comorbidities. Men had higher risks of major adverse cardiac events than women for all HEART score categories but the risk for men was significantly higher among low-risk HEART scores (0.4% versus 0.1%). CONCLUSION: Women with low-risk HEART scores are hospitalized or stress tested less than men, which is likely appropriate, and women have better outcomes than men. Use of the HEART score has the potential to reduce sex disparities in acute coronary syndrome care.

Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis.

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients' data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7-10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7-10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7-10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7-10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.

Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score.

STUDY OBJECTIVE: Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes. METHODS: We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome. RESULTS: We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670). CONCLUSION: Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.

The Accuracy of Interqual Criteria in Determining the Observation versus Inpatient Status in Older Adults with Syncope.

BACKGROUND: McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. OBJECTIVE: We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope. METHODS: We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights. RESULTS: We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%). CONCLUSIONS: In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.

Opioid Prescribing Practices for Pediatric Headache.

OBJECTIVES: To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type. STUDY DESIGN: A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit. RESULTS: A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P < .001). CONCLUSIONS: Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe-A Qualitative Study on the Decisionmaking Process of Emergency Department Providers.

STUDY OBJECTIVE: Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation. METHODS: From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians. RESULTS: Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors. CONCLUSION: The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

Conversion to Persistent or High-Risk Opioid Use After a New Prescription From the Emergency Department: Evidence From Washington Medicaid Beneficiaries.

STUDY OBJECTIVE: We describe the overall risk and factors associated with transitioning to persistent opioid or high-risk use after an initial emergency department (ED) opioid prescription. METHODS: A retrospective cohort study of Washington Medicaid beneficiaries was performed with linked Medicaid and prescription drug monitoring program files. We identified adults who had no record of opioid prescriptions in the previous 12 months, and who filled a new opioid prescription within 1 day of an ED discharge in 2014. We assessed the risk of persistent opioid use or high-risk prescription fills within 12 months after the index visit. Logistic regression was used to assess the association between pertinent variables and conversion to persistent or high-risk use. RESULTS: Among 202,807 index ED visits, 23,381 resulted in a new opioid prescription. Of these, 13.7% led to persistent or high-risk opioid prescription fills within 12 months compared with 3.2% for patients who received no opioids at the index visit. Factors associated with increased likelihood of persistent opioid or high-risk prescription fills included a history of skeletal or connective-tissue disorder; neck, back, or dental pain; and a history of prescribed benzodiazepines. The highest conversion rates (37.3%) were observed among visits in which greater than or equal to 350 morphine milligram equivalents were prescribed. Conversion rates remained greater than 10% even among visits resulting in lower-dose opioid prescriptions. CONCLUSION: Medicaid recipients are at moderate risk for conversion to persistent or high-risk opioid use after a new ED prescription. Longer or higher-dose prescriptions are associated with increased risk for conversion; however, even visits that lead to guideline-concordant prescriptions bear some risk for long-term or high-risk use.

Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome.

STUDY OBJECTIVE: Professional guidelines recommend 72-hour cardiac stress testing after an emergency department (ED) evaluation for possible acute coronary syndrome. There are limited data on actual compliance rates and effect on patient outcomes. Our aim is to describe rates of completion of noninvasive cardiac stress testing and associated 30-day major adverse cardiac events. METHODS: We conducted a retrospective analysis of ED encounters from June 2015 to June 2017 across 13 community EDs within an integrated health system in Southern California. The study population included all adults with a chest pain diagnosis, troponin value, and discharge with an order for an outpatient cardiac stress test. The primary outcome was the proportion of patients who completed an outpatient stress test within the recommended 3 days, 4 to 30 days, or not at all. Secondary analysis described the 30-day incidence of major adverse cardiac events. RESULTS: During the study period, 24,459 patients presented with a chest pain evaluation requiring troponin analysis and stress test ordering from the ED. Of these, we studied the 7,988 patients who were discharged home to complete diagnostic testing, having been deemed appropriate by the treating clinicians for an outpatient stress test. The stress test completion rate was 31.3% within 3 days and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the ordered test. The 30-day rates of major adverse cardiac events were low (death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid receipt of stress testing was not associated with improved 30-day major adverse cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54). CONCLUSION: Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.

Prevalence of Pulmonary Embolism Among Emergency Department Patients With Syncope: A Multicenter Prospective Cohort Study.

STUDY OBJECTIVE: The prevalence of pulmonary embolism among patients with syncope is understudied. In accordance with a recent study with an exceptionally high pulmonary embolism prevalence, some advocate evaluating all syncope patients for pulmonary embolism, including those with another clear cause for their syncope. We seek to evaluate the pulmonary embolism prevalence among emergency department (ED) patients with syncope. METHODS: We combined data from 2 large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of pulmonary embolism-related investigations (ie, D-dimer, ventilation-perfusion scan, or computed tomography [CT] pulmonary angiography) and 30-day adjudicated outcomes: pulmonary embolism or nonpulmonary embolism outcome (arrhythmia, myocardial infarction, serious hemorrhage, and death). RESULTS: Of the 9,374 patients enrolled, 9,091 (97.0%; median age 66 years, 51.9% women) with 30-day follow-up were analyzed: 547 (6.0%) were evaluated for pulmonary embolism (278 [3.1%] had D-dimer, 39 [0.4%] had ventilation-perfusion scan, and 347 [3.8%] had CT pulmonary angiography). Overall, 874 patients (9.6%) experienced 30-day serious outcomes: 818 patients (9.0%) with nonpulmonary embolism serious outcomes and 56 (prevalence 0.6%; 95% confidence interval 0.5% to 0.8%) with pulmonary embolism (including 8 [0.2%] out of 3521 patients diagnosed during the index hospitalization and 7 [0.1%] diagnosed after the index visit). Eighty-six patients (0.9%) died, and 4 deaths (0.04%) were related to pulmonary embolism. Only 11 patients (0.1%) with a nonpulmonary embolism serious condition had a concomitant pulmonary embolism. CONCLUSION: The prevalence of pulmonary embolism is very low among ED patients with syncope, including those hospitalized after syncope. Although an underlying pulmonary embolism may cause syncope, clinicians should be cautious about indiscriminate investigations for pulmonary embolism.

Effect of a HEART Care Pathway on Chest Pain Management Within an Integrated Health System.

STUDY OBJECTIVE: We describe the association of implementing a History, ECG, Age, Risk Factors, and Troponin (HEART) care pathway on use of hospital care and noninvasive stress testing, as well as 30-day patient outcomes in community emergency departments (EDs). METHODS: We performed a prospective interrupted-time-series study of adult encounters for patients evaluated for suspected acute coronary syndrome. The primary outcome was hospitalization or observation, noninvasive stress testing, or both within 30 days. The secondary outcome was 30-day all-cause mortality or acute myocardial infarction. A generalized estimating equation segmented logistic regression model was used to compare the odds of the primary outcome before and after HEART implementation. All models were adjusted for patient and facility characteristics and fit with physicians as a clustering variable. RESULTS: A total of 65,393 ED encounters (before, 30,522; after, 34,871) were included in the study. Overall, 33.5% (before, 35.5%; after, 31.8%) of ED chest pain encounters resulted in hospitalization or observation, noninvasive stress testing, or both. Primary adjusted results found a significant decrease in the primary outcome postimplementation (odds ratio 0.984; 95% confidence interval [CI] 0.974 to 0.995). This resulted in an absolute adjusted month-to-month decrease of 4.39% (95% CI 3.72% to 5.07%) after 12 months' follow-up, with a continued trend downward. There was no difference in 30-day mortality or myocardial infarction (0.6% [before] versus 0.6% [after]; odds ratio 1.02; 95% CI 0.97 to 1.08). CONCLUSION: Implementation of a HEART pathway in the ED evaluation of patients with chest pain resulted in less inpatient care and noninvasive cardiac testing and was safe. Using HEART to risk stratify chest pain patients can improve the efficiency and quality of care.

Clinical Benefit of Hospitalization for Older Adults With Unexplained Syncope: A Propensity-Matched Analysis.

STUDY OBJECTIVE: Many adults with syncope are hospitalized solely for observation and testing. We seek to determine whether hospitalization versus outpatient management for older adults with unexplained syncope is associated with a reduction in postdisposition serious adverse events at 30 days. METHODS: We performed a propensity score analysis using data from a prospective, observational study of older adults with unexplained syncope or near syncope who presented to 11 emergency departments (EDs) in the United States. We enrolled adults (≥60 years) who presented with syncope or near syncope. We excluded patients with a serious diagnosis identified in the ED. Clinical and laboratory data were collected on all patients. The primary outcome was rate of post-ED serious adverse events at 30 days. RESULTS: We enrolled 2,492 older adults with syncope and no serious ED diagnosis from April 2013 to September 2016. Mean age was 73 years (SD 8.9 years), and 51% were women. The incidence of serious adverse events within 30 days after the index visit was 7.4% for hospitalized patients and 3.19% for discharged patients, representing an unadjusted difference of 4.2% (95% confidence interval 2.38% to 6.02%). After propensity score matching on risk of hospitalization, there was no statistically significant difference in serious adverse events at 30 days between the hospitalized group (4.89%) and the discharged group (2.82%) (risk difference 2.07%; 95% confidence interval -0.24% to 4.38%). CONCLUSION: In our propensity-matched sample of older adults with unexplained syncope, for those with clinical characteristics similar to that of the discharged cohort, hospitalization was not associated with improvement in 30-day serious adverse event rates.

Comparison of 30-Day Serious Adverse Clinical Events for Elderly Patients Presenting to the Emergency Department With Near-Syncope Versus Syncope.

STUDY OBJECTIVE: Controversy remains in regard to the risk of adverse events for patients presenting with syncope compared with near-syncope. The purpose of our study is to describe the difference in outcomes between these groups in a large multicenter cohort of older emergency department (ED) patients. METHODS: From April 28, 2013, to September 21, 2016, we conducted a prospective, observational study across 11 EDs in adults (≥60 years) with syncope or near-syncope. A standardized data extraction tool was used to collect information during their index visit and at 30-day follow-up. Our primary outcome was the incidence of 30-day death or serious clinical events. Data were analyzed with descriptive statistics and multivariate logistic regression analysis adjusting for relevant demographic or historical variables. RESULTS: A total of 3,581 patients (mean age 72.8 years; 51.6% men) were enrolled in the study. There were 1,380 patients (39%) presenting with near-syncope and 2,201 (61%) presenting with syncope. Baseline characteristics revealed a greater incidence of congestive heart failure, coronary artery disease, previous arrhythmia, nonwhite race, and presenting dyspnea in the near-syncope compared with syncope cohort. There were no differences in the primary outcome between the groups (near-syncope 18.7% versus syncope 18.2%). A multivariate logistic regression analysis identified no difference in 30-day serious outcomes for patients with near-syncope (odds ratio 0.94; 95% confidence interval 0.78 to 1.14) compared with syncope. CONCLUSION: Near-syncope confers risk to patients similar to that of syncope for the composite outcome of 30-day death or serious clinical event.

Variation in diagnostic testing for older patients with syncope in the emergency department.

BACKGROUND: Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope. METHODS: We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit. RESULTS: While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129. CONCLUSION: Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.

QTc prolongation as a marker of 30-day serious outcomes in older patients with syncope presenting to the Emergency Department.

BACKGROUND: Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope. METHODS: This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of <451; 451-470; 471-500, and >500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED. RESULTS: The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals <451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals >500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis. CONCLUSIONS: In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.

Recurrent syncope is not an independent risk predictor for future syncopal events or adverse outcomes.

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode. METHODS: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events. RESULTS: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had >1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90-1.31; p = 0.387). CONCLUSION: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events.

Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study.

BACKGROUND: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope. METHODS: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs. RESULTS: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18). CONCLUSIONS: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.

Does Prescription Opioid Shopping Increase Overdose Rates in Medicaid Beneficiaries?

STUDY OBJECTIVE: The link between prescription opioid shopping and overdose events is poorly understood. We test the hypothesis that a history of prescription opioid shopping is associated with increased risk of overdose events. METHODS: This is a secondary analysis of a linked claims and controlled substance dispense database. We studied adult Medicaid beneficiaries in 2014 with prescription opioid use in the 6 months before an ambulatory care or emergency department visit with a pain-related diagnosis. The primary outcome was a nonfatal overdose event within 6 months of the cohort entry date. The exposure of interest (opioid shopping) was defined as having opioid prescriptions by different prescribers with greater than or equal to 1-day overlap and filled at 3 or more pharmacies in the 6 months before cohort entry. We used a propensity score to match shoppers with nonshoppers in a 1:1 ratio. We calculated the absolute difference in outcome rates between shoppers and nonshoppers. RESULTS: We studied 66,328 patients, including 2,571 opioid shoppers (3.9%). There were 290 patients (0.4%) in the overall cohort who experienced a nonfatal overdose. In unadjusted analyses, shoppers had higher event rates than nonshoppers (rate difference of 4.4 events per 1,000; 95% confidence interval 0.8 to 7.9). After propensity score matching, there were no outcome differences between shoppers and nonshoppers (rate difference of 0.4 events per 1,000; 95% confidence interval -4.7 to 5.5). These findings were robust to various definitions of opioid shoppers and look-back periods. CONCLUSION: Prescription opioid shopping is not independently associated with increased risk of overdose events.

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study.

STUDY OBJECTIVE: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.