Improving Syncope Risk Stratification in Older Adults

描述(由申请人提供)：每年有740,000例晕厥(一过性意识丧失)导致急诊科(ED)就诊，导致250,000人入院，每年的医院费用为24亿美元。目前还没有有效的预测工具来识别可能有随后心脏死亡或严重心脏事件风险的老年患者(60岁)。因此，高达85%的患有晕厥的老年人住院进行诊断评估。然而，没有证据表明入院可以提高诊断效率、生活质量或死亡率。现有范式的基本问题 护理包括不准确的风险评估和缺乏将预测的风险与适当的临床行动相匹配的证据基础。此外，现有的研究几乎没有关于如何对老年人进行风险分层和评估，老年人对诊断的不确定性有不成比例的解释， 卫生服务使用，后果严重。因此，在过去的30年里，实践模式没有改变。越来越大的限制医疗成本的压力增加了这个问题的专题性，晕厥最近被确定为Medicare Recovery Audit承包商收回医疗上不必要的住院支出的首要条件之一。必须开发创新的护理模式，以提高ED评估的效率和价值。为了解决这些需求，我们建议对来自四个急诊科的3700名患有不明原因晕厥的老年人进行前瞻性、观察性研究。我们的具体假设是：1)2.与非结构化的医生评估和已公布的风险模型相比，明确的标准将改善风险分层；以及3.目前的护理模式成本高昂，临床效益低。与现有护理相比，基于风险的决策可以安全地降低成本。为了评估这些假设，我们的建议有以下连续的目标：具体目标1.描述与现有护理相关的诊断率、诊断率、治疗率和诊断性入院和检测费用。具体目标2.推导和验证不明原因晕厥后30天心源性死亡和严重心脏结局的新风险预测模型。具体目标3.估计实施基于风险的决策算法的诊断收益和成本。我们的研究将导致针对一种常见且昂贵的综合征的创新护理算法，我们目标的完成将促进老年人晕厥评估的范式转变。

DESCRIPTION (provided by applicant): There are 740,000 annual events of syncope (transient loss of consciousness) that lead to an emergency department (ED) visit, resulting in 250,000 admissions and $2.4 billion in yearly hospital costs. There are currently no effective prediction tools to identify older patients (agee60 years) who may be at risk for subsequent cardiac death or serious cardiac events. As a result, up to 85% of older adults with syncope are hospitalized for diagnostic evaluation. However, there is no evidence that admission improves diagnostic yield, quality-of-life, or mortality. Fundamental problems with the existing paradigm of care include inaccurate risk assessment and the lack of an evidence base to match predicted risk with appropriate clinical actions. Furthermore, existing research is virtually silent on how t risk stratify and evaluate older adults, who disproportionately account for diagnostic uncertainty, health service use, and serious outcomes. As a result, practice patterns have not changed over the past 30 years. Mounting pressures to constrain health care costs increase the topicality of this problem, and syncope was recently identified as one of the top conditions targeted by Medicare Recovery Audit Contractors for repossession of medically unnecessary inpatient expenditures. Innovative care models must be developed to improve the efficiency and value of the ED evaluation. To address these needs, we propose a prospective, observational study of 3,700 older adults with unexplained syncope enrolled from four emergency departments. Our specific hypotheses are that: 1.) current patterns of care are costly with low clinical benefit; 2. explicit criteria will improve risk stratification compared to unstructured physician assessment and published risk models; and 3.) risk-based decision-making can safely reduce costs compared to existing care. To assess these hypotheses, our proposal has the following sequential Aims: Specific Aim 1. Describe rates, diagnostic yield, therapeutic yield, and costs of diagnostic admission and testing associated with existing care. Specific Aim 2. Derive and validate a novel risk prediction model for 30-day cardiac death and serious cardiac outcomes after unexplained syncope. Specific Aim 3. Estimate diagnostic yield and costs of implementing risk-based decision algorithms. Our study will result in innovative care algorithms for a common and costly syndrome, and completion of our Aims will facilitate a paradigm shift in the evaluation of syncope in older adults.