Improving Syncope Risk Stratification in Older Adults

描述（由申请人提供）：每年有740，000起晕厥事件（短暂性意识丧失）导致急诊室（艾德）就诊，导致250，000人入院，每年住院费用为24亿美元。目前还没有有效的预测工具来识别老年患者（年龄60岁），他们可能有随后发生心源性死亡或严重心脏事件的风险。因此，高达85%的老年晕厥患者住院进行诊断评估。然而，没有证据表明入院可以提高诊断率、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证据基础，以匹配预测的风险与适当的临床行动。此外，现有的研究几乎没有涉及如何对老年人进行风险分层和评估，老年人不成比例地解释了诊断的不确定性， 卫生服务使用和严重后果。因此，过去30年来，实践模式没有改变。越来越大的压力，以限制医疗保健费用增加了这个问题的话题性，晕厥最近被确定为医疗保险恢复审计承包商收回医疗不必要的住院费用的首要条件之一。必须开发创新的护理模式，以提高艾德评估的效率和价值。为了满足这些需求，我们提出了一项前瞻性的观察性研究，3,700名老年人与不明原因的晕厥登记从四个急诊科。我们的具体假设是：1）。目前的护理模式成本高，临床效益低; 2.与非结构化医生评估和已发表的风险模型相比，明确的标准将改善风险分层;以及3.）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，我们的建议有以下顺序目标：具体目标1。描述率，诊断率，治疗率，诊断入院和与现有护理相关的检测费用。具体目标2。推导并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型风险预测模型。具体目标3。估计诊断率和实施基于风险的决策算法的成本。我们的研究将为一种常见且昂贵的综合征提供创新的护理算法，我们的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.