Syncope evaluation unit: organization and benefits Dr. Angel Moya ESC congress Paris 30 august 2011

Transcription

1 Syncope evaluation unit: organization and benefits Dr. Angel Moya ESC congress Paris 30 august 2011

2 DECLARATION OF CONFLICT OF INTEREST none

3 Why to setup a syncope Unit Syncope is a prevalent condition in general population Although not all patients with syncope look for medical attention, it is a frequent medical problem The management of syncope is costly and consumes resources The pattern of how syncope is investigated is not uniform The diagnostic yield is not satisfactory

4 Epidemiology (Historical studies) Dermkisian (1958) Williams (1962) Murdoch (1980) Lipsitz (1985) Cosín (1989) Population Age Prevalence Air force personel % Students % Army % Elderly % General population %

5 Epidemiology 6.2/1,000 person year 190/549 (35%) Soteriades et al. NEJM 2002 Ganzeboom et al. JCE 2006 Overall: Faints: 9.5/1,000 Falls: 29.8/1,000 Malasana et al: PACE 2011

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7 Syncope in ED Admissions Day (1982) 3% OESIL (1999) 0.9% 57,6% Blanc (2002, 2005) 1.2% - 1.3% 62.7% SEEDS (2004) 43%-98% Disertori (2003) 0.95% 46% McCarthy (2009) 1.1% Baron (2010) 1.14% 26% Dacarett (2011) 1.3% 46%

8 Syncope in ED Admissions Day (1982) 3% OESIL (1999) 0.9% 57.6% Blanc (2002, 2005) 1.2% - 1.3% 62.7% SEEDS (2004) 43%-98% Disertori (2003) 0.95% 46% McCarthy (2009) 1.1% 51.4% Baron (2010) 1.14% 26% Dacarett (2011) 1.3% 46%

9 Management of syncope in the Emergency Department: a single hospital observational case series based on the application of ESC guidelines. McCarthy F, McMahon CG, Geary U, Plunkett PK, Kenny RA, Cunningham CJ. Europace 2009; 11: syncope in ED Indication for hospitalization n = 46 Safe for discharge n = 168 Appropriately admitted Inappropriately discharged Appropriately discharged Inappropriately admitted n = 46 (100%) n = 0 (100%) n = 104 (61.9%) n = 64 (38.1%)

10 Cost per patient ( ) N = 203 Hospital stay 3,718 (1,436 5,679) Dx tests 1,141 (155 3,577) Treatments 6,299 ( ) Total 11,157 (1,651 31,762)

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12 Evaluation cost ( ) Hospital stay 1, ,226 Total 2, ,626 Hospital stay (days)

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14 Cost analysis per Visit/Admission with Faint and Falls in the State of Utah Faint Fall Inpatient admission payment ($) 12,640 19,194 Outpatient visit payment ($) Emergency department visit ($) 1, Mean payment 2,517 3,200 Malasana et al. PACE 2011.

15 Disertori et al. Europace 2003.

16 Dx yield in observational studies

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18 Unexplained syncope 25% 28%

19 Admitted patients 62.7% 46.7%

20 Syncope Management Unit Outpatient unit Facilities for HUTT, CSM, ECG monitoring Staffed by physicians trained in internal medicine and gerontology Acces to neurology and cardiology physicians

21 Rapid acces system Acute hospital admission General practitioner or other specialists Accident emergency dept. In patients 1 w Urgent outpatients 1-3 w No urgent outpatients < 6 w

22 Rapid acces system Acute hospital admission General practitioner or other specialists Accident emergency dept. In patients 1 w Urgent outpatients 1-3 w No urgent outpatients < 6 w

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25 Hospital Large medium public general hospitals 24 h emergency dept. On site facilities for all indicated test for assessing syncope (TT, EPS, ECG monitoring, other tests) Syncope Unit Managed by cardiologist Patients had preferential access to tests and admissions Other specialists (neurologists, psychiatrists, )

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29 Strict adherence to syncope guidelines Use of a decision making software, based on 2004 ESC guidelines (EGSYS software) Training of a specific physician in each center

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33 Syncope Unit: 1 physician, 2 nurses 2 dedicated rooms in Cardiology dept. Physician in ER trained to follow syncope guidelines Patient evaluation in ER Initial evaluation according guidelines Risk stratification according OESIL score: > 2, or relevant cardiac or neurologic disease admission < 2, discharged and referred to SU (24 48 h)

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35 Syncope Unit Organization The organization of a Syncope Unit must adapt to each hospital but basic concepts are: Rapid access of patients with syncope of unknown origin Patients can be referred from ED, in hospital, general practitioner A physician (or a team of physicians), that centralizes the diagnostic process, following current guidleines Preferential access to relevant tests for the diagnosis of syncope (NM, cardiac, neurologic..)

36 Syncope Unit Benefits Reduces the cost of the diagnostic process Reducing inappropriate admissions Reducing useless tests Accelerating the diagnosis Increases the diagnostic yield Reducing the number of patients with unexplained syncope Allows specific treatment Decrease of recurrences at FU Reduction of cost at FU