Organisation of Syncope Management Units: The North American Experience

Organisation of Syncope Management Units: The North American Experience

D.G. B

, F. L

, K.G. L

, S. S

Introduction

European Society of Cardiology (ESC) guidelines provide a structured approach to the diagnosis and treatment of patients with syncope [1].

Among its recommendations, the ESC Syncope Task Force favoured wider use of specialised multifaceted medical units to improve the management of syncope patients. In essence, whether a physical space or a ‘virtual’ unit, the syncope management unit (SMU) would bring to bear appropriate multidis- ciplinary skills and experience more efficiently than has typically been the case [1-3].

In North America, the SMU concept has yet to be widely accepted. In part, this may be due to absence of professional organisation advocacy. The American College of Emergency Physicians has offered a ‘clinical policy’ cov- ering the appropriate emergency department management of patients pre- senting with apparent syncope [4]. However, beyond this policy statement, there are as yet no comprehensive North American guidelines regarding the optimal evaluation and treatment of patients with transient loss of con- sciousness who are thought to have suffered a syncope event.

SMU Status in the US

In order to ascertain the current status of SMUs in North America, we sur- veyed United States and Canadian medical centres in terms of their approaches to syncope evaluation. With regard to survey target sites, since

Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine,

University of Minnesota Medical School, Minneapolis, Minnesota, USA

syncope evaluation has increasingly become the responsibility of cardiolo- gists/electrophysiologists, we focused the survey on medical centres in which that specialty was strongly represented.

In terms of the survey itself, we were specifically interested in determin- ing:

− Factors that impact the decision to form or not to form an SMU

− What physicians currently think about the potential utility of an SMU

− The preferred nature of the SMU, were it to be formed

In a preliminary review of study findings, only 2 of 22 reporting centres (9%) had organised an SMU. Of the two centres with an SMU, the unit was described as a ‘physical space’ in one case and as a ‘virtual unit’ (i.e., not a defined physical entity) in the other. In both cases the units were lead by a cardiologist/electrophysiologist. In one unit, only cardiology/electrophysiol- ogy participated, whereas in the second unit a variety of other specialties were also involved, including internal medicine, neurology, paediatric cardi- ology, and geriatrics.

Among the 20 reporting medical centres without an SMU, only 5/20 (25%) indicated that plans were being made to establish such a unit.

However, 65% of respondents indicated that they would favour establishing an SMU. An approximately equal number indicated confidence that an SMU would reduce the cost of establishing an appropriate diagnosis in syncope patients. Further, in terms of the organisational make-up of the SMU, most respondents favoured a multidisciplinary unit comprising at a minimum the following medical specialties: cardiology/electrophysiology, internal medi- cine, and neurology. Approximately one-half of the respondents included psychiatric expertise as a necessary SMU element.

The vast majority of respondents (> 90%) indicated that they preferred cardiology/electrophysiology to be the SMU ‘director’ or chief organiser.

However, given that the survey target sites were selected primarily from the Heart Rhythm Society (formerly North American Society of Pacing and Electrophysiology, NASPE) directory, it was inevitably heavily biased toward this specialty, and this may account for the overwhelming preference for car- diology/electrophysiology.

The survey also attempted to address the key reasons underlying the absence of an SMU at those responding institutions not having such units currently. The most common impediments were lack of leadership (55% of respondents) and an insufficient number of interested individuals (50% of respondents). However, while most respondents thought that an SMU would improve syncope management efficiency, 35% of respondents evinced ambivalence toward SMU development on the grounds that there is currently inadequate evidence of the utility of SMUs for improving diagnostic yields and reducing cost. Multi-centre studies comparing diagnostic and treatment

656 D.G. Benditt et al.

outcomes, along with financial data, would be very helpful for promoting adoption of the SMU concept, if SMU performance proved favourable.

Economic Issues Impacting SMU Development

Improved understanding of resource requirements for evaluation and treat- ment of patients with cardiovascular disease is of increasing importance in the North America [5–7]. Measurements of medical care costs rely primarily on tracking International Classification of Diseases (ICD-9) codes [6, 7]. In this regard, the direct and indirect costs for treatment of arteriosclerotic dis- eases in the USA in 1993, est imated from Health Care Financing Administration (HCFA) national health expenditures and survey data from the National Centre for Health Statistics, were in excess of US$200 billion [7].

Clearly, even modest cost reductions in this sector would pay a substantial dividend. In contrast, the management of syncope is estimated to be approx- imately $1 billion annually [8]. While the syncope numbers are probably imprecise due to sampling issues and incorrect diagnoses, they nonetheless represent a relatively small proportion of the total cost of cardiovascular care. Consequently, it is not surprising that relatively little attention has been paid to issues surrounding optimisation of the management of patients who present with syncope and other forms of transient loss of consciousness.

Impact of SMU on Costs

Many factors contribute to the cost of syncope evaluation. These include the frequency with which syncope is the principal presenting medical problem to hospital emergency departments and clinics, which is probably similar in the USA to the 1% of annual emergency department visits reported from Western Europe [1, 9]. However, of perhaps greater importance is the man- ner in which diagnostic and treatment challenges are managed after presen- tation at the emergency department or clinic. A recent report detailing an Italian hospital experience quantified the extent to which low-yield, cost- ineffective tests were requested by physicians investigating presumed syn- cope [10]. High-yield tests were frequently overlooked. In contrast, Kenny et al. have amply demonstrated the potential cost savings associated with a well-organised SMU. Specifically, they demonstrated savings in excess of US

$ 4 million in one year alone at a single hospital in Newcastle, UK, due to

more efficient management of syncope and ‘fall’ patients [2]. The economic

benefit arose in large measure from reduced readmission rates and a marked

reduction of hospital in-patient days. Similar benefits may be achievable in

North America, although only rarely has such an experience been published

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Organisation of Syncope Management Units: The North American Experience

[11]. The respondents to our survey, whether or not familiar with the Newcastle experience, appear to agree with the notion that an SMU structure offers an opportunity to reduce cost per reliable diagnosis.

Conclusions

In summary, the SMU is uncommon in North America. Furthermore, rela- tively few arrhythmia specialty centres are contemplating establishment of such a facility, although most survey respondents believe that an SMU would be helpful. The survey findings suggest that establishment of such a unit is impeded by lack of leadership, resource limitations within medical centres, and absence of convincing published data regarding SMU effectiveness.

Thus, at least in the near term, the SMU will remain the exception rather than the rule in North American medical practice.

Acknowledgements

The authors wish to express their appreciation to the many clinicians who responded to the survey, and to Barry L.S. Detloff and Wendy Markuson, who collated survey data and assisted in preparation of the manuscript.

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