How to Assess Risk of Syncope Readmission

Identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.

There are four primary causes for syncope readmissions, new research shows.

Syncope accounts for about 3% of total emergency department visits. In 2000, the total cost of care for the treatment of syncope was estimated at $2.4 billion annually.

The new research, which was published this month in the Journal of the American Heart Association, found syncope readmissions were more costly than initial hospital admissions for syncope. The median cost of a syncope/collapse hospital admission was $19,439. The median cost of an all-cause 30-day readmission was $26,127.

The identification of syncope causes and predictors can help clinicians formulate care plans to avoid hospital readmissions.

The JAHA research, which examined more than 282,000 syncope admissions, identifies the causes and predictors. Four primary causes for readmissions were identified:

1. Syncope/collapse was the most common single diagnosis for 30-day readmissions at 7.9% of patients
    
2. Combined cardiac causes tallied 17.2% of readmitted patients, with arrhythmia accounting for the largest percentage of patients at 7.2%, followed by congestive heart failure at 3.7%
    
3. Combined infectious causes tallied 13.7% of readmitted patients, with septicemia accounting for the largest percentage of patients at 3.7%, followed by urinary tract infection at 2.9%
    
4. Combined neurological causes tallied 10.9% of readmitted patients, with acute cerebrovascular disease accounting for the largest percentage of patients at 3.2% followed by seizures at 2.2%
    

The research found that 9.3% of syncope patients were readmitted to a hospital within 30 days of a hospital admission. Eight factors were associated with a high risk for readmission:

1. Cardiac disease, specifically congestive heart failure, atrial fibrillation/flutter, and coronary artery disease
    
2. Diabetes mellitus
    
3. Chronic obstructive pulmonary disease
    
4. Anemia
    
5. Discharge to an extended-care facility
    
6. Discharge to home with home healthcare services
    
7. Leaving against medical advice
    
8. Inpatient length of stay longer than three days
    

Avoiding readmission
 

There are several benefits to identifying syncope patients who are at high risk of readmission, says Amer Kadri, MD, lead author of the JAHA research and a clinical assistant professor of medicine at Cleveland Clinic's Medicine Institute.

"The primary benefit is better patient care. That reflects higher survival, lower early readmission, and a better quality of life. From an administrative point of view, that would also decrease the burden on our resources and healthcare system," he told HealthLeaders via email.

Taking a thorough patient history and conducting a detailed physical examination are cornerstones of syncope diagnosis and treatment, Kadri says. "Once you know what the pathology is, it becomes easier to manage it appropriately."

Syncope patients at high risk for readmission require further measurement and monitoring before and after discharge, he says. For example, Kadri says patients discharged to an extended care facility (ECF) should trigger a "high-risk syncope pathway" of care:

• The hospital-based care team should ensure that the ECF care team has information about what happened to the patient during hospitalization
   
• There should be an effective management plan hand-off, including a printed discharge summary attached to the patient's chart
   
• There should be a physician-to-physician phone call between the hospital-based clinician and the accepting physician at the ECF
   
• Social workers or case managers should arrange specialty clinic follow-up appointments
   
• A pharmacist should review pre-admission and discharge medication lists

Thorough assessment
 

All clinical variables should be considered when assessing a syncope patient's readmission risk, Kadri says.

Syncope can be a symptom rather than an underlying disease, which necessitates a thorough assessment, he says.

"Syncope is defined by transient loss of consciousness due to generalized cerebral hypoperfusion. That means syncope can be caused by any pathology that produces decreased brain blood perfusion followed by loss of consciousness with complete resolution shortly after," Kadri says.

For example, changes in medication can result in syncope, he says.

"If a patient reports recurrent syncope and presyncope—near fainting—in the morning there may have been a recent adjustment of their antihypertension medication, and they can suffer from low blood pressure, slow heart rate, or even more serious conditions like heart block. In this case, syncope would be a side effect of the medicine rather than a disease."

The JAHA research shows that considering all variables helps to identify true risk factors for readmission, he says.

"In our model, we found that older age—as an isolated variable—was a risk factor for readmission; however, when we implemented all other variables together, advancing age was not associated with higher risk of readmission."