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Am J Emerg Med. 2019 May;37(5):810-816. doi: 10.1016/j.ajem.2018.07.043. Epub 2018 Jul 23.

Variation in diagnostic testing for older patients with syncope in the emergency department.

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Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, United States of America. Electronic address:
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University, Portland, OR, United States of America.
Department of Biostatistics, University of California Los Angeles Fielding School of Public Health, Los Angeles, CA, United States of America.
Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States of America.
Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States of America.
Department of Emergency Medicine, University of Rochester, NY, United States of America.
Department of Emergency Medicine, William Beaumont Hospital-Troy, Troy, MI, United States of America.
Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America.
Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI, United States of America.
Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX, United States of America.
Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America.
Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States of America.
Department of Emergency Medicine, Northeast Ohio Medical University, Rootstown, OH, United States of America.
Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States of America.



Older adults presenting with syncope often undergo intensive diagnostic testing with unclear benefit. We determined the variation, frequency, yield, and costs of tests obtained to evaluate older persons with syncope.


We conducted a prospective, multicenter observational cohort study in 11 academic emergency departments in the United States of 3686 patients aged ≥60 years presenting with syncope or presyncope. We measured the frequency, variation, yield, and costs (based on Medicare payment tables) of diagnostic tests performed at the index visit.


While most study rates were similar across sites, some were notably discordant (e.g., carotid ultrasound: mean 9.5%, range 1.1% to 49.3%). The most frequently-obtained diagnostic tests were initial troponin (88.6%), chest x-ray (75.1%), head CT (42.5%) and echocardiogram (35.5%). The yield or proportion of abnormal findings by diagnostic test ranged from 1.9% (electrocardiogram) to 42.0% (coronary angiography). Among the most common tests, echocardiogram had the highest proportion of abnormal results at 22.1%. Echocardiogram was an outlier in total cost at $672,648, and had a cost per abnormal test of $3129.


Variation in diagnostic testing in older patients presenting with syncope exists. The yield and cost per abnormal result for common tests obtained to evaluate syncope are also highly variable. Selecting tests based on history and examination while also prioritizing less resource intensive and higher yield tests may ensure a more informed and cost-effective approach to evaluating older patients with syncope.


Cost; Diagnostic testing; Emergency department; Near syncope; Syncope; Variation; Yield


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