Improving Syncope Risk Stratification in Older Adults

改善老年人晕厥风险分层

基本信息

批准号：
8435281
负责人：
Benjamin C Sun
金额：
$ 81.5万
依托单位：
OREGON HEALTH & SCIENCE UNIVERSITY
依托单位国家：
美国
项目类别：
财政年份：
2013
资助国家：
美国
起止时间：
2013-02-01 至 2018-01-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/8435281
关键词：
Accident and Emergency department Accounting Address Admission activity Age Algorithms Biological Markers Cardiac Cardiac Death Caring Cause of Death Cessation of life Characteristics Clinical Contractor Data Decision Making Diagnostic Diagnostic tests Elderly Electrocardiogram Enrollment Evaluation Event Expenditure Goals Health Care Costs Health Services Hospital Costs Hospitalization Hospitals Incidence Inpatients Lead Medicare Methods Modeling Observational Study Outcome Patient Admission Patients Pattern Patterns of Care Physicians Publishing Quality of life Recovery Research Retrospective Studies Risk Risk Assessment Statistical Methods Stratification Syncope Syndrome Testing Therapeutic Uncertainty Unconscious State United States Validation Visit Work base cost evidence base high risk improved innovation mortality novel older patient pressure prospective public health relevance tool

项目摘要

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.

描述（由申请人提供）：每年有 740,000 起晕厥（短暂意识丧失）事件导致急诊室 (ED) 就诊，导致 250,000 人入院，每年的医院费用为 24 亿美元。目前尚无有效的预测工具来识别可能面临后续心源性死亡或严重心脏事件风险的老年患者（60 岁）。因此，高达 85% 的晕厥老年人需要住院接受诊断评估。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。现有范式的根本问题护理包括不准确的风险评估以及缺乏将预测风险与适当的临床行动相匹配的证据基础。此外，现有的研究实际上没有提及如何对老年人进行风险分层和评估，老年人过多地考虑了诊断的不确定性，卫生服务的使用和严重后果。因此，过去30年来，实践模式没有改变。限制医疗保健费用的压力越来越大，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上不必要的住院支出的首要条件之一。必须开发创新的护理模式，以提高急诊评估的效率和价值。为了满足这些需求，我们提议对来自四个急诊科的 3,700 名患有不明原因晕厥的老年人进行一项前瞻性观察性研究。我们的具体假设是：1.）当前的护理模式成本高昂，临床效益低； 2. 与非结构化的医生评估和已发布的风险模型相比，明确的标准将改善风险分层； 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，我们的提案有以下连续目标：具体目标 1. 描述与现有护理相关的诊断入院和检测的费率、诊断率、治疗率以及成本。具体目标 2. 推导并验证一种新的风险预测模型，用于预测不明原因晕厥后 30 天心源性死亡和严重心脏结局。具体目标 3. 估计实施基于风险的决策算法的诊断率和成本。我们的研究将为一种常见且昂贵的综合征带来创新的护理算法，并且完成我们的目标将促进老年人晕厥评估的范式转变。