Abstract 266: Referral Pathways in the Evaluation of Syncope

Background: The evaluation of syncope is challenging and is often associated with a high volume of repeat diagnostic testing. Early use of an implantable cardiac monitor (ICM) is recommended for patients with unexplained syncope following initial non-diagnostic workup. However, limited data is available on the patient journey prior to ICM. The aim of this study was to characterize healthcare utilization and referral pathways experienced during syncope evaluation, prior to insertion of ICM. Methods: ICM patients were identified in the 2014-2016 U.S. Medicare Fee-for-service claims database. Included patients were ≥18 years of age, had a syncope claim within 3 months prior to ICM insertion, and had continuous enrollment for ≥2 years baseline. Syncope-related encounters were defined as unique healthcare visits with a syncope diagnosis code. All specialist consultations within an encounter were captured. Results: Of 982 patients identified, 550 (56%) were female; mean age was 74 years. Mean time from first syncope encounter to ICM insertion was 236 days (min-max 1-1,081), with mean of 4.7 (min-max 1-30) total syncope-related encounters per patient. Out of 6 possible service locations, patients presented at a mean of 2.2 (min-max 1-5) different sites of service for syncope; 38% (375 of 982) of patients had been seen at ≥3 sites of service. Of 982 patients, 362 (37%) had presented to the ED, 399 (41%) had been hospitalized, 668 (68%) had been seen in outpatient hospital, and 534 (54%) in an office setting. A mean of 2.9 (min-max 0-9) specialist types had been consulted per patient, out of a total of 11 possible categories. One quarter of patients (745) had seen a cardiologist, 300 (10%) had seen an electrophysiologist (EP), and 155 (5.3%) a neurologist (Table). During initial syncope encounter, a cardiologist was consulted in 449 (27%) and EP in only 105 (6.2%) of patients. Conclusion: Wide variability was observed in both time and patient pathway between first syncope presentation and ICM. A more standardized approach to the triage and management of syncope patients has potential to reduce the volume of repeat evaluations and diminish associated delays in establishing diagnosis and appropriate treatment.