Intensive Education on Evidence-Based Evaluation of Syncope Increases Sudden Death Risk Stratification but Fails to Reduce Use of Neuroimaging

Abstract

We sought to determine whether aggressive education on evidence-based guidelines would affect the use of resources. Specifically, we sought to educate providers about the role of neuroimaging as well as sudden death risk stratification. We reviewed 1092 consecutive cases involving patients who were admitted for syncope. We retrospectively reviewed 30 months of admissions for baseline characteristics and then initiated an intensive monthly education campaign directed toward internal medicine physicians-in-training focusing on evidence-based guidelines for a 13-month period. There were 721 patients (66.0%) evaluated before the education intervention and 371 patients (34.0%) evaluated after the education intervention. After the intervention, there was no change in the use of computed tomography (52.3% vs 55.5%; P = .31) or magnetic resonance imaging (20.2% vs 16.7%; P = .16) of the head or carotid ultrasonography (4.7% vs 6.2%; P = .30). The referral rate for electrophysiologic study significantly increased from 6.4% at baseline to 11.3% (P = .006) after intervention, with an overall diagnostic yield of 28.4%. Of those with identified structural heart disease, the referral rate went from 5.7% to 19.0% (P = .03). Only 66 of 1092 patients who presented with syncope ultimately required a pacemaker or defibrillator implantation during hospitalization. With intensive education, there was no decrease in neuroimaging, despite a low diagnostic yield. We were able to increase sudden death risk stratification using electrophysiologic studies without evidence of overuse of implantable device-based therapy. Intensive education allows increased adherence to guidelines for mortality reduction; however, further attempts to reduce the lower yield imaging will require methods other than education of hospital-based physicians.