Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

Published:August 22, 2018DOI:



      To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.


      We analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.


      From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: −3.1%; 95%CI −4.7, −1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: −2.2%; 95%CI −3.0, −1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: −0.6%; 95%CI −2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI −1.9, 2.0]; −0.9% [95%CI −3.1, 1.3]; and −1.2% [95%CI −5.3, 2.9], respectively).


      Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.


      ED (emergency department), ACEP (American College of Emergency Physicians), NHAMCS (National Hospital Ambulatory Medical Care Survey), NCHS (National Center for Health Statistics), CT (computer tomography), MRI (magnetic resonance imaging), CCS (clinical classification software), AHRQ (Agency for Healthcare Research and Quality)


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