Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers



      Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines.


      Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo.


      Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change.


      Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.


      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lamb L.E.
        • Green H.C.
        • Combs J.J.
        • Cheeseman S.A.
        • Hammond J.
        Incidence of loss of consciousness in 1,980 Air Force personnel.
        Aerosp Med. 1960; 31: 973-988
        • Anderson J.B.
        • Czosek R.J.
        • Knilans T.K.
        • Marino B.S.
        The effect of paediatric syncope on health-related quality of life.
        Cardiol Young. 2012; 22: 583-588
        • Giada F.
        • Silvestri I.
        • Rossillo A.
        • Nicotera P.G.
        • Manzillo G.F.
        • Raviele A.
        Psychiatric profile, quality of life and risk of syncopal recurrence in patients with tilt-induced vasovagal syncope.
        Europace. 2005; 7: 465-471
        • Linzer M.
        • Pontinen M.
        • Gold D.T.
        • Divine G.W.
        • Felder A.
        • Brooks W.B.
        Impairment of physical and psychosocial function in recurrent syncope.
        J Clin Epidemiol. 1991; 44: 1037-1043
        • Rose M.S.
        • Koshman M.L.
        • Ritchie D.
        • Sheldon R.
        The development and preliminary validation of a scale measuring the impact of syncope on quality of life.
        Europace. 2009; 11: 1369-1374
        • Santhouse J.
        • Carrier C.
        • Arya S.
        • Fowler H.
        • Duncan S.
        A comparison of self-reported quality of life between patients with epilepsy and neurocardiogenic syncope.
        Epilepsia. 2007; 48: 1019-1022
        • Faddis M.N.
        • Rich M.W.
        Pacing interventions for falls and syncope in the elderly.
        Clin Geriatr Med. 2002; 18: 279-294
        • Shen W.K.
        • Sheldon R.S.
        • Benditt D.G.
        • et al.
        2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2017; 70: e39-e110
        • Shen W.K.
        • Decker W.W.
        • Smars P.A.
        • et al.
        Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management.
        Circulation. 2004; 110: 3636-3645
        • Canzoniero J.V.
        • Afshar E.
        • Hedian H.
        • Koch C.
        • Morgan D.J.
        Unnecessary hospitalization and related harm for patients with low-risk syncope.
        JAMA Intern Med. 2015; 175: 1065-1067
        • Thiruganasambandamoorthy V.
        • Taljaard M.
        • Stiell I.G.
        • et al.
        Emergency department management of syncope: need for standardization and improved risk stratification.
        Intern Emerg Med. 2015; 10: 619-627
        • Probst M.A.
        • Kanzaria H.K.
        • Gbedemah M.
        • Richardson L.D.
        • Sun B.C.
        National trends in resource utilization associated with ED visits for syncope.
        Am J Emerg Med. 2015; 33: 998-1001
        • Probst M.A.
        • McConnell J.K.
        • Weiss R.E.
        • et al.
        Estimating the cost of care for emergency department syncope patients: comparison of three models.
        West J Emerg Med. 2017; 18: 253-257
        • Abadie B.Q.
        • Hansen B.
        • Walker J.
        • et al.
        An atrial fibrillation transitions of care clinic improves atrial fibrillation quality metrics.
        JACC Clin Electrophysiol. 2020; 6: 45-52
        • Chou S.C.
        • Nagurney J.M.
        • Weiner S.G.
        • Hong A.S.
        • Wharam J.F.
        Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy.
        American Journal of Emergency Medicine. 2019; 37: 1037-1043
        • Damschroder L.J.
        • Aron D.C.
        • Keith R.E.
        • Kirsh S.R.
        • Alexander J.A.
        • Lowery J.C.
        Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
        Implementation science : IS. 2009; 4: 50
        • Tabak R.G.
        • Khoong E.C.
        • Chambers D.A.
        • Brownson R.C.
        Bridging research and practice: models for dissemination and implementation research.
        Am J Prev Med. 2012; 43: 337-350
        • Rye M.
        • Torres E.M.
        • Friborg O.
        • Skre I.
        • Aarons G.A.
        The Evidence-based Practice Attitude Scale-36 (EBPAS-36): a brief and pragmatic measure of attitudes to evidence-based practice validated in US and Norwegian samples.
        Implementation science : IS. 2017; 12: 44
        • Helfrich C.D.
        • Li Y.F.
        • Sharp N.D.
        • Sales A.E.
        Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework.
        Implementation science : IS. 2009; 4: 38
        • Hagedorn H.J.
        • Heideman P.W.
        The relationship between baseline organizational readiness to change assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study.
        Implementation science : IS. 2010; 5: 46
        • Bardyn T.P.
        • Patridge E.F.
        • Moore M.T.
        • Koh J.J.
        Health sciences libraries advancing collaborative clinical research data management in universities.
        J eSci Librariansh. 2018; 7
        • Ando H.
        • Cousins R.
        • Young C.
        Achieving saturation in thematic analysis: development and refinement of a codebook.
        Comprehensive Psychology. 2014; 3 ([03.CP.3.4])
        • Guest G.
        • Bunce A.
        • Johnson L.
        How many interviews are enough?:an experiment with data saturation and variability.
        Field Methods. 2006; 18: 59-82
        • Williams N.J.
        • Glisson C.
        • Hemmelgarn A.
        • Green P.
        Mechanisms of change in the ARC organizational strategy: increasing mental health clinicians' EBP adoption through improved organizational culture and capacity.
        Adm Policy Ment Health. 2017; 44: 269-283
        • Mohammadi M.M.
        • Poursaberi R.
        • Salahshoor M.R.
        Evaluating the adoption of evidence-based practice using Rogers's diffusion of innovation theory: a model testing study.
        Health promotion perspectives. 2018; 8: 25-32
        • Ruzek J.I.
        • Eftekhari A.
        • Crowley J.
        • Kuhn E.
        • Karlin B.E.
        • Rosen C.S.
        Post-training beliefs, intentions, and use of prolonged exposure therapy by clinicians in the veterans health administration.
        Adm Policy Ment Health. 2017; 44: 123-132
        • Glisson C.
        • Hemmelgarn A.
        • Green P.
        • Dukes D.
        • Atkinson S.
        • Williams N.J.
        Randomized trial of the availability, responsiveness, and continuity (ARC) organizational intervention with community-based mental health programs and clinicians serving youth.
        J Am Acad Child Adolesc Psychiatry. 2012; 51: 780-787
        • Glisson C.
        • Hemmelgarn A.
        • Green P.
        • Williams N.J.
        Randomized trial of the Availability, Responsiveness and Continuity (ARC) organizational intervention for improving youth outcomes in community mental health programs.
        J Am Acad Child Adolesc Psychiatry. 2013; 52: 493-500
        • Blase K.
        • Fixsen D.
        Core intervention components: identifying and operationalizing what makes programs work. ASPE research brief.
        US Department of Health and Human Services, 2013