Background: The approach to managing and admitting patients with syncope in an emergency setting lacks standardization. Our study aims to investigate how regional variation in management of emergency department (ED) patients presenting with syncope impacts outcomes and resource utilization in this patient population.

Methods: We used the 2006 to 2014 Nationwide Emergency Department Sample to identify adults ≥ 18 years old with an ICD-9 principal diagnosis code (780.2) of syncope. Basic patient demographics, socio-economic and comorbidity characteristics were compared across pre-defined federal geographic regions in the US: Northeast, Midwest, South and West. ED service charges were adjusted for inflation using the Consumer Price Index with 2019 as the reference year. Multivariate logistic regression models were constructed to compare hospitalization rates and mortality among regions with the Northeast as the reference while accounting for possible confounders. Similarly, negative binomial regression models were constructed to compare ED service charges and inpatient length of hospital stay.

Results: From 2006 to 2014, 9,132,176 adult syncope ED visits were included in the analysis. Syncope visits in the Northeast (n=1,831,889) accounted for 20.1% of all included visits; visits in the Midwest (n=2,060,940) accounted for 22.6%; visits in the South (n=3,527,814) accounted for 38.6% and visits in the West (n=1,711,533) accounted for 18.7%. Mean age was 56 years with 57.7% being female. The majority (65.2%) of the syncope visits were to hospital EDs without a trauma designation and 42.2% of the visits were evaluated and treated in metropolitan non-teaching hospitals. The Northeast region had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, AOR 0.58; 95% CI 0.52-0.65, p<0.001), the Midwest (17.2%, AOR 0.51; 95% CI 0.46-0.58, p<0.001) and the West (15.8%, AOR 0.45; 95% CI 0.39-0.51, p<0.001). The overall risk-adjusted Syncope hospitalization rate significantly declined over the study period from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (Ptrend <0.001). The Northeast region had the lowest risk-adjusted ED service charge per visit ($3,320) followed by the Midwest ($4,675, IRRadj 1.41; 95% CI 1.30-1.52, p<0.001), the West ($4,814, IRRadj 1.45; 95% CI 1.31-1.60, p<0.001) and the South ($4,969, IRRadj 1.50; 95% CI 1.38-1.62, p<0.001). Overall, ED service charges increased during the study period from $3,047/visit (95% CI $2,912-$3,182) in 2006 to $6,267/visit (95% CI $5,947-$6,586) in 2014 (Ptrend <0.001). Compared to the Northeast, all regions had significantly lower risk-adjusted inpatient length of hospital stay (all p<0.001) but only the West had a significantly lower mortality (AOR 0.53; 95% CI 0.33-0.87, p<0.001).

Conclusions: We found significant regional variability in hospitalization rates, mortality, ED service charges and inpatient length of hospital stay in ED patients presenting with syncope. Standardized practices for management of this patient population are needed to reduce variability and the impact of such variability on healthcare delivery optimization and allocation of expensive resources.