Original Article

CME Article: Characteristics of Syncope Admissions Among Hospitals of Varying Teaching Intensity

Authors: Michael I. Ellenbogen, MD, Daniel J. Brotman, MD, Jungwha Lee, PhD, MPH, Kimberly Koloms, MS, Kevin J. O’Leary, MD, MS


Objectives: Previous work suggests that hospitals’ teaching status is correlated with readmission rates, cost of care, and mortality. The degree to which teaching status is associated with the management of syncope has not been studied extensively. We sought to characterize the relation between teaching status and inpatient syncope management.

Methods: We created regression models to characterize the relation between teaching status and cardiac ischemic evaluations (cardiac catheterization and/or stress test) during syncope admissions. Admissions with a primary diagnosis of syncope in Maryland and Kentucky between 2007 and 2014 were included.

Results: The dataset included 71,341 syncope admissions at 151 hospitals. Overall, 15% of patients had an ischemic evaluation. There was a significantly lower likelihood of an ischemic evaluation at major teaching hospitals relative to nonteaching hospitals (adjusted odds ratio 0.75, 95% confidence interval 0.71–0.79), but a higher likelihood of an ischemic evaluation at minor teaching hospitals (adjusted odds ratio 1.21, 95% confidence interval 1.16–1.25).

Conclusions: By definition, the syncope admissions included were unexplained or idiopathic cases, and thus likely to be lower-risk syncope cases. Those with a known etiology are coded by the cause of syncope, as dictated by coding guidelines. It is likely that many of these ischemic evaluations represent low-value care. Financial incentives and processes of care at major teaching hospitals may be driving this trend, and efforts should be made to better understand and replicate these at minor teaching and nonteaching hospitals.

Posted in: Syncope1

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Shahian DM, Nordberg P, Meyer GS, et al. Contemporary performance of U.S. teaching and nonteaching hospitals. Acad Med 2012;87:701-708.
2. Burke LG, Frakt AB, Khullar D, et al. Association between teaching status and mortality in US hospitals. JAMA 2017;317:2105-2113.
3. Mendu ML, McAvay G, Lampert R, et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009;169:1299-1305.
4. Sun BC. Quality-of-life, health service use, and costs associated with syncope. Prog Cardiovasc Dis 2013;55:370-375.
5. Sun BC, Emond JA, Camargo CA, Jr. Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 2005;95:668-671.
6. Soteriades ES, Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med 2002;347:878-885.
7. Moore BJ, White S, Washington R, et al. Identifying increased risk of readmission and In-hospital mortality using hospital administrative data: the AHRQ Elixhauser Comorbidity Index. Med Care 2017;55:698-705.
8. Centers for Disease Control and Prevention. ICD-9-CM official guidelines for coding and reporting. https://www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf. Published October 1, 2011. Accessed March 1, 2018.
9. Lin GA, Dudley RA, Lucas FL, et al. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA 2008;300:1765-1773.
10. Alshekhlee A, Shen WK, Mackall J, et al. Incidence and mortality rates of syncope in the United States. Am J Med 2009;122:181-188.
11. Shen WK, Sheldon RS, Benditt DG, 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. Circulation 2017;136:e60-e122.
12. Peterson ED, Roe MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:1912-1920.
13. Mueller SK, Lipsitz S, Hicks LS. Impact of hospital teaching intensity on quality of care and patient outcomes. Med Care 2013;51:567-574.
14. Ellenbogen MI, Ma M, Christensen NP, et al. Differences in routine laboratory ordering between a teaching service and a hospitalist service at a single academic medical center. South Med J 2017;110:25-30.
15. Valencia V, Arora VM, Ranji SR, et al. A comparison of laboratory testing in teaching vs nonteaching hospitals for 2 common medical conditions. JAMA Intern Med 2018;178:39-47.