Syncope diagnostic evaluation in a southern European population: patterns of clinical practice and cost implications.

backgroundSyncope is a common cause of emergency department visits and is associated with heterogeneous clinical practice and substantial hospital resource use. We primarily aimed to quantify the direct per-patient hospital costs of syncope. Secondary aims were to characterize patterns of resource utilization, determine the cost structure by care pathway and functional component, and identify determinants of total per-patient cost. Additionally, we estimated the potential emergency department cost savings resulting from adherence to the 2018 European Society of Cardiology syncope guidelines.

methodsWe conducted an observational, retrospective cohort study at a private hospital in Lisbon, Portugal, from 1 January to 31 December 2023, including pediatric (< 18 years) and adult (≥ 18 years) patients with a principal emergency department diagnosis of syncope (ICD-9-CM 780.2/992.1). Direct costs were assessed by micro-costing (bottom-up approach) from the hospital perspective (base year 2023), with patient-level analysis. Total per-patient cost was modeled using a generalized linear model as a function of age, sex, etiology, and total number of comorbidities as predictors. Potential emergency department savings were estimated using a counterfactual simulation of guideline-concordant diagnostic testing.

resultsWe analyzed 375 patients (mean age 49.4 ± 26.5 years; 60.3% female). Etiology was established in 41.1% of the cohort, with reflex syncope predominating (32.3%), whereas 58.1% remained unexplained. Aggregate total cost was €661,992.74, with a mean of €1,765.31 per patient. Costs ranged from €408 per patient for emergency department-only management to €13,048 for episodes requiring hospitalization. Diagnostic testing accounted for 63.3% of total cost. In multivariable analysis, age ≥ 80 years, male sex, higher comorbidity burden and cardiac etiology were associated with significantly higher hospital costs. Potential emergency department diagnostic-testing savings were €80,228.28, corresponding to €213.94 per patient.

conclusionSyncope was associated with substantial hospital costs in a context of marked practice variation and intensive diagnostic testing. Structured, guideline-aligned care pathways may support more selective diagnostic evaluation and efficient use of healthcare resources. CLINICAL TRIAL NUMBER: Not applicable.