Reducing Unnecessary Diagnostic Testing in Pediatric Syncope: A Quality Improvement Initiative


Our aim was to reduce the frequency of unnecessary testing used by pediatric cardiologists in the evaluation of pediatric patients with syncope or pre-syncopal symptoms without negatively affecting patient outcomes. Guidelines for cardiac testing in pediatric patients with syncope were developed and disseminated to members of our pediatric cardiology division. Educational brochures and water bottles labeled with tips on preventing syncope were made available to families and providers in our clinics. Compliance to the guidelines was tracked and shared with providers. Segmented regression analysis was used to model cardiac testing utilization and guideline compliance by provider over time before and after the implementation of the guidelines. A pre-intervention cohort of 237 patients (June 2014–May 2015) was compared to 880 post-intervention patients (August 2015–June 2019). There was a significant decrease in the utilization of unnecessary tests [odds ratio (OR) 0.3; 95% confidence interval (CI) 0.14, 0.65; p = 0.002] after the intervention. Charges associated with patient evaluation were significantly lower in the post-intervention cohort (interquartile range $0, $1378 vs $0, $213; p = 0.005). Post-intervention visits to emergency departments within our system were significantly decreased, with no change in the incidence of cardiac arrest, hospitalization for syncope, or referral to pediatric electrophysiologists. We demonstrated a significant reduction in the use of unnecessary testing and associated charges by developing guidelines related to the evaluation of pediatric patients with syncope or pre-syncopal symptoms. There was no demonstrable negative impact on patient outcomes.

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Data Availability

De-identified patient data have been retained to verify all reports within this manuscript.





Chest x-ray


Emergency department


Vasovagal syncope


Standard deviation


Interquartile range


Odds ratio


Confidence interval


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Statistical support through the University of Utah Study Design and Biostatistics Center for this investigation was supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764).

Author information




MW designed data collection, collected data, drafted the initial manuscript, and reviewed and revised the manuscript. JM coordinated and supervised data collection, designed data analysis, and reviewed and revised the manuscript. LK conceptualized and designed the study and reviewed and revised the manuscript. MP and AW designed data collection and critically reviewed the manuscript for important intellectual content. CZ carried out the analysis and critically reviewed and revised the manuscript. CC conceptualized and designed the study, implemented the guidelines, designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content.

Corresponding author

Correspondence to Melissa M. Winder.

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All the authors declared that they have no conflict of interest.

Ethical Approval

This quality improvement study was approved and provided exempt status by the University of Utah Institutional Review Board (IRB_00126778) and Primary Children’s Hospital Privacy Board.

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Winder, M.M., Marietta, J., Kerr, L.M. et al. Reducing Unnecessary Diagnostic Testing in Pediatric Syncope: A Quality Improvement Initiative. Pediatr Cardiol (2021).

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  • Pediatric
  • Syncope
  • Cardiac disease
  • Quality improvement
  • Diagnostic test