The San Francisco Syncope Rule vs physician judgment and decision making.
OBJECTIVE
To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope.


METHODS
In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions.


RESULTS
During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes.


CONCLUSIONS
Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.
Quinn
James V
JV
Division of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA. quinnj@stanford.edu
Stiell
Ian G
IG
McDermott
Daniel A
DA
Kohn
Michael A
MA
Wells
George A
GA
D002983:Clinical Competence; D002985:Clinical Protocols; D015331:Cohort Studies; D004635:Emergency Medicine / Q000379:methods* / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007600:Judgment; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods; D012495:San Francisco; D013575:Syncope / Q000175:diagnosis*; D014218:Triage / Q000379:methods