Decision Aid Leads More Patients to Skip Stress Tests

Reed Miller

April 10, 2012

April 10, 2012 (Rochester, Minnesota) — Chest-pain patients at low risk for acute coronary syndrome are more engaged in decisions about their care and less likely to undergo stress testing if they read a decision aid that clearly explains their risk and management options, according to results of a new study published online April 10, 2012 in Circulation: Cardiovascular Quality and Outcomes [1].

Dr Erik Hess (Mayo Clinic, Rochester, MN) and colleagues developed a printed decision aid for patients presenting to the emergency department with symptoms of nontraumatic chest pain. Their single-center study of the decision aid's benefits to these patients "provides important insights into the potential impact of incorporating validated prediction models in a patient-centered way into the flow of care and the impact of a decision aid on the patient and physician experience of care in the acute setting," Hess et al argue. "Data from this investigation suggest that shared decision-making interventions in patients with acute cardiovascular conditions may have a positive impact on knowledge transfer and decisional quality and match resource use to patient needs and preferences."

The decision aid describes the rationale for and results of their initial ECG, cardiac troponin testing, and serial cardiac-markers tests as well as the rationale for possible further cardiac stress testing. The decision aid depicts the patient's pretest probability of ACS within 45 days with a risk communication pictograph clearly showing that the percentage of patients with similar test results who suffered a heart attack within 45 days is very small. The aid also explains management options, including urgent cardiac stress testing, follow-up with a cardiologist within three days, or follow-up with the patient's own primary-care physician.

In the 204-patient randomized Chest Pain Choice trial, the 101 patients who received the decision aid showed significantly greater knowledge of their risk and options than patients who did not (average of 3.6 vs 3.0 questions correct on a follow-up quiz). On the OPTION (observing patient involvement) questionnaire, the patients who read the decision aid scored an average of 26.6, while the average score for the other patients was only 7.0.

Importantly, patients who read the decision aid were significantly less likely to choose to be admitted to the hospital for additional stress testing (58% vs 77%), but there were no major adverse events after discharge in either group.

Since there were no major adverse cardiac events within 30 days of the patients' discharge from the hospital, Hess et al believe an important next step will be to rigorously assess the utility of stress testing this type of low-risk patient who presents to the emergency department with chest pain. Multicenter studies will show whether or not this decision aid can work in healthcare settings other than the emergency department of Saint Mary's Hospital at the Mayo Clinic in Rochester, MN. However, so far, the results suggest that the rate of cardiac stress testing of low-risk patients presenting to the emergency department with chest pain to rule out acute MI can be safely reduced and "more appropriately tailored" to the patient's risk, according to the study authors.

The 2010 Patient Protection and Affordable Care Act tries to promote shared decision-making between patients and clinicians by creating shared decision-making resource centers and funding research to create shared decision-making tools, Hess et al point out, but this study is first trial of shared decision making for patients with possible ACS presenting to the emergency department.

"Further work will also need to assess what, if any, synergies emerge when policies sensitive to professional preferences, including managing the risk of liability and considering throughput of generously reimbursed clinical services, are aligned with these patient preferences," Hess et al explain. Also, they call for this shared-decision approach to be tested for other types of cardiovascular conditions, including coronary disease and heart failure, according to the authors.

The project was funded by an investigator-initiated grant from the Foundation for Informed Medical Decision Making. The investigative team has not had and does not have any for-profit-seeking intentions for the Chest Pain Choice decision aid.


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