COMMENTARY

If Shared Decisions Can Make It in the Emergency Department, They Can Make It Anywhere

John Mandrola, MD

Disclosures

April 04, 2016

The numbers are staggering. Billions of dollars are spent caring for people who present to emergency departments with chest pain. Many of these cases are low-risk patients. Stress tests, CT angiograms, and cardiac catheterizations are expensive, as are the false positives.

Dr Eric Hess (Mayo Clinic, Rochester, MN), along with other leaders in emergency medicine, set out to reduce costs and improve the care of low-risk patients who present to the emergency department with chest pain.

Their idea: let the patient help. Hess presented the Chest Pain Choice Trial, as a late-breaking clinical trial on the second day of the American College of Cardiology (ACC) 2016 Scientific Sessions.[1]

The research team designed a one-page decision aid to assist the care of patients presenting to emergency departments with chest pain. Decision aids are not easy to make. The team used an evidence-synthesis tool to estimate the risk of future acute coronary syndrome. Then designers, study team members, patients, doctors, and other stakeholders contributed to the wording and layout of the decision aid. They then did field testing of it.

Decision Aid Description

Part one of the decision aid is titled: Your chest-pain diagnosis. It says, "Your initial results are negative for a heart attack." It explains that initial enzymes and ECG are normal.

Part two of the decision aid addresses: What you can do? "Examining your risk will help you and your doctor decide together whether or not you should have additional heart testing. These extra tests include a stress test or coronary CT angiogram." The decision aid explains the two tests in clear language.

Part three includes Personal risk evaluation. "The risk of having a heart attack within the next 45 days can be estimated by comparing you with people with similar factors (seven of them, age, gender, race, etc) who came to emergency department with chest pain." Importantly, the decision aid expresses these risks in prose, numbers, and grid plots.

The fourth part of the decision aid has the question: Would you prefer to have additional heart testing during this emergency-department visit or decide later during an outpatient appointment? It offers multiple choices, including a) having the stress or angiogram while there; b) be seen by a cardiologist in 2 to 3 days; c) be seen by primary care; or d) let the emergency-department doctor decide.

Hess said presentation of this decision aid took an extra 90 seconds. In the session, he showed images of clinicians kneeling by the bedside of patients, two humans making a decision together with the tool.

The Trial

The four-part one-page decision aid was tested in a Patient-Centered Outcomes Research Institute–funded patient-level randomized clinical trial in five US cities. Patients were excluded if they had an ischemic ECG, elevated troponin, known coronary disease, or recent cocaine use or were unable to provide informed consent. Outcome measures included decision-quality metrics (patient knowledge, degree of participation, and acceptability), 30-day major adverse cardiac events (MACE), and healthcare resource use.

In the head-to-head comparison, 451 patients in the standard-care group were compared with 447 in the decision-aid intervention group. The cohort was typical of patients who present with low-risk chest pain: young, mostly female, and low risk.

Patients in the intervention group scored significantly higher on knowledge scores, measures of patient acceptability (clarity of information, would recommend to others), and measures of clinician acceptability (helpfulness, would recommend to others, and would want to use for other decisions).

On safety, as assessed by major adverse cardiac events, researchers found no significant differences.

The percent of patients admitted to the emergency-department observation unit for stress testing or angiography and stress testing and coronary CT within 30 days all were lower in the decision-aid group.

The authors concluded that the Chest Pain Choice decision aid increased patient knowledge and engagement, safely decreased resource use, and was acceptable to patients and clinicians.

Comments

When I wrote my preview for the ACC meeting, this smaller study did not stand out. That was a mistake. This is important. The phrase that comes to mind is win-win-win. Everybody can love this work.

Payers and policy makers like the cost savings. More important than savings, though, is the idea of sharing decisions in an emergency setting. If shared decision-making can happen in busy emergency departments, it can happen in most places.

Patients, who are actually human beings like you and me, get the benefit of being treated as equal partners. The research team didn't look at patient satisfaction scores. Any guess on how spending an extra few minutes kneeling down at the bedside with a useful decision aid would affect satisfaction scores?

Doctors may benefit the most. Here, they get help in making decisions that often cause cognitive dissonance. They know most of these tests are not necessary and could lead to harm from overdiagnosis and overtreatment. That's one of the likely reasons doctors' acceptance of the decision aid was even better than patients'.

Dr Hess received a provocative question after his talk. A panelist asked whether adverse cardiac events was an appropriate end point. Hess told me it caught him by surprise. Initially, I thought to myself, how could adverse events not be a measure?

The questioner noted that there was no a priori reason to think a decision aid would affect outcomes. Hess responded that the research team felt it was important to show this approach didn't worsen outcomes.

I'd ask you to consider a tough question. What if patient knowledge and involvement scores go up but outcomes worsen slightly? That's the thing with shared decisions. When you remove fear and ignorance from the medical decision, some people may not choose what the guidelines say. Doctors have to be ready for the fact that people vary in what's important to them.

The Chest Pain Choice Trial delivered positive results, but more importantly, it heralds in the new role of the physician—as trusted advisor rather than protector from all bad things.

JMM

Comments

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