Shared Decision Making in Low-Risk Chest Pain: Safe, Fewer Tests

Patrice Wendling

April 07, 2016

CHICAGO, IL — A single-page shared decision-making tool helps low-risk chest patients who present to the emergency department better understand their health status and options and may reduce the use of stress tests and imaging, possibly cutting costs, all without increasing risk, a new study suggests[1].

Videotaping revealed use of the Chest Pain Choice (CPC) aid added just 1.3 minutes to the patient encounter, study author Dr Erik Hess (Mayo Clinic, Rochester, MN) said during a late-breaking trial session at the American College of Cardiology (ACC) 2016 Scientific Sessions.

The four-part decision aid was developed at the Mayo Clinic using patient-friendly language and graphics to educate and facilitate discussion on how heart attack is ruled out, explain stress testing and coronary CT angiography, provide personal risk evaluation, and detail options for follow-up testing. The CPC was previously evaluated in a pilot study.

Panelist Dr David Wood (Imperial College London, UK) told heartwire from Medscape this approach is much more than just education and runs contrary to the paternalistic approach to medicine where clinicians inform the patient of their diagnosis and how they are going to be managed.

"I imagine there's a great deal of such paternalistic medicine out there, and I think one of the reasons that physicians are sometimes a little reluctant to adopt this approach is because of time; one to inform the patient, two to give time to the patient to reflect on what they've been told and think about whether this fits their needs; and then to come back and have a conversation where you have a shared decision. That's a much longer process," he said. "But perhaps this may not add that much."

The Chest Pain Choice Trial was conducted at six emergency departments in five states. Adults with chest pain considered for emergency department observation admission for stress testing or coronary CT angiography were randomized to treatment using the CPC (n=447) or standard care (n=451). A patient-advisory group selected patient knowledge, assessed via questionnaire, as the primary outcome.

Patients treated with the CPC were more knowledgeable than those given standard care about what their risks were for ACS and their available management options (mean score 4.23 vs 3.56; P<0.001), Hess said. Patient-engagement scores also more than doubled (18 vs 8; P<0.001).

More CPC patients said the information they received was extremely clear (P=0.01) and that they would recommend a similar approach to others (P=0.004).

Likewise, physicians in the intervention arm viewed the information as extremely clear, 66% said they would recommend using Chest Pain Choice to other clinicians, and a similar percentage said they would want to use the aid for other clinical decisions (all P<0.001), Hess said.

During a press briefing, Dr Frederick Masoudi (University of Colorado Hospital, Aurora) said patient-centered care has become a "buzzword in modern medicine" and that numerous tools have been developed to foster this kind of interaction. "While some of these aids have been shown to improve decision quality, most of them just end up sitting on shelves and have never been used in care" because they lack clinical acceptability, he said.

When pressed later as whether he'd use Chest Pain Choice in his own hospital, Masoudi told heartwire , "As described, I would. Because the patients get engaged in the decision making, it provides individualized risk estimates for their particular situation. . . . And it appeared to be very little burden."

But Is It Safe?

In the intervention arm, seven patients underwent revascularization, four had MIs, and one MACE was reported within 30 days of discharge. In the control arm, there were four revascularizations, one MI, and no MACE. No patients died in either arm.

The MACE occurred in a woman who was sent home after a negative nuclear stress test but returned to the emergency department within 30 days and diagnosed with a non-ST-segment-elevation MI. The data safety monitoring board judged the MACE was not related to the intervention, Hess said.

Panelist Dr Kim Eagle (University of Michigan Hospitals and Health Center, Ann Arbor) questioned the higher rate of events with the intervention, observing, "It's not statistically meaningful, but it's a signal that's a little bit uncomfortable."

Hess responded that the study enrolled people with real disease and "that the encouraging thing is that all of those events occurred in patients who decided with their clinician to be admitted to the hospital. So it's part of the natural course of their disease."

Roughly two-thirds of patients had dyslipidemia; the mean pretest probability for ACS was 3.8% in the control arm and 3.6% in the intervention arm.

Patients treated using the Chest Pain Choice had a 15% lower rate of emergency-department admissions for stress testing or coronary CT than controls (P<0.001). They were also less likely to undergo stress testing within 30 days (P<0.013) or coronary CT within 30 days, although the latter did not reach statistical significance (P=0.12).

Hess pointed out earlier in his talk that chest pain is the second-most common reason patients visit the emergency department and that physicians are acutely aware that 1.5% of acute coronary syndrome is missed. This scenario prompts advanced cardiac testing in many low-risk patients that often results in false-positive findings, unnecessary procedures, and increased costs.

Wood told heartwire that this is an important trial because it demonstrates the impact of shared decision-making on the use of additional and expensive resources. "This does have real implications for our practice," he said.

The study was funded by the Patient-Centered Outcomes Research Institute. Hess reports no relevant financial relationships. Wood reports consultant fees/honoraria from Ferrer Internacional and serving as a speaker for Amgen and Sanofi. Masoudi reports no relevant financial relationships.

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