A Prospective Evaluation of Shared Decision‐making Regarding Analgesics Selection for Older Emergency Department Patients With Acute Musculoskeletal Pain

Abstract

Objectives Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. Methods This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants’ desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. Results Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. Conclusions In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and on provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction.

Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities

“…Exclusion of cognitively impaired patients also occurs in emergency medicine studies of shared decision-making (Holland et al, 2016) and elder abuse (Eulitt, Tomberg, Cunningham, Counselman, & Palmer, 2014). Other studies do not exclude cognitively impaired subjects, but do not assess for it either (Koehler et al, 2009; Tanne et al, 2000), which limits clinician’s ability to extrapolate the findings to cognitively frail individuals.…”

Development and Testing of Shared Decision Making Interventions for Use in Emergency Care: A Research Agenda

“…5,6,8 Internationally, there are accepted standards for systematic and transparent development of decision aids that include (1) understanding how patients best prepare for discussing specific decisions, (2) discovering how clinicians best prepare to discuss specific decisions with patients, (3) expert review by patients not involved in producing the decision aid, (4) expert review by health professionals not involved in producing the decision aid, (5) field testing with patients who are facing the decision, and (6) field testing with practitioners who counsel patients who face the decision. 17 There are only a few studies reporting the testing of ED-specific decision aids, and fewer still that meet the above criteria, particularly regarding the involvement of clinicians and patients/surrogates in the development process. 1 …”

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

“…[14][15][16] Older patients are also more likely to express a preference to leave decisions to their doctor or have their doctor make the final decision after considering their opinion. 17 For these patients, providing information in an easily accessible form is a first step in enabling patients to understand their condition, thereby reducing anxiety, improving insight, and supporting engagement in SDM. 18,19 Other benefits of patient education include improved adherence to treatment regimens, better alignment of care with patients' goals and values, and transition to self-management.…”

“…74,75 In addition, persistent musculoskeletal pain may increase risk of falls, poor sleep, lower quality of life, and mortality. 17,[76][77][78][79] SDM may improve pain management in older ED patients. In the ED, SDM is associated with greater satisfaction with discharge pain medications and a greater average pain reduction at 1 week.…”

“…In the ED, SDM is associated with greater satisfaction with discharge pain medications and a greater average pain reduction at 1 week. 17,80 Older adults often discontinue analgesics due to unexpected and undesirable side effects, and SDM has the potential to help patients and providers identify appropriate treatments and mitigate or at least anticipate these side effects. SDM also may make these challenging patient care decisions more rewarding for emergency physicians: primary physicians who receive SDM training report greater satisfaction with patient interactions and greater confidence in their ability to treat patients with chronic pain.…”