The Chest Pain Choice Decision Aid

Abstract

Background-Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. Methods and Results-The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24 -72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (nϭ103), decision aid patients (nϭ101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34 -1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6 -21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. Conclusions-Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.

Emergency Physician Perceptions of Shared Decision‐making

“…Many have advocated its use as a potential avenue to facilitate patient engagement, increase patient satisfaction and knowledge, and decrease resource utilization, while maintaining patient safety. 7,9,[22][23][24] The 2016 Academic Emergency Medicine consensus conference on SDM will likely set the primary research agenda moving forward. 22 However, given the recent call to action within EM to provide high-value, cost-conscious care-including specifically through SDM tools-understanding physician beliefs on the barriers they face within this domain is critical to achieving this goal.…”

“…1,3 SDM programs have been shown to enhance knowledge base, reduce decisional conflict, set more realistic expectations, improve agreement between preferences and ultimate health care choices, increase active decision-making, and possibly lower health care costs and utilization. 1,[4][5][6][7][8] For example, one of the most methodologically robust and highly cited studies of SDM in emergency medicine (EM) focused on cardiac stress testing in ED patients with chest pain deemed to be low risk for acute coronary syndrome. Patients were randomized to usual care or care aided by an evidenced-based decision aid intended to educate and engage patients in the choice either to be admitted for urgent cardiac stress testing or to have outpatient follow-up with a physician within 72 hours.…”

“…Patients who engaged in SDM with the decision aid had greater knowledge and engagement and less often decided to be admitted for stress testing. 7 Despite the potential benefits of SDM, it may be particularly difficult to integrate into emergency department (ED) care. This clinical environment involves unscheduled acute care with a previously unfamiliar provider in an emotionally charged context.…”

“…The few robust studies of SDM in EM have demonstrated that SDM is in fact feasible in practice and that time-related barriers may be overcome. 7,9,19 However, it remains unclear if the typical EP has adopted SDM into his or her regular practice and, if not, for what reasons. Understanding EP perceptions regarding this topic is critical to facilitate increased adoption of SDM in EM.…”

Patient-centered Treatment Decisions for Urethral Stricture: Conjoint Analysis Improves Surgical Decision-making

“…[23][24][25][26][27][28] Although conjoint analysis has thus far been used as an analytical technique to determine treatment preferences, our results offer a potential new use for conjoint analysis as a practical decision support mechanism. As much as patients are helped by the process of defining their values and goals, if this information can then be provided to the physician caring for these patients, physicians can gain a better understanding of patient goals and hopefully better orient their discussion and treatment options toward individual patients' values.…”