ACC.16: Shared decision-making tool helps inform patients with chest pain about their risks and options

CHICAGO – Patients who presented to the emergency department with chest pain had significantly fewer follow-up stress tests and were significantly more knowledgeable about their risks and their management options if they used a shared decision-making tool with physicians than if they only received standard counseling, according to a randomized trial.

Lead researcher Erik Hess, MD, an emergency medicine physician and health services researcher at the Mayo Clinic, presented the results during a late-breaking session at the ACC scientific session on April 3. The Patient-Centered Outcomes Research Institute funded the study.

“From a human rights perspective, patients have made it clear that one way they interpret the idea of ‘care with dignity’ is being involved in their health care decisions,” Hess said in a news release. “This trial shows that doing so can have a beneficial effect on patient knowledge, as well as other outcomes such as patient engagement and, sometimes, appropriate utilization of testing. I would recommend that this intervention be adopted more widely.”

Hess said that chest pain is the second most common complaint in U.S. emergency departments and accounts for approximately eight million emergency department visits each year. Although low-risk patients typically undergo stress testing, they often have false positive results that lead to unnecessary procedures and increased costs. He cited data that showed physicians miss approximately 1.5 percent of patients with acute coronary syndromes when assessing chest pain.

This trial included 899 patients with chest pain who visited six emergency departments in Sacramento, California; Rochester, Minnesota; Indianapolis, Indiana; Philadelphia, Pennsylvania; and Jacksonville, Florida. Patients were excluded if they had an ischemic ECG, elevated troponin levels, known coronary artery disease, used cocaine within 72 hours or were unable to provide informed consent.

Patients were randomized in a 1:1 ratio to receive standard physician counseling or the Chest Pain Choice tool, a one-page document developed at the Mayo Clinic and designed at Carnegie Mellon University. The tool has four sections, assures patients they are not having a heart attack, tells them if they should undergo a stress test or coronary CT angiography and provides a personalized risk estimate for each patient. Healthcare providers worked with patients to decipher the Chest Pain Choice tool and decide the next steps.

The groups were well balanced at baseline. The mean age was approximately 50 years old, and approximately 57 percent of patients were female.

Patients who received the Chest Pain Choice tool were twice as engaged in the decision-making process, according to an objective analysis of videotaped interactions between physicians and patients. In addition, 53 percent of patients in the Chest Pain Choice tool group and 44.6 percent of the standard care group answered questions correctly about their risk and options following chest pain.

Of the patients in the Chest Pain Choice tool group, 68.9 percent said they would recommend the way they shared information with their physicians, while 43.6 percent said they felt conflicted. Meanwhile, 61.2 percent of patients in the control group said they would recommend the way they shared information with their physicians, while 46.4 percent said they felt conflicted.

The rates of major adverse events such as revascularization, MI, death and major adverse cardiovascular event within 30 days of discharge were similar between the groups.

Stress tests were performed in 37.4 percent of patients in the Chest Pain Choice tool group and 46.3 percent of patients in the control group, which was a statistically significant different. Patients in the Chest Pain Choice tool group also had a lower rate of coronary CT angiography, but the difference was not significant.

“Although in this case some of the impact of the decision aid was modest, the decision aid did improve decision quality and just as importantly for implementation was viewed favorably by clinicians and took very small amounts of time to use in practice,” Frederick Masoudi, MD, of the University of Colorado, said at a news conference. “Incorporating patients into their decision-making did not lead to worse outcomes and probably saved money. This study goes beyond the typical assessment of decision aids by assessing the clinical acceptability downstream effects of clinical events and resource use. I look forward to the implementation of this instrument in clinical practice.”