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Shared decision-making tool may benefit patients with chest pain
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CHICAGO — A shared decision-making tool for patients with chest pain improved patient knowledge compared with standard care, according to findings presented at the American College of Cardiology Scientific Session.
Researchers conducted a trial of the Chest Pain Choice tool in 898 patients (mean age, 50 years; 57% women) presenting with chest pain to six EDs in five states. A successful pilot trial was earlier conducted in 201 patients at Mayo Clinic, where the tool was developed.
According to a press release, the tool includes a one-page printable information sheet that has descriptions and graphics depicting a patient’s specific risk profile. It includes items such as a pictogram to help visualize what it means to have 2% risk for MI in 45 days. The sheet is selected by health care providers after assessment of the patient’s medical history and initial test results. After the patient reviews the sheet, he or she has a discussion with the health care provider to determine what should be done next.
The patients were randomly assigned to receive the decision-making tool or standard care.
Outcomes of interest included patient knowledge, degree of patient participation, patient acceptability, major adverse CV events at 30 days, admission for stress testing and stress testing at 30 days.
Erik P. Hess, MD, emergency medicine physician and health services researcher at Mayo Clinic, said during a press conference that the intervention group scored higher in knowledge (4.23 (standard deviation, 1.54) vs. 3.56 (standard deviation, 1.5); P < .001) and in engagement based on the Option Scale (18 vs. 8; P < .001) compared with controls. On the knowledge questionnaire, patients the intervention group answered 53% of questions correctly vs. 44.6% for controls.
Erik P. Hess
In acceptability questionnaires filled out by patients, the intervention group was more likely than the control group to say the information was extremely clear (P = .01) and that they would recommend the process they underwent to others (P = .004), according to Hess.
Among doctors who filled out acceptability questionnaires, those from the intervention group were more likely than those from the control group to say that the process was extremely helpful, that they would recommend it to others and that they would want to use it for other decisions (P < .001 for all), Hess said.
There was one major adverse CV event at 30 days in the intervention group, deemed to be unrelated to the intervention, and none in the control group (P = 1), low and similar numbers of MI and revascularization in both groups, and no deaths in either group, the researchers found.
Stress tests were performed in 37.4% of patients in the intervention group vs. 46.3% in the control group (P < .013), the researchers found. Those in the intervention group were also less likely to be admitted to the ED observation unit (P < .001), although there was no significant difference in coronary CT within 30 days (P = .12).
"When patients are engaged in a decision-making process by the clinician using Chest Pain Choice, they are more knowledgeable regarding what their options are, they are substantially more engaged in the process, and we also observed a safe decrease in resource use, which was more tailored to patient preferences,” Hess said. – by Erik Swain
Reference:
Hess EP, et al. Joint ACC/JAMA Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; April 2-4, 2016; Chicago.
Disclosure: Hess reports no relevant financial disclosures.
Perspective
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Jeffrey T. Kuvin, MD, FACC, FAHA, FACP
The idea of talking to patients needs to be revisited. I think the idea of shared decision making is here upon us. Patients and the public are interested in this. What was shown is that this is feasible. In this small study, there was no effect on change in outcomes, which is helpful, but it makes clinicians think about what their role is in the world of metadata: How to talk to patients and how to engage patients, and how to help them understand what we think as clinicians, and how to make informed decisions. There is a lot of different testing that can be done and many different pathways, some of which are riskier than others. I think the patient needs to be part of that decision. We need more studies like this to help us understand whether this is a good thing. In general, I think it’s great to engage patients.
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