Tool Improves Shared Decision-Making for Low-Risk Angina

A web-based decision support tool for patients gave them more involvement in care decisions when presenting to the emergency department with low-risk chest pain, a randomized multicenter trial found.

The first multicenter trial for the electronic decision-making aid -- tested in six emergency departments across the U.S. -- found that users knew more about their risk for acute coronary syndromes (ACS) and options for care compared to those who got usual care (4.2 versus 3.6 questions correct, mean difference 0.66, 95% CI 0.46-0.86), reported Erik P. Hess, MD, of Mayo Clinic in Rochester, Minn., and colleagues in a study published online in The BMJ.

And with the tool, which offers a visual representation of 45-day estimated risk of ACS and a simple explanation of options for care, individuals had greater agency in the decision to be admitted or not (18.3 versus 7.9 points on patient involvement score, mean difference 7.9, 95% CI 9.1-11.5), and were less likely to get cardiac testing (37% versus 52%, P<0.001).

"In patients with chest pain who were otherwise being considered for admission to an observation unit and advanced cardiac testing, shared decision making facilitated by a decision aid increased patient knowledge and patient engagement, decreased decisional conflict, and did not significantly affect trust in physicians," the authors concluded.

"The decision aid was found to be acceptable to both patients and physicians, and its use, which took an average of one additional minute of clinician time, decreased the rate of admission to an observation unit for advanced cardiac testing and cardiac stress testing within 30 days of the emergency department visit."

There were no cardiac deaths in either arm, but one patient in the shared-decision arm had a major adverse cardiac event within 30 days of hospital discharge: a non-ST segment MI that occurred after a negative interpretation of nuclear perfusion stress testing during the index hospital visit. The event was ruled to be unrelated to the use of Chest Pain Choice.

Other tools for chest pain triage have been employed in the past, including calcium scores and the HEART Pathway.

Chest Pain Choice was previously validated at the emergency department of a hospital affiliated with Mayo Clinic, where it was developed. The present trial enrolled 898 adults with low-risk chest pain that were seen by 361 emergency clinicians (physicians, nurses, and physician assistants).

"We recommend clinicians consider using the decision aid in patients who present with acute chest pain, no known history of coronary artery disease, and initial negative electrocardiogram and troponin test results, and for whom the clinician is considering further cardiac investigations such as cardiac stress testing or coronary CT angiography," Hess and colleagues wrote.

The benefits of shared decision-making, however, may not exactly translate into decreased liability, they warned.

"While use of shared decision making might decrease clinician's liability risk by improving the patient-clinician relationship, enhancing communication (which is often at the root of lawsuits brought against clinicians after an adverse outcome), and decreasing the frequency of invasive procedures, shared decision making might increase liability risk if the care agreed on by the patient and clinician is sensible, but perhaps at odds with what other clinicians would have selected without patient input, as the latter is often used to determine 'standard of care.'"

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