The treatment, testing, education, and disposition of patients presenting to the emergency department with chest pain is of great concern to all emergency physicians—especially those patients who fall into low-risk categories. These low-risk chest pain patients are more likely to undergo unnecessary downstream procedures, suffer avoidable complications, and contribute to unnecessary healthcare expenditures. These patients are often faced with difficult decisions regarding their care as they confront emotional stress, medical uncertainty, and multiple means of assessing their risk for myocardial infarction. Emergency physicians also shoulder a large burden in this decision making process, as a shared-decision making model for patients presenting with chest pain has not been established in the ED setting.
Well, until now.
An exciting multicenter clinical trial has been underway since October 2013 aiming to establish a shared-decision making model with the Chest Pain Choice (CPC) decision aid—a novel tool that graphically displays a low-risk patient’s calculated risk of MI. It serves as a personalized resource for educating patients and discussing possible follow up testing options. With the aid of this educational intervention, the hope is that patients can be more actively involved in testing decisions and work with physicians to minimize unnecessary testing. As the trial is still actively recruiting, we will be eagerly awaiting the outcome; however, the results of the CPC decision aid’s single center study were very promising.
In 2012, the group led by Dr. Erik Hess tested a prototype of the CPC decision aid on a population of 204 patients in the ED of Saint Mary’s Hospital at the Mayo Clinic in Rochester, MN. Just like the current multicenter trial, this trial enrolled patients complaining of chest pain after initial negative ECG and troponin evaluation. Patients were randomized into a usual care and a CPC decision aid intervention arm by a study coordinator, who also refreshed participating clinician’s skills in utilizing the decision aid intervention prior to each use. All participating clinicians were trained to deliver this decision aid tool before the study’s onset.
The primary outcome of the study was patient knowledge measured by a post visit survey. The group also considered patient engagement in decision-making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Here is what they found.
Patients from the CPC decision aid group:
- Had significantly greater knowledge
- Mean difference 0.67 (95% CI, 0.34–1.0)
- Were more engaged in decision making, indicated by OPTION scores
- 26.6 versus 7.0; mean difference, 19.6 (95% CI, 1.6–21.6)
- Less frequent observation admissions for stress testing
- Absolute difference, 19% (95% CI, 6%–31%)
- There were no major adverse cardiac events after discharge in either group.
Dr. Hess’s group has expanded its work to 5 emergency departments across the US, hoping to test the CPC intervention with a more diverse population of chest pain patients. While most of the new trial looks to be a scaled up study, there are some notable changes—namely the CPC decision aid.
The authors of the study state that the intervention aid has been systematically revised through various rounds of focus groups and testing, yet for some the CPC decision aid leaves something to be desired.
Dr. Ryan Radeki of EM Literature of Note shares his concerns with the CPC decision aid in a post on his blog. He correctly points out that the CPC lacks specific information regarding the relative risks, benefits, potential complications, and costs of each cardiac testing modality. He argues that the omission of this information on the CPC aid precludes accurate patient education and true shared-decision making, flawing the study.
Dr. Hess commented on Dr. Radeki’s review, mentioning that various iterations of the CPC included this information. However, in the testing phase of these earlier prototypes, end-users found the added details about each testing method to be extraneous, if not counter-productive, to effective communication and shared-decision making.
Though I do not agree with Dr. Radeki’s views on the impact of the omission of certain information from the CPC, I do think his discussion with Dr. Hess invites a broader discussion about the information we give to patients as providers, how we deliver that information, and how our perspective as care providers biases our understanding of what information matters most to patients. Perhaps we overcomplicate matters or oversimplify them for our patients more than we realize. Maybe the patient education “gestalt” ought to be re-imagined to better describe the pivotal pieces of information central to effective patient-physician joint decision-making.
For the sake of future work, and to more directly answer some critiques of the CPC decision aid intervention, it would be interesting to see the authors’ data and validation for each iteration of the decision aid. This information might allow us to better understand analogous decision making situations and enhance our insight on how best to weigh the importance of information from an ED patient’s perspective.
Having a decision aid that can be personalized to an individual patient’s risk is a powerful tool that may grow to be a standard of care for patient education. Such easy to interpret infographic representations of risk—a potentially abstract and frightening concept for patients in emergency settings—are resources that can facilitate patient care, improve outcomes, and empower patients. If this trial is successful, there exists a huge potential for evaluating decision aids in other tough decisions facing emergency physicians and patients.
Decision aids open the door for shared-decision making in settings like the ED, where conversations alone may not be sufficient to educate patients to a level compatible with making informed decisions about their care in a team effort with healthcare providers. As we begin to embrace the reality of risk stratification and move away from the false absolution of a “rule out” mindset, shared-decision making with patients may be our most effective tool to deliver high quality, safe, cost efficient healthcare and ward off an endless litany of spiraling workups.
- Hess, Erik P., et al. “The Chest Pain Choice Decision Aid A Randomized Trial.” Circulation: Cardiovascular Quality and Outcomes 5.3 (2012): 251-259. PMID: 22496116
- Anderson, Ryan T., et al. “Effectiveness of the Chest Pain Choice decision aid in emergency department patients with low-risk chest pain: study protocol for a multicenter randomized trial.” Trials 15.1 (2014): 166. PMID: 24884807
Also, be sure to check out the Mayo Clinic’s page on shared decisions to learn more and try out some other decision aids (not meant for ED use).