Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial

Abstract

Objective: To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome.

Design: Multicenter pragmatic parallel randomized controlled trial.

Setting: Six emergency departments in the United States.

Participants: 898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain.

Interventions: Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events.

Results: Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P<0.001). There were no major adverse cardiac events due to the intervention.

Conclusions: Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240.

Fig 1 Decision aid to facilitate discussion between clinicians and patients on whether to be admitted to an observation unit in the emergency department for cardiac stress testing or to follow up with a clinician in 24-72 hours

Fig 2 Screen shot of quantitative pretest probability web tool. Figure displays 45 day probability of acute coronary syndrome for an African-American woman aged more than 50 years whose chest pain is not reproducible with palpation, is not diaphoretic, and there is no ST segment depression greater than 0.5 mm or T wave inversion deeper than −0.5 mm, incorporating the result of the first cardiac troponin test. In this case, a coordinator would select a decision aid demonstrating a 3 out of 100 risk, rounding up from 2.3% to prioritize patient safety

Fig 3 Participant flow diagram