Decision aid increases knowledge of ACS risk in patients with low-risk chest pain
medwireNews: Results of a randomized trial suggest that shared decision making facilitated by an aid increases knowledge of acute coronary syndrome (ACS) risk and reduces hospital admissions compared with usual care among patients with low-risk chest pain in the emergency department.
“The decision aid frames the decision for the patient, provides standardized terminology, and transparently communicates patient risk and the available management options in a manner that many clinicians might find difficult to reproduce without use of the decision aid,” the study authors write in The BMJ.
Erik Hess (Mayo Clinic, Rochester, Minnesota, USA) and colleagues found that among 898 individuals presenting with low-risk chest pain in six US emergency departments, 65.0% of 451 assigned to the “Chest Pain Choice” decision aid reported their 45-day risk for ACS within 10% of the correct value, compared with just 18.1% of 447 receiving usual care.
Additionally, patients assigned to the decision aid answered a mean of 4.2 of eight knowledge questions about their ACS risk and management options correctly, whereas those assigned to usual care answered a mean of 3.6 questions correctly. Participants in the decision-aid group also reported significantly lower decision conflict scale scores (43.5 vs 46.4), indicating less conflict with their physician.
A total of 37.3% of patients in the decision-aid group decided, together with their clinician, to be admitted to an observation unit for further testing, compared with 52.1% of those receiving usual care, a significant difference. Those assigned to the decision aid were more involved in the choice (observing patient involvement scale scores: 18.3 vs 7.9), and approximately two-thirds of clinicians said they would recommend the decision aid to others.
Given the implications of missing an ACS diagnosis, “clinicians have a low threshold to admit patients for prolonged observation and advanced cardiac testing,” say the study authors.
“As a consequence, low risk patients are often admitted for observation and cardiac stress testing or coronary computed tomography angiography,” which leads to “unnecessary hospital admissions, false positive test results, and unnecessary invasive downstream investigations,” they explain.
In an accompanying commentary, Anne Stiggelbout (Leiden University Medical Centre, Netherlands) and colleagues suggest that decision aid tools “will become the norm rather than the exception” in an era of personalized medicine. However, they caution that the complexity of the Chest Pain Choice tool “could hamper large scale implementation,” and note that the study authors were “unable to conclude with confidence that the tool decreased admissions safely.”
The commentators conclude that “giving patients more information about risk is not to be feared—on the contrary, sharing this information may well benefit both patients and the healthcare systems caring for them.”
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