Involving Low-Risk Patients in Chest Pain Test Decisions Eases Fears, Saves Money

Chicago, IL—Engaging better with patients who present to emergency departments (EDs) with low-risk chest pain and involving them in diagnostic plans can diffuse emotions and ultimately reduces costs with no downsides in terms of safety, a new study shows.

That shared decision-making can also improve patients’ level of knowledge about their health status and options, according to results from the Chest Pain Choice trial.

“Nothing about me without me,” said lead author Erik Hess, MD (Mayo Clinic, Rochester, MN), quoting Valerie Billingham’s advice for “patient dignity in the context of medical care” to start his presentation yesterday in a late-breaking trial session at the American College of Cardiology 2016 Scientific Sessions.

The study results are built around a tool of the same name, Chest Pain Choice, developed by investigators as a single-page guide for the care of low-risk chest pain patients. Using patient-oriented descriptions and graphics, it is meant to inspire discussions on how heart attack is ruled out, options for additional testing, personal risk assessment, and options for later follow-up and testing. Chest Pain Choice had previously been evaluated in a Mayo Clinic pilot study.

“When a patient develops chest pain and they present for emergency care, regardless of their risk profile they often feel like they are going to die of a heart attack,” Hess said. “So this is an emotionally charged situation for the patient.”

Clinicians, meanwhile, are aware that chest pain is the second most common reason why patients end up in the ED, he continued. “They’re acutely aware of the limitations of our current approaches to diagnosis and the non-negligible 1.5% miss rate of ACS. This scenario results in [many] low-risk patients undergoing advanced cardiac testing resulting in false positive test results, unnecessary procedures, [and] increased costs.”

More Knowledge, Less Resource Utilization

For their study, Hess and colleagues randomized 899 adults who presented to six EDS in five states to receive standard care or use of the Chest Pain Choice tool. All individuals had chest pain indicating possible ACS and were being considered for observation unit admission.

Patient knowledge, the primary outcome, was assessed via a questionnaire that asked patients about their risk and options. Those treated using Chest Pain Choice scored higher (53% vs 44.6%). Videotaped physician-physician interactions also showed greater patient engagement in decision making. Most physicians and patients allocated to the Chest Pain Choice arm found it acceptable to use. It added on average 1.3 minutes to the clinical encounter.

At 30-days, MACE rates were similar between the two groups.

Resource utilization was lower, with 15% fewer patients in the Chest Pain Choice group admitted to the ED observation unit for stress testing or coronary CT compared with controls. By 30 days, fewer patients in this arm had undergone stress testing (37.4% vs 44.6% in the control arm; P < .013). There also was a trend toward less use of coronary CT.

Requires ‘Pretty Minimal Investment’

“Patient-centered care I think has become a buzzword in modern medicine,” commented Frederick Masoudi, MD (University of Colorado Hospital, Aurora), at a press conference after the late-breaking trial session. “It means many things to different people. But undoubtedly, engaging patients in care and in making decisions are concordant with our values and are exemplary of what I consider patient-centered care. And traditionally we as clinicians have not done particularly well in conveying the risks and benefits of different decisions to patients in a manner that’s relevant to them on an individual level.”

Numerous tools to facilitate this sort of interaction have been developed, he said. “While some of these aids have been shown to improve decision quality, most of them just end up sitting on shelves and have never been used in care.” Thus, ease of use is key, and this study importantly shows the clinical acceptability of Chest Pain Choice, Masoudi stressed.

Asked to expound on what typically occurs in the ED, Hess told TCTMD that the “normal standard of care would be the clinician who’s caring for five or six patients simultaneously. The decision is usually made by themselves outside of the patient’s room. They walk in, and they probably don’t stand close to the patient.” They provide the test results and a recommended course of action, he said, then ask whether the patient is okay with it. Instead of engagement, “it’s kind of like a monologue that the patient would either agree or disagree with,” he added.

Initially, ED physicians at the various centers participating in the trial were worried that Chest Pain Choice would require too much time to use, but they soon incorporated it into their flow of care, Hess observed. The tool requires “pretty minimal investment, particularly if you consider the downstream effects if the patient stays in the hospital and has multiple nurses caring for them and multiple medications administered,” he said. “So the time saved with an additional one-and-a-half minutes of clinician investment is pretty significant.”

Source:

• Hess EP. Involving patients with low risk chest pain in discharge decisions: a multicenter trial. Presented at: American College of Cardiology 2016 Scientific Sessions. April 3, 2016. Chicago, IL.

Disclosures:

• Hess reports no relevant conflicts of interest.