An intriguing new tool that encourages shared decision-making between emergency providers and patients who present with low-risk chest pain shows promise toward improving care as well as patient knowledge. Evidence suggests the new tool ultimately leads to the more efficient use of resources. This is based on research presented at the American College of Cardiology’s 65th Annual Scientific Session held on April 2-5 in Chicago.
The tool, called Chest Pain Choice, was developed by researchers at the Mayo Clinic in Rochester, MN. It is designed to facilitate a discussion of whether the patient should be admitted to an ED observation unit for cardiac stress testing or to follow up with a clinician in 24-72 hours.
“When we designed it, we intentionally engaged with major stakeholders, recognizing that it really needed to work for all the parties involved,” explains Erik Hess, MD, an emergency physician and health services researcher at the Mayo Clinic. “We incorporated patient representatives initially, as well as designers, investigators, emergency physicians, and cardiologists in developing the prototype.”
For instance, one of the biggest concerns of providers was the effect the tool would have on workflow in the emergency setting.
“Prior research in the area of shared decision-making has usually been conducted in the outpatient setting in the context of having more time to make decisions,” Hess notes. “It presumed the patient would have the opportunity to grapple with their decision outside of the context of the clinical encounter, and so there would be videos developed or extensive pamphlets [to review]. Our clinicians essentially said there was no way they would use the tool if it was more than a page.”
Providers also voiced concern about the degree of understanding patients have regarding their risks when discussing various treatment options.
“Clinicians tend to feel that it is up to them to keep their patients safe, and they are not [always] confident at baseline when they are counseling patients that what they say connects, is processed, and could be recited back to them,” Hess observes. “The risk element is what physicians care about quite a bit.”
To meet these concerns, designers constructed a brief, one-page, patient-oriented tool that provides descriptions and graphics that illustrate a patient’s risk of experiencing a cardiac event in the next 45 days. The risk is depicted in three different formats that are considered best practices by health literacy experts, Hess explains.
“Some people might like pictures, some might like numbers, and others might like words,” he says.
Consequently, the tool illustrates risk through pictograms, showing, for example, that one out of 100 characters is at risk for having a cardiac event. Simultaneously, the tool describes this risk in numbers as well as in words.
“Whenever you communicate data to patients, it always has to have the same denominator,” Hess observes. “So [in all three forms of communication] we are always staying with the same denominator. We are not switching it around.”
Target a Subgroup of Chest Pain Patients
To examine the tool in practice, investigators designed a study involving 898 low-risk chest pain patients in six EDs in five states. Half the patients were randomized to receive a standard physician consultation and half underwent discussions with their physicians using the Chest Pain Choice tool.
To test their knowledge about their risks and options, all the patients in both groups filled out a questionnaire following their ED encounters.
The results showed that patients who discussed their risks with the physician using the decision aid answered 53% of the questions correctly, while patients randomized to standard consultations answered 44.6% of the questions correctly.
When asked to evaluate their experience of discussing their care with a physician, 68.9% of the patients who experienced the decision aid said they would recommend the method used during their discussions, while 61.2% of the patients receiving standard consultations recommended the method used in their cases.
Further, patients who discussed their risks using the decision tool were substantially less inclined to opt for admission to an ED observation unit for stress testing than patients who received standard physician consultations. Researchers report that there were no adverse heart events associated with use of the decision aid.
Hess stresses that the tool is not designed for patients who are so low risk that a physician is confident that those patients need no further workup; those patients were not even included in the study.
“The [study participants] were patients that the clinician was worried about enough to consider admitting them to observation for further testing, and at the time they were making the decision for further testing, they were unaware on average of the patients’ objective risks,” Hess explains. “Based on the physician exam and initial vital signs, these were the patients that the physicians were concerned enough about that they didn’t think they should necessarily go home immediately.”
Use More Inclusive Language
In the study, Hess notes the physicians in the intervention arm only ended up spending a little more than one minute longer to use the tool to engage in a discussion with patients about their options than those physicians engaging in traditional consultations. This proved to be less of a time limitation than what some physicians feared when they engaged in the study, Hess observes.
Further, use of tool has had a larger effect on the way some physicians communicate with patients.
“When you start using the tool, your approach to communicating with patients starts to change,” Hess notes. “Physicians often start to use more inclusive language.”
For example, when considering options for care, a physician will suggest that he or she and the patient look at the situation together, Hess explains.
“Communication styles have started to correlate with the use of the tool. There are definitely physicians who have actually started to change the way they interact with patients, and they want to use the tool in practice,” he says.
“There are super-users and people who are excited about it, but not everyone is a super-user,” Hess acknowledges. “Some physicians who have been caring for patients for years — their pattern of interaction is so ingrained that they just don’t seem to be as open to interacting with patients in a different way.”
Incorporate Into Workflow
Despite such challenges, based on the results of the study and clinician and patient feedback, efforts are under way locally to implement the tool, Hess explains.
“We are in the process of revising our observation unit protocols to systematize that patients are exposed to this decision aid, and that the physician has the conversation with them,” he says. “In every section of our ED, when [clinicians] are considering admitting a patient to the observation unit with an indication of chest pain, we are working through ways to incorporate [the tool] as part of the usual flow of care.”
In addition, investigators are exploring ways to make the tool available as an online application so that any clinician in the Mayo network will have access to the tool as a recommended decision aid for certain groups of chest pain patients. Further, once more sites have implemented the tool, Hess is hoping to design a study to measure its effect.
In addition to work with the tool at Mayo, Hess notes that clinicians at other sites around the country are experimenting with the decision tool, and in some cases, modifying it to be as contextually specific as possible. He expects more data on these efforts to be shared in the coming months.
“People are already simultaneously and dynamically working with me and sometimes independently, figuring out ways to use this in their own settings,” he says.
SOURCE
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Erik Hess, MD, Emergency Physician and Health Services Researcher, Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic College of Medicine, Rochester, MN. Email: [email protected].
