Circ: Adding patients two cents on stress testing may cut costs
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Shared decision making between patients and their physicians is a cornerstone in the Patient Protection and Affordable Care Act (PPACA), the authors wrote. The act has a number of provisions in support of decision aids, including certification of the tools, shared resource centers and grants to help assess decision aids. “Because cardiovascular disease is a leading cause of morbidity and mortality in the United States and there are several alternative strategies for evaluation and management in patients with ACS [acute coronary syndrome], shared decision making in cardiovascular disease is a high-impact area for physicians to engage patients in healthcare decisions,” the researchers argued.
Erik P. Hess, MD, of the emergency medicine department at the Mayo Clinic in Rochester, Minn., and colleagues designed what they described as the first prospective randomized trial of shared decision making for patients with possible ACS who present with chest pain at emergency departments. They noted that patients who are at low risk of ACS may undergo cardiac stress testing, which may lead to false results, unnecessary procedures, exposure to ionizing radiation and higher costs.
They speculated that patient preference was not driving this process and hypothesized that use of a decision aid would increase patient knowledge and engagement in the decision-making process and consequently decrease the proportion of patients who opt for stress testing. To test their hypothesis, Hess et al designed a decision aid that included a pictograph explaining the probability of ACS and management options for clinicians to use with patients presenting with chest pain at the emergency department.
They enrolled 204 patients older than 17 years and 51 clinicians at Saint Mary’s Hospital at the Mayo Clinic for the study. Patients with elevated initial cardiac troponin T levels were excluded to ensure patients were at low risk of ACS. The researchers randomized 101 patients to the intervention group and 103 patients to the control group.
The primary outcome was patient knowledge. Other outcomes addressed factors such as conflicted decisions; trust in the physician; engagement in the decision-making process; satisfaction with the decision aid; the proportion of patients who chose to undergo observation and cardiac stress testing; and major adverse cardiac events.
Ninety-nine percent of patients completed the post-visit self-administered survey; 98 percent had their patient-physician visit videotaped for analysis; and 98 percent completed phone interviews at the 30-day follow-up. The researchers checked the Social Security Death Index database for the remaining 2 percent of patients and found no death records.
The intervention group had significantly greater knowledge compared with the control group (3.6 vs. 3 questions answered correctly, respectively); were more engaged in decision making, based on observing patient involvement scores (26.6 vs. 7) and less frequently chose to undergo stress testing (58 percent vs. 77 percent). Neither group had major adverse cardiac events after discharge.
“This study suggests that low-risk patients don’t necessarily want extensive testing once a heart attack has been ruled out,” Hess said in a statement. “Informing patients of their risk and engaging them in the decision-making process may enable physicians and patients to work together to choose an approach to evaluation that is more in line with what patients want, without negatively affecting the results of their healthcare.”
The researchers also noted that patients who used the decision aid were less conflicted about their decisions than the control group and were equally trusting of their physicians as those who did not use the tool. When asked about the decision tool, 98 percent of clinicians responded it was helpful and 63 percent said they would use it again.
Hess and colleagues suggested that, based on their results, shared decision making tools may be useful for other cardiovascular conditions such as the management of coronary disease, heart failure, valvular heart disease and atrial fibrillation. But they noted the decision aid would be difficult to implement in settings where outpatient follow-up is unreliable. They also cautioned that the decision aid they designed applied only to patients with chest pain and not patients with potential ACS who present with other symptoms.
“Given that there were no major adverse cardiac events within 30 days of discharge, additional studies are needed to assess the utility of cardiac stress testing in patients presenting to the ED [emergency department] with chest pain but who are at low risk for ACS,” the authors wrote. “Further multicenter studies are also needed to evaluate the efficacy and safety of the decision aid in diverse healthcare settings.”
They concluded that patient involvement in decision making could have an impact on the rate of stress testing but said more work needs to be done to align policies with patient preferences.