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Quick Decision Aid Reduces Unnecessary Care for Some Chest Pain Patients

ROCHESTER, MN – Just one minute of time can make a big difference in emergency department utilization by patients reporting low-risk chest pain.

That’s according to a new study from Mayo Clinic researchers, which was published online in The BMJ. The key, according to researchers, is use of a shared decision-making aid to involve patients more in their own care decisions, leading to fewer unnecessary hospitalizations or advanced cardiac tests.

"Chest pain can be caused by a wide variety of problems," explained lead author Erik Hess, MD, an emergency medicine physician at Mayo Clinic. "While we recommend that people seek immediate medical help when experiencing chest pain, the next steps can vary – and be unnecessarily costly."

Concerned about missing a diagnosis of acute coronary syndrome, “clinicians have a very low risk threshold to admit patients for observation and advanced cardiac testing,” said Hess, who added, “Despite little possibility that these low-risk patients are experiencing acute coronary syndrome, emergency physicians are more likely to default to admission for observation and additional testing. This presents a substantial unnecessary burden and cost to the patient and the healthcare system."

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To alter that dynamic, the research team decided to introduce a shared decision-making approach, pointing out that use of the Chest Pain Choice decision aid allows ED physicians and patients with low-risk chest pain to estimate the risk for acute coronary syndrome within the next 45 days. Once that is determined, they can discuss whether hospital admission and advanced cardiac testing is necessary or whether a follow-up appointment with primary care or cardiology would be more appropriate.

To test that theory, the study team employed a randomized clinical trial across six EDs in five states, comparing usual care for 447 patients to 451 patients receiving the Chest Pain Choice decision aid intervention.

Results indicate that use of Chest Pain Choice led to greater patient knowledge, based on answers to eight questions, and more patient involvement in decision-making (using the OPTION scale).

In addition, a greater number of patients were able to correctly assess their own 45-day risk of acute coronary syndrome within 10% (65% vs. 18% in the usual care group).

Results also included less frequent admissions for observation – 37% vs. 52% – and more patients choosing to have additional cardiac stress testing performed in the outpatient setting – 30% vs. 17%.

The decision aid, according to the study authors, "took an average of one additional minute of clinician time."

"When patients are involved with their care decisions, it is more likely they will get the right care for their concerns," Hess emphasized. "We believe that the Chest Pain Choice decision aid will make it easier for patients and physicians to have a thoughtful discussion and make an individualized care plan that is less likely to overuse unnecessary services."