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Shared Decision-making Reduces Risks of Chest Pain Overtreatment

ROCHESTER, MN – Here’s a suggestion on how to avoid overtreatment of low-risk chest pain in the emergency department: Engage in shared decision-making with patients, which, according to new research, results in better care and more efficient use of resources.

A presentation at the American College of Cardiology's 65th Annual Scientific Session in Chicago reported that low-risk chest pain patients who talked through treatment options with an emergency physician showed improved knowledge of their health status and follow-up options, compared with patients who received standard counseling.

Noting that about 8 million ED visits in the United States each year are related to chest pain, background information in the Mayo Clinic-led study states that more than 90% of those patients are not experiencing a heart attack. At the same time, over-evaluation of low-risk patients can lead to false-positive test results, unnecessary hospital admissions, and exposure to ionized radiation.

Researchers tested their theory that a way to potentially decrease physician decisions to over-treat would be to engage patients in shared decision-making.

"An electrocardiogram and blood tests can tell us if a patient is having a heart attack,” explained lead author Erik Hess, MD. “Further testing may be needed to tell us if a patient faces an increased risk of heart attack in the near future. We wanted to know if there is value in discussing this further testing with patients."

For the study, which included about 900 patients visiting six EDs in five states, half of the patients --mean age 47.6, mostly female, with nearly half having hypertension and a family history of cardiac disease -- were randomly assigned to receive a physician discussion using Chest Pain Choice, the first patient-oriented tool designed to help shared decision-making between physicians and patients with chest pain. As part of that, patients were shown one-page information sheets with descriptions and graphics depicting a patient's specific risk, such as a 2% risk of having a heart attack in the next 45 days, as well as next steps for care.

Patients receiving the Chest Pain Choice information were able to correctly answer 53% of questions on a survey about their knowledge of risk and options, compared with 44.6% of the patients receiving standard physician consultation.

The patients receiving Chest Pain Choice also were more likely to say they would recommend the way they discussed care and options with their ED physicians than those who received standard care -- 68.9% vs. 61.2%.

"This trial shows that patient engagement in care can be beneficial to the patient's understanding and treatment, and can lead to better care and more efficient use of resources," Hess said in a Mayo Clinic press release. He emphasized that using Chest Pain Choice was associated with no major adverse heart events and led to a significantly lower proportion of patients receiving a stress test.

PDMR - Pediatric Emergency Medicine Reports-hz