ROCHESTER, MN—One day in 2011, Michel Demers experienced chest pain, headaches, and dizziness. He immediately got worried, thinking of his father, who had died at 50 from a heart attack.
As a stay-at-home dad, Demers had two small children to look after. He called his wife, Annie LeBlanc, PhD, a Mayo Clinic researcher. The two scrambled for childcare and then went to the emergency department at Mayo Clinic. Demers underwent numerous tests and received excellent care but still wasn’t sure how sick he might be.
Demers recalls feeling very anxious: “I was thinking, if they have to do so many tests, maybe I have a very big problem.”
Physicians wanted to monitor him overnight and run more tests the next morning, but the couple worried about the cost of an overnight stay and about care of their children. Demers spoke mostly French—the family had recently moved from Canada—so LeBlanc was uncomfortable leaving him on his own in the hospital.
“I started asking questions,” LeBlanc says. “I said, ‘Can you tell me his risk of a heart attack in the next month?’ And it was very uncomfortable. It really felt like we were asking too much.”
After about an hour and a half, a doctor told the couple the tests had come back negative: Demers was not having a heart attack, and his chest pain probably was caused by stress. Three hours into the visit, the two decided—against doctors’ recommendations, they note—to go home rather than stay overnight.
“We were getting the best of care,” LeBlanc reflects. “It was just not the care that we needed or wanted.”
Now, Demers and LeBlanc are patient and caregiver co-investigators of a PCORI-funded project that has tested a way to better inform patients about their care options and heart risks when they are being treated for chest pain in emergency departments. The study involved patients, like Demers, for whom tests had ruled out a heart attack and who were at low risk of heart attack.
Led by Erik P. Hess, MD, MS, an emergency medicine physician and researcher at Mayo Clinic, the study tested use of a decision aid: a single sheet of paper that explains patients’ risk levels for future heart attacks and their options for further testing—whether in the hospital or later in a doctor’s office.
The study results, recently published in The BMJ, were striking. Patients who used the decision aid in conversations with ER clinicians were less apt to decide to stay overnight for additional testing, and they faced no additional heart problems in the weeks that followed, as compared with patients who received only usual care.
Patients who used the decision aid also emerged with greater knowledge of both their heart risk and care options, and they got more involved in decisions about their care.
A Major Health Burden
Chest pain accounts for around 6.5 million visits to US emergency departments every year, according to the Centers for Disease Control and Prevention. But the vast majority of these visits do not end up being heart attacks.
Emergency physicians run tests to rule out a heart attack or unstable angina, a serious condition in which the heart doesn’t get enough blood flow. These tests miss about 1.5 percent of cases, and they don’t do a good job at predicting whether a patient will experience a serious heart problem in the coming weeks.
“The dilemma is how you manage patients who are at low risk for a cardiac event in a way that’s safe and doesn’t introduce undue burden on the patient,” Hess adds. Perhaps too often, he adds, doctors tend to be extra cautious and recommend that patients stay in the hospital for monitoring or undergo additional tests, such as stress testing or coronary computed tomography angiography. “There’s frequently a mismatch between the intensity of evaluation and patients’ risk,” he says.
In the ER, the level of stress and anxiety in patients is so high. You can’t begin to have discussions until they understand where they are in terms of risk.
Another issue is insufficient communication, Hess adds. “Patients don’t want to be left in the dark,” he says, but the rapid pace of emergency departments can mean that doctors might not have time to discuss patients’ future heart disease risks with them, or they make recommendations for further evaluation without taking patient preferences fully into account.
LeBlanc agrees. “In the ER, the level of stress and anxiety in patients is so high. You can’t begin to have discussions until they understand where they are in terms of risk,” she says.
Easing Communication under Stress
Coincidentally, LeBlanc herself is doing research on shared decision making. But during Demers’s ER visit, she did not think about patient involvement in healthcare decisions. “When I was in the ER with Michel, there was not an ounce of the researcher in me,” she says. “I sat there and apologized for asking questions.”
Shortly afterward, LeBlanc mentioned the experience to Hess. He soon asked the couple to join him in developing a proposal for PCORI-funded research on decision making in ERs and, after the project was approved, to help design the decision aid.
The tool is a single printed page with tailored information for patients. Demers and LeBlanc recommended using easy-to-understand wording, bulleting topics, and limiting the amount of text.
A doctor first applies an online tool that uses test results and characteristics such as sex and age to calculate a patient’s risk of upcoming heart problems. Then, the clinician goes to a collection of decision aids and prints out the piece of paper corresponding to that risk.
At Demers’s and LeBlanc’s urging, the first thing the page says is that the patient’s test results are negative for a heart attack. An easy-to-understand diagram illustrates a patient’s risk of heart attack in the next 45 days.
The aid also lays out a patient’s choices: further testing in the ER, following up with another doctor, or having the ER physician make the decision about next steps. The research team intends for the decision aid to help clinicians and patients discuss risk and treatment options, not to replace those conversations.
The dilemma is how you manage patients who are at low risk for a cardiac event in a way that’s safe and doesn’t introduce undue burden on the patient.
“Clinicians using our decision aid engaged patients more in the decision-making process, effectively transferring knowledge of individual risk and treatment options,” Hess says.
In the study, the research team randomly assigned 898 patients in emergency departments at six hospitals to receive either usual care or that care supplemented with the decision aid. All of the patients were considered low risk because they had tested negative for heart problems. After their visits, all the patients filled out a survey assessing their knowledge of their own risk and treatment options. It also asked how they felt about the ER experience, such as their trust in the clinicians who treated them and satisfaction with the decisions they made. Then, 45 days later, a research team member called each of the patients to find out whether they had gone on to experience any major heart problems, Hess’s team reported in The BMJ.
Largely because of conversations with Demers, LeBlanc, and other patients and caregivers, the study placed greatest emphasis on determining whether patients who used the decision aid emerged with greater understanding of risk and treatment options. “What really matters is that the patients’ information needs are met,” LeBlanc says.
In addition to learning more, those patients who used the decision aid felt more confident in their decisions, whether they stayed for further testing or went home.
And just 37 percent of patients who used the decision aid decided to stay at the hospital for further testing, compared with 52 percent of patients who received only usual care. The fewer patients choosing additional testing did not translate to more heart problems in the following days.
The choice to avoid more tests in the hospital could be a boon to emergency departments, Hess says. “The patients are not in there as long, so you can open up a treatment bed. Overcrowding and increased waiting times have been shown to decrease the quality of care.”
The clinicians, as well as the patients, learned more when the decision aid guided conversations. “The physician becomes aware of where a patient is coming from, of the nonmedical factors that affect a patient’s decision making,” Hess says. “It can provide a more meaningful interaction.” In the study, using the decision aid made the clinician-patient interaction take just an average of 1.3 minutes longer.
The next step for the project is to test the decision aid with more patients. But it may be put to use in some emergency departments before those trials are complete. The Mayo Clinic is planning to make routine use of the aid, as are at least two of the other emergency departments that participated in the study.
"What really matters here is that patients' needs were met when they used the decision aid,” LeBlanc says. “The challenge is: how do you make it a standard of care? That’s where we are right now.”
Shared Decision Making in the Emergency Department: The Chest Pain Choice Trial
Principal Investigator: Erik P. Hess, MD, MS
Goal: Test whether decisions informed by a personalized educational printout improve outcomes—and decrease unnecessary hospital admissions—for patients in the emergency department for chest pain.
PCORI Research Topic: Cardiovascular Disease
Posted: February 21, 2017; Updated: February 28, 2017