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What was the research about?

More than 8 million people go to the emergency room (ER) for chest pain every year in the United States. Even though the number of people having heart attacks has gone down in recent years, the number of people getting heart-imaging tests during ER visits after a doctor has said they didn’t have a heart attack is rising. Patients at low risk for having a heart attack in the near future may not need these tests.

The research team created a decision aid that gave patients information on their personal risk of having a heart attack. Decision aids help people choose between two or more healthcare options based on what is most important to them. This decision aid was a single printed page that showed patients their chest-pain diagnosis, their risk of having a heart attack in the near future, and their options for more tests. The patients talked with the doctors treating them in the ER about the information in the decision aid. The aim of the talks was to help patients and ER doctors decide together about whether patients would stay in the hospital for further tests or go home and wait to decide about further tests until they had an outpatient appointment with their doctor.

The research team wanted to see if the decision aid changed patients’ knowledge about their risk for having a heart attack in the near future, patients’ involvement in the decision about further heart testing, and the decisions they made. The team also looked at whether any patients had heart attacks or other severe heart problems during the 45 days after they visited the ER.

What were the results?

Compared with patients who didn’t use the decision aid, patients who used the decision aid

• Had more knowledge about their risk of heart attack
• Were more involved in making decisions in the ER
• Were less likely to decide with their doctors to stay in the ER
• Were less likely to decide to get more heart tests during the ER visit

No patients in the study died because of a heart attack or other severe heart problems.

Who was in the study?

The study included 898 patients at six hospitals in the United States. Patients in the study had gone to the ER for chest pain, but based on test results, had not had a heart attack. The average patient age was 50. About 60 percent of patients were white and 34 percent were black. About 60 percent of patients were female. Most had at least a high school diploma.

What did the research team do?

Doctors in the ER first confirmed that the patients had not had heart attacks and didn’t have a history of heart disease. Then, the research team assigned patients by chance to one of two groups. Patients in the first group got the decision aid with their personal risk information included. ER doctors used the decision aid to talk to patients about their options for heart testing and make a decision with them. Patients in the second group didn’t get a decision aid. ER doctors talked to these patients the way they usually talk to patients not in the study.

All patients took a survey at the end of their ER visits. The research team also made visual and audio recordings of more than half of the patients when they talked with their ER doctors. Forty-five days after patients left the ER, the research team asked them about the cardiac tests they had after their ER visit and whether they had a heart attack or other major heart problem since their ER visit.

What were the limits of the study?

The study included only patients who had chest pain. The research team didn’t design the decision aid for patients at risk for heart problems who come to the ER because of other symptoms.

How can people use the results?

Hospitals can use a decision aid like the one in this study with ER patients who have chest pain but no heart attack diagnosis. The decision aid could help ER patients and doctors work together to make the best decision for each patient.

Objective

To compare the effects of a decision aid versus usual care on patient knowledge of personal risk for acute coronary syndrome, choice of admission to the hospital for observation, and further cardiac testing in patients with possible acute coronary syndrome.

Study Design

This multicenter pragmatic parallel randomized controlled trial tested a decision aid that included personalized information about patients’ chest pain diagnosis, options for additional tests, and information on patients’ individual risk for acute coronary syndrome in the next 45 days. After reviewing the decision aid, patients engaged in a shared decision making conversation with attending ER clinicians, including doctors, nurses, and physician assistants. The primary study outcome was patients’ knowledge of their risk for acute coronary syndrome and options for future care, measured by patient answers to knowledge questions after ER visits. Secondary outcomes included patient involvement in the hospital-admission decision, proportion of patients who decided on admission for further cardiac testing, and 30-day rate of major adverse cardiac events.

The study included 898 adult patients who visited an ER for chest pain in six hospitals across the United States. The study included patients whose preliminary tests in the ER indicated that they had not had a myocardial infarction. In this study, 60% of patients were white, 34% were black, and 60% were female. The mean patient age was 50, and 30% had a high school education or less.

The research team randomized patients to one of two groups. Patients in the intervention group read and discussed the information in the decision aid with attending ER physicians during ER visits. Patients in the control group received usual care without the decision aid. Researchers collected postvisit survey data immediately after the intervention in the ER. Whenever possible, the research team made visual and audio recordings of the doctor-patient discussions to assess clinicians’ efforts to engage patients in the decision-making process. The research team contacted study patients 45 days after their ER visit to determine whether they experienced a major adverse cardiac event. For patients who the researchers could not reach, the researchers verified mortality status using a national database. The research team compared patient-level outcomes between the intervention and control groups, adjusting for intrasite and intraclinician correlations.

Results

Compared with patients in the control group, patients in the intervention group

• Had significantly greater knowledge about their risk of acute coronary syndrome
• Were more engaged in the decision-making process
• Were less likely to decide with their clinician to be admitted into the ER observation unit for cardiac testing (37% versus 52%)
• Were less likely to undergo cardiac stress testing within 30 days of their ER visit (38% versus 46%)

There were no deaths from cardiac or unknown causes in either group. One participant in the intervention group had a major adverse cardiac event following hospital discharge; the data safety monitoring board classified this event as unrelated to the study intervention. No participants in the control group had major adverse cardiac events.

Limitations

The research team was unable to contact 70 patients for follow-up assessment of secondary outcomes; however, the team verified 45-day mortality using an independent database and found no differences between treatment groups. The investigators were unable to obtain video recordings in 40% of encounters because of patient refusal and problems with recording equipment; however, the sample size was sufficient to examine the extent to which physicians engaged patients in shared decision making. Finally, the study included only patients who had chest pain. The research team didn’t design the decision aid for patients at risk for heart problems who come to the ER because of other symptoms.

Conclusions and Relevance

For patients visiting the ER for low-risk chest pain, the decision aid was an effective way to increase knowledge before deciding about hospital admission for observation or further cardiac testing. The decision aid was also effective in increasing patient engagement in the decision-making process.

Future Research Needs

Further research studies could examine how best to use the decision aid in the ER and whether larger studies confirm the findings from this study.