More than 8 million U.S. emergency departments (ED) visits are from patients with chest pain, which is the second most common reason to visit an ED. Standard protocol is to screen patients presenting with chest pain for acute coronary syndrome (ACS) — in other words, to determine if they are having a heart attack. If the patient is having a heart attack, he or she is admitted to the hospital for further observation and testing.
But the initial tests used to determine whether a patient is having a heart attack when they come to the ED miss 1.5 percent of patients with ACS. Because of this uncertainty, clinicians often admit patients who test negative, just to be safe. Even though less than one in 10 patients presenting to the ED with chest pain are having a heart attack and require admission, roughly half are admitted due to the uncertainty associated with the test.
Patients in the ED with chest pain but without ACS can be safely treated through outpatient follow-up care in the next 24-72 hours. Not only do most patients prefer to be treated outside of the hospital when possible, but studies estimate that these unnecessary chest pain hospital admissions cost the health care system $7 billion a year.
To address this issue, we (one of us, Dr. Hess and his research team) worked with the Knowledge and Evaluation Research Unit at the Mayo Clinic to create a "Chest Pain Choice" decision aid. The decision aid is designed to help clinicians and patients make an informed, shared decision about whether or not the patient should be admitted for observation — even in the stress-filled, fast-paced ED. We tested the decision aid using a randomized control trial at six EDs across the US. Results published in the British Medical Journal on December 4, 2016 show that the use of "Chest Pain Choice" increased patient engagement and knowledge and safely reduced unnecessary hospital admissions for cardiac testing — a multi-billion dollar opportunity to reduce waste in the U.S. health care system.
As our health care system continues to test new ways to deliver value-based health care, there is a growing recognition of the important role of shared decision making. Policymakers are actively creating ways to incentivize providers to build these tools into their routine practice through new Medicare payment models. To date, these efforts have primarily focused on decision making in the physician office. Research like ours shows tremendous potential for driving value-based care in the emergency setting through shared decision making. As we continue to build incentives for value-based care into our health care system, we should not leave the ED out.
A Growing Recognition Of The Value Of Shared Decision Making
Shared decision making is defined by the Informed Medical Decisions Foundation as a "collaborative process that allows patients and their providers to make health care decisions together. It takes into account the best clinical evidence available, as well as the patient's values and preferences."
New payment models designed by the Centers for Medicare and Medicaid Services (CMS) have increasingly incentivized shared decision making. In fact, in December 2016, the CMS Innovation Center announced a new Shared Decision Making Model (SDM Model) to test models of integrating shared decision making into clinical practice workflows of Accountable Care Organizations. At the outset, this model focuses on beneficiaries with six "preference-sensitive" conditions including certain heart conditions, orthopedic procedures, and types of cancer. This model builds on other CMS Innovation Center models, including the Oncology Care Model, Comprehensive Primary Care Initiative, and the Million Hearts: Cardiovascular Disease Risk Reduction Model which each include shared decision making as an important component of the model.
The use of shared decision making in practice has shown that better informed patients who understand their health care options tend to make better decisions about their own care, choosing care options that work for them and selecting care plans that they are more likely to follow. Ultimately, this combination of informed choices and increased adherence has been shown to both improve the quality of care and lower costs.
Shared Decision Making In The ED
Most shared decision making occurs in non-emergent care settings that offer patients more time to learn about their condition and consider their options. Moreover, in the case of a chronic condition such as cardiovascular disease or a newly diagnosed cancer, patients often know their physician well or anticipate getting to know their physicians soon through repeated visits.
These things are not true in the ED.
EDs are crowded and chaotic. Every year there are 136 million ED visits in the United States. ED clinicians have to be prepared for whatever walks through the door. Interruption is such a common occurrence that emergency care has been described as "interruption-driven," a term that means that day-to-day activities are more determined by frequent interruptions than tasks.
It's an ED clinician's job to constantly triage and move patients through the care process to be sure that the most-emergent cases are getting the attention they need.
In the ED, patients are scared, sick, and tired — and often not thinking beyond the acute issue of the moment. Clinicians are busy and constantly interrupted by situations that may be more urgent than the one at hand. In order to maximize efficiency and safety in the ED, clinicians are often required to make rapid decisions. These constant interruptions and consistent urgency contribute to a chaotic environment that is not an ideal setting for patients and clinicians to carefully consider different health care options.
Driven by a commitment to provide personalized care that respects patients' autonomy regardless of the circumstances, we set out to create a shared decision making process that would work under the unique circumstances of the ED where clinicians have limited time to explain and patients don't have energy to ask necessary questions. We focused on chest pain because it is the second most frequent reason that patients end up in the ED, those patients are often unnecessarily admitted to the hospital, and there is a high likelihood that we will see a spillover effect on routine emergency care if a risk-informed, patient-centered approach to such a common condition can be normalized in practice.
The 'Chest Pain Choice' Decision Aid
The "Chest Pain Choice" decision aid is a visual representation of a patient's risk of ACS within 45 days of their ED visit. Assessment tools are used to calculate risk based on patient information collected during their ED visit, including:
- Age
- Gender
- If chest pain is made worse when manual pressure is applied to the chest area
- If there is a history of coronary artery disease
- If the chest pain causes perspiration
- Findings on electrocardiograms (electronic tracings of the heart)
- Initial cardiac troponin result
Once the probability that a patient will experience ACS within 45 days of his or her ED visit is calculated, the patient is presented with a decision aid that is tailored to his or her personal risk profile. Clinicians were directed to be conservative in determining the level of risk to communicate to patients. For instance, if a patient's risk is 0.9 to 1.7 percent, clinicians would use a decision aid indicating a 2 percent risk.
The decision aid is an 11×14 piece of paper that communicates to patients the results of initial tests indicating that they are not having a heart attack, their personalized 45-day risk for a heart attack, and the available management options, including staying in the ED observation unit for cardiac stress testing, following up in the next 72 hours, or having the physician make the decision on their behalf.
Informed Patients And Improved Outcomes
In order to test the use of the "Chest Pain Choice" decision aid in the ED, 898 patients were enrolled in a randomized control trial in which roughly half the patients received care using "Chest Pain Choice." The other half received usual care. The study was completed at six EDs in different parts of the country from October 2013 to August 2015.
The trial found that patients treated using the decision aid were more knowledgeable about their care: "Chest Pain Choice" patients got an average of 4.2 questions correct on a questionnaire compared to an average of 3.6 questions correct for patients treated with usual care.
The trial also found that "Chest Pain Choice" patients were more involved in their treatment decisions, were admitted to the hospital less frequently, and had fewer tests in the next 45 days. In the trial, we monitored patients after they left the ED and determined that there were no major adverse cardiac events within 30 days due to the intervention.
Importantly, the trial found that using "Chest Pain Choice" added minimal time to a clinician's process, adding an average of 1.3 minutes per patient compared to usual care.
What's Next For Shared Decision Making In The ED?
This research has confirmed our belief that shared decision making has a vital place in the ED. Appropriately designed decision aids can create time and space for patient-clinician conversations that might not otherwise occur in the fast-paced ED environment. As a result, we are working on similar decision aids for discussing CAT scans for adults and children with minor head trauma.
As policymakers consider innovative ways to incentivize value-based personalized care and continue to recognize the important role that shared decision making plays in efforts to drive value, we should not exclude the ED.
Bringing shared decision making into the ED requires a significant cultural shift, but there are tremendous opportunities for increasing value to both patients and the health system.
Authors' Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
The Patient Centered Outcomes Research Institute has funded Dr. Hess' research
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