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BMJ. 2016 Dec 5;355:i6165. doi: 10.1136/bmj.i6165.

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

Author information

1
Department of Emergency Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55906, USA hess.erik@mayo.edu.
2
Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
3
Mayo Clinic Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Rochester, MN, USA.
4
Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
5
Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA.
6
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA.
7
Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
8
Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA.
9
Department of Emergency Medicine, Perelman School of Medicine, Philadelphia, PA, USA.
10
Rochester, MN, USA.
11
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
12
Health Research & Educational Trust, Chicago IL, USA.
13
Department of Emergency Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55906, USA.
14
Department of Emergency Medicine, Aventura Hospital and Medical Center, Aventura, FL, USA.
15
Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.

Abstract

OBJECTIVE:

 To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome.

DESIGN:

 Multicenter pragmatic parallel randomized controlled trial.

SETTING:

 Six emergency departments in the United States.

PARTICIPANTS:

 898 adults (aged >17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain.

INTERVENTIONS:

 Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events.

RESULTS:

 Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P<0.001). There were no major adverse cardiac events due to the intervention.

CONCLUSIONS:

 Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240.

PMID:
27919865
PMCID:
PMC5152707
DOI:
10.1136/bmj.i6165
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: JEH has research funding from Alere, Trinity, Siemens, and Roche and has consulted for Janssen. DBD has research funding from Siemens and Roche and has consulted for Janssen. All other authors have no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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