A short-cut review was carried out to establish whether shared decision making used alongside a decision aid can lead to greater patient satisfaction, lower healthcare resource use and non-inferior clinical outcomes in patients with suspected acute coronary syndromes. Four studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that the use of shared decision-making tools in the ED for management of patients with low-risk chest pain appears to be beneficial to the patient and the physician. Use of these shared decision-making tools appears to increase patient knowledge and satisfaction, while decreasing decision conflict and resource use, without causing additional negative outcomes for the patient.
- emergency departments
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A 72-year-old man presents to the ED with a 30 min episode of central chest pain, which radiated to the right shoulder and has now resolved. His only relevant medical history is hypertension, which is well controlled. His ECG and troponin are normal, so he is classed as low risk for an acute coronary syndrome (ACS). You are unsure whether to order further investigations, and wondering how useful it would be to implement shared decision tools in this situation.
In (patients with suspected ACS) does (shared decision making using alongside a decision aid versus standard care) lead to (greater patient satisfaction, lower healthcare resource use and non-inferior clinical outcomes)?
Ovid MEDLINE (R) <1946 to May week 1 2017>: 86 papers found.
(exp Acute Coronary Syndromes/OR exp Acute Myocardial Infarction/OR exp Myocardial Infarction/OR exp Angina, Unstable/OR (OR (myocard$ adj (ischem$ OR ischaem$ OR infarct$)).mp. OR exp Chest Pain/) AND (shared decision making OR shared decision$ OR shared medical decision$ OR decision aid OR decision tool OR joint decision$).mp) AND LIMIT to (English language and humans)
Ovid EMBASE <1974 to 2017 week 19>: 198 papers found.
Ovid EBM Reviews—Cochrane Central Register of Control Trials <up to April 2017>: 70 papers found.
Ovid EBM Reviews—Cochrane Database of Systematic Reviews <2015 to 10 May 2017>: 14 papers found.
(exp Acute Coronary Syndromes/OR exp Acute Myocardial Infarction/OR exp Myocardial Infarction/OR exp Angina, Unstable/OR (myocard$ adj (ischem$ OR ischaem$ OR infarct$)).mp. OR exp Chest Pain/) AND (exp shared decision making/OR (shared decision making OR shared decision$ OR shared medical decision$ OR decision aid OR decision tool OR joint decision$).mp) AND LIMIT to (human and English language)
Web of Science: Science Citation Index Expanded (SCI_EXPANDED) <1900 to present> AND Social Sciences Citation Index <1900 to present>: 103 papers found.
(TS=(Acute Coronary Syndromes OR Acute Myocardial Infarction OR Myocardial Infarction OR Angina OR Unstable angina OR myocardial ischemia OR ischemic myocardium OR Chest Pain) AND TS=(shared decision making OR shared decisions OR decision aid OR decision tool OR joint decision) AND TS=(emergency department OR Casualty OR ED OR emergency room OR emergency services OR accident and emergency OR A&E)) AND LANGUAGE: (English) AND DOCUMENT TYPES: (Article)
In total 471 papers were identified, of which 4 were found to be relevant and of sufficient quality for inclusion (see table 1).
Chest pain is a very common presentation, accounting for approximately 1% of presentations to general practitioners, 5% of presentations to the ED and up to 40% of hospital admissions 1 Doctors are often very cautious with patients who present with chest pain because of the risk of ACS or missed acute myocardial infarction. As a result physicians tend to have a low threshold for admitting patients to undertake investigations. Previous research has shown that doctors
There are multiple different scoring tools that are available in the ED that are designed to help calculate the risk of a patient’s chest pain being due to an ACS or MI, including the HEART score, the TIMI score and the GRACE score.2 Although these tools are helpful in determining the risk of a patient’s chest pain, low-risk patients are often still admitted and still undergo further investigations for the cause of their chest pain.3 However, in many different specialties of medicine, it has been shown that by involving patients in decisions about healthcare using shared decision-making strategies and sometimes decision aids or tools, patient knowledge and patient satisfaction increase, while decision conflict and resource use decrease, without having a negative effect on the outcomes of the patients.4 We have identified five studies that looked at the use of shared decision-making aids in the ED for patients who had low-risk chest pain and were being considered for admission and further investigation. Most of the studies used the HEART score to determine the patient’s risk, and all involved patients with no history of coronary artery disease who had the capacity to take part in shared decision making. However all the patients involved had the main presenting complaint of chest pain so this excluded anyone who presented to the ED with symptoms not including chest pain who were suspected of having an ACS or MI. All of the studies that we looked at showed that there was an increase in patient knowledge, both of the disease itself but also about their individual disease risk and what this meant in terms of further management. All these studies showed a reduction in decision conflict between the patient and physician, and all the decision aids used were shown to be acceptable for both the clinician and the physician, with one study3 indicating that physicians were keen to more shared decision-making tools available to them particularly for low-risk chest pain. There was a reduction in hospital admissions in the groups of patients who used the decision aids and a reduction in the amount of hospital resources that were used, both from admission and from further investigation and cardiac stress testing. Hess et al 5 also found that although fewer patients opted for cardiac stress testing—either as an inpatient or outpatient—a higher proportion of patients who were meant to have cardiac stress testing as outpatient went to this appointment compared with those who had not used the shared decision-making tool, which would indicate that resources were also used more effectively with fewer missed appointments.
Clinical bottom line
The use of shared decision-making tools in the ED for management of patients with low-risk chest pain appears to be beneficial to the patient and the physician. Use of these shared decision-making tools appears to increase patient knowledge and satisfaction, while decreasing decision conflict and resource use, without causing additional negative outcomes for the patient.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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