Shared decision-making tools can cut cardiac admissions in the emergency department by empowering patients and clinicians to make more informed choices about their care, according to research published in the British Medical Journal and discussed in a recent Health Affairs blog post.
The tool targets patients in the ED experiencing chest pains, an issue that yields nearly 8 million ED cases annually. And because the procedure used to detect acute coronary syndrome (ACS) has a 1.5 percent chance of producing a false positive or negative, ED clinicians tend to admit more patients than necessary, posing two primary challenges.
The high volume of potentially unnecessary ED admissions results in almost $7 billion in costs each year. Additionally, patients typically prefer to avoid hospital admission, opting to receive treatment on an outpatient basis whenever possible, the research team suggested.
The researchers created an aid targeted at helping patients make decisions about ED admissions alongside their providers. The tool, called Chest Pain Choice, includes a 45-day risk estimate for ACS and other information to help patients and providers make a joint decision.
After a successful pilot at the Mayo Clinic in which ED admissions lowered by 19 percent, the researchers deployed the tool on a wider scale at six geographically disparate EDs across the country. The study included 898 patients and a total of 361 clinicians.
While the tool was successful at Mayo Clinic, the researchers found negligible difference between ED admissions amongst intervention and control groups during this second round of testing. However, they did find that patients in the intervention group were more engaged in shared decision-making.
The researchers tested patient knowledge of their risk of ACS using a standardized eight-question quiz. Patients in the control group averaged 3.6 correct questions, compared to 4.2 correct questions for the intervention group, showing that the decision aid helps inform patients of their conditions.
The intervention group was also twice as likely to be involved in treatment decisions as those in the control group, and tended to have less decisional conflict with their providers, likely because they could engage in more meaningful conversations about their care.
Patients in the intervention group also saw no adverse health events in the 30 days following discharge from the ED. Clinicians reported an average increase of about one minute onto their current workloads.
According to the researchers, the decision tool was helpful because it eliminated one-size-fits-all risk assessments that lead to avoidable hospital admissions.
“Patient centered interventions such as those tested in this trial indicate that patients, when educated and informed of their risk, might choose with their clinician to undergo less extensive evaluation more closely tailored to their personalized risk,” the researchers said.
Despite these promising results, the researchers acknowledged that the decision aid is not useful for all patients. Patients with a history of acute coronary syndrome or who have an extremely high chance of having a serious condition during that visit should not use the tool and instead be admitted into the hospital, the researchers advised.
On the whole, however, the results of the study are promising, the researchers said. The study showed that providers can engage patients in shared decision-making, a goal the researchers prior thought was not feasible due to challenging time constraints in the ED. These results helped convince them otherwise.
According to the team, these findings open up avenues for driving and rewarding better patient engagement in various settings, not just in the doctor’s office or with chronic disease management patients.
“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,” the researchers concluded in Health Affairs.
“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.”