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

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6165 (Published 05 December 2016) Cite this as: BMJ 2016;355:i6165

Shared decision making for low-risk chest pain: looking ahead

We commend Hess et al for their well-designed and clinically useful pragmatic shared decision making study (1). This is sure to serve as an example for shared decision making research addressing other clinical scenarios, both in the emergency department and beyond.

Shared decision making is best suited for the fork in the road, a divergence of care where neither course is clearly superior (2). Such a decision, though equivocal from the clinician’s perspective, is “preference-sensitive” when seen in a patient-centered light. The Centers for Medicare and Medicaid Services applies shared decision making to conditions “for which the clinical evidence does not clearly support one treatment option, and the appropriate course of treatment depends on the values or preferences of the beneficiary regarding the benefits, harms, and scientific evidence for each treatment option” (3). This appears to be true at the moment regarding the site-of-care decision for many low-risk chest pain patients: should they go home to follow-up with their primary care provider or should they be admitted for short-term observation and provocative testing? Let’s educate our patients and help them decide.

But the field is rapidly changing: what is equivocal today may not be so in the coming years. The advent of highly sensitive troponin assays, with or without the use of refined risk stratification pathways, will help us identify emergency department patients with short-term risks of acute coronary syndrome sufficiently low to obviate the need for observation and advanced cardiac testing prior to home discharge (4-6). As evidence continues to accumulate that this practice is safe, clinicians will feel empowered to confidently shift the site of care in an outpatient direction for a growing number of low-risk chest pain patients. This shift in emergency department disposition is a familiar transition, and when done safely can be associated with increased patient convenience and satisfaction as well as a more responsible stewardship of healthcare resources. We have learned to do this with low-risk pneumonia (7) and are learning to do it with low-risk pulmonary embolism (8).

Even in this projected future of increasing outpatient care for low-risk chest pain, the best emergency department disposition will at times remain an open question. Here the patient’s preference elicited during shared decision making can be called upon to guide management, as Hess et al have shown (1). But absent the equipoise of “preference-sensitive” conditions, when the clinician believes that home management is the optimal disposition, we still need to do better at educating our patients about their risks and explaining to them the rationale of the recommendations we provide. The well-conceived, field-tested patient-centered decision aid that Hess and colleagues used in this study is readily adaptable for just this task. Whether we’re soliciting a patient’s tie-breaking opinion on site of care (shared decision making) or we’re informing them why we think a certain disposition is most appropriate (patient education), a clear, accessible pictographic decision aid can help us more clearly communicate our thoughts and leave the patient with a fuller understanding of their situation (1).

The next generation of electronic shared decision making tools may take this even further by incorporating principles from learning healthcare systems. These new tools that we envision would update risk calculators based on the most recent evidence and also tailor the risk profiling to the very population and heathcare setting where the patient is being treated. We also foresee a day when patient-specific preferences – their risk-tolerance, cultural affiliations and even prior shared decision making choices – are integrated into the electronic shared decision making interface that frames the patient-physician discussion. As we have learned from this study, with a good decision aid in hand, that extra patient-centered discussion takes only an extra minute. And we can’t imagine a minute better spent.

1. Hess EP, Hollander JE, Schaffer JT, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ 2016;355:i6165. DOI: 10.1136/bmj.i6165 [PMCID: PMC5152707]
2. Melnick ER, Probst MA, Schoenfeld E, et al. Development and testing of shared decision making interventions for use in emergency care: a research agenda. Acad Emerg Med 2016;23:1346-1353. DOI: 10.1111/acem.13045 [PMID: 27457137]
3. Centers for Medicare and Medicaid Services. Beneficiary Engagement Initiative: Shared Decision Making (SDM) Model. https://innovation.cms.gov/initiatives/beneficiary-engagement-sdm/ Accessed December 16, 2016.
4. Shah AS, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015;386(10012):2481-8. DOI: 10.1016/S0140-6736(15)00391-8 [PMCID: PMC4765710]
5. Than MP, Pickering JW, Aldous SJ, et al. Effectiveness of EDACS versus ADAPT Accelerated Diagnostic Pathways for chest pain: A pragmatic randomized controlled trial embedded within practice. Ann Emerg Med 2016;68:93-102.e1. DOI: 10.1016/j.annemergmed.2016.01.001 [PMID: 26947800]
6. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015;8:195-203. DOI: 10.1161/CIRCOUTCOMES.114.001384 [PMCID: PMC4413911]
7. Chalmers JD, Akram AR, Hill AT. Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis. Eur Respir J 2011;37:858-64. DOI: 10.1183/09031936.00065610 [PMID: 20729221]
8. Vinson DR, Zehtabchi S, Yealy DM. Can selected patients with newly diagnosed pulmonary embolism be safely treated without hospitalization? A systematic review. Ann Emerg Med 2012;60:651-662.e4. DOI: 10.1016/j.annemergmed.2012.05.041 [PMID: 22944455]

Competing interests: No competing interests

16 December 2016
David R Vinson
Clinical Researcher
Dustin W Ballard, Dustin G Mark, Uli K Chettipally
The CREST Network, The Permanente Medicine Group
Oakland, California