Friday, 1 December 2017

Shared decision making in patients with low risk chest pain: empowering patients to go home

In patients presenting to the ED with very low risk chest pain, can a structured approach to shared decision making provide some benefit? Specifically, does it improve general comprehension and decrease resource utilization all in a safe manner?

In this study, 898 patients in the USA were randomised to a shared decision making facilitated by a decision aid or to usual care.

Inclusion criteria were:
  • Adults presenting to the ED with chest pain
  • Non-ischemic ECG
  • Negative initial troponin
  • No known prior coronary artery disease
  • Treating doctor wanted to admit to an observation unit to get a stress test or CTCA

(Yes… in many countries most of these patients would never have been admitted in the first instance. There are clearly some issues of external validity.)

Results?

With the decision aid, 15% more patients decided not to be admitted compared to usual care (52% vs. 37%).

Oh… and out of 898 patients, how many cardiac events were there?

Six.

This obviously begs the question as to why the vast majority of these patients could be sent home regardless of the decision aid.

Nevertheless, I think it does send the message that a structured approach to shared decision making may provide a better framework to educate our patients.


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