1
|
Medhi D, Kamidi SR, Mamatha Sree KP, Shaikh S, Rasheed S, Thengu Murichathil AH, Nazir Z. Artificial Intelligence and Its Role in Diagnosing Heart Failure: A Narrative Review. Cureus 2024; 16:e59661. [PMID: 38836155 PMCID: PMC11148729 DOI: 10.7759/cureus.59661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2024] [Indexed: 06/06/2024] Open
Abstract
Heart failure (HF) is prevalent globally. It is a dynamic disease with varying definitions and classifications due to multiple pathophysiologies and etiologies. The diagnosis, clinical staging, and treatment of HF become complex and subjective, impacting patient prognosis and mortality. Technological advancements, like artificial intelligence (AI), have been significant roleplays in medicine and are increasingly used in cardiovascular medicine to transform drug discovery, clinical care, risk prediction, diagnosis, and treatment. Medical and surgical interventions specific to HF patients rely significantly on early identification of HF. Hospitalization and treatment costs for HF are high, with readmissions increasing the burden. AI can help improve diagnostic accuracy by recognizing patterns and using them in multiple areas of HF management. AI has shown promise in offering early detection and precise diagnoses with the help of ECG analysis, advanced cardiac imaging, leveraging biomarkers, and cardiopulmonary stress testing. However, its challenges include data access, model interpretability, ethical concerns, and generalizability across diverse populations. Despite these ongoing efforts to refine AI models, it suggests a promising future for HF diagnosis. After applying exclusion and inclusion criteria, we searched for data available on PubMed, Google Scholar, and the Cochrane Library and found 150 relevant papers. This review focuses on AI's significant contribution to HF diagnosis in recent years, drastically altering HF treatment and outcomes.
Collapse
Affiliation(s)
- Diptiman Medhi
- Internal Medicine, Gauhati Medical College and Hospital, Guwahati, Guwahati, IND
| | | | | | - Shifa Shaikh
- Cardiology, SMBT Institute of Medical Sciences and Research Centre, Igatpuri, IND
| | - Shanida Rasheed
- Emergency Medicine, East Sussex Healthcare NHS Trust, Eastbourne, GBR
| | | | - Zahra Nazir
- Internal Medicine, Combined Military Hospital, Quetta, Quetta, PAK
| |
Collapse
|
2
|
Babione JN, Ocampo W, Haubrich S, Yang C, Zuk T, Kaufman J, Carpendale S, Ghali W, Altabbaa G. Human-centred design processes for clinical decision support: A pulmonary embolism case study. Int J Med Inform 2020; 142:104196. [DOI: 10.1016/j.ijmedinf.2020.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
|
3
|
|
4
|
Choi DJ, Park JJ, Ali T, Lee S. Artificial intelligence for the diagnosis of heart failure. NPJ Digit Med 2020; 3:54. [PMID: 32285014 PMCID: PMC7142093 DOI: 10.1038/s41746-020-0261-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/12/2020] [Indexed: 12/12/2022] Open
Abstract
The diagnosis of heart failure can be difficult, even for heart failure specialists. Artificial Intelligence-Clinical Decision Support System (AI-CDSS) has the potential to assist physicians in heart failure diagnosis. The aim of this work was to evaluate the diagnostic accuracy of an AI-CDSS for heart failure. AI-CDSS for cardiology was developed with a hybrid (expert-driven and machine-learning-driven) approach of knowledge acquisition to evolve the knowledge base with heart failure diagnosis. A retrospective cohort of 1198 patients with and without heart failure was used for the development of AI-CDSS (training dataset, n = 600) and to test the performance (test dataset, n = 598). A prospective clinical pilot study of 97 patients with dyspnea was used to assess the diagnostic accuracy of AI-CDSS compared with that of non-heart failure specialists. The concordance rate between AI-CDSS and heart failure specialists was evaluated. In retrospective cohort, the concordance rate was 98.3% in the test dataset. The concordance rate for patients with heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction, heart failure with preserved ejection fraction, and no heart failure was 100%, 100%, 99.6%, and 91.7%, respectively. In a prospective pilot study of 97 patients presenting with dyspnea to the outpatient clinic, 44% had heart failure. The concordance rate between AI-CDSS and heart failure specialists was 98%, whereas that between non-heart failure specialists and heart failure specialists was 76%. In conclusion, AI-CDSS showed a high diagnostic accuracy for heart failure. Therefore, AI-CDSS may be useful for the diagnosis of heart failure, especially when heart failure specialists are not available.
Collapse
Affiliation(s)
- Dong-Ju Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin Joo Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Taqdir Ali
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Republic of Korea
| | - Sungyoung Lee
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Republic of Korea
| |
Collapse
|
5
|
Lee B, Hershey D, Patel A, Pierce H, Rhee KE, Fisher E. Reducing Unnecessary Testing in Uncomplicated Skin and Soft Tissue Infections: A Quality Improvement Approach. Hosp Pediatr 2020; 10:129-137. [PMID: 31941651 DOI: 10.1542/hpeds.2019-0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Skin and soft tissue infections are common pediatric diagnoses with substantial costs. Recent studies suggest blood cultures are not useful in management of uncomplicated skin and soft tissue infections (uSSTIs). Complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein are also of questionable value. We aimed to decrease these tests by 25% for patients with uSSTIs admitted to the pediatric hospital medicine service within 3 months. METHODS An interdisciplinary team led a quality improvement (QI) project. Baseline assessment included review of the literature and 12 months of medical records. Key stakeholders identified drivers that informed the creation of an electronic order set and development of a pediatric hospital medicine-emergency department collaborative QI project. The primary outcome measure was mean number of tests per patient encounter. Balancing measures included unplanned readmissions and missed diagnoses. RESULTS Our baseline-year rate was 3.4 tests per patient encounter (573 tests and 169 patient encounters). During the intervention year, the rate decreased by 35% to 2.2 tests per patient encounter (286 tests and 130 patient encounters) and was sustained for 14 months postintervention. There were no unplanned readmissions or missed diagnoses for the study period. Order set adherence was 80% (83 out of 104) during the intervention period and sustained at 87% postintervention. CONCLUSIONS Our interdisciplinary team achieved our aim, reducing unnecessary laboratory testing in patients with an uSSTI without patient harm. Awareness of local culture, creation of an order set, defining appropriate patient selection and testing indications, and implementation of a collaborative QI project helped us achieve our aim.
Collapse
Affiliation(s)
- Begem Lee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Daniel Hershey
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Aarti Patel
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Heather Pierce
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Erin Fisher
- Rady Children's Hospital-San Diego, San Diego, California; and
- Department of Pediatrics, University of California, San Diego, San Diego, California
| |
Collapse
|
6
|
Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
7
|
Yu HW, Hussain M, Afzal M, Ali T, Choi JY, Han HS, Lee S. Use of mind maps and iterative decision trees to develop a guideline-based clinical decision support system for routine surgical practice: case study in thyroid nodules. J Am Med Inform Assoc 2019; 26:524-536. [PMID: 31087071 DOI: 10.1093/jamia/ocz001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/26/2018] [Accepted: 01/06/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The study sought to develop a clinical decision support system (CDSS) for the treatment of thyroid nodules, using a mind map and iterative decision tree (IDT) approach to the integration of clinical practice guidelines (CPGs). MATERIALS AND METHODS Thyroid nodule CPGs of the American Thyroid Association and Korean Thyroid Association were analyzed by endocrine surgeons (domain experts) and computer scientists. Clinical knowledge from the CPGs was expressed using mind maps. The mind maps were analyzed and converted into IDTs. The final IDT was implemented as a set of candidate rules (3700) for a knowledge-based CDSS. The system was evaluated via a retrospective review of the medical records of 483 patients who had undergone thyroidectomy between January and December 2015 at a single tertiary center (Seoul National University Hospital Bundang, Korea). RESULTS Concordance between CDSS recommendations and treatment in routine clinical practice was 78.9%. In the 21.1% discordant cases, deviation from the CDSS treatment recommendation was mainly attributable to (1) refusal of the patient to undergo total thyroidectomy and (2) conversion from lobectomy to total thyroidectomy following an unexpected histological finding during intraoperative frozen biopsy lymph node analysis. CONCLUSIONS The present study demonstrated that a knowledge-based CDSS is feasible in the treatment of thyroid nodules. A high-quality knowledge-based CDSS was developed, and medical domain and computer scientists collaborated effectively in an integrated development environment. The mind map and IDT approach represents a pioneering method of integrating knowledge from CPGs.
Collapse
Affiliation(s)
- Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | - Taqdir Ali
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Korea
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sungyoung Lee
- Department of Computer Science and Engineering, Kyung Hee University, Yongin, Korea
| |
Collapse
|
8
|
Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
Collapse
|
9
|
Schaffer JT, Hess EP, Hollander JE, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Inselman J, Herrin J, Montori VM, Shah ND. Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial. Acad Emerg Med 2018; 25:293-300. [PMID: 29218817 DOI: 10.1111/acem.13355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 11/09/2017] [Accepted: 12/01/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system. OBJECTIVES The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days. METHODS This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures. RESULTS Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74-47.9) in the intervention arm. CONCLUSIONS Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.
Collapse
Affiliation(s)
| | - Erik P. Hess
- Department of Emergency Medicine Division of Emergency Medicine Research Mayo Clinic Rochester MN
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Judd E. Hollander
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University Indianapolis IN
| | | | - Deborah B. Diercks
- Department of Emergency Medicine University of Texas Southwestern Dallas TX
| | - Russell Jones
- Department of Emergency Medicine University of California Davis Sacramento CA
| | - Kelly P. Owen
- Department of Emergency Medicine University of California Davis Sacramento CA
| | - Zachary F. Meisel
- Department of Emergency Medicine Perelman School of Medicine Philadelphia PA
| | | | - Annie Leblanc
- Knowledge and Evaluation Research Unit Rochester MN
- Caregiver Representative Rochester MN
| | - Jonathan Inselman
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Jeph Herrin
- Yale University School of Medicine New Haven CT
- Health Research & Educational Trust Chicago IL
| | - Victor M. Montori
- Division of Endocrinology Diabetes, Metabolism, and Nutrition Department of Internal Medicine Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Nilay D. Shah
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| |
Collapse
|
10
|
Newton EH. Addressing overuse in emergency medicine: evidence of a role for greater patient engagement. Clin Exp Emerg Med 2017; 4:189-200. [PMID: 29306268 PMCID: PMC5758625 DOI: 10.15441/ceem.17.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/05/2017] [Accepted: 06/30/2017] [Indexed: 01/01/2023] Open
Abstract
Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.
Collapse
Affiliation(s)
- Erika H. Newton
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
11
|
Ward A, Body R. BET 2: Sharing decisions for patients with suspected cardiac chest pain in the emergency department. Emerg Med J 2017; 34:854-857. [DOI: 10.1136/emermed-2017-207286.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
12
|
Rising KL, Hollander JE, Schaffer JT, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Shah ND, Inselman J, Herrin J, Montori VM, Hess EP. Effectiveness of a Decision Aid in Potentially Vulnerable Patients: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial. Med Decis Making 2017; 38:69-78. [DOI: 10.1177/0272989x17706363] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. We test the hypotheses that use of the Chest Pain Choice (CPC) decision aid (DA) would be similarly effective in potentially vulnerable subgroups but increase knowledge more in patients with higher education and trust in physicians more in patients from racial minority groups. Methods. This was a secondary analysis of a multicenter randomized trial in adults with chest pain potentially due to acute coronary syndrome. The trial compared an intervention group engaged in shared decision making (SDM) using CPC to a control group receiving usual care (UC). We assessed for subgroup effects based on age, sex, race, income, insurance, education, literacy, and numeracy. We dichotomized each characteristic and tested for interactions using regression models with indicators for arm assignment and study site. Results. Of 898 patients (451 DA, 447 UC), over 50% were female, over one-third were black, nearly one-third had a high school education or less, and over 60% had “low” health literacy. The DA did not increase knowledge more in patients with higher education ( P for interaction = 0.06) but did increase knowledge more in the “typical” than in the “low” numeracy subgroup (10.6% v. 4.7%, absolute difference [AD] = 5.9%, P for interaction = 0.025). The DA did not significantly increase patient trust in physicians in racial minorities ( P for interaction = 0.06) but did increase trust more in patients with “low” literacy compared with those with “typical” literacy (3.7% v. –1.4%, AD = 5.1, P for interaction = 0.011). Conclusions. CPC benefited all sociodemographic groups to a similar extent, with greater knowledge transfer in patients with higher numeracy and greater physician trust in patients with “low” health literacy. Tailoring SDM interventions to patient characteristics may be necessary for optimal effectiveness.
Collapse
Affiliation(s)
- Kristin L. Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Judd E. Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Jason T. Schaffer
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Carlos A. Torres
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Deborah B. Diercks
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Russell Jones
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Kelly P. Owen
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Zachary F. Meisel
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Michel Demers
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Annie Leblanc
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Nilay D. Shah
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Jonathan Inselman
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Jeph Herrin
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Victor M. Montori
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| | - Erik P. Hess
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA (KLR, JEH)
- Department of Emergency Medicine, Indiana University, Indianapolis, Indiana, USA (JTS, JAK)
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, Florida, USA (CAT)
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, USA (DBD)
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA (RJ, KPO)
| |
Collapse
|
13
|
Hess EP, Hollander JE, Schaffer JT, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Shah ND, Inselman J, Herrin J, Castaneda-Guarderas A, Montori VM. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ 2016; 355:i6165. [PMID: 27919865 PMCID: PMC5152707 DOI: 10.1136/bmj.i6165] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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.
Collapse
Affiliation(s)
- Erik P Hess
- Department of Emergency Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55906, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Rochester, MN, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jason T Schaffer
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA
| | - Carlos A Torres
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Russell Jones
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Kelly P Owen
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Zachary F Meisel
- Department of Emergency Medicine, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Annie Leblanc
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Inselman
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Rochester, MN, USA
| | - Jeph Herrin
- Health Research & Educational Trust, Chicago IL, USA
| | - Ana Castaneda-Guarderas
- Department of Emergency Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55906, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Department of Emergency Medicine, Aventura Hospital and Medical Center, Aventura, FL, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
14
|
Probst MA, Kanzaria HK, Frosch DL, Hess EP, Winkel G, Ngai KM, Richardson LD. Perceived Appropriateness of Shared Decision-making in the Emergency Department: A Survey Study. Acad Emerg Med 2016; 23:375-81. [PMID: 26806170 PMCID: PMC5308213 DOI: 10.1111/acem.12904] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/12/2015] [Accepted: 11/16/2015] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The objective was to describe perceptions of practicing emergency physicians (EPs) regarding the appropriateness and medicolegal implications of using shared decision-making (SDM) in the emergency department (ED). METHODS We conducted a cross-sectional survey of EPs at a large, national professional meeting to assess perceived appropriateness of SDM for different categories of ED management (e.g., diagnostic testing, treatment, disposition) and in common clinical scenarios (e.g., low-risk chest pain, syncope, minor head injury). A 21-item survey instrument was iteratively developed through review by content experts, cognitive testing, and pilot testing. Descriptive and multivariate analyses were conducted. RESULTS We approached 737 EPs; 709 (96%) completed the survey. Two-thirds (67.8%) of respondents were male; 51% practiced in an academic setting and 44% in the community. Of the seven management decision categories presented, SDM was reported to be most frequently appropriate for deciding on invasive procedures (71.5%), computed tomography (CT) scanning (56.7%), and post-ED disposition (56.3%). Among the specific clinical scenarios, use of thrombolytics for acute ischemic stroke was felt to be most frequently appropriate for SDM (83.4%), followed by lumbar puncture to rule out subarachnoid hemorrhage (73.8%) and CT head for pediatric minor head injury (69.9%). Most EPs (66.8%) felt that using and documenting SDM would decrease their medicolegal risk while a minority (14.2%) felt that it would increase their risk. CONCLUSIONS Acceptance of SDM among EPs appears to be strong across management categories (diagnostic testing, treatment, and disposition) and in a variety of clinical scenarios. SDM is perceived by most EPs to be medicolegally protective.
Collapse
Affiliation(s)
- Marc A Probst
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hemal K Kanzaria
- The Department of Emergency Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Dominick L Frosch
- The Patient Care Program, Gordon and Betty Moore Foundation, Palo Alto, CA
- The Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Erik P Hess
- The Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Gary Winkel
- The Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ka Ming Ngai
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lynne D Richardson
- The Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
15
|
Wallace E, Uijen MJM, Clyne B, Zarabzadeh A, Keogh C, Galvin R, Smith SM, Fahey T. Impact analysis studies of clinical prediction rules relevant to primary care: a systematic review. BMJ Open 2016; 6:e009957. [PMID: 27008685 PMCID: PMC4800123 DOI: 10.1136/bmjopen-2015-009957] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Following appropriate validation, clinical prediction rules (CPRs) should undergo impact analysis to evaluate their effect on patient care. The aim of this systematic review is to narratively review and critically appraise CPR impact analysis studies relevant to primary care. SETTING Primary care. PARTICIPANTS Adults and children. INTERVENTION Studies that implemented the CPR compared to usual care were included. STUDY DESIGN Randomised controlled trial (RCT), controlled before-after, and interrupted time series. PRIMARY OUTCOME Physician behaviour and/or patient outcomes. RESULTS A total of 18 studies, incorporating 14 unique CPRs, were included. The main study design was RCT (n=13). Overall, 10 studies reported an improvement in primary outcome with CPR implementation. Of 6 musculoskeletal studies, 5 were effective in altering targeted physician behaviour in ordering imaging for patients presenting with ankle, knee and neck musculoskeletal injuries. Of 6 cardiovascular studies, 4 implemented cardiovascular risk scores, and 3 reported no impact on physician behaviour outcomes, such as prescribing and referral, or patient outcomes, such as reduction in serum lipid levels. 2 studies examined CPRs in decision-making for patients presenting with chest pain and reduced inappropriate admissions. Of 5 respiratory studies, 2 were effective in reducing antibiotic prescribing for sore throat following CPR implementation. Overall, study methodological quality was often unclear due to incomplete reporting. CONCLUSIONS Despite increasing interest in developing and validating CPRs relevant to primary care, relatively few have gone through impact analysis. To date, research has focused on a small number of CPRs across few clinical domains only.
Collapse
Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Maike J M Uijen
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Medical school, Radboud University, Nijmegen, The Netherlands
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Atieh Zarabzadeh
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Claire Keogh
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Rose Galvin
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
16
|
Mouw M, Balatiouk-Lance T, Brown LH. Can physician and patient gestalt lead to a shared decision to reduce unnecessary radiography in extremity trauma? Am J Emerg Med 2016. [DOI: 10.1016/j.ajem.2015.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
17
|
Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
Collapse
Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| |
Collapse
|
18
|
Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701-11. [PMID: 26414967 DOI: 10.7326/m14-1772] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
DESCRIPTION Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense. METHODS The literature search encompassed studies indexed by MEDLINE (1966-2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE. BEST PRACTICE ADVICE 1 Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. BEST PRACTICE ADVICE 2 Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria. BEST PRACTICE ADVICE 3 Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE. BEST PRACTICE ADVICE 4 Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted. BEST PRACTICE ADVICE 5 Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff. BEST PRACTICE ADVICE 6 Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.
Collapse
Affiliation(s)
- Ali S. Raja
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeffrey O. Greenberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Amir Qaseem
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Thomas D. Denberg
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Nick Fitterman
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | - Jeremiah D. Schuur
- From Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts; American College of Physicians, Philadelphia, Pennsylvania; Hofstra North Shore Long Island Jewish School of Medicine, Huntington, New York; and Carilion Clinic, Roanoke, Virginia
| | | |
Collapse
|
19
|
Can physician and patient gestalt lead to a shared decision to reduce unnecessary radiography in extremity trauma? Am J Emerg Med 2015; 33:1692-9. [DOI: 10.1016/j.ajem.2015.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/12/2015] [Accepted: 08/14/2015] [Indexed: 11/21/2022] Open
|
20
|
Brooker JA, Hastings JW, Major-Monfried H, Maron CP, Winkel M, Wijeratne HRS, Fleischman W, Weingart S, Newman DH. The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates. Acad Emerg Med 2015; 22:883-6. [PMID: 26118834 DOI: 10.1111/acem.12708] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/15/2014] [Accepted: 02/02/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVES For patients in whom acute coronary syndrome (ACS) is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. The study aim was to determine, at the point of care, how much less frequently physicians report that they would admit possible ACS patients if there was either zero or a defined medicolegal risk. METHODS This was a point-of-care emergency physician survey. Research assistants approached physicians at or immediately following the moment of disposition decisions for patients who were being admitted for ACS. The primary outcome measures were the proportion of physicians reporting that patients would not have been admitted if medicolegal issues were of no concern and the proportion of physicians reporting that patients would not have been admitted if there was an "acceptable miss rate" of 1% to 2% for ACS patients. RESULTS During the 3-month study period, 576 patients were admitted to an inpatient unit or to the ED observation protocol. Physicians were approached in 271 cases, and 259 surveys were completed. When presented with hypothetical zero medicolegal risk, physicians answered that they would not have admitted the patients in 30% of cases. With a hypothetical 1% to 2% acceptable miss rate, physicians indicated that they would not have admitted the patients in 29% of the cases. CONCLUSIONS ED medicolegal and professional concerns may substantially increase admissions for possible ACS. An acceptable miss rate or a zero medicolegal risk environment could potentially lead to a major reduction in admissions that physicians feel to be clinically unnecessary.
Collapse
Affiliation(s)
- Julie A. Brooker
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - Jeffrey W. Hastings
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - Hannah Major-Monfried
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - Chad P. Maron
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - Maia Winkel
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - H. R. Sagara Wijeratne
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| | - William Fleischman
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- Robert Wood Johnson Clinical Scholars Program; Yale University School of Medicine; New Haven CT
| | - Scott Weingart
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
- The Department of Emergency Medicine; Stony Brook University; Stony Brook NY
| | - David H. Newman
- The Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York NY
| |
Collapse
|
21
|
Kanzaria HK, Brook RH, Probst MA, Harris D, Berry SH, Hoffman JR. Emergency physician perceptions of shared decision-making. Acad Emerg Med 2015; 22:399-405. [PMID: 25807995 DOI: 10.1111/acem.12627] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/10/2014] [Accepted: 10/22/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated. METHODS As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM. RESULTS A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose." CONCLUSIONS Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.
Collapse
Affiliation(s)
- Hemal K. Kanzaria
- Robert Wood Johnson Foundation Clinical Scholars program; University of California Los Angeles; Los Angeles CA
- U.S. Department of Veterans Affairs; University of California Los Angeles; Los Angeles CA
| | - Robert H. Brook
- David Geffen School of Medicine; University of California Los Angeles; Los Angeles CA
- Jonathan and Karin Fielding School of Public Health; University of California Los Angeles; Los Angeles CA
- RAND Corporation; Santa Monica CA
| | - Marc A. Probst
- The Department of Emergency Medicine; Mount Sinai Medical Center; New York NY
| | - Dustin Harris
- David Geffen School of Medicine; University of California Los Angeles; Los Angeles CA
| | | | - Jerome R. Hoffman
- Emergency Medicine Center; University of California Los Angeles; Los Angeles CA
| |
Collapse
|
22
|
Pernès JM, Dupouy P, Labbé R, Sotirov Y, Pongas D, Mansour H, Gaux JC. Management of acute chest pain: A major role for coronary CT angiography. Diagn Interv Imaging 2015; 96:1105-12. [PMID: 25767006 DOI: 10.1016/j.diii.2014.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 05/31/2014] [Accepted: 09/02/2014] [Indexed: 11/26/2022]
Abstract
Most patients presenting with acute chest pain (ACP) at the emergency unit do not have any marked electrocardiogram abnormalities or known history of heart disease. Identifying the few patients who have, or will actually develop acute coronary syndrome in this group that is considered to be at low risk, is an actual clinical challenge for emergency department physicians. In these patients, the goal of complementary non-invasive morphological or functional imaging tests is to exclude heart disease. The diagnostic values of coronary CT angiography include a sensitivity of 96% and a negative likelihood ratio of 0.09, which are highly contributory to the diagnosis, and the integration of this imaging test into a decision tree algorithm appears to be the least expensive strategy with the best cost/effective ratio. Coronary CT angiography is indicated in the presence of ACP associated with an inconclusive electrocardiogram, in the absence of any other obvious diagnoses, when the ultrasensitive troponin assay is negative or the dynamic changes are modest, slow and/or inconclusive. Ideally, coronary CT angiography should be performed within 3 to 48hours after the initial consultation.
Collapse
Affiliation(s)
- J-M Pernès
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France.
| | - P Dupouy
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - R Labbé
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - Y Sotirov
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - D Pongas
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - H Mansour
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| | - J-C Gaux
- Pôle cardiovasculaire interventionnel et d'imagerie, hôpital Privé Antony, rue Velpeau, 92160 Antony, France
| |
Collapse
|
23
|
Safdar B, Nagurney JT, Anise A, DeVon HA, D'Onofrio G, Hess EP, Hollander JE, Legato MJ, McGregor AJ, Scott J, Tewelde S, Diercks DB. Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup. Acad Emerg Med 2014; 21:1350-60. [PMID: 25413468 PMCID: PMC6402042 DOI: 10.1111/acem.12527] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 07/20/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age-matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex- and gender-specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy-makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in-person meetings, and Web-based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in-person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex-specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex-specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex-specific variations in biology, as well as patient-provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient-centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.
Collapse
Affiliation(s)
- Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, CT
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Collins SP, Storrow AB. Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making. JACC-HEART FAILURE 2014; 1:273-280. [PMID: 24159563 DOI: 10.1016/j.jchf.2013.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.
Collapse
Affiliation(s)
- Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee.
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee
| |
Collapse
|
25
|
Patient preferences and acceptable risk for computed tomography in trauma. Injury 2014; 45:1345-9. [PMID: 24742979 DOI: 10.1016/j.injury.2014.03.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/17/2014] [Accepted: 03/19/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rising use of computed tomography (CT) to evaluate patients with trauma has increased both patient costs and risk of cancer from ionizing radiation, without demonstrable improvements in outcome. Patient-centred care mandates disclosure of the potential risks, costs and benefits of diagnostic testing whenever possible. OBJECTIVE We sought to determine (1) patient preferences regarding emergency department (ED) real-time discussions of risks and costs of CT during their trauma evaluations; and (2) whether varying levels of odds of detection of life-threatening injury (LTI) were associated with changes in patient preferences for CT. METHODS Excluding patients already receiving CT and patients with altered mental status, we surveyed adult, English-speaking patients at four Level I verified trauma centres. After informing subjects of cancer risks associated with chest CT, we used hypothetical scenarios with varying LTIs to assess patients' preferences regarding CT. RESULTS Of 941 patients enrolled, 50% were male and their mean age was 42 years. Most patients stated they would prefer to discuss CT radiation risks (73.5%, 95% CI [66.1-80.8]) and costs (53.2%, 95% CI [46.1-60.4]) with physicians. As the odds of detecting LTI decreased, preferences for receiving CT decreased accordingly: LTI 25% (desire 91.2%, 95% CI [89.4-93.1]), LTI 10% (desire 79.3%, 95% CI [76.7-81.9]), LTI 5% (desire 69.1%, 95% CI [66.1-72.1]) and LTI <2% (desire 53.8%, 95% CI [50.6-57.0]). If the LTI was <2% and subjects were required to pay $1000 out-of-pocket, only 34.5% (95% CI 31.4-37.5) would opt for CT. CONCLUSION Most non-critically injured patients prefer to discuss radiation risks and costs of CT prior to receiving imaging. As the odds of detecting LTI decrease, fewer patients prefer to have CT; at an LTI threshold of 2%, approximately half of patients would prefer to forego CT. Adding out-of-pocket costs reduced this proportion to one-third of patients.
Collapse
|
26
|
Storrow AB, Jenkins CA, Self WH, Alexander PT, Barrett TW, Han JH, McNaughton CD, Heavrin BS, Gheorghiade M, Collins SP. The burden of acute heart failure on U.S. emergency departments. JACC. HEART FAILURE 2014; 2:269-77. [PMID: 24952694 PMCID: PMC4429129 DOI: 10.1016/j.jchf.2014.01.006] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF). BACKGROUND Patients with AHF are often admitted and are associated with high readmissions and cost. METHODS We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics. RESULTS There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure. CONCLUSIONS A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.
Collapse
Affiliation(s)
- Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Pauline T Alexander
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Benjamin S Heavrin
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
27
|
Anderson RT, Montori VM, Shah ND, Ting HH, Pencille LJ, Demers M, Kline JA, Diercks DB, Hollander JE, Torres CA, Schaffer JT, Herrin J, Branda M, Leblanc A, Hess EP. Effectiveness of the Chest Pain Choice decision aid in emergency department patients with low-risk chest pain: study protocol for a multicenter randomized trial. Trials 2014; 15:166. [PMID: 24884807 PMCID: PMC4031497 DOI: 10.1186/1745-6215-15-166] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 04/23/2014] [Indexed: 11/10/2022] Open
Abstract
Background Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization. Methods/Design This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up. Discussion This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs. Trial registration NCT01969240.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Erik P Hess
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| |
Collapse
|
28
|
Peitz GW, Troyer J, Jones AE, Shapiro NI, Nelson RD, Hernandez J, Kline JA. Association of body mass index with increased cost of care and length of stay for emergency department patients with chest pain and dyspnea. Circ Cardiovasc Qual Outcomes 2014; 7:292-8. [PMID: 24594550 DOI: 10.1161/circoutcomes.113.000702] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High body mass index (BMI) increases the probability of indeterminate findings on diagnostic studies, length of stay, and cost of care for hospitalized patients. No study has examined the economic and operational impact of BMI in patients with chest complaints presenting to the emergency department (ED). The objective was to measure the association of BMI with the main outcomes of cost of care, length of stay (including time in the ED and time in the wards if admitted), and radiation exposure in patients presenting to the ED with chest pain and dyspnea. METHODS AND RESULTS This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic electrocardiograms, and no obvious diagnosis. Patients were followed for the main outcomes for 90 days. Outcomes that were stratified by BMI in 5 categories, underweight, normal weight, overweight, obese, and morbidly obese, were compared using the Kruskall-Wallis rank test, and the independent predictive value of BMI was tested with multivariate regressions. Compared with medical costs for normal weight patients, costs were 22% higher for overweight patients (P=0.077), 28% higher for obese patients (P=0.020), and 41% higher for morbidly obese patients (P=0.015). Morbidly obese patients without computerized tomographic scanning stayed in the hospital 34% longer than normal weight patients (P=0.073), and morbidly obese patients with computerized tomographic scanning stayed in the hospital 44% longer than normal weight patients (P=0.083). BMI was not a significant predictor of radiation exposure. Morbidly obese patients had the highest proportion (87%) of no significant cardiopulmonary diagnosis for 90 days after computerized tomographic pulmonary angiography. CONCLUSIONS BMI was associated with increases in cost of care and length of hospital stay for patients with chest pain and dyspnea. These results emphasize a need for specific protocols to manage morbidly obese patients presenting to the ED with chest pain and dyspnea. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique identifier: NCT01059500.
Collapse
|
29
|
Geyer BC, Xu M, Kabrhel C. Patient preferences for testing for pulmonary embolism in the ED using a shared decision-making model. Am J Emerg Med 2014; 32:233-6. [DOI: 10.1016/j.ajem.2013.11.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/08/2013] [Accepted: 11/08/2013] [Indexed: 11/26/2022] Open
|
30
|
Chen JC, Cooper RJ, Lopez-O'Sullivan A, Schriger DL. Measuring patient tolerance for future adverse events in low-risk emergency department chest pain patients. Ann Emerg Med 2014; 64:127-36, 136.e1-3. [PMID: 24530111 DOI: 10.1016/j.annemergmed.2013.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 12/11/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We assess emergency department (ED) patients' risk thresholds for preferring admission versus discharge when presenting with chest pain and determine how the method of information presentation affects patients' choices. METHODS In this cross-sectional survey, we enrolled a convenience sample of lower-risk acute chest pain patients from an urban ED. We presented patients with a hypothetical value for the risk of adverse outcome that could be decreased by hospitalization and asked them to identify the risk threshold at which they preferred admission versus discharge. We randomized patients to a method of numeric presentation (natural frequency or percentage) and the initial risk presented (low or high) and followed each numeric assessment with an assessment based on visually depicted risks. RESULTS We enrolled 246 patients and analyzed data on 234 with complete information. The geometric mean risk threshold with numeric presentation was 1 in 736 (1 in 233 with a percentage presentation; 1 in 2,425 with a natural frequency presentation) and 1 in 490 with a visual presentation. Fifty-nine percent of patients (137/234) chose the lowest or highest risk values offered. One hundred fourteen patients chose different thresholds for numeric and visual risk presentations. We observed strong anchoring effects; patients starting with the lowest risk chose a lower threshold than those starting with the highest risk possible and vice versa. CONCLUSION Using an expected utility model to measure patients' risk thresholds does not seem to work, either to find a stable risk preference within individuals or in groups. Further work in measurement of patients' risk tolerance or methods of shared decisionmaking not dependent on assessment of risk tolerance is needed.
Collapse
Affiliation(s)
- Jennifer C Chen
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA.
| | - Richelle J Cooper
- UCLA Emergency Medicine Center, University of California, Los Angeles, CA
| | | | - David L Schriger
- UCLA Emergency Medicine Center, University of California, Los Angeles, CA
| |
Collapse
|
31
|
Kline JA, Jones AE, Shapiro NI, Hernandez J, Hogg MM, Troyer J, Nelson RD. Multicenter, Randomized Trial of Quantitative Pretest Probability to Reduce Unnecessary Medical Radiation Exposure in Emergency Department Patients With Chest Pain and Dyspnea. Circ Cardiovasc Imaging 2014; 7:66-73. [DOI: 10.1161/circimaging.113.001080] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Use of pretest probability can reduce unnecessary testing. We hypothesize that quantitative pretest probability, linked to evidence-based management strategies, can reduce unnecessary radiation exposure and cost in low-risk patients with symptoms suggestive of acute coronary syndrome and pulmonary embolism.
Methods and Results—
This was a prospective, 4-center, randomized controlled trial of decision support effectiveness. Subjects were adults with chest pain and dyspnea, nondiagnostic ECGs, and no obvious diagnosis. The clinician provided data needed to compute pretest probabilities from a Web-based system. Clinicians randomized to the intervention group received the pretest probability estimates for both acute coronary syndrome and pulmonary embolism and suggested clinical actions designed to lower radiation exposure and cost. The control group received nothing. Patients were followed for 90 days. The primary outcome and sample size of 550 was predicated on a significant reduction in the proportion of healthy patients exposed to >5 mSv chest radiation. A total of 550 patients were randomized, and 541 had complete data. The proportion with >5 mSv to the chest and no significant cardiopulmonary diagnosis within 90 days was reduced from 33% to 25% (
P
=0.038). The intervention group had significantly lower median chest radiation exposure (0.06 versus 0.34 mSv;
P
=0.037, Mann–Whitney
U
test) and lower median costs ($934 versus $1275;
P
=0.018) for medical care. Adverse events occurred in 16% of controls and 11% in the intervention group (
P
=0.06).
Conclusions—
Provision of pretest probability and prescriptive advice reduced radiation exposure and cost of care in low-risk ambulatory patients with symptoms of acute coronary syndrome and pulmonary embolism.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01059500.
Collapse
Affiliation(s)
- Jeffrey A. Kline
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - Alan E. Jones
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - Nathan I. Shapiro
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - Jackeline Hernandez
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - Melanie M. Hogg
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - Jennifer Troyer
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| | - R. Darrel Nelson
- From the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (J.A.K.); Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); Department of Emergency Medicine Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (N.I.S.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.H., M.M.H.); Belk College Business, University of North Carolina at Charlotte (J.T.); and Department of
| |
Collapse
|
32
|
Kline JA, Shapiro NI, Jones AE, Hernandez J, Hogg MM, Troyer J, Nelson RD. Outcomes and radiation exposure of emergency department patients with chest pain and shortness of breath and ultralow pretest probability: a multicenter study. Ann Emerg Med 2013; 63:281-8. [PMID: 24120629 DOI: 10.1016/j.annemergmed.2013.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 08/30/2013] [Accepted: 09/10/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Excessive radiation exposure remains a concern for patients with symptoms suggesting acute coronary syndrome and pulmonary embolism but must be judged in the perspective of pretest probability and outcomes. We quantify and qualify the pretest probability, outcomes, and radiation exposure of adults with both chest pain and dyspnea. METHODS This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic ECGs, and no obvious diagnosis. Pretest probability for both acute coronary syndrome and pulmonary embolism was assessed with a validated method; ultralow risk was defined as pretest probability less than 2.5% for both acute coronary syndrome and pulmonary embolism. Patients were followed for diagnosis and total medical radiation exposure for 90 days. RESULTS Eight hundred forty patients had complete data; 23 (3%) had acute coronary syndrome and 15 (2%) had pulmonary embolism. The cohort received an average of 4.9 mSv radiation to the chest, 48% from computed tomography pulmonary angiography. The pretest probability estimates for acute coronary syndrome and pulmonary embolism were less than 2.5% in 227 patients (27%), of whom 0 of 277 (0%; 95% confidence interval 0% to 1.7%) had acute coronary syndrome or pulmonary embolism and 7 of 227 (3%) had any significant cardiopulmonary diagnosis. The estimated chest radiation exposure per patient in this ultralow-risk group was 3.5 mSv, including 26 (3%) with greater than 5 mSv radiation to the chest and no significant cardiopulmonary diagnosis. CONCLUSION One quarter of patients with chest pain and dyspnea had ultralow risk and no acute coronary syndrome or pulmonary embolism but were exposed to an average of 3.5 mSv radiation to the chest. These data can be used in a clinical guideline to reduce radiation exposure.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN.
| | - Nathan I Shapiro
- Department of Emergency Medicine and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Alan E Jones
- Department Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | | | - Melanie M Hogg
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | | | - R Darrell Nelson
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| |
Collapse
|
33
|
A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care. Am J Emerg Med 2013; 31:1520-4. [DOI: 10.1016/j.ajem.2013.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/05/2013] [Accepted: 07/17/2013] [Indexed: 01/08/2023] Open
|
34
|
Kline JA, Stubblefield WB. Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea. Ann Emerg Med 2013; 63:275-80. [PMID: 24070658 DOI: 10.1016/j.annemergmed.2013.08.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/18/2013] [Accepted: 08/23/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Pretest probability helps guide diagnostic testing for patients with suspected acute coronary syndrome and pulmonary embolism. Pretest probability derived from the clinician's unstructured gestalt estimate is easier and more readily available than methods that require computation. We compare the diagnostic accuracy of physician gestalt estimate for the pretest probability of acute coronary syndrome and pulmonary embolism with a validated, computerized method. METHODS This was a secondary analysis of a prospectively collected, multicenter study. Patients (N=840) had chest pain, dyspnea, nondiagnostic ECGs, and no obvious diagnosis. Clinician gestalt pretest probability for both acute coronary syndrome and pulmonary embolism was assessed by visual analog scale and from the method of attribute matching using a Web-based computer program. Patients were followed for outcomes at 90 days. RESULTS Clinicians had significantly higher estimates than attribute matching for both acute coronary syndrome (17% versus 4%; P<.001, paired t test) and pulmonary embolism (12% versus 6%; P<.001). The 2 methods had poor correlation for both acute coronary syndrome (r(2)=0.15) and pulmonary embolism (r(2)=0.06). Areas under the receiver operating characteristic curve were lower for clinician estimate compared with the computerized method for acute coronary syndrome: 0.64 (95% confidence interval [CI] 0.51 to 0.77) for clinician gestalt versus 0.78 (95% CI 0.71 to 0.85) for attribute matching. For pulmonary embolism, these values were 0.81 (95% CI 0.79 to 0.92) for clinician gestalt and 0.84 (95% CI 0.76 to 0.93) for attribute matching. CONCLUSION Compared with a validated machine-based method, clinicians consistently overestimated pretest probability but on receiver operating curve analysis were as accurate for pulmonary embolism but not acute coronary syndrome.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN.
| | - William B Stubblefield
- Department of Emergency Medicine, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
35
|
Tak HJ, Ruhnke GW, Meltzer DO. Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients. JAMA Intern Med 2013; 173:1195-205. [PMID: 23712712 PMCID: PMC4390034 DOI: 10.1001/jamainternmed.2013.6048] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. OBJECTIVE To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. DESIGN AND SETTING Survey study in an academic research setting. PARTICIPANTS A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21,754 (69.6%) of admitted patients. MAIN OUTCOMES AND MEASURES The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs. RESULTS The mean length of stay was 5.34 days, and the mean hospitalization costs were $14,576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and $865 (95% CI, $155-$1575) higher total hospitalization costs (P = .02). CONCLUSIONS AND RELEVANCE Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.
Collapse
Affiliation(s)
- Hyo Jung Tak
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | | | | |
Collapse
|
36
|
Abstract
BACKGROUND Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations. METHODS A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported. RESULTS All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60-0.70), ACEP 74.3% (95% CI, 0.70-0.79), NICE 86.7% (95% CI, 0.83-0.90), and NOC 90.5% (95% CI, 0.87-0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported. DISCUSSION Some 10%-35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.
Collapse
|
37
|
Flynn D, Knoedler MA, Hess EP, Murad MH, Erwin PJ, Montori VM, Thomson RG. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med 2012; 19:959-67. [PMID: 22853804 DOI: 10.1111/j.1553-2712.2012.01414.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many decisions in the emergency department (ED) may benefit from patient involvement, even though this setting has been considered least conducive to shared decision-making (SDM). OBJECTIVES The objective was to conduct a systematic review to evaluate the approaches, methods, and tools used to engage patients or their surrogates in SDM in the ED. METHODS Five electronic databases were searched in conjunction with contacting content experts, reviewing selected bibliographies, and conducting citation searches using the Web of Knowledge database. Two reviewers independently selected eligible studies that addressed patient involvement and engagement in decision-making in the ED setting via the use of decision support interventions (DSIs), defined as decision aids or decision support designed to communicate probabilistic information on the risks and benefits of treatment options to patients as part of an SDM process. Eligible studies described and assessed at least one of the following outcomes: patient knowledge, experiences and perspectives on participating in treatment or management decisions, clinician or patient satisfaction, preference for involvement and/or degree of engagement in decision-making and treatment preferences, and clinical outcomes (e.g., rates of hospital admission/readmission, rates of medical or surgical interventions). Two reviewers extracted data on study characteristics, methodologic quality, and outcomes. The authors also assessed the extent to which SDM interventions adhered to good practice for the presentation of information on outcome probabilities (eight probability items from the International Patient Decision Aid Standards Instrument [IPDASi]) and had comprehensive development processes. RESULTS Five studies met inclusion criteria and were synthesized using a narrative approach. Each study was of satisfactory methodologic quality and used a DSI to engage patients or their surrogates in decision-making in the ED across four domains: 1) management options for children with small lacerations; 2) options for rehydrating children presenting with vomiting or diarrhea or both; 3) risk of bacteremia (and associated complications), tests, and treatment options for febrile children; and 4) short-term risk of acute coronary syndrome (ACS) in adults with low-risk nontraumatic chest pain. Three studies had poor IPDASi probabilities and development process scores and lacked development informed by theory or involvement of clinicians and patients in development and usability testing. Overall, DSIs were associated with improvements in patients' knowledge and satisfaction with the explanation of their care, preferences for involvement, and engagement in decision-making and demonstrated utility for eliciting patients' preferences and values about management and treatment options. Two computerized DSIs (designed to predict risk of ACS in adults presenting to the ED with chest pain) were shown to reduce health care use without evidence of harm. None of the studies reported lack of feasibility of SDM in the ED. CONCLUSIONS Early investigation of SDM in the ED suggests that patients may benefit from involvement in decision-making and offers no empirical evidence to suggest that SDM is not feasible. Future work is needed to develop and test additional SDM interventions in the ED and to identify contextual barriers and facilitators to implementation in practice.
Collapse
Affiliation(s)
- Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
38
|
Hess EP, Knoedler MA, Shah ND, Kline JA, Breslin M, Branda ME, Pencille LJ, Asplin BR, Nestler DM, Sadosty AT, Stiell IG, Ting HH, Montori VM. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes 2012; 5:251-9. [PMID: 22496116 DOI: 10.1161/circoutcomes.111.964791] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. METHODS AND RESULTS The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24-72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34-1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6-21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. CONCLUSIONS Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.
Collapse
Affiliation(s)
- Erik P Hess
- Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Schuur JD, Baugh CW, Hess EP, Hilton JA, Pines JM, Asplin BR. Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care. Acad Emerg Med 2011; 18:e52-63. [PMID: 21676050 PMCID: PMC3717297 DOI: 10.1111/j.1553-2712.2011.01096.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.
Collapse
Affiliation(s)
- Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | | | | | | | | | | |
Collapse
|
40
|
Pierce MA, Hess EP, Kline JA, Shah ND, Breslin M, Branda ME, Pencille LJ, Asplin BR, Nestler DM, Sadosty AT, Stiell IG, Ting HH, Montori VM. The Chest Pain Choice trial: a pilot randomized trial of a decision aid for patients with chest pain in the emergency department. Trials 2010; 11:57. [PMID: 20478056 PMCID: PMC2881067 DOI: 10.1186/1745-6215-11-57] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 05/17/2010] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Chest pain is a common presenting complaint in the emergency department (ED). Despite the frequency with which clinicians evaluate patients with chest pain, accurately determining the risk of acute coronary syndrome (ACS) and sharing risk information with patients is challenging. The aims of this study are (1) to develop a decision aid (CHEST PAIN CHOICE) that communicates the short-term risk of ACS and (2) to evaluate the impact of the decision aid on patient participation in decision-making and resource use. METHODS/DESIGN This is a protocol for a parallel, 2-arm randomized trial to compare an intervention group receiving CHEST PAIN CHOICE to a control group receiving usual ED care. Adults presenting to the Saint Mary's Hospital ED in Rochester, MN USA with a primary complaint of chest pain who are being considered for admission for prolonged ED observation in a specialized unit and urgent cardiac stress testing will be eligible for enrollment. We will measure the effect of CHEST PAIN CHOICE on six outcomes: (1) patient knowledge regarding their short-term risk for ACS and the risks of radiation exposure; (2) quality of the decision making process; (3) patient and clinician acceptability and satisfaction with the decision aid; (4) the proportion of patients who decided to undergo observation unit admission and urgent cardiac stress testing; (5) economic costs and healthcare utilization; and (6) the rate of delayed or missed ACS. To capture these outcomes, we will administer patient and clinician surveys after each visit, obtain video recordings of the clinical encounters, and conduct 30-day phone follow-up. DISCUSSION This pilot randomized trial will develop and evaluate a decision aid for use in ED chest pain patients at low risk for ACS and provide a preliminary estimate of its effect on patient participation in decision-making and resource use. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT01077037.
Collapse
Affiliation(s)
- Meghan A Pierce
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Erik P Hess
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Kline
- Emergency Medicine Research, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Nilay D Shah
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
| | - Maggie Breslin
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- SPARC Design Studio, Center for Innovation, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan E Branda
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Laurie J Pencille
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Brent R Asplin
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Nestler
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Annie T Sadosty
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henry H Ting
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic Rochester, MN, USA
| |
Collapse
|
41
|
Abstract
Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.
Collapse
|
42
|
Kline JA, Courtney DM, Than MP, Hogg K, Miller CD, Johnson CL, Smithline HA. Accuracy of very low pretest probability estimates for pulmonary embolism using the method of attribute matching compared with the Wells score. Acad Emerg Med 2010; 17:133-41. [PMID: 20370742 DOI: 10.1111/j.1553-2712.2009.00648.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Attribute matching matches an explicit clinical profile of a patient to a reference database to estimate the numeric value for the pretest probability of an acute disease. The authors tested the accuracy of this method for forecasting a very low probability of venous thromboembolism (VTE) in symptomatic emergency department (ED) patients. METHODS The authors performed a secondary analysis of five data sets from 15 hospitals in three countries. All patients had data collected at the time of clinical evaluation for suspected pulmonary embolism (PE). The criterion standard to exclude VTE required no evidence of PE or deep venous thrombosis (DVT) within 45 days of enrollment. To estimate pretest probabilities, a computer program selected, from a large reference database of patients previously evaluated for PE, patients who matched 10 predictor variables recorded for each current test patient. The authors compared the outcome frequency of having VTE [VTE(+)] in patients with a pretest probability estimate of <2.5% by attribute matching, compared with a value of 0 from the Wells score. RESULTS The five data sets included 10,734 patients, and 747 (7.0%, 95% confidence interval [CI] = 6.5% to 7.5%) were VTE(+) within 45 days. The pretest probability estimate for PE was <2.5% in 2,975 of 10,734 (27.7%) patients, and within this subset, the observed frequency of VTE(+) was 48 of 2,975 (1.6%, 95% CI = 1.2% to 2.1%). The lowest possible Wells score (0) was observed in 3,412 (31.7%) patients, and within this subset, the observed frequency of VTE(+) was 79 of 3,412 (2.3%, 95% CI = 1.8% to 2.9%) patients. CONCLUSIONS Attribute matching categorizes over one-quarter of patients tested for PE as having a pretest probability of <2.5%, and the observed rate of VTE within 45 days in this subset was <2.5%.
Collapse
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
| | | | | | | | | | | | | |
Collapse
|