Shared Decision Making in the ED for Patients with Low-Risk Chest - - PowerPoint PPT Presentation

Shared Decision Making in the ED for Patients with Low-Risk Chest Pain: The Chest Pain Choice Decision Aid

Uli K. Chettipally, MD, MPH. CREST Network Kaiser Permanente PI: Erik P. Hess MD MSc

PCORI Funding:

• Original Research funded through PCORI’s

Assessment of Prevention, Diagnosis, and Treatment Options (APDTO), December 2012

• Dissemination & Implementation funding: Limited

Funding Announcement: Dissemination and Implementation of PCOR Research Results; December 2017

Background

• Chest Pain ‐ 2nd most common

complaint in US EDs

• 1.5% Acute Coronary Syndrome

missed

• Low risk patients frequently

admitted for cardiac testing

• False positive test results,

unnecessary procedures,  cost

Effects of Decision Aids

Patient knowledge ↑ Accuracy of risk perception ↑ Major elective surgery ↓ PSA screening ↓ Value concordant care decisions ↑

Stacey et al. Cochrane Collaboration, 2017

Evidence synthesis (ACS risk estimation tool) Observations clinical encounter

Designers Study team Patients Clinicians Stakeholders

Initial prototype Field testing Modified prototype

Final Decision Aid Evaluation (trial)

Prior work

Research Study

Objective: Test the effectiveness of Chest Pain Choice in a pragmatic multicenter RCT Design:

• Patient level RCT
• Allocation concealed by password‐protected, web‐based

randomization scheme

• Dynamic randomization
• 1:1 ratio

Eligibility criteria

• Inclusion
• Adults with chest pain considered for EDOU

admission for stress testing or coronary CTA

• Exclusion
• Ischemic ECG
• Elevated troponin
• Known CAD
• Cocaine use within 72 hours
• Unable to provide informed consent or use DA

Study Outcomes

• Decision quality

Patient knowledge** Engagement in decision‐making (OPTION scale) Acceptability

• CV endpoints

Safety: 30‐day MACE Resource use

• Admitted to EDOU for stress testing or coronary CT
• 30‐day rate of stress testing/coronary CT

Main Findings

Engaging patients in SDM using Chest Pain Choice:

•  patient knowledge and engagement
• Was acceptable to patients and clinicians
• 1 additional minute of clinician time
• Safely  resource use

Limitations:

• Limited power to definitively demonstrate safety
• Effectiveness outside RCT unknown

Decision aid acceptability (patient)

20 40 60 80 100

Control Intervention

%

P=0.01 P=0.004

Decision aid acceptability (clinician)

20 40 60 80 100 Helpfulness (extremely helpful) Would recommend to others Would want to use for

• ther

decisions P<0.001

Control Intervention

%

P<0.001 P<0.001

Safety

Variable Control (n=447) Intervention (n=451) P-value Revascularization 4 (1%) 7 (2%) 0.37 MI 1 (0%) 4 (1%) 1.0 Death 0 (0%) 0 (0%) 1.0 MACE within 30 days of discharge 0 (0%) 1 (0%) 1.0

Resource Use

Control Intervention

% P<0.001 P=0.12 20 40 60 80 100 Admitted to EDOU for stress test or coronary CT Stress test within 30 days Coronary CT within 30 days P<0.013

D&I Project Aim: Implement the Chest Pain Choice decision aid in 5 EDs in 3 large health systems (KP Northern Calif; Mayo Clinic; UAB Birmingham) If successful, this D&I project will result in:

• Routine, sustainable use of an effective decision aid in these settings.
• Improved care for 30,000+ patients presenting to the ED with chest pain.
• Improved patient experience, reduced use of unnecessary and unwanted

services.

• Model for adoption of SDM approach in other EDs and health systems.

Evaluation Plan will measure:

• Clinician: awareness of decision aid; knowledge of the Patient‐Centered

Chest Pain Pathway; engagement of patients in SDM, risk communication

• Patient: involvement in decision; satisfaction with decision; admissions to

hospital, to observation, discharged home; subsequent ED visits, hospitalizations, adverse cardiac events, mortality

Keys to successful implementation

• Patient and key stakeholder engagement

–hospital administrator, clinical champions, health informatics, nursing and advanced practice leadership

• Co‐create a dissemination toolkit

–Components: Evidence‐based Patient‐centered Chest Pain pathway, brief educational videos, EMR integration)

• Integrate DA into clinical and EMR workflow
• Track outcomes and adherence

Stakeholder Engagement

Stakeholders supporting successful implementation of this project include:

• Patient and caregiver representatives
• Clinical champions—including nursing, operations, and administrative

leadership staff—at participating sites

• Support from Emergency Department Chairs

Stakeholders with potential to expand reach in future efforts:

• American Heart Association
• UnitedHealth Group
• American College of Emergency Physicians
• Emergency Quality Network (E‐QUAL), a CMS‐funded Transforming Clinical

Practice Initiative

• High Value Healthcare Collaborative (includes 14 major U.S. health

systems)

EMR App Store Model

24

Contextual Launch from EMR workflow

The HEART Pathway EMR App

Data analytics Point of care decision support & Shared Decision Making Contextual launch in EMR workflow

Thank You!

Uli K. Chettipally, MD, MPH.

www.KPCREST.net