Among patients with chest pain who are being considered for admission to an observation unit and for advanced cardiac testing, shared decision making facilitated by a decision aid increased patient knowledge and engagement, decreased decisional conflict, and did not affect trust in clinicians, according to a study published in BMJ.

Erik P Hess, MD, from the Department of Emergency Medicine and the Knowledge and Evaluation Research Unit at the Mayo Clinic, Rochester, Minnesota, and colleagues conducted a multicenter randomized controlled trial at 6 emergency departments in the United States to compare the effectiveness of shared decision making with usual care in patients with possible acute coronary syndrome.

The study included 898 adults older than 17 years of age with chest pain who were being considered for admission to an observation unit for cardiac testing. A total of 361 emergency clinicians, including emergency physicians, nurse practitioners, and physician assistants, cared for the patients.

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The participants were randomly assigned by an electronic, web-based system to shared decision making facilitated by a decision aid (n=451) or to usual care (n=447). The primary outcome of the study was patients’ knowledge of their risk for acute coronary syndrome, which was measured with a post-visit survey administered to the patients after their meeting with a clinician. Secondary outcomes included involvement in the decision to be admitted, proportion of patients admitted for testing, and the 30-day rate of major adverse events.

Participants in the shared decision making group had a greater knowledge of their risk for acute coronary syndrome and options for care. These patients answered more questions correctly compared with the usual care group (4.2 vs 3.6; mean difference, 0.66).

Compared with usual care, participants in the shared decision making group were more involved in the decision (observing patient involvement scores: shared decision making, 18.3 vs usual care, 7.9) and less frequently decided with their clinician to be admitted (decision aid, 37% vs usual care, 52%). Researchers observed no major adverse cardiac events due to the intervention.

“Findings from this trial suggest that patients can be effectively educated and engaged in the emergency care setting in decisions about testing and follow-up and that it is feasible to do so in the flow of clinical care,” the study authors wrote.

“In addition, when risk estimates from validated prediction models are shared with patients, and patients are invited to apply their informed values and preferences to decisions, rates of admission and testing did not increase. Rather, patient centered interventions such as those tested in this trial indicate that patients, when educated and informed of their risk, might choose with their clinician to undergo less extensive evaluation more closely tailored to their personalized risk.”


  1. Hess EP, Hollander JE, Schaffer JT, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ. 2016. doi:10.1136/bmj.6165