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Estimating Risk for Potential ACS in the ED

Estimating Risk for Potential ACS in the ED
Author Information (click to view)

David H. Newman, MD

Director of Clinical Research
Associate Professor, Emergency Medicine
Department of Emergency Medicine
Icahn School of Medicine at Mount Sinai

David H. Newman, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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David H. Newman, MD (click to view)

David H. Newman, MD

Director of Clinical Research
Associate Professor, Emergency Medicine
Department of Emergency Medicine
Icahn School of Medicine at Mount Sinai

David H. Newman, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Both physicians and patients appear to overestimate the risk of heart attack or death for possible acute coronary syndrome (ACS), according to a study. Improved methods of communicating risk are needed for managing patients with suspected ACS.
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Throughout EDs in the United States, acute coronary syndrome (ACS) is a common concern and frequently leads to more extensive evaluations using accelerated diagnostic protocols. When ACS is a suspected, disposition decisions usually depend heavily on perceptions of the risk of near-term adverse events, such as death or myocardial infarction (MI). Theoretically, the primary purpose of hospital admission is to mitigate these risks. “Decisions to admit patients with suspected ACS should be based, in part, on an assessment of how much hospitalization will decrease their risks for adverse events,” explains David H. Newman, MD.

Characterizing Discussions

In a study published in Annals of Emergency Medicine, Dr. Newman and colleagues sought to characterize risk assessment discussions between patients and physicians at admission and assess accuracy of risk estimates when ACS is suspected. “Our exploratory study primarily aimed to characterize the content of conversations surrounding disposition decisions,” adds Dr. Newman. It was hypothesized that the conversation content may reflect inaccurate risk estimates and poor convergence of risk perceptions between patients and their physicians.

For the research, investigators collected 425 matched-pair surveys of patients admitted for possible ACS and their physicians in two EDs. After the disposition conversation, trained research assistants administered surveys that asked about perceived and communicated risk estimates and the purpose of admission. The primary outcome measure was agreement in assessment of the risk of MI, which was defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other.

Important Findings

According to the results, patients reported discussing the likelihood of their symptoms’ being due to MI in 65% of cases, whereas physicians reported this in just 46% of cases. The median estimate of short-term (30-day) risk was 5% for physicians, compared with 8% for patients. After their discussion, about two-thirds of patients reported that this estimate of risk remained the same or increased after their conversation (Figure). “Even immediately after patients discussed the reasons for being admitted to the hospital with their doctors, it appears that there is no alignment about those reasons most of the time,” says Dr. Newman.

The study by Dr. Newman and colleagues also showed that risk agreement within 10% occurred in just 36% of cases overall. Patients’ median estimates of the mortality of MI at home versus in the hospital were 80% and 10%, respectively, whereas physician estimates were 15% and 10%. The definition of agreement was met in only about one-third of patient-physician pairs (Table). “This suggests that patient-doctor communication is largely flawed,” Dr. Newman says. “Decisions to admit patients to the hospital—which is both costly and burdensome—are being made without patients understanding why they are being admitted.”

Better Strategies Needed

Misperceptions of the risks and benefits of a wide variety of medical screenings and interventions have been the focus of many studies in recent years as the U.S. healthcare system has made it a priority to reduce costs and improve patient outcomes. The study by Dr. Newman and colleagues showed that patient risk estimations generally became less accurate after their discussion with physicians, a finding that signifies the need to do improve how patients are being informed by their providers.

Considerable resources are often devoted to pursuing more in-depth evaluations to further stratify risk, help manage short-term events, and identify patients who may benefit from revascularization. However, achieving these goals is especially difficult in the ED setting due to a variety of reasons. “Many variables, such as medico-legal concerns, professional and financial pressures, and risk avoidance, may be contributing factors that influence physician behaviors,” says Dr. Newman. All of these can increase the likelihood of admission or observation in patients with potential ACS.

Looking Ahead

While findings of the study are not definitive, Dr. Newman says they can be helpful in that the data can be used to develop educational efforts and more rigorous research on patient-physician communication surrounding admission decisions. “Risk communication in the emergency room is not always straightforward, especially when it comes to managing suspected ACS,” Dr. Newman says. “The complex interplay of variables is difficult to dissect, and what patients are told may inflate their hopes, fears, or expectations.”

Efforts are needed to ensure that communication on disposition decisions in patients with suspected ACS is effective, according to Dr. Newman. “Education should be directed toward physicians about communicating risk with patients during disposition decisions,” he says. “This can help ensure that the considerable resources being used to manage this patient group are appropriate.”

 

 

Readings & Resources (click to view)

Newman DH, Ackerman B, Kraushar ML, et al. Quantifying patient-physician communication and perceptions of risk during admissions for possible acute coronary syndromes. Ann Emerg Med. 2015 Mar 5 [Epub ahead of print]. Available at: http://www.annemergmed.com/article/S0196-0644(15)00087-6/fulltext

Hermann LK, Newman DH, Pleasant WA, et al. Yield of routine provocative cardiac testing among patients in an emergency department–based chest pain unit. JAMA Intern Med. 2013;173:1128-1133.

Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. Arch Intern Med. 2012;172:1506-1509.

Kosowsky JM. Approach to the ED patient with “low-risk” chest pain. Emerg Med Clin North Am. 2011;29:721-727.

Hess EP, Knoedler MA, Shah ND, et al. The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes. 2012;15:251-259.

Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;15:51-58.

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