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Background

Patients at low risk for acute coronary syndrome (ACS) are frequently admitted for observation and cardiac testing at a substantial burden and cost to the patient and the health care system. We compared the effectiveness of shared decision-making facilitated by the Chest Pain Choice (CPC) decision aid with usual care (UC) in the choice of admission for observation and further cardiac testing or referral for outpatient evaluation in patients with possible ACS.

Methods

This was a multicenter pragmatic parallel randomized controlled trial conducted in 6 geographically diverse US emergency departments. Participants included adults (> 17 years of age) with a primary complaint of chest pain who were being considered for observation unit admission for cardiac testing. Patients were randomly assigned (1: 1) to CPC or to UC. The primary outcome, selected by patient and caregiver representatives, was patient knowledge; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, the 30-day rate of major adverse cardiac events, and 45-day health care utilization. We also conducted a prespecified analysis to assess the heterogeneity of effect of CPC in potentially vulnerable patient groups.

Results

We assessed 3236 patients for eligibility and enrolled 898 patients (451 CPC, 447 UC) from October 2013 to August 2015. Compared with UC, CPC patients had greater knowledge (questions correct: 4.2 CPS vs 3.6 UC; mean difference [MD] 0.66; 95% CI, 0.46-0.86), were more involved in the decision to be admitted (observing patient involvement [OPTION] scores: 18.3 CPC vs 7.9 UC …