title: Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.
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.
  
  
  METHODS
  Multicenter pragmatic parallel randomized controlled trial.
  
  
  METHODS
  Six emergency departments in the United States.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Department of Emergency Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55906, USA hess.erik@mayo.edu.|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.
authors.forename: Erik P
authors.initials: EP
authors.lastname: Hess
authors.affiliation: Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.affiliation: Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Schaffer
authors.affiliation: Department of Emergency Medicine, Indiana University, Indianapolis, IN, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kline
authors.affiliation: Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, USA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Torres
authors.affiliation: Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Diercks
authors.affiliation: Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA.
authors.forename: Russell
authors.initials: R
authors.lastname: Jones
authors.affiliation: Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA.
authors.forename: Kelly P
authors.initials: KP
authors.lastname: Owen
authors.affiliation: Department of Emergency Medicine, Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Zachary F
authors.initials: ZF
authors.lastname: Meisel
authors.affiliation: Rochester, MN, USA.
authors.forename: Michel
authors.initials: M
authors.lastname: Demers
authors.affiliation: 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.
authors.forename: Annie
authors.initials: A
authors.lastname: Leblanc
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
authors.affiliation: Mayo Clinic Robert D and Patricia E Kern Center for the Science of Healthcare Delivery, Rochester, MN, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Inselman
authors.affiliation: Health Research & Educational Trust, Chicago IL, USA.
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.affiliation: 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.
authors.forename: Ana
authors.initials: A
authors.lastname: Castaneda-Guarderas
authors.affiliation: 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.
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis*; D000328:Adult; D000359:Aftercare; D000553:Ambulatory Care; D001291:Attitude of Health Personnel; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D002755:Choice Behavior; D003220:Conflict, Psychological; D003657:Decision Making; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006757:Hospital Units; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis*; D019370:Observation; D010342:Patient Acceptance of Health Care; D010358:Patient Participation; D017060:Patient Satisfaction; D018570:Risk Assessment; D035502:Trust