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Cardiovascular Rounds

Increasing patient knowledge, decreasing avoidable testing

Jake Hartman

Reducing avoidable testing has become a key focus for CV leaders nationwide, yet many have voiced concerns around how patients will perceive physician decisions to forego screenings. Despite these fears, an intriguing study in the most recent Circulation: Cardiovascular Quality and Outcomes suggests that if patients are given the right information and engaged in the decision making process, they are more likely to opt out of avoidable and potentially unnecessary tests.

Providing patients with more information
The study hinged on the use of a printed decision aid developed by Dr. Erik Hess and his colleagues at Mayo Clinic for patients presenting in the ED with chest pain but at low risk for acute coronary syndrome (ACS). The guide itself included the results of the patient’s initial tests (ECG, serial cardiac-markers and cardiac troponin), explained the rationale for performing a stress test, and depicted graphically the patient’s likelihood of ACS within 45 days based on historical outcomes for patients with similar test results. The aid also provided the spectrum of “next step” options for the patient: undergo a cardiac stress test, follow up with a cardiologists in the next three days, or follow up with the patient’s own primary care physician.

To evaluate the efficacy of this tool, the study’s authors randomized 204 patients presenting with chest pain and deemed to be at low risk for ACS, with 101 patients provided the decision guide and the other 103 serving as the control group. The study found an increase in both knowledge and engagement among patients receiving the guide, with those individuals answering more question correctly on a post-visit survey (3.6 vs. 3.0) and attaining much higher patient involvement scores on the OPTION questionnaire (26.6 vs. 7.0) than the control group.

The most interesting result, however, is the frequency with which the patients chose to undergo stress tests. The group provided the decision aid ordered the tests one-forth less often than those who did not (55% vs. 77%). None of the patients in this trial experienced adverse events following discharge, suggesting that the change in testing frequency did not negatively impact outcomes.

Patients don’t necessarily prefer more care
As the health care industry enters into an era of value-based reimbursement, ever more attention is being paid to eliminating procedures and tests with limited or no medical necessity. Despite this growing pressure, many physicians and administrators have long contended that patient preference has hindered their ability to reduce unnecessary exams, essentially claiming that patients tend to favor more testing.

This study seems to contradict that assertion, demonstrating that low-risk patients do notalways seek extensive testing, though they may need to be provided additional information to make a truly informed decision. When that information is available and clear, patients opt to forego unnecessary tests more than we would anticipate, potentially assisting our physicians and hospitals in limiting avoidable care.

More from the Roundtable
The need to deliver appropriate care has been an ongoing subject of study for the Cardiovascular Roundtable. Members can access our recent publication, the New Economics of Quality, which addresses the growing need for high-quality, high-value care in the shifting payment environment, as well as register for our upcoming webconference The Implications of Appropriateness Use on CV Growth Strategy which will provide you with all the latest on this subject.