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Patient preference to participate in shared decision making for performing a CT scan in the emergency department
YAJEM-56748; No of Pages 2 American Journal of Emergency Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Patient preference to participate in shared decision making for performing a CT scan in the emergency department
To the Editor Computerized tomography (CT) imaging is widely used in US emergency departments (ED) and represents a major source of carcinogenic radiation [1]. There is evidence that patients desire to be made aware of potential risks associated with radiation exposure [2]. Shared Decision Making (SDM) is a principle of the doctor-patient relationship that involves sharing of information and the agreement about which therapeutic option to implement. SDM has been used successfully in clinical decisions such as hospital admissions for chest pain and surgery for appendicitis [3,4]. It is currently unknown if shared decision making is beneficial in the decision to order a CT scan in the ED. As part of a pilot study with the eventual goal of creating a decision aid to facilitate shared decision making about CT scans, our objective was to assess the desire of ED patients to participate in the decision process regarding CT scan use. Our secondary objective was to describe differences in patients who want to participate versus those who do not want to participate. Approximately 100 subjects who received a CT scan in the ED were enrolled from June to August 2016 as part of a prospective cohort study. If verbally consented, adult subjects were interviewed in the ED by a research assistant after a CT scan had been ordered but prior to ED disposition. Subjects were interviewed at least 1 h after the order had been placed in the electronic medical record (EMR) or after patient received the CT scan to ensure that the clinician had the opportunity to discuss imaging options with the patient. Measurements: Subjects completed a questionnaire asking about their desired versus the actual level of participation in the SDM process, whether risks and benefits for ordering a CT scan were discussed, and whether their concerns about CT scans were addressed. The answer choices for each question were ranked 1–5; with 1 indicating no discussion/involvement and 5 indicating thorough discussion/involvement. Of the 102 subjects who were enrolled, 58% were female, the median age was 46.5, and 48% received an abdominal CT scan. 48% of patients desired to “participate fully in the decision to perform CT scan,” compared to 44% who “did not want to participate in the decision to perform CT.” 74% were not made aware by their providers of any risks associated with obtaining a CT scan while 76% of all patients did not have a discussion with their providers about the risks for not obtaining a CT scan (Table 1). Of those subjects who wanted to participate fully, there was no difference in median age, sex, type of CT scan, discussion of risks by physician, or explanation of alternatives by physician. Patients who wanted full participation were more likely to have concerns about CT scans (23% versus 11%, p = 0.02) but also felt more involved in the decision process (31% versus 20%, p = 0.04.)
In the majority of doctor-patient interactions, there was no discussion of risks regarding CT scan usage or a discussion of alternatives. Among patients who wanted to participate, they were more likely to have concerns about radiation exposure than patients who did not want to participate. However, their increase concern was not associated with an increased rate of discussion about risks or alternatives. This mismatch in patient expectation and observed doctor-patient interaction may signal an area for improvement in communication (Table 2). Interestingly, patients who wanted to participate more did feel more involved in the decision process despite no observed increase in actual discussion risks. It is possible that patient's sense of involvement goes beyond simple discussion of risk and perhaps the physicians were able to acknowledge the desire for participation in less measurable ways. It is also possible that providers adjust their discussion when they sense a patient has more concerns or more desire for involvement. An individual physician's practice may vary between patients in order to match the perceived desire. Future research will explore whether the discussion of risks, benefits or alternatives to a CT scan leads to optimization of resource utilization. For many patients with mild to moderate symptoms, alternatives to a CT scan may be appropriate. In addition, future research will need to measure for potential negative associations with SDM including the possibility of increased length of stay and increased rates of missed diagnoses. The complicating factor in all these episodes of care is that patient desires not only vary by individual preference but also may vary by clinical condition and other factors. For example, it is likely that there are conditions, such as critical illnesses or head injuries, when a more traditional paternalistic approach may serve the patients preference better. Ultimately, we hope to create a dynamic support system that is sensitive to both patient desires and the clinical condition in order to both improve communication and resource utilization.
Table 1 Description of study subjects. Description of study subjects
N
%
Total % female Age (median and CI) Type of CT Abd CT Chest CT Head CT Spine CT Other CT Wanted to participate fully in decision to perform CT Did not want to participate in decision Physician did not discuss any risks of having a CT scan Physician did not discuss any risks of not having a CT scan Had concerns about CT scan Provider asked about desired level of participation
102 59 46.5
58% 39–53
49 15 26 10 2 49 45 63 63 36 33
48% 15% 25% 10% 2% 48% 44% 74% 76% 35% 32%
http://dx.doi.org/10.1016/j.ajem.2017.06.020 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Ijaz H, et al, Patient preference to participate in shared decision making for performing a CT scan in the emergency department, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.06.020
2
Patient preference to participate in shared decision making for performing a CT scan in the emergency department
References
Table 2 Comparing patients by desire to participate in decision-making. Characteristic
Wanted to participate
Did not want to participate
Total % female Age (median) Type of CT Abdominal Chest Head Spine Other Feel involved in decision process Physician explained alternatives Discussed risks of no CT Discussed risks of CT Had concerns about CT scans Provider asked about desired level of participation
49 26 46
45 29 53
22 9 11 6 1 31 24 18 19 23 27
22 6 13 4 0 20 21 19 20 11 5
Funding sources/disclosures N/A/none. HI, CM, PEK, LMR, ACM reports no conflicts of interest.
p-Value
0.26 0.24 0.81
0.04 0.27 0.59 0.42 0.02 b0.0001
[1] Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84. [2] Shyu JY, Sodickson AD. Communicating radiation risks to patients and referring physicians in the emergency department setting. Br J Radiol 2016;89(1061). [3] Kindermann DR, McCarthy ML, Ding R, et al. Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus. J Emerg Med 2014;46:791–9. [4] Hess EP, Marin J, Mills A. Medically unnecessary advanced diagnostic imaging and shared decision-making in the emergency department: opportunities for future research. Acad Emerg Med 2015;22:475–7.
Hamza Ijaz BS Chloe Michel BS Paige E. Kulie MPH Lorna M. Richards MA Andrew C. Meltzer MD* Department of Emergency Medicine, George Washington University Hospital, Washington, DC, United States *Corresponding author at: Department of Emergency Medicine, 2120 L Street NW Suite 400, George Washington University Hospital, Washington, DC 20037, United States. E-mail address: [email protected] (A.C. Meltezer). 5 April 2017 Available online xxxx
Acknowledgements None.
Please cite this article as: Ijaz H, et al, Patient preference to participate in shared decision making for performing a CT scan in the emergency department, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.06.020
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Patient preference to participate in shared decision making for performing a CT scan in the emergency department
To the Editor Computerized tomography (CT) imaging is widely used in US emergency departments (ED) and represents a major source of carcinogenic radiation [1]. There is evidence that patients desire to be made aware of potential risks associated with radiation exposure [2]. Shared Decision Making (SDM) is a principle of the doctor-patient relationship that involves sharing of information and the agreement about which therapeutic option to implement. SDM has been used successfully in clinical decisions such as hospital admissions for chest pain and surgery for appendicitis [3,4]. It is currently unknown if shared decision making is beneficial in the decision to order a CT scan in the ED. As part of a pilot study with the eventual goal of creating a decision aid to facilitate shared decision making about CT scans, our objective was to assess the desire of ED patients to participate in the decision process regarding CT scan use. Our secondary objective was to describe differences in patients who want to participate versus those who do not want to participate. Approximately 100 subjects who received a CT scan in the ED were enrolled from June to August 2016 as part of a prospective cohort study. If verbally consented, adult subjects were interviewed in the ED by a research assistant after a CT scan had been ordered but prior to ED disposition. Subjects were interviewed at least 1 h after the order had been placed in the electronic medical record (EMR) or after patient received the CT scan to ensure that the clinician had the opportunity to discuss imaging options with the patient. Measurements: Subjects completed a questionnaire asking about their desired versus the actual level of participation in the SDM process, whether risks and benefits for ordering a CT scan were discussed, and whether their concerns about CT scans were addressed. The answer choices for each question were ranked 1–5; with 1 indicating no discussion/involvement and 5 indicating thorough discussion/involvement. Of the 102 subjects who were enrolled, 58% were female, the median age was 46.5, and 48% received an abdominal CT scan. 48% of patients desired to “participate fully in the decision to perform CT scan,” compared to 44% who “did not want to participate in the decision to perform CT.” 74% were not made aware by their providers of any risks associated with obtaining a CT scan while 76% of all patients did not have a discussion with their providers about the risks for not obtaining a CT scan (Table 1). Of those subjects who wanted to participate fully, there was no difference in median age, sex, type of CT scan, discussion of risks by physician, or explanation of alternatives by physician. Patients who wanted full participation were more likely to have concerns about CT scans (23% versus 11%, p = 0.02) but also felt more involved in the decision process (31% versus 20%, p = 0.04.)
In the majority of doctor-patient interactions, there was no discussion of risks regarding CT scan usage or a discussion of alternatives. Among patients who wanted to participate, they were more likely to have concerns about radiation exposure than patients who did not want to participate. However, their increase concern was not associated with an increased rate of discussion about risks or alternatives. This mismatch in patient expectation and observed doctor-patient interaction may signal an area for improvement in communication (Table 2). Interestingly, patients who wanted to participate more did feel more involved in the decision process despite no observed increase in actual discussion risks. It is possible that patient's sense of involvement goes beyond simple discussion of risk and perhaps the physicians were able to acknowledge the desire for participation in less measurable ways. It is also possible that providers adjust their discussion when they sense a patient has more concerns or more desire for involvement. An individual physician's practice may vary between patients in order to match the perceived desire. Future research will explore whether the discussion of risks, benefits or alternatives to a CT scan leads to optimization of resource utilization. For many patients with mild to moderate symptoms, alternatives to a CT scan may be appropriate. In addition, future research will need to measure for potential negative associations with SDM including the possibility of increased length of stay and increased rates of missed diagnoses. The complicating factor in all these episodes of care is that patient desires not only vary by individual preference but also may vary by clinical condition and other factors. For example, it is likely that there are conditions, such as critical illnesses or head injuries, when a more traditional paternalistic approach may serve the patients preference better. Ultimately, we hope to create a dynamic support system that is sensitive to both patient desires and the clinical condition in order to both improve communication and resource utilization.
Table 1 Description of study subjects. Description of study subjects
N
%
Total % female Age (median and CI) Type of CT Abd CT Chest CT Head CT Spine CT Other CT Wanted to participate fully in decision to perform CT Did not want to participate in decision Physician did not discuss any risks of having a CT scan Physician did not discuss any risks of not having a CT scan Had concerns about CT scan Provider asked about desired level of participation
102 59 46.5
58% 39–53
49 15 26 10 2 49 45 63 63 36 33
48% 15% 25% 10% 2% 48% 44% 74% 76% 35% 32%
http://dx.doi.org/10.1016/j.ajem.2017.06.020 0735-6757/© 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Ijaz H, et al, Patient preference to participate in shared decision making for performing a CT scan in the emergency department, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.06.020
2
Patient preference to participate in shared decision making for performing a CT scan in the emergency department
References
Table 2 Comparing patients by desire to participate in decision-making. Characteristic
Wanted to participate
Did not want to participate
Total % female Age (median) Type of CT Abdominal Chest Head Spine Other Feel involved in decision process Physician explained alternatives Discussed risks of no CT Discussed risks of CT Had concerns about CT scans Provider asked about desired level of participation
49 26 46
45 29 53
22 9 11 6 1 31 24 18 19 23 27
22 6 13 4 0 20 21 19 20 11 5
Funding sources/disclosures N/A/none. HI, CM, PEK, LMR, ACM reports no conflicts of interest.
p-Value
0.26 0.24 0.81
0.04 0.27 0.59 0.42 0.02 b0.0001
[1] Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84. [2] Shyu JY, Sodickson AD. Communicating radiation risks to patients and referring physicians in the emergency department setting. Br J Radiol 2016;89(1061). [3] Kindermann DR, McCarthy ML, Ding R, et al. Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus. J Emerg Med 2014;46:791–9. [4] Hess EP, Marin J, Mills A. Medically unnecessary advanced diagnostic imaging and shared decision-making in the emergency department: opportunities for future research. Acad Emerg Med 2015;22:475–7.
Hamza Ijaz BS Chloe Michel BS Paige E. Kulie MPH Lorna M. Richards MA Andrew C. Meltzer MD* Department of Emergency Medicine, George Washington University Hospital, Washington, DC, United States *Corresponding author at: Department of Emergency Medicine, 2120 L Street NW Suite 400, George Washington University Hospital, Washington, DC 20037, United States. E-mail address: [email protected] (A.C. Meltezer). 5 April 2017 Available online xxxx
Acknowledgements None.
Please cite this article as: Ijaz H, et al, Patient preference to participate in shared decision making for performing a CT scan in the emergency department, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.06.020