An innovative decision aid effectively involved patients with type 2 diabetes mellitus in decisions about their medications but did not improve adherence or HbA(1c) levels. Trial Registration clinicaltrials.gov Identifier: NCT00388050.

Background-Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. Methods and Results-The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24 -72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (nϭ103), decision aid patients (nϭ101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34 -1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6 -21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. Conclusions-Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.

The authors share lessons learned from their development ofStatin Choice, a decision aid for patients with diabetes who are considering using statins to reduce their cardiovascular risk.

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Shared decisionmaking (SDM) has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention SDM has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain regarding the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how SDM should be approached in clinical practice. We believe SDM should be the preferred or default approach to decisionmaking, except in clinical situations where three factors interfere. These three factors are lack of: 1) clinical uncertainty or equipoise, 2) patient decisionmaking ability, and 3) time, all of which can render SDM infeasible. Clinical equipoise refers to scenarios in which there are two or more medically reasonable management options. Patient decisionmaking ability refers to a patient’s capacity and willingness to participate in his/her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the SDM conversation. In scenarios where there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion employed as appropriate. If time or patient capacity are lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of SDM and how it can be employed in practice. Finally, we highlight five common misconceptions regarding SDM in the ED. With an improved understanding of SDM, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.