The 2016 Academic Emergency Medicine Consensus Conference, “Shared Decision Making in the Emergency Department: Development of a Policy‐relevant Patient‐centered Research Agenda” Diagnostic Testing Breakout Session Report

Abstract

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude “worst case” diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further work-up, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM; 2) critical elements of and potential barriers to SDM discussions on diagnostic testing; and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

“…Included articles used qualitative study designs, with the majority using interviews [ 44 , 46 – 48 , 50 – 52 , 55 – 57 ], followed by focus groups [ 44 , 46 , 51 , 54 ], observation [ 49 , 53 ], and conference breakout session [ 45 ].…”

The Yield of Computed Tomography of the Head Among Patients Presenting With Syncope: A Systematic Review

“…The results of our review also indicate that the choice of CT head among patients with syncope will be amenable to shared decision making (SDM), as usually a worst‐case scenario approach is taken rather than the most likely scenario. The issue of CT head in syncope also fulfills the SDM appropriateness criteria (e.g., pretest probability can be estimated, testing equipoise exists, test performance data are emerging about risks, and benefits are available) identified at the 2016 AEM consensus conference on SDM in the ED on diagnostic testing …”

“…The Choosing Wisely Campaign in Canada and the United States both recommend against using CT of the head for low‐risk ED patients with syncope . Additionally, the Society for Academic Emergency Medicine in the United States, through consensus conferences in 2015 and 2016, aimed to optimize ED diagnostic imaging utilization and reduce unnecessary diagnostic testing to reduce health care costs and unintended consequences . While clinical decision tools such as the NEXUS‐II, Canadian CT Head Rule, and New Orleans Criteria exist for patients with head injury related to the fall during syncope, there is a lack of appropriate synthesis of preexisting literature regarding the usefulness of CT head to identify a serious underlying intracranial conditions potentially related to syncope .…”

From Ruling Out to Ruling In: Putting POCUS in Focus

“…These objectives may not align well with the patient's goals: analgesia, risk‐stratification, reassurance, and guidance. The incorporation of patient values and concerns into a two‐way exchange of information, commonly referred to as shared decision making, may explicitly help providers reframe their own expectations of testing goals . As such, the choice of an initial imaging study need not be mutually exclusive of additional diagnostic testing.…”