On 2014 Jun 20, Erik Hess commented:

Thank you for these insightful comments. This is Dr. Erik Hess, the PI on this multicenter trial. What is not necessarily intuitive and may not be immediately apparent to the reader is the how the process of decision aid development determines the content selected for inclusion. The main factor that determines what information is included in the decision aid is how the information facilitates a conversation between the clinician and the patient and what information the end-users find relevant to the decision at hand (not what insights seem to make good theoretical sense outside the context of the clinical encounter). In the process of decision aid development we used prototypes of the tool in real ED encounters and, with each use, elicited feedback from both the clinician and the patient regarding the clarity, usefulness, and relevance of the information to the discussion and whether the decision aid was a distractor (brought undue focus on itself) or facilitated a conversation. In one of the earlier iterations of the tool (there were over 15 iterations) the patient and stakeholder advisory group did make a similar comment -- that more information comparing the test characteristics, degree of radiation exposure, and cost of each of the diagnostic modalities and the risks and benefits of the follow-up options might be helpful. However, when we included this information on the DA and tested it in clinical encounters we were told by the clinicians and patients who used it in practice that the information was not needed for decision making, brought undue focus on the decision aid itself rather than promoting a conversation, and was confusing (information overload when used in real time). Note that as a compromise a reference to the different stress testing modalities and some of their key differences are referred to as a footnote on the bottom left of the decision aid but we reduced the amount of information, chose a smaller font, and put the information in a footnote so as to not distract from the conversation. In addition, though the test characteristics between CTA and the various stress testing modalities differ, there is no difference in the relative risk of MI between each of these modalities, as they are diagnostic modalities, not treatments. At best, they further refine prognosis but do not change it.

See the responses and related blog conversation at http://www.emlitofnote.com/2014/06/a-shared-decision-making-trial-but.html

On 2014 Jun 18, Ryan Radecki commented:

Post-publication critique:

A Shared Decision-Making Trial … But Fatally Flawed?

Shared decision-making is developing as the proposed solution to many of the problems with resource utilization today. Rather than embrace “zero miss” practice without properly involving patients as the decision-makers, we are now encouraged to offer the patient choices regarding their diagnostic and treatment decisions. By sharing the decision – and the risk – I find patients quite amenable to forgoing much low-yield testing....

http://www.emlitofnote.com/2014/06/a-shared-decision-making-trial-but.html

On 2014 Jun 18, Ryan Radecki commented:

Post-publication critique:

A Shared Decision-Making Trial … But Fatally Flawed?

Shared decision-making is developing as the proposed solution to many of the problems with resource utilization today. Rather than embrace “zero miss” practice without properly involving patients as the decision-makers, we are now encouraged to offer the patient choices regarding their diagnostic and treatment decisions. By sharing the decision – and the risk – I find patients quite amenable to forgoing much low-yield testing....

http://www.emlitofnote.com/2014/06/a-shared-decision-making-trial-but.html

On 2014 Jun 20, Erik Hess commented:

Thank you for these insightful comments. This is Dr. Erik Hess, the PI on this multicenter trial. What is not necessarily intuitive and may not be immediately apparent to the reader is the how the process of decision aid development determines the content selected for inclusion. The main factor that determines what information is included in the decision aid is how the information facilitates a conversation between the clinician and the patient and what information the end-users find relevant to the decision at hand (not what insights seem to make good theoretical sense outside the context of the clinical encounter). In the process of decision aid development we used prototypes of the tool in real ED encounters and, with each use, elicited feedback from both the clinician and the patient regarding the clarity, usefulness, and relevance of the information to the discussion and whether the decision aid was a distractor (brought undue focus on itself) or facilitated a conversation. In one of the earlier iterations of the tool (there were over 15 iterations) the patient and stakeholder advisory group did make a similar comment -- that more information comparing the test characteristics, degree of radiation exposure, and cost of each of the diagnostic modalities and the risks and benefits of the follow-up options might be helpful. However, when we included this information on the DA and tested it in clinical encounters we were told by the clinicians and patients who used it in practice that the information was not needed for decision making, brought undue focus on the decision aid itself rather than promoting a conversation, and was confusing (information overload when used in real time). Note that as a compromise a reference to the different stress testing modalities and some of their key differences are referred to as a footnote on the bottom left of the decision aid but we reduced the amount of information, chose a smaller font, and put the information in a footnote so as to not distract from the conversation. In addition, though the test characteristics between CTA and the various stress testing modalities differ, there is no difference in the relative risk of MI between each of these modalities, as they are diagnostic modalities, not treatments. At best, they further refine prognosis but do not change it.

See the responses and related blog conversation at http://www.emlitofnote.com/2014/06/a-shared-decision-making-trial-but.html