Abstract
Objectives: The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope. Methods: Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized. Results: The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA. Conclusions: We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 425-433 |
| Number of pages | 9 |
| Journal | Academic Emergency Medicine |
| Volume | 25 |
| Issue number | 4 |
| DOIs | |
| State | Published - Apr 2018 |
ASJC Scopus subject areas
- Emergency Medicine
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In: Academic Emergency Medicine, Vol. 25, No. 4, 04.2018, p. 425-433.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Development of a Patient Decision Aid for Syncope in the Emergency Department
T2 - the SynDA Tool
AU - Probst, Marc A.
AU - Hess, Erik P.
AU - Breslin, Maggie
AU - Frosch, Dominick L.
AU - Sun, Benjamin C.
AU - Langan, Marie Noelle
AU - Richardson, Lynne D.
N1 - Funding Information: From the Department of Emergency Medicine (MAP, LDR) and the Department of Medicine, Division of Cardiology (MNL), Mount Sinai Medical Center, New York, NY; the Department of Emergency Medicine, Mayo Clinic (EPH), Rochester, MN; the School of Visual Arts (MB), New York, NY; the Palo Alto Medical Foundation Research Institute (DLF), Palo Alto, CA; and the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Heath & Science University (BCS), Portland, OR. Received September 21, 2017; revision received December 11, 2017; accepted December 27, 2017. This research was previously presented as an oral abstract at the Society for Medical Decision Making Conference, Vancouver, BC, Oct 2016. This work was supported by the National Institutes of Health, National Heart Lung, and Blood Institute (grant 1K23HL032052). The authors have no potential conflicts to disclose. Supervising Editor: D. Mark Courtney, MD. Address for correspondence and reprints: Marc A. Probst, MD, MS; e-mail: mprobst@gmail.com. ACADEMIC EMERGENCY MEDICINE 2018;25:425–433. Funding Information: The first author received funding from the National Institutes of Health (grant K23HL132052) to develop this tool. The funding agency did not play any role in the planning, design, conduct, collection, analysis, or data interpretation; in writing this report; or in the decision to submit this manuscript for publication. From January to November 2016, we developed a paper-based DA to facilitate SDM for hemodynamically stable, alert adult patients who present to the ED after a syncopal episode and have an unremarkable ED diagnostic evaluation. The decision in question is ED disposition: admit for observation versus discharge home with follow-up with a primary care physician/cardiologist for further evaluation. Our team consisted of emergency physician-researchers with expertise in SDM and syncope (MP, BS, EH), a cardiologist (ML), as well as a health psychologist (DF) and an interaction designer (MB) with previous experience developing SDM tools for acute care settings. We followed the systematic development process put forth by the International Patient Decision Aid Standards (IPDAS) Collaboration. These steps included assembly of the steering group, assessment of patient and clinician needs, review and synthesis of the evidence, drafting of a prototype, alpha-testing with iterative redrafting, and field testing. Development occurred in two broad phases: exploratory interviews to inform initial prototype development and iterative modification of this prototype. The institutional review board at our center reviewed and approved all study procedures. All patients and clinicians provided informed consent before participation. Development of the DA was conducted at a high-volume, urban, academic medical centers in New York City. Our study population consisted of actual ED syncope patients, emergency clinicians (physician assistants, resident and attending physicians), ED nurses, and attending cardiologists. In phase 1A, we conducted semistructured interviews via telephone with a convenience sample of practicing attending emergency physicians at our medical center. Key ?opinion leaders? (clinicians with seniority, in leadership positions, or who were held in high regard by their peers) were sought out and initially contacted via e-mail. All interviews were conducted by the lead author (MP), an emergency physician with training in qualitative research methods, and consisted of 11 open-ended questions regarding ED management of syncope, clinical decision making, potential barriers and facilitators to SDM, and recommendations regarding DA content (see Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1111/acem.13373/full). Physicians were not compensated for their time. In phase 1B, we conducted semistructured interviews via telephone with syncope patients after ED discharge. Trained research assistants screened the electronic ED track-board for potential participants based on eligibility criteria, i.e., chief complaint of syncope, age over 40, English speaking, without evidence of intoxication, and deemed clinically stable by the treating team. Patients were approached in the ED prior to discharge and contacted over the phone within 4 to 5 days. All interviews were conducted by the lead author (MP) and consisted of nine open-ended questions regarding their experience as patients in the ED, their desire to be involved in medical decisions, and their preferred mode of information sharing (see Data Supplement S2, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1111/acem.13373/full). Patients were offered a $20 gift card for participating. All interviews in phase 1 were performed one on one, audio-recorded, and analyzed by the lead author to identify recurring themes. Using input from the patient and physician interviews, an initial prototype of the Syncope DA, named SynDA, was created by our interaction designer (see Figure). SynDA is a paper-based, 11 ? 17-inch, patient DA with four main sections: 1) explanation of syncope and its causes, 2) explanation of potential future risks, 3) a personalized 30-day risk estimate for serious adverse events using the Canadian Syncope Risk Score (5), and 4) presentation of four options for further care. This prototype was then used as a basis for discussion for the interviews in phase 2. In phase 2A, we conducted in-person, semistructured interviews with a convenience sample of 20 physicians, nurses, and physician assistants from emergency medicine and attending cardiologists from our academic medical center. Senior emergency medicine residents were also included since they are often responsible for having the disposition discussion with patients. All questions were centered on the content and design of the DA. Clinicians were initially contacted via e-mail to determine their willingness to participate and to schedule in-person interviews. Physicians were not compensated for their time. All interviews in phase 2A were performed one on one, In phase 2B, the lead author and interaction designer pilot-tested a prototype of the SynDA tool in the ED with 12 individual syncope patients after the diagnostic evaluation was complete but prior to ED discharge. Our approach to DA development involves an iterative process of using the DA in clinical encounters, obtaining feedback from the patient and clinician regarding how well the DA facilitates an evidence-informed conversation that brings to light patient factors relevant to the decision at hand, refining the DA based on this feedback, using it again in the clinical setting, and obtaining additional feedback until no new themes emerge (thematic saturation is reached). In prior work this has been reached after approximately 15 iterations of the DA. In this study, patients were identified by the lead author using the electronic track-board in the ED. Patients were presented the prototype under hypothetical conditions, i.e., ?if your doctor were to show you this tool, how would you react?? Similar phrasing was used for all other phase 2b questioning. The tool was not used to guide clinical management in any way. Open-ended questions were posed regarding clarity, ease of use, and quantity of information. Brief cognitive interviews were then performed to assess comprehension and interpretation of the information provided in the tool. Patients were again offered a $20 gift card for participating. Interviews in phase 2b were performed two on one with the lead author and interaction designer eliciting feedback from the patient while in the ED. Interviews in phase 2 were not recorded. Rather written notes were taken during the interviews and subsequently reviewed by the research team. The SynDA tool was iteratively modified after each set of interviews after discussion with the research team. The process continued until the investigators were confident that the DA could successfully and consistently foster a dialogue between an individual patient and his or her treating clinician in the clinical scenario in question, i.e., a patient visit for syncope with a normal ED evaluation. For the interviews in phase 1, the qualitative data analysis was performed by the first author, a clinician-researcher with previous training and experience in qualitative research. Audio-recordings were listened to and notes were taken to identify key themes. Subsequent interviews were conducted until no new themes arose. For the interviews in phase 2, written notes were taken in real time during the interviews with patients and clinicians. These notes were then used to iteratively modify the DA after discussion with the rest of the research team. Subsequent interviews in phase 2 were performed until no new feedback was received from the interviewees. The first author received funding from the National Institutes of Health (grant K23HL132052) to develop this tool. The funding agency did not play any role in the planning, design, conduct, collection, analysis, or data interpretation; in writing this report; or in the decision to submit this manuscript for publication. Funding Information: The first author received funding from the National Institutes of Health (grant K23HL132052) to develop this tool. The funding agency did not play any role in the planning, design, conduct, collection, analysis, or data interpretation; in writing this report; or in the decision to submit this manuscript for publication. Publisher Copyright: © 2017 by the Society for Academic Emergency Medicine
PY - 2018/4
Y1 - 2018/4
N2 - Objectives: The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope. Methods: Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized. Results: The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA. Conclusions: We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.
AB - Objectives: The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope. Methods: Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized. Results: The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA. Conclusions: We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.
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U2 - 10.1111/acem.13373
DO - 10.1111/acem.13373
M3 - Article
AN - SCOPUS:85042198721
SN - 1069-6563
VL - 25
SP - 425
EP - 433
JO - Academic Emergency Medicine
JF - Academic Emergency Medicine
IS - 4
ER -