MI risk message isn’t getting through between patients and providers

When talking with emergency room doctors about chest pain, patient risks for acute coronary syndromes aren’t being conveyed. According a study published online March 4 in Annals of Emergency Medicine, even after talking to their doctor, patient estimates for MI mortality risks were hugely overestimated.

Focusing on patients admitted to the emergency department for chest pain, David H. Newman, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues surveyed 425 patient-physician pairs. Researchers looked for agreement of risk estimates for MI to determine communication accuracy. They reported risk agreement between patient and provider within 10 percent in only 36 percent of cases.

As a result, 65 percent of patients reported MI as the likely cause of chest pain; physicians reported that number as closer to 46 percent. Physicians estimated short-term risk for MI around 5 percent after discussions, while patients originally estimated around 8 percent, reporting either the same or increased risk following conversations with their physician.

In particular, huge gaps were seen when patients were asked to estimate their risk of mortality from MI at home: Physicians estimated risk around 15 percent at home, while patients estimated it at 80 percent. Both patients and physicians agreed mortality risk in hospital was around 10 percent.

With a wide gap between what physicians believe they’re telling patients and what patients understand they heard, communication is breaking down somewhere. In a press release, Newman commented on the fact that two-thirds of the time patients and physicians are in disagreement about what was said. “In many ways, it seems almost like we're ships passing in the night. To us, what this suggests is that patient-doctor communication is largely ineffective, and that a costly and potentially burdensome decision--admission to the hospital--is being made without patients understanding 'why,' and thus without being able to participate in that decision,” he said.

An accompanying editorial written by Erik P. Hess, MD, MSC, from the Mayo Clinic in Rochester, Minn., was particularly concerned about physicians' own overestimation of risk. Post-hoc risk prediction put actual risk for MI or death at less than 2 percent, lower even than the estimated risk given by physicians.

In the same press release, Hess stated, “Risk communication in the [emergency room] is far from straightforward and physicians and patients may have very different ideas of what constitutes ‘low risk.’ That said, we have to do a better job of telling our patients the facts without inflating either their hopes or their fears.”

Better tools and decision aids may be needed to improve communication and help better educate patients on their conditions. Also, “[d]irected education for physicians about risk prediction and communication with patients at disposition decision may be useful to potentially affect the considerable resource use that is devoted to this group of patients,” wrote Newman et al.