Shared Decision-Making for the Promotion of Patient-Centered Imaging in the ED: Suspected Kidney Stones

Study Overview
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Brief Summary
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Although a CT scan is required for some Emergency Department patients with signs and symptoms of a kidney stone, recent evidence has shown that routine scanning is unnecessary and may expose young patients to significant cumulative radiation, increasing their risk of future cancers. Shared Decision-Making may facilitate diagnostic imaging decisions that are more inline with patients' values and preferences. By comparing a shared approach to diagnostic decision-making to a traditional, physician-directed approach, this study lays the foundation for a future randomized trial that will reduce radiation exposure, improve engagement, and improve the quality and patient-centeredness of Emergency Department care.

Official Title
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Shared Decision-Making for the Promotion of Patient-Centered Imaging in the Emergency Department: Suspected Kidney Stones

Conditions
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Shared Decision-making, Kidney Stone, Emergencies, Radiation Exposure, Communication

Intervention / Treatment
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* Behavioral: Decision Aid
* Other: Standardized Educational Material (informational pamphlet)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18-55, with acute flank pain - for whom clinician believes acute flank pain may be from renal colic who are deemed by the treating clinician to be at low risk for dangerous alternative diagnoses. Clinician is considering imaging patient for kidney stones (any imaging) Exclusion Criteria: Recent trauma related to pain (including minor such as lifting/turning) Pregnancy (previous or discovered during ED visit) Recent surgical procedure on abdomen or pelvis (30d) Recent urologic procedure (30d) Recent childbirth (30d) Signs of Systemic Infection: Fever >100.9 (101 and up), SBP <90, HR>120 Moderate or severe abdominal tenderness or rebound/guarding, consistently present (present for more than one exam, or present after patient treated with pain medication) Second doctor's visit (ED, PCP, urgent care) for THIS episode of pain (previous similar visits ok if pain gone for >30d in between episodes) (if seen at PCP or urgent care in same day or 24 hour period, this is not an exclusion, but if seen at PCP/urgent care or ED 1-30 days prior to index visit, with same pain, excluded) Known history of one kidney or other urological/renal abnormality (including neurogenic bladder, ESRD and paraplegia; or if solitary kidney discovered on US) Known malignancy (any) within past year (or received treatment in the past 12 months) Immunocompromised (chronic steroids, HIV, crohns, immunomodulators or severely ill chronically) On anticoagulation Crisis patient (behavioral health)/belligerent Lacks capacity for medical decision-making Unlikely to respond to follow-up calls (IVDA, homeless, no phone) Clinician is concerned for alternative diagnosis requiring CT scan (appendicitis) (>5% likelihood by clinician gestalt) Patient is not improving clinically and clinician is considering admission

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Shared Decision-Making (via Decision Aid)<br>The intervention is a decision aid, which both encourages and facilitates a shared decision-making conversation between the clinician and the patient. The decision aid educates patients regarding evidence-based approaches to the management of suspected kidney stones in the ED. Clinicians will receive training specific to this decision aid, though the decision aid is designed to be used with no additional training. | Behavioral: Decision Aid<br>* Decision aid to facilitated shared decision-making<br>Other: Standardized Educational Material (informational pamphlet)<br>* Pamphlet with information about kidney stones<br>|
| Active Comparator: standardized educational intervention (pamphlet +usual care)<br>The control arm will receive Usual Care and a standardized educational intervention (pamphlet). This intervention (pamphlet) contains information about kidney stones. Usual care for this clinical scenario generally involves the clinician choosing the management plan. Clinicians of subjects assigned to the usual care group will be asked to practice usual, evidence-based medical care, without shared decision-making. | Other: Standardized Educational Material (informational pamphlet)<br>* Pamphlet with information about kidney stones<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility | Is this study feasible? We will collect number of patients screened, number approached, number consented, number randomized and whether follow-up was completed (was patient contacted). An enrollment of at least three patients per month will indicate feasibility. | Up to 12 months | 
| Fidelity | Does the DA do what we think it is doing? Fidelity will be examined after 50 patients are enrolled: conversations between patients and clinicians will be scored for whether shared decision-making occurred. If SDM is NOT occurring in the intervention group (>75% of interactions) or IS occurring in the usual care group (>50% of interactions), fidelity will not be considered met. | Up to 12 months | 
| Patient Knowledge | We hypothesize that the intervention group will have increased knowledge regarding radiation exposure and diagnostic options. This will be tested with a 10 question Knowledge Test developed by stakeholders for this study and delivered at the end of the index visit. The scores for this test range from 0-10 with 10 indicating higher knowledge (more correct answers) | Measured at the end of the index visit. (Day 0) | 
| CT scan rate | We hypothesize that SDM will lead to a change in CT scans performed at the index visits and in the first 60 days | Day 0 and Day 60 (Day 60 evaluation will include all days from 0-60) | 
| Radiation exposure | We hypothesize that SDM will lead to a change in exposure to radiation. We will record radiation exposure for each CT done between day 0 and day 60, as indicated by DLP on CT reports. | Day 0 and Day 60 (Day 60 evaluation will include all days from 0-60) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Satisfaction | Measure of satisfaction (HCAHPS measure: Provider rating where 0 = worst provider possible and 10 = best provider possible) | Day 0, end of visit | 
| Patient engagement | Measure of engagement: CollaboRATE 3-question measure (where 10/10 for all three is the highest score possible, and 0/0 is the lowest possible, with highest indicating better patient engagement) | Day 0, end of visit | 
| Patient engagement | Measure of engagement: modified CPS (Scale from 1-5, where 1 indicates the doctor made the decision, 5 indicates the patient made the decision, and 2,3, and 4 indicate levels of shared decision-making) | Day 0, end of visit | 
| Patient engagement | Measure of engagement: direct SDM question (Measures patients' perception of Did SDM occur on a likert scale of 1-7 with 1 = no and 7 = yes, and higher scores = more SDM) | Day 0, end of visit | 
| Occurrence of SDM | As involved question: Were you as involved in today's decisions as you would have liked to be? With three response options: Yes, No, and There were no decisions for me to be involved in Greater proportion of patients choosing yes indicates more SDM. | Day 0, end of visit | 
| Occurrence of SDM | Whether SDM took place from a third party observer's perspectives: OPTION-5 Score (where scale goes from 0-5, and is re-scaled to 0-100, where higher score indicates more SDM) | Day 0, end of visit | 
| Overall Radiation Burden | Radiation burden from diagnostic imaging (numeric DLP from CT reports) | within 60 days from index ED visit | 
| Trust in physician | Trust in physician scale (0-25 with 25 indicating higher trust in the physician) | Day 0, end of visit | 
| ED revisits | Repeat visits to any Emergency Department | 60 days | 
| Safety: missed diagnosis | High Risk Diagnoses with Complications, as previously described by Smith-Bindman. | 60 days from index ED visit | 
| ED Length of Stay | Total minutes of ED stay | Day 0, end of visit | 
| Implementation Outcomes | Clinician's perceptions of the conversation/intervention. We will ask about whether the clinician found the decision aid helpful, whether they would recommend it to another clinician, and whether they would use it again (likert scale 1-7 for each, with higher number indicating more acceptance/helpfulness) | Day 0, end of visit | 
| Qualitative evaluation | We will ask open ended questions to providers about their interaction, to ask about what went well, what did not, how else could SDM be facilitated, how this intervention would work outside of a study, what other feedback they have. This will be collected via recorded interview and open ended questions. | Day 0, end of visit |