Patient Perspectives on the Current Paradigm of Non-Invasive Cardiac Testing Through an Emergency Department Observation Unit: A Survey Study

BACKGROUND: Emergency department observation units (EDOU) facilitate cardiac testing after initial ED evaluation for acute coronary syndrome. While this approach offers multiple safety and compliance benefits, it also poses patient-facing costs and inconveniences that outpatient approaches might alleviate. Despite the clinical emphasis on shared decision-making when deciding to pursue further testing in the EDOU or ambulatory care setting, little is known about patient preferences on the matter. To inform the selection and design of care delivery models for patient-centered comparative analysis, we aimed to understand patient perspectives on their experiences undergoing cardiac observation and testing in our EDOU. METHODS: This iteratively developed and refined cross-sectional survey study enrolled a convenience sample of adults in an EDOU awaiting cardiac test results. Subjects completed a survey that included questions regarding expectations, experiences, quality of life, and perceived advantages/disadvantages of the EDOU stay. Subjects scored items as binary, numerical, and categorical responses; Likert scales; satisfaction ratings; and voluntary free text. We abstracted supplemental clinical data from the electronic health record. The primary outcome was binary willingness to participate in a hypothetical alternative outpatient testing program in lieu of the EDOU. After stratifying subjects by the primary outcome, we tabulated subject characteristics, survey responses, and subsequent clinical courses for pairwise comparison with t-tests, Wilcoxon rank-sum tests, chi-square tests, and Fisher's exact tests. RESULTS: Of 100 subjects, 61% were willing to participate in a hypothetical outpatient program. Subjects willing to participate in the outpatient program had similar demographics, comorbidities, cardiac risk profiles, test results, cardiac procedures, and subsequent hospital courses to those who were not willing. Subjects valued the perceived benefits of rapid testing and safety in the EDOU but acknowledged the perceived drawbacks of financial cost and the need to make alternative arrangements in their absence from home. Subjects' perceived convenience of the hypothetical outpatient program was the strongest predictor of willingness to participate. CONCLUSIONS: In this convenience sample of EDOU patients, subjects valued the timeliness and safety of hospital-based testing but noted the financial and opportunity costs. Most were willing to participate in a hypothetical outpatient testing program, but this was contingent on its perceived convenience. These findings inform the selection of patient-centered outcomes for comparative analysis of different care models to pursue additional cardiac testing after ED evaluation for acute coronary syndrome.