Patients benefit when they know test implications beforehand

Providing information about the meaning of normal findings before a stress test is conducted may lead to less anxiety, fewer drugs and reduced pain.

By Victoria Stagg Elliott — Posted Feb. 26, 2007

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Explaining in advance the meaning of normal results from a cardiac stress test can lead patients to view these findings as more reassuring. The patients are also less likely to continue to experience chest pain and take cardiovascular drugs one month later, according to a study by researchers at the University of Auckland, New Zealand. Their findings were published last month in the British Medical Journal.

The study randomized into three groups 92 patients with chest pain who were referred for the procedure. One group received usual care; a second, a pamphlet explaining the test and the meaning of normal results; and the third, which received the pamphlet and a brief session with a health psychologist to review the information. At one-month follow-up visits, those in the third group scored higher on tests measuring reassurance and were more likely to have had their pain disappear. A trend of taking fewer cardiovascular drugs was also noted.

"A simple, low-cost intervention that explains the meaning of normal results before investigations is likely to reduce patients' concerns about symptoms and unnecessary future medical care and investigations," wrote the authors.

Those who research patient-physician relationship issues praised the paper for measuring the impact of human interaction -- not just in regard to how patients feel, but also on their symptoms and the number of medications they take.

"This confirms what we have thought in terms of the importance of human communication," said William Branch, MD, president of the American Academy on Communication in Healthcare. "A person explaining things is much more effective than doing it with a pamphlet or not doing it at all."

This paper also provides insight into why normal test results, whether related to heart health or other issues, might not always be viewed by patients as good news.

"We all wish that normal results were greeted by patients with the same kind of glee that we greet them," said Rita Charon, MD, PhD, director of the narrative medicine program at Columbia University's College of Physicians and Surgeons in New York. "This helped me understand what's missing. Without preparation, the information that the heart is healthy does not get assimilated, and they just keep worrying."

Patient-physician communication experts have several theories on why an early explanation could have such an impact. Previous studies found that patients may be worried, even after medical investigations turn up nothing. The authors and others suggest that early reassurance could reduce the chance that patients develop negative ideas about what the test means between being referred for it and receiving the results. The advance explanations might also give patients additional opportunities to hear the information and absorb it.

"A cardiac stress test is a pretty mundane, everyday kind of thing for physicians," said Paul Haidet, MD, MPH, a general internist at Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston. "But physicians need to realize that it's not in the mind of the patient. For our patients, it may be the first time they're encountering it. It's not a mundane thing. It could be a sentinel event in their life."

Heart specialists also suggest symptoms may disappear because if patients believe there is nothing wrong, they might stop paying attention.

"The mind is very powerful," said W. Douglas Weaver, MD, vice president of the American College of Cardiology and professor of medicine at Henry Ford Health System in Detroit. "When patients are worried, they are much more sensitive to detecting and counting every symptom as it happens. If they are reassured that there's nothing wrong, they are much more likely to blow it off."

But while numerous experts found the study intriguing, many also viewed it as inconclusive. The number of patients was small. In addition, any impact of the intervention is unknown for participants whose tests found something wrong and were excluded from the final analysis.

Other debate focused on whether the methodology of the study truly demonstrated that it was the timing of the intervention that made the difference. Some wondered whether it was actually the fact that patients had a greater number of opportunities to have information repeated and get questions answered.

"This is just very preliminary. I don't think that they have proven that talking to people before is a better way than talking with them after," said Dr. Branch, who is also director of the division of general internal medicine at Emory University School of Medicine in Atlanta.

Other questions stemming from the study surrounded the type of health professional needed to carry out the intervention and the time it required. The paper also called the session "brief" but did not report the actual amount of time taken.

"Different perspectives," said Jeffrey Samet, MD, MPH, professor of medicine and public health at Boston University School of Medicine. "Brief to the psychologist can be incredibly lengthy to a physician."

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Quantifying reassurance

Objective: Determine the impact of providing information about the meaning of normal results of a diagnostic test before it's conducted.

Participants: 92 patients with chest pain referred for an exercise stress test.

Methods: Subjects were randomized to receive either usual care, a pamphlet explaining the test and the implications of normal findings, or the pamphlet and a brief session with a health psychologist to answer any questions.

Results: Patients with abnormal findings were excluded from the final analysis, but those whose exercise stress tests were unremarkable were more likely to be reassured if they were in the group who had a session with a psychologist and received the pamphlet. Only 17% of this group still experienced chest pain one month later. They also were less likely to be taking any cardiovascular drugs. About 28% of those who just received the pamphlet were still symptomatic, along with 36% of the control group.

Conclusions: Providing information about the meaning of normal test results before testing can improve reassurance and reduce future chest pain.

Source: British Medical Journal, Jan. 26

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External links

"Effect of providing information about normal test results on patients' reassurance: randomised controlled trial," abstract, British Medical Journal, online Jan. 26 (link)

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