In Patients with Suspected Coronary Artery Disease, the Test Provides Emotional Reassurance and Allays Uncertainty
Potential Benefits Seen for Knowing Patients' State of Mind, Not Only Physical State
Mar 31, 2005
Each year, millions of Americans undergo diagnostic tests aimed at spotting heart disease, cancer, and other illnesses.
And while we know a lot about what these tests and their results mean for the body, we still know very little about how they affect a patient's state of mind.
Now, a Weill Medical College of Cornell University study that focused on cardiac stress testing may give researchers a powerful new tool to study those types of psychological effects.
The study found that, in patients with chest pain suggestive of coronary artery disease (CAD), the results of standard treadmill tests provided individuals with reassurance – an emotional variable that's been difficult to measure until now.
"That's one of the major contributions of this paper, because if we can find ways of measuring reassurance, we can then use those methods in future studies on other diagnostic tests, and perhaps incorporate those findings into clinical decision-making," said co-researcher Dr. Lisa Kern, Assistant Professor of Public Health and Medicine at Weill Cornell Medical College in New York City. Dr. Kern is also Assistant Attending Epidemiologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
The findings appear in the March-April issue of Medical Decision Making. Because of its broader significance to the discipline, the journal's editors are highlighting the study as the lead article for that issue.
Lead researcher Dr. Alvin I. Mushlin is the Nanette Laitman Distinguished Professor and Chair of the Department of Public Health at Weill Cornell Medical College, as well as Public Health Physician-in-Chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
He noted that we still know little about the psychological impact of diagnostic testing on patients.
"It's a relatively unexplored area of medicine," he said.
In this prospective cohort study, one of the largest to date on the subject, researchers tracked the attitudes of 320 patients referred for treadmill stress testing by 44 different primary-care practices in the Rochester, NY, area. The patients, who averaged 56 years of age, had all come to their doctors with chest pain or other symptoms suggestive of coronary artery disease.
Using methods that gauged patient levels of physical pain, anxiety, uncertainty, and views on the future (i.e., expectations regarding lifespan), the researchers measured each patient's attitudes toward the stress test and their own sense of uncertainty about their health – both before the test and then one week later.
The result: "There appears to be a real psychological benefit to testing in terms of reassurance and a decline in patient uncertainty," Dr. Mushlin said.
In general, patients were less worried following the stress test, their symptoms bothered them less than before testing, and they revised their estimate of their expected lifespan a little bit upward, based on the test results.
"Part of this overall benefit came from the fact that people who didn't end up having CAD outnumbered those who tested positive for the condition," Dr. Mushlin noted. "But, on the other hand, we didn't find any diagnosis-related psychological harm when people tested positive for CAD, either. In fact, there was an indication that these people were at least relieved to know exactly what it was they had."
Previous research conducted by the same team has hinted that the psychological boost provided by testing may also impel some patients to engage in healthy lifestyle change, although the researchers cautioned that more study is needed to confirm that.
Dr. Kern explained that this study is different from, and adds to, the few other studies that have measured the value of diagnostic information to patients with suspected heart disease. This study included patients who were actually referred for testing during the course of their regular medical care, involved a larger sample size, and included more detailed and specific measurements than other studies.
Dr. Mushlin emphasized, "If these findings are confirmed, then the methods we used here should be applied to other evaluations focused on a wide range of diagnostic tests."
Testing for the more subtle psychological benefits of stress tests, cancer screening, and other common diagnostic interventions is important, Dr. Mushlin explained, because the potential benefit of test results for a patient's state of mind have long been overlooked by clinicians and policymakers.
"In order to develop intelligent cost-containment measures and for guidelines to be broadly accepted, it's important to understand and factor in all perspectives. Interventions that look right now like they might not be cost-effective, in terms of patient benefit, may turn out to be very cost-effective when we include these emotional factors in the mix," he said.
Funding for this study was provided by a grant from the Agency for Health Care Policy and Research of the Department of Health and Human Services.
Co-researchers included Mary Paris, MPH; David R. Lambert, MD; and Geoffrey Williams, MD, PhD – all from the University of Rochester.