Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis

Parental decision making involvement and decisional conflict: a descriptive study

Background

Decisional conflict is a state of uncertainty about the best treatment option among competing alternatives and is common among adult patients who are inadequately involved in the health decision making process. In pediatrics, research shows that many parents are insufficiently involved in decisions about their child’s health. However, little is known about parents’ experience of decisional conflict. We explored parents’ perceived decision making involvement and its association with parents’ decisional conflict.

Method

We conducted a descriptive survey study in a pediatric tertiary care hospital. Our survey was guided by validated decisional conflict screening items (i.e., the SURE test). We administered the survey to eligible parents after an ambulatory care or emergency department consultation for their child.

Results

Four hundred twenty-nine respondents were included in the analysis. Forty-eight percent of parents reported not being offered treatment options and 23% screened positive for decisional conflict. Parents who reported being offered options experienced less decisional conflict than parents who reported not being offered options (5% vs. 42%, p < 0.001). Further, parents with options were more likely to: feel sure about the decision (RR 1.08, 95% CI 1.02–1.15); understand the information (RR 1.92, 95% CI 1.63–2.28); be clear about the risks and benefits (RR 1.12, 95% CI 1.05–1.20); and, have sufficient support and advice to make a choice (RR 1.07, 95% CI 1.03–1.11).

Conclusion

Many parents in our sample experienced decisional conflict after their clinical consultation. Involving parents in the decision making process might reduce their risk of decisional conflict. Evidence based interventions that support parent decision making involvement, such as shared decision making, should be evaluated and implemented in pediatrics as a strategy to reduce parents’ decisional conflict.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0899-4) contains supplementary material, which is available to authorized users.

Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices

BACKGROUND

Randomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow. We sought to develop and reliably implement a decision aid for treatment of children with juvenile idiopathic arthritis.

METHODS

To design our decision aid, we partnered with patient, parent, and clinician stakeholders from the Pediatric Rheumatology Care and Outcomes Improvement Network. Six sites volunteered to use quality improvement methods to implement the decision aid. Four of these sites collected parent surveys following visits to assess outcomes. Parents reported on clinician use of the decision aid and the amount of shared decision making and uncertainty they experienced. We used chi-square tests to compare eligible visits with and without use of the decision aid on the experience of shared decision making and uncertainty.

RESULTS

After 18 rounds of testing and revision, stakeholders approved the decision aid design for regular use. Qualitative feedback from end-users was positive. During the implementation project, the decision aid was used in 35% of visits where starting or switching medication was discussed. Clinicians used the decision aid as intended in 68% of these visits. The vast majority of parents reported high levels of shared decision making following visits with (64/76 = 84%) and without (80/95 = 84%) use of the decision aid (p = 1). Similarly, the vast majority of parents reported no uncertainty following visits with (74/76 = 97%) and without (91/95 = 96%) use of the decision aid (p = 0.58).

CONCLUSIONS

Although user acceptability of the decision aid was high, reliable implementation in routine clinical care proved challenging. Our parsimonious approach to outcome assessment failed to detect a difference between visits with and without use of our aid. Innovative approaches are needed to facilitate use of decision aids and the assessment of outcomes.

Identifying a conceptual shift in child and adolescent-reported treatment decision making: "Having a say, as I need at this time"

BACKGROUND

Professional organizations and governments recommend child and adolescent involvement in cancer treatment decision making (TDM) despite minimal evidence that children prefer involvement, how best to include them, and the result of doing so.

PROCEDURE

Using descriptive qualitative research methods, we interviewed 20 children ages 9-17 years about their TDM preferences and experiences. We shifted our conceptualizations as findings emerged about how children with cancer viewed their decisional experiences. Results from constant comparative analysis of participant interviews yielded a new construct, "Having a say, as I need at this time" ('Having a Say'), which focuses more broadly on child communication preferences and the dynamism of those preferences. Ten additional interviews confirmed 'Having a Say' results.

RESULTS

Children's contextually related 'Having a Say' preferences ranged from not wanting to hear information at this time, to being included in treatment discussions, to choosing a treatment option. Children reported both positive and negative effects of being involved (or not) in treatment discussions as they preferred. Children's preferences assumed the presence and involvement of their parents and doctors. Illness conditions (e.g., stage of treatment; symptom distress) informed child communication preferences more so than the child's age.

CONCLUSIONS

The 'Having a Say' construct challenges the dominant shared TDM paradigm, which presumes it is best to involve children in their treatment decisions. 'Having a Say' is both a developmental and conceptual fit for children that can inform future research to develop and test clinical care approaches to meet child and adolescent communication needs.

A Pilot Randomized Trial of a Video Patient Decision Aid to Facilitate Early Intervention Referrals From Primary Care

Many young children identified with developmental concerns in pediatric settings do not receive early intervention (EI). We assessed the impact of a video decision aid and text message reminder on knowledge and attitudes regarding developmental delay and EI as well as referral completion. We conducted a pilot randomized controlled trial in an urban setting and enrolled 64 parent-child dyads referred to EI. Compared with controls, participants who received the intervention demonstrated increased knowledge regarding developmental delay and EI as well as more favorable attitudes in certain topics. Although we did not find a significant difference between arms in EI intake and evaluation, we found a pattern suggestive of increased intake and evaluation among participants with low health literacy in the intervention arm. Additional study is needed to identify strategies that improve the EI referral process for families and to understand the potential targeted role for decision aids and text messages.

High Levels of Decisional Conflict and Decision Regret When Making Decisions About Biologics

OBJECTIVES

The aim of the study was to understand the association between parents' perceptions of the decision process and the decision outcomes in decisions about the use of biologics in pediatric chronic conditions.

METHODS

We mailed surveys to parents of children with inflammatory bowel disease or juvenile idiopathic arthritis who had started treatment with biologics in the prior 2 years and were treated at either of 2 children's hospitals. The survey included measures of the decision process, including decision control and physician engagement, and decision outcomes, including conflict and regret. We used means and frequencies to assess the response distributions. General linear models were used to test the associations between decision process and decision outcomes.

RESULTS

We had 201 respondents (response rate 54.9%). Approximately 47.0% reported using shared decision making. Each physician engagement behavior was experienced by the majority of parents, with the highest percentage reporting that their child's physician used language they understood and listened to them. Approximately 48.5% of parents had decisional conflict scores of 25 or greater, indicating high levels of conflict. Approximately 28.2% had no regret, 31.8% had mild regret, and the remaining 40.0% had moderate to severe regret. Shared decision making was not associated with improved decisional conflict, but physician engagement behaviors were associated with both decisional conflict and regret.

CONCLUSIONS

Improving decision outcomes will require more than just focusing on who parents perceive as controlling the final decision. Developing interventions that facilitate specific physician engagement behaviors may decrease parents' distress around decision making and improve decision outcomes.

Development and Testing of Shared Decision Making Interventions for Use in Emergency Care: A Research Agenda

Decision aids are evidenced-based tools designed to increase patient understanding of medical options and possible outcomes, facilitate conversation between patients and clinicians, and improve patient engagement. Decision aids have been used for shared decision making (SDM) interventions outside of the ED setting for more than a decade. Their use in the ED has only recently begun to be studied. This article provides background on this topic and the conclusions of the 2016 Academic Emergency Medicine consensus conference SDM in practice work group regarding "Shared Decision Making in the Emergency Department: Development of a Policy-Relevant, Patient-Centered Research Agenda." The goal was to determine a prioritized research agenda for the development and testing of SDM interventions for use in emergency care that was most important to patients, clinicians, caregivers, and other key stakeholders. Using the nominal group technique, the consensus working group proposed prioritized research questions in six key domains: 1) content (i.e., clinical scenario or decision area), 2) level of evidence available, 3) tool design strategies, 4) risk communication, 5) stakeholders, and 6) outcomes.

Barriers to and facilitators of implementing shared decision making and decision support in a paediatric hospital: A descriptive study

OBJECTIVE

To explore multiple stakeholders' perceived barriers to and facilitators of implementing shared decision making and decision support in a tertiary paediatric hospital.

METHODS

An interpretive descriptive qualitative study was conducted using focus groups and interviews to examine senior hospital administrators', clinicians', parents' and youths' perceived barriers to and facilitators of shared decision making and decision support implementation. Data were analyzed using inductive thematic analysis.

RESULTS

Fifty-seven stakeholders participated. Six barrier and facilitator themes emerged. The main barrier was gaps in stakeholders' knowledge of shared decision making and decision support. Facilitators included compatibility between shared decision making and the hospital's culture and ideal practices, perceptions of positive patient and family outcomes associated with shared decision making, and positive attitudes regarding shared decision making and decision support. However, youth attitudes regarding the necessity and usefulness of a decision support program were a barrier. Two themes were both a barrier and a facilitator. First, stakeholder groups were uncertain which clinical situations are suitable for shared decision making (eg, new diagnoses, chronic illnesses, complex decisions or urgent decisions). Second, the clinical process may be hindered if shared decision making and decision support decrease efficiency and workflow; however, shared decision making may reduce repeat visits and save time over the long term.

CONCLUSIONS

Specific knowledge translation strategies that improve shared decision making knowledge and match specific barriers identified by each stakeholder group may be required to promote successful shared decision making and decision support implementation in the authors' paediatric hospital.

Promoting participation in healthcare situations for children with JIA: a grounded theory study

Children's right to participate in their own healthcare has increasingly become highlighted in national and international research as well as in government regulations. Nevertheless, children's participation in healthcare is unsatisfactorily applied in praxis. There is a growing body of research regarding children's participation, but research from the children's own perspective is scarce. The aim of this study was thus to explore the experiences and preferences for participation in healthcare situations among children with juvenile idiopathic arthritis (JIA) as a foundation for creating strategies to promote their participation in pediatric healthcare. Twenty children, aged 8 to 17 years, with JIA were interviewed individually and in focus groups. In order to increase the children's opportunities to express their own experiences, different interview techniques were used, such as draw-and-tell and role play with dolls. The analysis was conducted with a constructivist grounded theory. The result explores children's perspective of influencing processes promoting their participation in healthcare situations. The core category that emerged was, "Releasing fear and uncertainty opens up for confidence and participation," and the categories related to the core category are, "surrounded by a sense of security and comfort," and "strengthened and supported to become involved." In conclusion, the knowledge gained in this study offers new insights from the perspective of children themselves, and can constitute a valuable contribution to the understanding of necessary conditions for the development of specific interventions that promote participation among children in healthcare situations.

Consideration of Insulin Pumps or Continuous Glucose Monitors by Adolescents With Type 1 Diabetes and Their Parents: Stakeholder Engagement in the Design of Web-Based Decision Aids

PURPOSE

This article describes the stakeholder-driven design, development, and testing of web-based, multimedia decision aids for youth with type 1 diabetes who are considering the insulin pump or continuous glucose monitoring and their parents. This is the initial phase of work designed to develop and evaluate the efficacy of these decision aids in promoting improved decision-making engagement with use of a selected device.

METHODS

Qualitative interviews of 36 parents and adolescents who had previously faced these decisions and 12 health care providers defined the content, format and structure of the decision aids. Experts in children's health media helped the research team to plan, create, and refine multimedia content and its presentation. A web development firm helped organize the content into a user-friendly interface and enabled tracking of decision aid utilization. Throughout, members of the research team, adolescents, parents, and 3 expert consultants offered perspectives about the website content, structure, and function until the design was complete.

RESULTS

With the decision aid websites completed, the next phase of the project is a randomized controlled trial of usual clinical practice alone or augmented by use of the decision aid websites.

CONCLUSIONS

Stakeholder-driven development of multimedia, web-based decision aids requires meticulous attention to detail but can yield exceptional resources for adolescents and parents contemplating major changes to their diabetes regimens.

Clarifying the Predictive Value of Family-Centered Care and Shared Decision Making for Pediatric Healthcare Outcomes Using the Medical Expenditure Panel Survey

OBJECTIVES

To estimate (1) family-centered care (FCC) and shared decision-making (SDM) prevalence, and (2) associations of FCC and SDM (FCC/SDM) with health care outcomes among U.S. children.

DATA SOURCE

The Medical Expenditure Panel Survey Household Component (MEPS-HC), a nationally representative survey of the noninstitutionalized, civilian population.

STUDY DESIGN

Secondary analyses of prospectively collected data on 15,764 U.S. children were conducted to examine FCC/SDM prevalence in year 1 and associations of FCC/SDM in year 1 with health services utilization, medical expenditures, and unmet health care needs in year 2.

DATA COLLECTION/EXTRACTION METHODS

We combined four MEPS-HC longitudinal files from 2007 to 2011.

PRINCIPAL FINDINGS

FCC/SDM prevalence in year 1 varied from 38.6 to 93.7 percent, and it was lower for composites with more stringent scoring approaches. FCC/SDM composites with stringent scoring approaches in year 1 were associated with reduced unmet needs in year 2. FCC/SDM, across all year 1 composites, was not associated with health services utilization or medical expenditures in year 2. FCC/SDM year 1 subcomponents describing consensus building and mutual agreement were consistently associated with unmet health care needs in year 2.

CONCLUSIONS

FCC/SDM composites with stringent scoring approaches measuring consensus building and mutual agreement may have the greatest utility for pediatric health care quality improvement efforts.

Pediatric Resident Preparedness and Educational Experiences With Informed Consent

OBJECTIVE

Informed consent is an essential component of optimal patient care. Scant data exist about pediatric residents' experiences, comfort level, and educational exposure to informed consent discussions.

METHODS

Electronic survey of a random selection of members of the American Academy of Pediatrics Section for Medical Students, Residents, and Fellows regarding consent practices and processes for 5 commonly encountered pediatric procedures/situations: lumbar puncture, neonatal central line, pediatric sedation, intubation, and administration of blood products.

RESULTS

Overall response rate was 34.7% (1071 participants of 3084 invited). Responses from 622 active categorical pediatric residents were analyzed. Almost all respondents (99%) endorsed the importance of informed consent for best patient care. Observation was the most frequently reported educational modality. Over 90% had obtained consent for lumbar puncture and blood products but only 27.6% for intubation. Between 9% and 31% of respondents reported obtaining consent for specific procedures in which they were not expected to actively participate. Depending on the procedure, a variable number of respondents reported not feeling prepared to discuss the benefits (1-23%) or risks (2-31%) of these procedures with patients and/or parents. Respondents felt significantly less prepared to discuss risks (P < .05 for each procedure).

CONCLUSIONS

A significant percentage of respondents reported not feeling comfortable with discussing key components of informed consent. A minority of respondents reported being engaged in obtaining consent for procedures in which they are not expected to actively participate. Best practices for resident involvement in informed consent discussions need to be defined and incorporated into resident education.

Concordance of Expert and Parental Opinion about Hypospadias Surgical Outcome Is Severity Dependent

INTRODUCTION

Hypospadias is a male congenital condition where the opening of the urethral meatus is not located in the typical anatomical position. It has been a challenge for empirical studies to ascertain the level of concordance of opinion among parents and urologists with regard to surgical outcomes according to hypospadias severity.

MATERIALS AND METHODS

Parents of children who had undergone hypospadias repair were recruited for this study (n = 104). A set of questionnaires that included some items with Likert scale were created to evaluate postsurgical satisfaction by parents and urologists. SAHLSA-50, a validated instrument for adult Spanish-speaking adults, was used to assess health literacy. Cohen's kappa (κ) coefficient was used to assess interobserver agreement and Chi Square "Goodness of Fit" Test was used to determine probability of satisfaction.

FINDINGS

Concordance on the level of satisfaction with surgical outcomes for Type cases I was slight (κ = 0.20; CI 95% 0-0.60), for Type II cases was moderate (κ = 0.54; CI 95% 0.13-0.94), and for Type III cases was substantial (κ = 0.62; CI 95% 0-0.56). However, the probability of satisfaction did not change according to severity (Chi Square "Goodness of Fit" Test; parents, p = 0.84; pediatric urologists, p = 0.92). These results cannot be explained by parental health literacy according to SAHLSA-50 test scores.

CONCLUSION

The level of concordance of opinion among parents and urologists with regard to their level of satisfaction with surgical outcomes is related to hypospadias severity, whereby the greatest level of concordance of opinion was achieved among most severe cases. This study underscores the need for longer follow-up to properly assess satisfaction with hypospadias repair, especially for the less severe forms of the condition.