Stakeholder-Engaged Measure Development for Pediatric Obstructive Sleep-Disordered Breathing: The Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents

Surgeon Information-Sharing, Parent Verbal Engagement, and Parent Knowledge of Pediatric Adenotonsillectomy

OBJECTIVE

We characterize clinician information-sharing and parent verbal engagement during pediatric adenotonsillectomy consultations and evaluate whether these behaviors relate to disease-specific knowledge for parents of children with obstructive sleep-disordered breathing (OSDB).

STUDY DESIGN

Mixed-methods sequential explanatory analysis.

SETTING

Outpatient otolaryngology clinics.

METHODS

We analyzed audio-recorded communication during outpatient encounters for children undergoing initial evaluation for adenotonsillectomy. We identified discrete triadic instances of clinician discussion of individual risks and benefits, parent verbal responses coded as passive ("Right") or active ("Would that repeat the recovery time?"), and corresponding parent answer (correct or incorrect) on a postconsult knowledge questionnaire. Primary outcomes included parent knowledge and decisional conflict. We qualitatively analyzed substantive questions asked by parents during the encounter.

RESULTS

In 30 consults, clinicians (n = 8) provided 156 instances of discussion (101 risk, 55 benefit), to which parents provided 34% active responses. Clinician discussion of risks and benefits was associated with greater parent knowledge (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.25-6.09; P < .001), however parent active engagement was not associated with greater parent knowledge (OR = 1.04, 95% CI: 0.42-2.58, P = .93). Parents demonstrated greater knowledge of benefits than risks (χ2  = 23.16, V = 1.13; P < .001). Parents who responded actively (OR = 0.26, 95% CI: 0.09-0.72; P = .010) or had greater knowledge (OR = 0.41, 95% CI: 0.21-0.81; P = .010) had less decisional conflict.

CONCLUSION

Clinician information-sharing was associated with greater parent knowledge about OSDB treatment. Greater parent engagement and knowledge were independently associated with less decisional conflict. These findings may inform clinicians' approaches to counseling and engaging parents in decisions for surgery.

Identifying barriers to obstructive sleep-disordered breathing care: Parental perspectives

OBJECTIVE

Despite established clinical practice guidelines for pediatric obstructive sleep-disordered breathing (SDB), disparities persist for this common condition. Few studies have investigated parental experiences about challenges faced in obtaining SDB evaluation and tonsillectomy for their children. To better understand parent-perceived barriers to treatment of childhood SDB, we administered a survey to assess parental knowledge of this condition.

MATERIALS & METHODS

A cross-sectional survey was designed to be completed by parents of children diagnosed with SDB. Two validated surveys were administered: 1) Barriers to Care Questionnaire and 2) Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. Logistic regression modeling was performed to assess for predictors of parental barriers to SDB care and knowledge.

RESULTS

Eighty parents completed the survey. Mean patient age was 7.4 ± 4.6 years, and 48 (60%) patients were male. The survey response rate was 51%. Patient racial/ethnic categories included 48 (60.0%) non-Hispanic White, 18 (22.5%) non-Hispanic Black, and 14 (17.5%) Other. Parents reported challenges in the 'Pragmatic' domain, including appointment availability and cost of healthcare, as the most frequently described barrier to care. Adjusting for age, sex, race, and education, parents in the middle-income bracket ($26,500 - $79,500) had higher odds of reporting greater barriers to care than parents in the highest (>$79,500) income tier (OR 5.536, 95% CI 1.312-23.359, P = 0.020) and lowest income tier (<$26,500) (OR 3.920, 95% CI 1.096-14.020). Parents whose children had tonsillectomy (n = 40) answered only a mean 55.7% ± 13.3% of questions correctly on the knowledge scale.

CONCLUSION

Pragmatic challenges were the most encountered barrier that parents reported in accessing SDB care. Families in the middle-income tier experienced the greatest barriers to SDB care compared to lower and higher income families. In general, parental knowledge of SDB and tonsillectomy was relatively low. These findings represent potential areas of improvement to target interventions to promote equitable care for SDB.

Development of a Decision Aid for Parents Who Elect Tonsillectomy for Obstructive Sleep Apnea

OBJECTIVE

To develop a novel patient decision aid (PtDA) for parents considering tonsillectomy for their children diagnosed with obstructive sleep apnea (OSA) and compare it to validated scales related to decision making in this context. These included scales for decisional conflict (DC) and shared decision making (SDM).

METHODS

A parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic was conducted comparing a validated Decisional Conflict Scale (DCS) with a new PtDA that included an SDM scale, parental treatment goals, and knowledge about adenotonsillectomy and OSA. DCS scores range from 0 to 100 with values less than 25 considered to be low DC. The DQ was determined by a score on the PtDA. The PtDA was composed of a knowledge score, SDM score and 5 related values scored along a continuum (these were: resolution of symptoms, avoiding anesthesia, avoiding surgery, avoiding pain/bleeding, and resumption of normal behavior). A high score meant that all answers were consistent with choosing tonsillectomy and imply better DQ.

RESULTS

A total of 89 parents or guardians participated in the study. The mean DC score was 4.32 (95% CI: 2.57-6.07). The mean DQ score was 22.69 (95% CI: 21.86-23.51). Mean values score was 5.35 (95% CI: 5.05-5.65). The mean knowledge score was 9.00 (95% CI: 8.60-9.40). SDM score mean was 8.38 (95% CI: 7.85-8.91). Using Spearman's rho, DC versus DQ inversely correlated with a coefficient -.209 via a 2-tailed test (P = .05). Cronbach's alpha for the DQ score was .78.

CONCLUSION

DC scores overall were low for the group. DQ, as measured with the novel PtDA, had an inverse correlation with DC scores, suggesting validity of the proposed PtDA. Our instrument has potential use as a PtDA for parents who are offered tonsillectomy for their children.

Assessment of Parental Choice Predisposition for Tonsillectomy in Children

Importance

The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known.

Objective

To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication.

Design, Setting, and Participants

Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist.

Main Outcomes and Measures

The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents).

Results

A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34).

Conclusions and Relevance

In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Pediatric Sleep Tools: An Updated Literature Review

Since a thorough review in 2011 by Spruyt, into the integral pitfalls of pediatric questionnaires in sleep, sleep researchers worldwide have further evaluated many existing tools. This systematic review aims to comprehensively evaluate and summarize the tools currently in circulation and provide recommendations for potential evolving avenues of pediatric sleep interest. 144 "tool"-studies (70 tools) have been published aiming at investigating sleep in primarily 6-18 years old per parental report. Although 27 new tools were discovered, most of the studies translated or evaluated the psychometric properties of existing tools. Some form of normative values has been established in 18 studies. More than half of the tools queried general sleep problems. Extra efforts in tool development are still needed for tools that assess children outside the 6-to-12-year-old age range, as well as for tools examining sleep-related aspects beyond sleep problems/disorders. Especially assessing the validity of tools has been pursued vis-à-vis fulfillment of psychometric criteria. While the Spruyt et al. review provided a rigorous step-by-step guide into the development and validation of such tools, a pattern of steps continue to be overlooked. As these instruments are potentially valuable in assisting in the development of a clinical diagnosis into pediatric sleep pathologies, it is required that while they are primary subjective measures, they behave as objective measures. More tools for specific populations (e.g., in terms of ages, developmental disabilities, and sleep pathologies) are still needed.

Decision Quality Among Parents Who Are Offered Ventilation Tube Insertion for Their Children

Objective:

To develop a Decision Quality (DQ) tool to measure parents’ DQ concerning ventilation tube (VT) insertion in their children.

Method:

Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT.

Results:

Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman’s rho for DQ score versus DC score was −0.458, P < .001.

Conclusions:

DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.

Parental health literacy in pediatric otolaryngology: A pilot study

OBJECTIVES

Pediatric otolaryngology bears the highest frequency of elective surgical cases in children, but little is known regarding the health literacy of these children's parents. In a questionnaire-based pilot study, we assessed parental health literacy in our pediatric otolaryngology clinic and evaluated its relation to personal demographics. We also evaluated postoperative and diagnosis-based leaflets for readability using validated measures.

METHODS

Parents completed the Short Assessment of Health Literacy-English (SAHL-E) and were defined as low (0-14) or high (>14) literacy based on mean scores.

RESULTS

Fifty parents participated (mean SAHL-E score, 17.6), and all scored >14, indicating proficient health literacy. No differences existed in mean or median scores based on demographics. Continued education after high school was associated with higher scores (P = 0.003) and was the only significant variable in multivariable linear regression. All leaflets were at or below the recommended reading level for public health information.

CONCLUSIONS

Parents generally had high health literacy.

Evaluation of Parental Perspectives and Concerns About Pediatric Tonsillectomy in Social Media

Importance

Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgical procedure. Twitter offers an opportunity to evaluate parental understanding and experience of tonsillectomy care.

Objective

To identify parental perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter.

Design, Setting, and Participants

In this qualitative study, social media platform Twitter was searched for posts (tweets) published between January 1, 2008, and December 31, 2017, by US-based parents about their child's tonsillectomy. Modified grounded theory was applied to develop a coding taxonomy to classify the tweets. Tweets were assessed for thematic synthesis and classification, and descriptive statistics were obtained for each theme.

Main Outcomes and Measures

Themes of parental experiences and perspectives about their child's tonsillectomy.

Results

Of the 5801 total tweets retrieved, 782 (13.5%) satisfied the inclusion criteria. Tweets were categorized under 2 overarching themes: procedural concerns (549 tweets [70.2%]) and attitudes or experiences (498 [63.7%]). Common tweets under procedural concerns mentioned surgical indication for tonsillectomy (55 tweets [7.0%]); eg, "strep-I think it's tonsil removing time…") and recovery (227 tweets [29.0%]), including child's attitude (89 tweets [11.4%]; eg, "so hard to get my daughter to eat") and parental experience (87 tweets [11.1%]; eg, "tonsillectomy recovery sucks for the parent as much as the kid!"). Common tweets regarding attitudes or experiences included the tenor of overall care (225 tweets [28.6%]; eg, "Tonsillectomy is a bear") and fears or apprehensions (209 tweets [26.6%]).

Conclusions and Relevance

These social media findings may be used to guide clinicians in educating and counseling parents as well as further engaging parents and children in shared decision making for tonsillectomy.