Treating childhood intermittent distance exotropia: a qualitative study of decision making

Family risk communication preferences in pediatric surgery: A scoping review

BACKGROUND

Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

METHODS

A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

RESULTS

A total of 6370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

CONCLUSION

Eliciting families' preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

LEVEL OF EVIDENCE

Level IV (Scoping Review).

Shared Decision Making in Ophthalmology: A Scoping Review

PURPOSE

Shared decision making (SDM) has been associated with improved patient satisfaction and outcomes in both medical and surgical specialties, but its role in ophthalmology has not been systematically examined. Using a scoping review of the literature, the purpose of this study was to explore the characteristics, implementation, and outcomes of SDM in ophthalmology.

DESIGN

Scoping review of the literature.

METHODS

Searches were conducted in PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through August 2021 for SDM in ophthalmology. The resulting 1602 studies were screened by 2 independent reviewers with 57 full-text articles examined for inclusion of an ophthalmologic diagnosis, as well as discussion of SDM or patient decision aids. Nineteen studies were eligible and qualitatively coded for 11 predetermined codes, which included patient outcomes, patient and physician requests for SDM, and methods of implementation.

RESULTS

Of 19 included studies, all emphasized the value of SDM for ophthalmology and 2 studies reported improved patient outcomes. The most commonly examined topics were chronic ophthalmic diseases, such as cataracts and glaucoma. Limitations to SDM implementation were also universally discussed, including patients' lack of disease knowledge, communication barriers, and time restrictions. Although patient decision aids are an effective tool to mitigate these limitations, these have only been established for the subjects of cataracts and glaucoma.

CONCLUSION

SDM is a methodology for patient-centered care that is regarded as a potentially useful tool in the field of ophthalmology. However, significant barriers exist to its effective implementation. Evidence-based research on if and how these barriers should be attenuated, as well as the development of additional patient decision aids for different ophthalmic diseases, are needed.

Shared decision making and patients satisfaction with strabismus care-a pilot study

BACKGROUND

Strabismus is a complex disease that has various treatment approaches each with its own advantages and drawbacks. In this context, shared decisions making (SDM) is a communication process with the provider sharing all the relevant treatment alternatives, all the benefits, and risks of each procedure, while the patient shares all the preferences and values regarding his/her choices. In that way, SDM is a bidirectional process that goes beyond the typical informed consent. Therefore, it is known a little of the extent to which SDM influences the satisfaction with the treatment outcome along with strabismus patients. To study this correlation, an SDM-Q-9 questionnaire was provided within surgical consultations where treatment decisions were made; the SDM-Q-9 aims to assess the relationship between the post-operative patient's satisfaction and their SMD score.

METHODS

The study is considered a prospective observational pilot study. Eligible patients were adult patients diagnosed with strabismus, who had multiple treatment options, were given at the right of choice without being driven into a physician's preference. Ninety-three strabismus patients were asked to fill out the SDM-Q-9 questionnaire related to their perception of SDM during the entire period of strabismus treatment. After the treatment, patients were asked to rate their satisfaction level with the surgical outcome as excellent, good, fair, and poor. Descriptive statistics and the linear regression statistical tests (Spearman, Mann Whitney U, and Kriskal-Wallis) were used as analysis tools.

RESULTS

The average age of the participants was 24, where 50.6% were women. The mean SDM-Q-9 score among patients was 32 (IQR = 3). The postoperative patient satisfaction was rated as being excellent by 16 (17.2%) patients, good by 38 (40.9%), fair by 32 (34.4%), and poor by 7 patients (7.5%). Data analysis by linear regression statistical tests showed a positive correlation between the SDM-Q-9 score and the patient satisfaction related to the surgery outcome (B = 0.005, p < 0.001). Criteria in assessing patients' satisfaction were age, gender, and strabismus type. A positive correlation between SDM and real satisfaction (r = 0.834, p < 0.01) was found with age, and no significant relationship was found while taking into consideration the responder's gender and the strabismus type.

CONCLUSIONS

Assessing patient satisfaction after choosing a treatment for strabismus method helped us evaluate the gaps in constructive dialogue that would lead to a positive outcome for both patient and clinician. The correlation between the SDM process and the patients' satisfaction with surgery outcome, adjusted by age, has been established. These findings can serve as a springboard to further communicative improvements related to the SDM process and between patients and physicians, thereby consequently leading to patients' satisfaction raise in strabismus care. The study underlines the importance of further analysis and validation of on-ground interactions among the adolescent and adult patients and the clinicians across the strabismus management trajectory. A multicentral study and its validation will follow.

Schielen oder nicht Schielen? – Strabismus divergens intermittens, eine besondere Schielform

Hintergrund

Schielen tritt bei ca. 5–7 % der gesunden Kinder auf. Außenschielen ist mit 1,24 % weltweit seltener als Innenschielen. Der Strabismus divergens intermittens stellt mit 40–90 % die häufigste divergente Schielform dar. Das klinische Bild wurde von vielen AutorInnen beschrieben. Dennoch stellt es durch die Variabilität der Befunde eine therapeutische Herausforderung dar.

Material und Methode

Es wurden im Rahmen einer Literaturrecherche die Ergebnisse von Studien zum Strabismus divergens intermittens mit Fokus auf klinisches Bild, Untersuchungskriterien und Therapieansätze gesammelt und die Ergebnisse dargestellt.

Resultate

Der Strabismus divergens intermittens zeichnet sich durch eine besondere Binokularsituation und bisher ursächlich nicht vollends geklärte Symptome (Photophobie, Kneifen) aus. Konservative Therapien dienen der Entlastung des visuellen Systems, in vielen Fällen ist aber eine Schieloperation nötig. In der präoperativen Beurteilung ist der Stabilität des Schielwinkels besonderes Augenmerk zu schenken, als Entscheidungshilfe hinsichtlich Schieloperation hat sich der New Castle Control Score bewährt.

Schlussfolgerung

Die klinischen Charakteristika des Strabismus divergens intermittens sind klar beschrieben. Hinsichtlich therapeutischer Ansätze zeigen sich im internationalen Vergleich Unterschiede. Die Bedeutung der Einbeziehung der Eltern („shared decision making“) bei der Beurteilung der Schielhäufigkeit und bei der Operationsentscheidung ist zu betonen.

Associations of Eye-Related Quality of Life With Vision, Visuomotor Function, and Self-Perception in Children With Strabismus and Anisometropia

Purpose

To evaluate associations between eye-related quality of life (ER-QOL) assessed by the Child Pediatric Eye Questionnaire (Child PedEyeQ) and functional measures (vision, visuomotor function, self-perception) in children with strabismus, anisometropia, or both. Our hypothesis was that children with functional deficits would have lower ER-QOL, and if so, these associations would support the convergent construct validity of the Child PedEyeQ.

Methods

We evaluated 114 children (ages 5-11 years) with strabismus, anisometropia, or both. Each child completed the Child PedEyeQ to assess four Rasch-scored domains of ER-QOL: Functional Vision, Bothered by Eyes/Vision, Social, and Frustration/Worry. In addition, children completed one or more functional tests: visual acuity (n = 114), Randot Preschool Stereoacuity (n = 92), contrast balance index (suppression; n = 91), Readalyzer reading (n = 44), vergence instability (n = 50), Movement Assessment Battery for Children-2 manual dexterity (n = 57), and Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (n = 44).

Results

Child PedEyeQ Functional Vision domain scores were correlated with self-perception of physical competence (rs = 0.65; 95% confidence interval [CI], 0.35-0.96) and reading speed (rs = 0.47; 95% CI, 0.16-0.77). Bothered by Eyes/Vision domain scores were correlated with self-perception of physical competence (rs = 0.52; 95% CI, 0.21-0.83). Moderate correlations were observed between Social domain scores and vergence instability (rs = -0.46; 95% CI, -0.76 to -0.15) and self-perception of physical competence (rs = 0.43; 95% CI, 0.12-0.73) and peer acceptance (rs = 0.49; 95% CI, 0.18-0.80). Frustration/Worry domain scores were moderately correlated with self-perception of physical competence (rs = 0.41; 95% CI, 0.10-0.71) and peer acceptance (rs = 0.47; 95% CI, 0.16-0.77).

Conclusions

Strong and moderate correlations were observed between functional measures and Child PedEyeQ domain scores. These associations provide supporting evidence that the Child PedEyeQ has convergent construct validity.

Comparison Between Parental Observations and Clinical Evaluation Findings in Korean Pediatric Patients With Intermittent Exotropia

PURPOSE

To compare parental observations with the clinical evaluation findings in pediatric patients with intermittent exotropia and evaluate the clinical factors associated with the parental observations.

METHODS

This prospective study included either one or both parents of pediatric patients with intermittent exotropia who visited the clinic between January and May 2019. The parental observations were assessed through a questionnaire that included questions on the age of onset, usually deviated eye, degree of awareness, and frequency of exotropia. These findings were compared with those of the clinical evaluations, including the amount of ocular deviation and level of control.

RESULTS

A total of 100 parents (mean age: 39.7 years; 78 women) of 95 pediatric patients (mean age: 8.2 years; 47 girls) with intermittent exotropia participated in the study. The parental observation and clinical evaluation findings on the usually deviated eye showed good concordance (74%). The degree of parental awareness did not show any association with the amount of deviation. However, it showed a statistically significant increase associated with the worsening level of distance control (P = .04). The parental observations of the frequency of exotropia significantly increased with the worsening of the level of near (P = .037) and overall (P = .019) control.

CONCLUSIONS

Parental observations are more likely to correlate with the level of control than with the amount of ocular deviation in pediatric patients with intermittent exotropia. [J Pediatr Ophthalmol Strabismus. 2020;57(3):199-203.].

Barriers and facilitators of pediatric shared decision-making: a systematic review

BACKGROUND

Shared decision-making (SDM) is rarely implemented in pediatric practice. Pediatric health decision-making differs from that of adult practice. Yet, little is known about the factors that influence the implementation of pediatric shared decision-making (SDM). We synthesized pediatric SDM barriers and facilitators from the perspectives of healthcare providers (HCP), parents, children, and observers (i.e., persons who evaluated the SDM process, but were not directly involved).

METHODS

We conducted a systematic review guided by the Ottawa Model of Research Use (OMRU). We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, PubMed, and PsycINFO (inception to March 2017) and included studies that reported clinical pediatric SDM barriers and/or facilitators from the perspective of HCPs, parents, children, and/or observers. We considered all or no comparison groups and included all study designs reporting original data. Content analysis was used to synthesize barriers and facilitators and categorized them according to the OMRU levels (i.e., decision, innovation, adopters, relational, and environment) and participant types (i.e., HCP, parents, children, and observers). We used the Mixed Methods Appraisal Tool to appraise study quality.

RESULTS

Of 20,008 identified citations, 79 were included. At each OMRU level, the most frequent barriers were features of the options (decision), poor quality information (innovation), parent/child emotional state (adopter), power relations (relational), and insufficient time (environment). The most frequent facilitators were low stake decisions (decision), good quality information (innovation), agreement with SDM (adopter), trust and respect (relational), and SDM tools/resources (environment). Across participant types, the most frequent barriers were insufficient time (HCPs), features of the options (parents), power imbalances (children), and HCP skill for SDM (observers). The most frequent facilitators were good quality information (HCP) and agreement with SDM (parents and children). There was no consistent facilitator category for observers. Overall, study quality was moderate with quantitative studies having the highest ratings and mixed-method studies having the lowest ratings.

CONCLUSIONS

Numerous diverse and interrelated factors influence SDM use in pediatric clinical practice. Our findings can be used to identify potential pediatric SDM barriers and facilitators, guide context-specific barrier and facilitator assessments, and inform interventions for implementing SDM in pediatric practice.

TRIAL REGISTRATION

PROSPERO CRD42015020527.