Shared decision-making in pediatrics: a national perspective

The Barriers to Shared Decision-making in Exercise Prescription for Children With Asthma: A Qualitative Study From Parents' Perspective

INTRODUCTION

The knowledge of barriers from the parental perspective is essential for facilitating shared decision-making in the field of pediatric asthma.

METHOD

Participants who were parents of children with a diagnosis of asthma were recruited, and in-depth, semistructured interviews were conducted. The interview transcripts were analyzed thematically using framework methods.

RESULTS

Seventeen participants undertook interviews. Three themes and nine subthemes emerged: (1) decision-making need level-limited understanding of decision-making knowledge, ambiguity regarding self-empowerment roles, and lack of family member support; (2) decision-making support level-insufficient ability to evaluate information, inefficient communication with health care professionals, and excessive use of professional terminology; and (3) decision-making outcome level-doubts about the final decision-making choices, time constraints on decision-making, and absence of mechanisms to track decisions made.

DISCUSSION

The findings would serve as crucial foundations for the development of decision-aid programs within the context of pediatric asthma.

The causal impact of shared decision making on pain outcomes: Gender matters

This national US study determined the causal impact of shared decision making (SDM) on pain outcomes, including any overall pain and the subcategories of any acute pain and any chronic pain. We additionally examined whether the causal impact of SDM on overall pain is moderated by gender, race-ethnicity, clinician-patient racial-ethnic concordance, and clinician-patient gender concordance. We used national US data from the 2003-2017 Medical Expenditure Panel Survey, which were externally valid to the US national non-institutionalized population, employed a standard measure of shared decision making, and applied an internally-valid two-stage least squares approach that used the peer SDM behavior of similar clinicians as an instrument. The instrument was sufficiently strong and statistically uncorrelated with patient characteristics. We found a large impact of SDM on both female and male chronic pain outcomes, where the effect for females was approximately 50% larger than for males, with a 10 percentage point increase in SDM quality resulted fewer females experiencing chronic pain that interfered with everyday activities (-24.8 percentage points; 95% confidence interval [CI]: 43.3, -6.4) than males (-16.5 percentage points; 95% CI: 32.9, -1.0). We estimated that a 10 percentage point national increase in the SDM index would thus result in 10.1 million fewer females and 5.7 million fewer males in the US experiencing chronic pain that interfered with their daily activities. Policy implications include both increasing the quality of SDM for all patients and educating male patients on the value of SDM.

Correlates of perceived shared decision making with parents of children with special healthcare needs: Findings from the PART-CHILD study

OBJECTIVE

To assess the extent of perceived shared decision making (SDM) with parents of pediatric patients and to examine its association with characteristics of patients, professionals, and healthcare facilities.

METHODS

Parents of pediatric patients (n = 4383) were recruited in 15 social pediatric centers in Germany and provided information on perceived SDM (binary CollaboRATEpediatric score: optimal versus suboptimal extent of SDM), child age and sex, type of impairment, appointment, and healthcare professional present at the appointment. Organizational characteristics were assessed in a cross-sectional survey of staff at the study sites.

RESULTS

Overall, 58.4% of parents reported an optimal extent of SDM. The optimal extent of SDM was more likely reported by parents of girls (OR=1.27, p < 0.001) and children with physical (as opposed to cognitive and combined) impairments (OR=1.30, p = 0.006), and after appointments attended by allied health professionals (OR=1.28, p = 0.004). In addition, parents in facilities receiving financing in addition to compensation by statutory health insurance funds were less likely to report an optimal extent of perceived SDM.

CONCLUSION

While SDM with parents was mostly related to individual characteristics of children and professionals at appointments, organizational characteristics seemed less relevant in our study.

PRACTICE IMPLICATIONS

Staff should be made aware of lower SDM with parents of boys, older children, and those with cognitive impairments, and trained to improve the SDM in these groups.

Shared decision-making in psoriasis care: Evaluation of how patients' perception of clinicians' delivery of care changes by age and sex

BACKGROUND

Shared decision-making (SDM) refers to a collaborative process in which clinicians assist patients in making medically informed, evidence-based decisions that align with their values and preferences. There is a paucity of literature on SDM in dermatology.

OBJECTIVE

We aim to assess whether male and female psoriasis patients evaluate their clinicians' engagement in SDM differently across different age groups.

METHODS

Cross-sectional study using data from the 2014-2017 and 2019 Medical Expenditure Panel Surveys (MEPS).

RESULTS

A weighted total of 7,795,608 psoriasis patients were identified. SDM Scores ranged from 1 to 4, with 4 representing the most favorable patient evaluation of their clinicians' engagement in SDM. We conducted multivariate linear regression to compare mean SDM Scores in male psoriasis patients versus female psoriasis patients across different patient age groups. Female patients ages 60-69 perceived significantly greater clinician engagement in SDM compared to age-matched male patients (female patient perception of SDM 3.65 [95%CI:3.61-3.69] vs. male patient perception of SDM 3.50 [95%CI:3.43-3.58], p<0.005). The same trend of older female patients evaluating their clinicians' engagement in SDM significantly higher than their age-matched male counterparts exists for the age group >70 (p<0.005). No significant differences between male and female patients' evaluations of their clinicians' engagement in SDM were demonstrated in subjects younger than 60. All calculations were adjusted for demographic and clinical factors.

CONCLUSIONS

Compared to older male psoriasis patients, older female psoriasis patients evaluated their clinicians to be more engaged in shared decision-making.

Shared decision-making and satisfaction with care in patients with psoriasis: A population-based study in the United States

BACKGROUND

Shared decision-making (SDM) is a critical component of the patient-physician relationship. Although SDM has been reported to improve patient knowledge in other fields, it is still relatively unknown in dermatology.

OBJECTIVE

To determine the association between SDM and satisfaction with care among patients with psoriasis.

METHODS

Cross-sectional study using data from the 2014 to 2017 and 2019 Medical Expenditure Panel Survey.

RESULTS

A weighted total of 3,715,027 patients with psoriasis were identified. The average SDM score was 3.6 (of 4), and the average satisfaction with care score was 8.6 (of 10). Approximately 42% of the cohort reported having a high SDM (score, ≥3.9). Patients who had high SDM had, on average, 85% higher satisfaction with care (P < .001) after adjusting for covariates.

LIMITATIONS

The results of our study should be interpreted within the context of the Medical Expenditure Panel Survey database. The ability to measure SDM was limited by the 7 items from Medical Expenditure Panel Survey, which may not fully capture active participation in shared decision-making.

CONCLUSION

A majority of patients with psoriasis are not participating in highly SDM. It is important to construct a framework for carrying out SDM efficiently to enhance physician-patient communication and improve patient outcomes.

Shared Decision-Making and Emergency Department Use Among People With High Blood Pressure

INTRODUCTION

Forty-seven percent of all adults in the US have a diagnosis of high blood pressure. Among all US emergency department (ED) users, an estimated 45% have high blood pressure. The success of high blood pressure interventions in reducing ED visits is partially predicated on patients' adherence to treatment plans. One method for promoting adherence to treatment plans is shared decision-making between patients and medical providers.

METHODS

We conducted a cross-sectional observational study using 2015-2019 Medical Expenditure Panel Survey data. We used studies on shared decision-making as a guide to create a predictor variable for shared decision-making. We determined covariates according to the Andersen Behavioral Model of Health Services Use. ED use was the outcome variable. We used cross tabulation to compare covariates of ED use and multivariable logistical regression to assess the association between shared decision-making and ED use. Our sample size was 30,407 adults.

RESULTS

Less than half (39.3%) of respondents reported a high level of shared decision-making; 23.3% had 1 or more ED visits. In the unadjusted model, respondents who reported a high level of shared decision-making were 20% less likely than those with a low level of shared decision-making to report 1 or more ED visits (odds ratio [OR], 0.80; 95% CI, 0.75-0.86; P <.001). After adjusting for covariates, a high level of shared decision-making was still associated with lower odds of ED use (OR, 0.86; 95% CI, 0.76-0.97; P = .01).

CONCLUSION

Shared decision-making may be an effective method for reducing ED use among patients with high blood pressure.

Shared decision-making and satisfaction with care: a population-based study in patients with acne with skin of colour in the USA

Little is known about differences in shared decision-making and patient satisfaction with acne care among different ethnicities and races. We conducted a cross-sectional study to determine differences between patients with acne who are White and those with skin of colour (SOC), i.e. (i) engagement in shared decision-making, and (ii) patient satisfaction with care, using the 2009-2017 and 2019 Medical Panel Expenditure Survey. Patients with acne with SOC were nearly two times more likely to engage in high shared decision-making compared with White patients [adjusted odds ratio 1.80, 95% confidence interval (CI) 1.30-2.51, P < 0.001]. Patients with SOC with acne reported lower satisfaction with care compared with White patients (β = -0.38, 95% CI -0.69 to -0.06, P = 0.02). Patients with SOC who had acne reported higher levels of shared decision-making than White patients. However, compared with the White patients, patients with SOC report lower satisfaction with their care. There may be other factors contributing to lower satisfaction with care in patients with SOC who have acne.

Ethical and practical considerations related to data sharing when collecting patient-reported outcomes in care-based child health research

Purpose

The collection and use of patient reported outcomes (PROs) in care-based child health research raises challenging ethical and logistical questions. This paper offers an analysis of two questions related to PROs in child health research: (1) Is it ethically obligatory, desirable or preferable to share PRO data collected for research with children, families, and health care providers? And if so, (2) What are the characteristics of a model best suited to guide the collection, monitoring, and sharing of these data?

Methods

A multidisciplinary team of researchers, providers, patient and family partners, and ethicists examined the literature and identified a need for focus on PRO sharing in pediatric care-based research. We constructed and analyzed three models for managing pediatric PRO data in care-based research, drawing on ethical principles, logistics, and opportunities to engage with children and families.

Results

We argue that it is preferable to share pediatric PRO data with providers, but to manage expectations and balance the risks and benefits of research, this requires a justifiable data sharing model. We argue that a successful PRO data sharing model will allow children and families to have access to and control over their own PRO data and be engaged in decision-making around how PROs collected for research may be integrated into care, but require support from providers.

Conclusion

We propose a PRO data sharing model that can be used across diverse research settings and contributes to improved transparency, communication, and patient-centered care and research.

Pediatric Caregiver Version of the Shared Decision Making Process Scale: Validity and Reliability for ADHD Treatment Decisions

OBJECTIVE

Shared decision making (SDM) is recommended for common pediatric conditions; however, there are limited data on measures of SDM in pediatrics. This study adapted the SDM Process scale and examined validity and reliability of the scale for attention-deficit/hyperactivity disorder (ADHD) treatment decisions.

METHODS

Cross-sectional survey of caregivers (n = 498) of children (aged 5-13) diagnosed with ADHD, who had made a decision about ADHD medication in the last 2 years. Surveys included the adapted SDM Process scale (scores range 0-4, higher scores indicate more SDM), decisional conflict, decision regret, and decision involvement. Validity was assessed by testing hypothesized relationships between these constructs. A subset of participants was surveyed a week later to assess retest reliability.

RESULTS

Pediatric Caregiver version of the SDM Process scale (M = 2.8, SD = 1.05) showed no evidence of floor or ceiling effects. The scale was found to be acceptable (<1% missing data) and reliable (intraclass correlation coefficient = 0.74). Scores demonstrated convergent validity, as they were higher for those without decisional conflict than those with decisional conflict (2.93 vs 2.46, P < .001, d = 0.46), and higher for caregivers who stated they made the decision with the provider than those who made the decision themselves (3.0 vs 2.7; P = .003). Higher scores were related to less regret (r = -0.15, P < .001), though the magnitude of the relationship was small.

CONCLUSIONS

The adapted Pediatric Caregiver version of the SDM Process scale demonstrated acceptability, validity and reliability in the context of ADHD medication decisions made by caregivers of children 5-13. Scores indicate pediatricians generally involve caregivers in decision making about ADHD medication.

Perspectives of Clinicians on Shared Decision Making in Pediatric CKD: A Qualitative Study

RATIONALE & OBJECTIVE

Clinical decision-making priorities may differ among children, their parents, and their clinicians. This study describes clinicians' perspectives on shared decision making in pediatric chronic kidney disease (CKD) and identifies opportunities to improve shared decision making and care for children with CKD and their families.

STUDY DESIGN

Semistructured interviews.

SETTING & PARTICIPANTS

Fifty clinicians participated, including pediatric nephrologists, nurses, social workers, surgeons, dietitians, and psychologists involved in providing care to children with CKD. They worked at 18 hospitals and 4 university research departments across 11 countries (United States of America, Canada, Australia, People's Republic of China, United Kingdom, Germany, France, Italy, Lithuania, New Zealand, and Singapore).

ANALYTICAL APPROACH

Interview transcripts were analyzed thematically.

RESULTS

We identified 4 themes: (1) striving to blend priorities (minimizing treatment burden, emphasizing clinical long-term risks, achieving common goals), (2) focusing on medical responsibilities (carrying decisional burden and pressure of expectations, working within system constraints, ensuring safety is foremost concern), (3) collaborating to achieve better long-term outcomes (individualizing care, creating partnerships, encouraging ownership and participation in shared decision making, sensitive to parental distress), and (4) forming cumulative knowledge (balancing reassurance and realistic expectations, building understanding around treatment, harnessing motivation for long-term goals).

LIMITATIONS

Most clinicians were from high-income countries, so the transferability of the findings to other settings is uncertain.

CONCLUSIONS

Clinicians reported striving to minimize treatment burden and working with children and their families to manage their expectations and support their decision making. However, they are challenged with system constraints and sometimes felt the pressure of being responsible for the child's long-term outcomes. Further studies are needed to test whether support for shared decision making would promote strategies to establish and improve the quality of care for children with CKD.

Family involvement in medical decision making in Europe and the United States: A replication and extension in five Countries

BACKGROUND

In 2018, Alden et al. showed that the desired degree of family involvement in medical decisions is an individual preference that is largely independent from East-West cultural stereotypes. At the same time, individual-level interdependence influenced whether patients preferred more individual or more family involvement in their decision making together with their medical care provider. The present study provides empirical evidence and adds evidence for Europe for which no such data previously existed.

METHODS

The present study is a direct replication and extension of the original Alden et al. (2018) study (N = 2031; Australia, China, Malaysia, India, South Korea, Thailand, United States [U.S.]), however, using survey data from four European countries (Austria, Belgium, Germany, Netherlands) and the United States (U.S.) with a total sample size of N = 2750.

RESULTS

Random effects within-between models replicated the original primary finding that those with higher self-involvement in medical decision making preferred less family involvement. Furthermore, patients with lower self-independence, higher relational interdependence, and stronger beliefs in social hierarchy are more likely to want their families involved in medical decisions besides their health care provider.

CONCLUSIONS

These observed relationships are largely consistent both within and across the four European countries and the U.S. In conclusion, the results point to the importance of avoiding cultural stereotypes and instead, recognizing that patient desires for family involvement in medical decision making vary dramatically within cultures depending on multiple individual differences. Furthermore, a growing body of evidence suggests that these antecedents of family involvement as well as the construct itself may be measurable in diverse cultures with high levels of confidence in their reliability and validity.

Trust in Physicians, Anxiety and Depression, and Decision-Making Preferences among Parents of Children with Serious Illness

Objective: To assess parental decision-making preferences when caring for a child with serious illness and to evaluate for an association between preferences and parental trust in physicians, and potential modification of this association by parental anxiety or depression. Methods: We analyzed cross-sectional data from 200 parents of 158 children in the United States who had life-threatening illnesses and whose attending physicians thought that the parents would have to make major medical decision in the next 12 to 24 months. Parents completed measures of decision-making preferences, trust in physicians, anxiety, and depression. Results: Higher reported levels of trust were associated with lower preferences for autonomous decision making (Spearman correlation = -0.24; 95% confidence interval [CI] = -0.36 to -0.01; p < 0.008). Among parents with higher levels of trust, increasing anxiety scores were associated with decreasing preference for autonomy, whereas among parents with lower levels of trust, increasing anxiety scores showed an increasing preference for autonomy (regression coefficient = -0.01; 95% CI = -0.02 to -0.001; p ≤ 0.03). Conclusions: Decreasing trust in physicians is associated with a higher preference for autonomous decision making. Parents who have higher levels of anxiety exhibit this association more strongly. Decision support for parents of children with serious illness should use strategies to respect parental decision-making preferences, address potential distrust, and provide mental health support to parents who are anxious or depressed.

Parental experience and decision-making for epilepsy surgery: A systematic review of qualitative and quantitative studies

OBJECTIVE

In selected children with drug-resistant epilepsy (DRE), epilepsy surgery is the most effective treatment option, but unfortunately remains highly underutilized. One of the critical obstacles to pursuing surgical therapy is parents/caregivers' decision against surgery or to delay the surgery until no other treatment option exists. Understanding caregiver decision-making around epilepsy surgery can improve patient/caregiver experience and satisfaction while facilitating appropriate decision-making that optimizes clinical outcomes. The current review systematically explores the existing evidence on caregiver experience and the decision-making process toward epilepsy surgery.

METHODS

The study was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. Databases (PubMed Ovid, PubMed Medline, Web of Science, CINHAL, PsycInfo) were systematically searched in February 2021 using a defined search strategy and inclusion/exclusion criteria. Total 1304 articles were screened for titles and abstracts, and 54 full-text articles were retrieved for further assessment. We included 14 articles with critical quality assessment using two different tools for qualitative and questionnaire-based studies. A qualitative content analysis was performed to characterize caregiver experience, perception, and decision-making toward favorable or unfavorable opinions of epilepsy surgery.

RESULTS

Four concepts generated from the analysis may act as enablers or barriers to decision-making around epilepsy surgery: 1. Access to knowledge and information, 2. Communication and coordination issues, 3. Caregiver's emotional state, and 4. Socioeconomic effects. Subsequently, we provided a narrative synthesis of practice recommendations and a conceptual framework to adopt multi-pronged interventions to overcome identified diverse barriers to effective caregiver decision-making.

CONCLUSION

Multiple influences impact how caregivers decide about epilepsy surgery for their children, with no single factor identified as the primary driver for or against surgery. However, limited research has explored these influences. Future studies should focus on quantitatively examining factors to identify significant variables most likely to influence caregiver decision-making, ultimately overcoming barriers that limit utilization of epilepsy surgery as a treatment tool.

Clinical Care Strategies That Support Parents of Children With Complex Chronic Conditions

OBJECTIVES

Children with complex chronic conditions often receive inpatient and end-of-life care in the ICU, yet little is known about the clinical care strategies that best support this unique group of parents. This study aimed to elucidate supportive clinical care strategies identified by bereaved parents of children with complex chronic conditions.

DESIGN

Qualitative analysis of 21 open-response items from the cross-sectional "Survey of Caring for Children with Complex Chronic Conditions" querying communication, decision-making, and end-of-life experiences.

SETTING

Large tertiary care children's hospital.

PATIENTS

Parents of children with complex chronic conditions who received care at a large academic institution and died between 2006 and 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

An iterative multistage thematic analysis of responses was used to identify key themes pertaining to clinical care strategies that support parents of children with complex chronic conditions. Open-ended responses were analyzed from 110 of 114 (96%) of survey respondents. The majority of parents had children with congenital/chromosomal complex chronic conditions who died 3.9 years (interquartile range, 2.2-6.7 yr) prior to their parents' study participation. Although informational themes related to clear honest communication, consistent messaging, and enhanced care coordination were identified, parents emphasized the relational aspects of clinical care including inclusivity of their expertise about their child's needs, recognition of their unique experience as parents, and maintenance of connection with clinicians through bereavement.

CONCLUSIONS

Clinical care strategies that support parents of children with complex chronic conditions reflect the unique needs of this group of children. Relational strategies such as including parents as experts in their child's care were paramount to parents of children with complex chronic conditions throughout their child's medical journey and at end of life.

Decision Making in Pediatric Plastic Surgery: Autonomy and Shared Approaches

BACKGROUND

Although shared decision-making is essential to patient-centered healthcare, its role in pediatric plastic surgery remains unclear. The objective of this study was to define the preferred level of involvement in surgical decision-making among children, caregivers, and surgeons.

METHODS

The authors surveyed pediatric plastic surgery patients (n = 100) and their caregivers regarding their preferences on child involvement during surgical decision-making. Fleiss' kappa was used to assess agreement between groups. Bivariate Chi-square tests and multinomial logistic regression were used to assess the relationship between decision-making preferences and select demographic factors.

RESULTS

Only 34% of children and their caregivers agreed upon their decision-making preferences (k = 0.04). The majority of children (40%) and caregivers (67%) favored shared decision-making between the patient, caregiver, and surgeon. Only 16% of children preferred physician-driven decisions, while 20% of children desired complete autonomy. Children's preferences were significantly associated with their age; the relative risk of children deferring to caregivers or surgeons over a shared approach was lower for adolescents and teens compared to children under 10 years old (relative risk = 0.20; 95% confidence interval: 0.054-0.751; P = 0.02). Caregiver's preferences did not change based on the child's age, but rather were related to the child's gender. Caregivers were more likely to choose the option that gave the child more autonomy when the child was male.

CONCLUSIONS

While most caregivers preferred a shared approach to decision-making, children desired greater autonomy, particularly with increasing age. Since there was limited agreement between caregivers and children, surgeons must be cognizant of differing preferences when discussing treatment plans to optimize both patient and parent satisfaction.

Shared Decision-making With Parents of Hospitalized Children: A Qualitative Analysis of Parents' and Providers' Perspectives

OBJECTIVES

Shared decision-making (SDM) is the pinnacle of patient-centered care and has been shown to improve health outcomes, especially for children with chronic medical conditions. However, parents perceive suboptimal involvement during hospitalization. The objective was to explore the perspectives of parents of hospitalized children and their hospital providers on facilitators and barriers to SDM in the hospital and identify strategies to increase SDM.

METHODS

A qualitative study was conducted by using semistructured interviews with parents of hospitalized children with and without complex chronic conditions and their pediatric hospital medicine faculty. Parents and faculty were matched and individually interviewed on the same day. Two investigators iteratively coded transcripts and identified themes using modified grounded theory, with an additional author reviewing themes.

RESULTS

Twenty-seven parents and 16 faculty participated in the interviews. Four themes emerged: (1) parents and providers value different components of SDM; (2) providers assume SDM is easier with parents of children with medical complexity; (3) factors related to providers, parents, patients, and family-centered rounds were identified as barriers to SDM; and (4) parents and providers identified strategies to facilitate SDM in the hospital.

CONCLUSIONS

There is a discrepancy between parents' and providers' understanding of SDM, with parents most valuing their providers' ability to actively listen and explain the medical issue and options with them. There are many barriers that exist that make it difficult for both parties to participate. Several strategies related to family-centered rounds have been identified that can be implemented into clinical practice to mitigate these barriers.

Utilizing Community Engagement Studios to inform patient experience in a multicenter randomized control trial

OBJECTIVE

To determine whether a community engagement approach can provide feedback for implementation of valuable measures to improve the outcome of a clinical trial.

METHODS

Review of the results from a Community Engagement Studio (CE Studio) for the ValEAR trial: an NIH-funded, multi-institutional study designed to research the efficacy of valganciclovir in the treatment of congenital cytomegalovirus (cCMV)-induced hearing loss. Participants were given information about the trial then asked a series of questions to assess their input on the merits or weaknesses affecting their participation in the trial.

RESULTS

Thirteen parents whose children have congenital CMV infection were recruited for the CE Studio. The overall theme from the responses was a desire to advance the field but a need to clearly understand the risks and benefits of participation. Many requested more educational resources, more printed materials, or greater access to researchers if questions arose. Many welcomed having patient stories and information displayed in a dedicated website or through social media.

CONCLUSION

This community engagement approach provided useful feedback from families similar to those expected to be potential enrollees in the CMV ValEAR trial. In response to parental comments, two educational videos were created: one on the general topic of cCMV and the other specific to the CMV ValEAR trial. Researchers who wish to optimize their clinical trial's success should consider incorporating a CE Studio into their study design.

Shared decision making, satisfaction with care and medication adherence among patients with diabetes

OBJECTIVES

We examined factors associated with shared decision making and whether shared decision-making (SDM) was associated with satisfaction with care or with adherence to anti-diabetic medication.

METHODS

A retrospective study was conducted using 2011-2014 Medical Expenditure Panel Survey (MEPS) data. Inclusion criteria were 18 years or older and visit to a usual source of care during the prior 12 months. Exclusion criteria were reported cognitive limitation, proxy response, less than two prescription fills, or missing data on study variables. SDM was assessed using seven MEPS items. Satisfaction with care was assessed using a single MEPS item 12 months after SDM measurement. Adherence was assessed using Medication Possession Ratio in 12 months after SDM measurement.

RESULTS

The weighted sample of 797 respondents represented 15.6 million with diabetes. Being older, male, or uninsured were associated with low SDM. High SDM was associated with higher satisfaction (p < 0.0001). SDM was not associated with adherence.

CONCLUSIONS

Patients with higher SDM were more satisfied with their healthcare. We did not find association between SDM and adherence to antidiabetic medication.

PRACTICE IMPLICATIONS

Involvement in SDM is encouraged to improve patient satisfaction. Providers may consider age, sex and insurance status in facilitating communications to improve SDM.

Parent Perspectives in Shared Decision-Making for Children With Medical Complexity

OBJECTIVE

Shared decision-making (SDM) may improve outcomes for children with medical complexity (CMC). CMC have lower rates of SDM than other children, but little is known about how to improve SDM for CMC. The objective of this study is to describe parent perspectives of SDM for CMC and identify opportunities to improve elements of SDM specific to this vulnerable population.

METHODS

Interviews with parents of CMC explored SDM preferences and experiences. Eligible parents were ≥18 years old, English- or Spanish-speaking, with a CMC <12 years old. Interviews were recorded, transcribed, and analyzed by independent coders for shared themes using modified grounded theory. Codes were developed using an iterative process, beginning with open-coding of a subset of transcripts followed by discussion with all team members, and distillation into preliminary codes. Subsequent coding reviews were conducted until no new themes emerged and existing themes were fully explored.

RESULTS

We conducted interviews with 32 parents (27 in English, mean parent age 34 years, standard deviation = 7; mean child age 4 years, standard deviation = 4; 50% with household income <$50,000, 47% with low health literacy) in inpatient and outpatient settings. Three categories of themes emerged: participant, knowledge, and context. Key opportunities to improve SDM included: providing a shared decision timeline, purposefully integrating patient preferences and values, and addressing uncertainty in decisions.

CONCLUSION

Our results provide insight into parent experiences with SDM for CMC. We identified unique opportunities to improve SDM for CMC that will inform future research and interventions to improve SDM for CMC.

Children with Asthma and Communication with Healthcare Provider: Instrument Development

PURPOSE

Communication among healthcare providers, caregivers and children with asthma is challenging and sometimes may exclude the child. This may result in delay in recognizing and responding appropriately to asthma symptoms. The purpose was to test an instrument's subscale for content validity related to communication with the healthcare provider by examining age appropriateness, readability and clarity for children with asthma.

DESIGN AND METHODS

This was a mixed method explanatory sequential design to examine age appropriateness, readability and clarity for a 15-item subscale of an instrument for children. The qualitative arm (focus groups) was used to enrich the questionnaire. The sample included children ages 8 to 12 with asthma (N = 25).

RESULTS

The perspective of children with asthma provided enriched information to influence the development of instrument subscale on communication.

CONCLUSIONS

The subscale revealed internal consistency with Cronbach Alpha 0.85. One of the children reported that using the term "provider" was clearer as oppose to healthcare provider. Children participating in the study found readable and clear. A readability analysis revealed the items were readable at a 6th grade level.

PRACTICE IMPLICATION

Although the instrument is designed for primary care providers (physicians, nurse practitioners, physician assistants), the information gained from this pilot increases understanding about including the child in a triadic discussion. Further research will lead to next step toward computing reliability of the full measure and a factor analysis.

Shared decision-making in older children and parents considering elective adenotonsillectomy

OBJECTIVES

Shared decision-making describes a collaborative process in which healthcare providers and patients/families make treatment decisions using the best available evidence, while taking into account the patient's values and preferences. The objectives of this study were to assess the level of decisional conflict and shared decision-making experienced by older children and their parents when considering elective adentonsillectomies.

DESIGN

A prospective cohort study.

SETTING

Paediatric otolaryngology clinic in a teaching hospital.

PARTICIPANTS

Participants included 53 children older than 9 years and their parents who underwent consultation for tonsillectomy with or without adenoidectomy.

MAIN OUTCOMES MEASURES

Children and parents completed the Decisional Conflict Scale (DCS) and Shared Decision-Making Questionnaire-Patient Version (SDM-Q-9). Surgeons completed the Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc).

RESULTS

Overall, 10 (19%) parents and 18 (34%) children reported clinically significant decisional conflict. Parents who opted not to proceed with surgery had significantly higher DCS scores than those who decided to proceed with surgery. Both parents and children SDM-Q-9 and total DCS scores were significantly negatively correlated. Physician SDM-Q-Doc and parent total DCS scores were negatively correlated, while parent and physician SDM scores were positively correlated.

CONCLUSIONS

Many older children and parents reported significant decisional conflict when considering elective paediatric otolaryngology surgery. Decisional conflict levels for both children and parents decreased with greater perceived levels of shared decision-making. Older children did not appear to discern the same levels of shared decision-making as parents and surgeons. Future research should assess methods to implement shared decision-making into clinical practice for clinicians, parents and children when appropriate.

Exploring national trends of patient- and family-centered care among US children

We explored national trends in the receipt of high-quality patient-physician communication and patient empowerment through behavioral health counseling among children in the United States. We used data from the Medical Expenditure Panel Survey from 2010 to 2014. We employed two measures of patient- and family-centered care (PFCC): (1) a composite measure of high-quality patient-physician communication ( n = 34,629) and (2) patient empowerment through behavioral health counseling about healthy eating ( n = 36,527) and exercise ( n = 38,318). We used multivariate logistic regression models to estimate the variation of receiving PFCC by social determinants of health over time. Rates of receiving behavioral health counseling about healthy eating (53-60%) and exercise (37-42%) were lower than the rate of receiving high-quality physician-patient communication (92-93%). Parents were significantly more likely to report receiving high-quality physician-patient communication in 2014 than in 2010 (odds ratio 1.37, confidence interval 1.08-1.67); however, no association was found for empowerment through behavioral health counseling. Low income and parental educational attainment, and lack of insurance were associated with lower odds of receiving behavioral health counseling. Results showed significant variation of physician-patient communication and empowerment by social and demographic factors. The results suggest more providers need to empower parents and their children to self-care through behavioral health counseling.

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.

What stops practitioners discussing medication breaks in children and adolescents with ADHD? Identifying barriers through theory-driven qualitative research

National and international guidelines on the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents call for annual reviews to assess continuing need for medication by considering brief periods without medication, referred to as 'Drug holidays'. However, drug holidays are reactively initiated by families, or recommended by practitioners if growth has been suppressed by medication rather than proactively to check the need. There is little evidence of planned, practitioner-initiated drug holidays from methylphenidate. The aim of this study was to identify what stops practitioners from routinely discussing planned drug holidays from methylphenidate with children, adolescents, and their parents. Practitioners involved in shared-care prescribing for children and adolescents with ADHD in one UK County were included. Interviews with 8 general practitioners (GPs) and 8 Child and Adolescent Mental Health Service (CAMHS) practitioners were conducted. Transcripts were analysed qualitatively against the components of the Capability-Opportunity-Motivation-Behaviour (COM-B) model. Possible interventions for increasing prescribers' engagement with planned drug holidays were considered in response. Multiple barriers to practitioner engagement in planned drug holidays from methylphenidate were identified. Capability, in terms of knowledge and skills, was not a barrier identified for CAMHS practitioners but was for GPs. Opportunity was a main barrier for both groups, who reported lack of time and the absence of educational material about drug holidays. Motivation was more complex to define, with CAMHS practitioners questioning the need for drug holidays and GPs being more accepting due to worries about long-term medication side effects as well as cost savings. 'Education' and 'enablement' interventions were identified as key activities targeting all three components, which could feasibly increase uptake of practitioner-initiated planned drug holidays from methylphenidate. The application of the COM-B system identified a number of key barriers to practitioner engagement with drug holidays in children and adolescents with ADHD. Accordingly, a number of interventions could be developed to facilitate change. For example, educating and training GPs about ADHD management and drug holidays, and developing a decision aid to help families make informed decisions about whether or not to implement drug holidays could be used.

Provider use of a participatory decision-making style with youth and caregivers and satisfaction with pediatric asthma visits

Background

We conducted a randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to engage the youth during clinic visits. We examined whether the intervention was associated with 1) providers including youth and caregiver inputs more into asthma treatment regimens, 2) youth and caregivers rating providers as using more of a participatory decision-making style, and 3) youth and caregivers being more satisfied with visits.

Methods

English- or Spanish-speaking youth aged 11–17 years with persistent asthma and their caregivers were recruited from four pediatric clinics and randomized to the intervention or usual care groups. The youth in the intervention group watched the video with their caregivers on an iPad and completed a one-page asthma question prompt list before their clinic visits. All visits were audiotaped. Generalized estimating equations were used to analyze the data.

Results

Forty providers and their patients (n=359) participated in this study. Providers included youth input into the asthma management treatment regimens during 2.5% of visits and caregiver input during 3.3% of visits. The youth in the intervention group were significantly more likely to rate their providers as using more of a participatory decision-making style (odds ratio=1.7, 95% confidence interval=1.1, 2.5). White caregivers were significantly more likely to rate the providers as more participatory (odds ratio=2.3, 95% confidence interval=1.2, 4.4). Youth (beta=4.9, 95% confidence interval=3.3, 6.5) and caregivers (beta=7.5, 95% confidence interval=3.1, 12.0) who rated their providers as being more participatory were significantly more satisfied with their visits. Youth (beta=−1.9, 95% confidence interval=−3.4, −0.4) and caregivers (beta=−8.8, 95% confidence interval=−16.2, −1.3) who spoke Spanish at home were less satisfied with visits.

Conclusion

The intervention did not increase the inclusion of youth and caregiver inputs into asthma treatment regimens. However, it did increase the youth’s perception of participatory decision-making style of the providers, and this in turn was associated with greater satisfaction.

Parent Communication Prompt to Increase Shared Decision-Making: A New Intervention Approach

OBJECTIVE

Shared decision-making (SDM) is the process by which patients, clinicians, and in pediatrics, parents/caregivers, discuss treatment options, communicate available evidence for or against the different options, share preferences and values, and eventually arrive at a joint decision. This study evaluates the use of a novel, universally applicable, SDM intervention, provided to parents, intended to promote engagement and participation with their child's clinician.

METHODS

Two-arm randomized controlled trial comparing the impact of a SDM-focused intervention prompt to a neutral comparison prompt on perception of SDM participation. Participants included English-speaking parents of children (0-17 years) attending one Developmental-Behavioral Pediatric (DBP) clinic and their child's clinician. Prior to visit start, parents received either the intervention prompt encouraging engagement with the clinician in decision-making, or the comparison prompt reminding them to request a school/work excuse note if needed. After the visit, SDM was assessed by both parents and DBP clinicians. SDM was scored as present if the respondent answered "strongly agree" to all SDM-related items. Logistic regression tested effects of visit, child, parent, clinician characteristics, and intervention group status on parent-reported SDM. Cohen's kappa assessed alignment between parent and clinician perceptions of SDM.

RESULTS

Of 88 parents screened, 50 (61%) met eligibility criteria and agreed to participate (intervention n = 26; comparison n = 24). Eligible participants (parents and clinicians) for analysis completed the surveys with no missing data. Overall, SDM was present in 76% of parents and 34% of clinicians. With high rates of parent-reported SDM in both intervention and comparison groups, no main intervention effect was detected. Compared to the comparison group, there was greater alignment between parent and clinician perception of SDM in the intervention group.

CONCLUSIONS

Parent and clinician enrollment and data collection with minimal loss suggest that this novel approach is easy to use and could be employed in future outpatient studies exploring SDM. In this clinical setting, both intervention and comparison group parents reported high levels of SDM participation and no main group effect was detected. Further study of this novel parent-directed SDM intervention approach is needed in a larger sample with greater variability in parent-reported SDM to determine its efficacy.

A pilot study of observed physician-parent-child communication and child satisfaction in a gastroenterology clinic

BACKGROUND

Child participation in pediatric medical visits is low. In this pilot study, we sought to better understand relationships between observed communication and child-reported perceptions of communication in a clinical setting.

MATERIALS AND METHODS

For this cross-sectional observational study, pediatric gastroenterology appointments (n=39) were videotaped and coded to quantify various adult affective (eg, chit-chat, empathy) and facilitative (eg, asking questions, encouraging responses) behaviors toward the child, interference with child participation (eg, interrupting or ignoring child), and child verbal participation. Post-visit surveys assessed child perceptions of having voice in the clinical encounter, ease of understanding, and satisfaction with communication.

RESULTS

Parent and provider chit-chat was associated with child-reported ease of understanding. Provider facilitation was positively associated with child participation, but affective communication strategies were not. Physician interference was negatively associated with ease of understanding but positively associated with perception of voice.

CONCLUSION

Facilitative communication may improve outcomes by enhancing child participation and thus exchange of medical information, whereas chit-chat appears to positively impact children's perceptions of communication.

Shared Decision Making among Children with Medical Complexity: Results from a Population-Based Survey

OBJECTIVE

To compare the rates of shared decision making (SDM) reported by parents of children with medical complexity (CMC) with the rates of SDM reported by parents of noncomplex children with special health care needs (CSHCN).

STUDY DESIGN

We examined the 2009-2010 National Survey of Children with Special Health Care Needs, a representative survey of 40 242 parents of CSHCN. CMC was defined as needing or using more medical care than usual, seeing 2 or more subspecialists, and positive response on at least 3 other items on the CSHCN screener. We identified 3 subgroups each of CMC and noncomplex CSHCN by sentinel diagnoses: asthma, seizures, and other diagnoses. SDM was defined as a binary composite variable, derived from 4 discrete items. We constructed 4 stepwise multivariable models to assess the relative odds of SDM, adjusted for sociodemographic characteristics (age, income, language, race, ethnicity, and marital status), behavioral comorbidity, family-centered care, and patient-centered medical home.

RESULTS

The study population included 39 876 respondents. Compared with noncomplex CSHCN, CMC had a lower likelihood of SDM (aOR, 0.76; 95% CI, 0.64-0.91), which persisted in diagnostic subgroups: CMC with asthma (aOR, 0.67; 95% CI, 0.49-0.92) and CMC with other diagnoses (aOR, 0.74; 95% CI, 0.58-0.94), but not CMC with seizures (aOR, 0.95; 95% CI, 0.59-1.51).

CONCLUSIONS

SDM is less common for CSHCN with complex needs than those without complex needs. Health system interventions targeting future-oriented care planning may improve SDM for CMC.

Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis

OBJECTIVE

The purpose of the study was to investigate parental preference of continuous pulse oximetry in infants and children with bronchiolitis.

MATERIALS AND METHODS

A cross-sectional prospective study was conducted at Hamad Medical Corporation in Qatar. Parents of infants and children <24 months old and hospitalized with bronchiolitis were offered an interview survey.

RESULTS

A total of 132 questionnaires were completed (response rate 100%). Approximately 90% of participants were 20-40 years of age, and 85% were females. The mean age of children was 7.2±5.8 months. Approximately eight in ten parents supported the idea of continuous pulse oximetry in children with bronchiolitis. Almost 43% of parents believed that continuous pulse-oximetry monitoring would delay their children's hospital discharge. Interestingly, approximately 85% of caregivers agreed that continuous pulse oximetry had a good impact on their children's health. In addition, around one in two of the participants stated that good bedside examinations can obviate the need for continuous pulse oximetry. Furthermore, 80% of parents believed that continuous pulse-oximetry monitoring would give the health-care provider a good sense of security regarding the child's health. Finally, being a male parent was associated with significantly increased risk of reporting unnecessary fatigue, attributed to the sound of continuous pulse oximetry (P=0.031).

CONCLUSION

Continuous pulse-oximetry monitoring in children with bronchiolitis was perceived as reassuring for parents. Involving parents in decision-making is considered essential in the better management of children with bronchiolitis or any other disease. The first step to decrease continuous pulse oximetry will require provider education and change as well. Furthermore, we recommend proper counseling for parents, emphasizing that medical technology is not always essential, but is a complementary mode of managing a disease.

Trends in Patient-Perceived Shared Decision Making Among Adults in the United States, 2002-2014

To ascertain changes in shared decision making (SDM), we analyzed data from the nationally representative Medical Expenditure Panel Survey. We aggregated responses to questions into a 7-point SDM composite score. Between 2002 and 2014, the mean SDM composite score increased from 4.4 to 5.0 (P <.01), indicating greater patient-perceived SDM. In multivariate modeling, SDM scores were higher for black vs white patients (+0.33 points) and those with a same-race/ethnicity usual source of care (+0.24 points; both P <.05). Scores were lower for patients with poor-perceived health (-0.41 points), Asian vs white race/ethnicity (-0.28 points), and no insurance (-0.17 points; all P <.05). Improvement efforts should target Americans without a same-race/ethnicity usual source of care and with poor-perceived health.

Parent Preferences for Shared Decision-making in Acute Versus Chronic Illness

OBJECTIVES

The goal of this study was to examine preferences for shared decision-making (SDM) in parents of acutely ill versus chronically ill children in the inpatient setting. Additionally, we explored the effect of parental perception of illness severity and uncertainty in illness on decision-making preference.

METHODS

In this cross-sectional study, we surveyed parents of children admitted to pediatric inpatient units at an academic, tertiary-care hospital. Surveys were administered in person and used validated tools to assess SDM preferences and uncertainty in illness. Descriptive statistics evaluated associations stratified by acute versus chronic illness, and multivariable analyses were performed.

RESULTS

Of the 200 parents who participated, the majority were women (78%), Hispanic (81.5%), English speaking (73%), between 30 and 39 years old (37.5%), and had an education achievement of less than a college degree (77%). The mean age of hospitalized children was 8.1 years, and half reported a chronic illness. Most parents preferred an active (43%) or collaborative (40%) role in SDM. There was no association with SDM preference by demographics, number of previous hospitalizations, perception of illness severity, or uncertainty. However, parents of chronically ill children significantly preferred a passive role in SDM when they perceived a high level of uncertainty in illness.

CONCLUSIONS

Most parents of hospitalized children prefer to take an active or collaborative role in SDM. However, parents of chronically ill children who perceive high levels of uncertainty surrounding their children's illness prefer a passive role, thus illustrating the complexity in decision-making among this parent population.

Treatment Collaboration When the Stakes Are High: Ethnographically Studying Family-Centered Care in an Outpatient Pediatric Specialty Clinic

Family-centered care (FCC) is vital for children with special health-care needs and serious chronic illnesses. Family–clinician collaboration and partnership formation are key FCC elements associated with improved health outcomes. However, FCC implementation barriers persist. Although some ethnographic research examines how FCC principles align with practice in inpatient settings, more studies are needed in outpatient specialty clinics. Using an FCC-oriented research team (clinicians, social science researchers, and families) blended multidisciplinary clinical knowledge and family/patient expertise with chronic illness. Our ethnographic study in a high-risk asthma outpatient clinic examined how FCC principles align with clinical practice, identified factors affecting partnership, and compared our findings to a large ethnographic study in an inpatient setting. Qualitative data from direct observation of 14 families with lengthy clinic visits were analyzed. Codes were applied to themes using FCC principles. Clinic visits had interactional and contextual elements that both aligned and misaligned with key FCC principles: information sharing, respect, participation, and collaboration. Recommendations for advancing FCC are outlined, and the importance of this step in light of ongoing health disparities is addressed.

Family-Centered Care Measurement and Associations With Unmet Health Care Need Among US Children

OBJECTIVE

Family-centered care (FCC), including shared decision making (SDM), has become increasingly emphasized in pediatric health care delivery. Past studies using national surveys have used different FCC measurement approaches without determining their validity. We, therefore, sought to develop an FCC measurement model with Medical Expenditure Panel Survey (MEPS) items previously used to assess FCC or SDM; and to determine temporal associations of FCC with unmet health care need.

METHODS

Four longitudinal MEPS data files (2007-2011) were combined. The study sample included 15,764 US children aged 0 to 17 years. Eight items assessed FCC, and 5 items assessed unmet health care need. We performed exploratory factor analyses to develop an FCC measurement model and fit a cross-lagged structural equation model to determine temporal associations between FCC and unmet health care need.

RESULTS

Results supported a 2-factor FCC model including family-provider communication and SDM. The family-provider communication factor was indicated by items reflecting general communication between the child's doctor and family. The SDM factor was indicated by items reflecting decision-making about the child's health care. Adjusted cross-lagged structural equation model results showed family-provider communication and SDM were associated with a reduced likelihood of unmet health care need the following year. Unmet health care need was not significantly associated with family-provider communication or SDM the subsequent year.

CONCLUSIONS

Study results support differentiating between family-provider communication and SDM as interrelated aspects of FCC in future pediatric health care quality measurement and improvement. Family-provider communication and SDM may reduce the likelihood of unmet health care need the following year among US children.

Who Decides: Me or We? Family Involvement in Medical Decision Making in Eastern and Western Countries

Background. Research suggests that desired family involvement (FI) in medical decision making may depend on cultural values. Unfortunately, the field lacks cross-cultural studies that test this assumption. As a result, providers may be guided by incomplete information or cultural biases rather than patient preferences. Methods. Researchers developed 6 culturally relevant disease scenarios varying from low to high medical seriousness. Quota samples of approximately 290 middle-aged urban residents in Australia, China, Malaysia, India, South Korea, Thailand, and the USA completed an online survey that examined desired levels of FI and identified individual difference predictors in each country. All reliability coefficients were acceptable. Regression models met standard assumptions. Results. The strongest finding across all 7 countries was that those who desired higher self-involvement (SI) in medical decision making also wanted lower FI. On the other hand, respondents who valued relational-interdependence tended to want their families involved – a key finding in 5 of 7 countries. In addition, in 4 of 7 countries, respondents who valued social hierarchy desired higher FI. Other antecedents were less consistent. Conclusion. These results suggest that it is important for health providers to avoid East–West cultural stereotypes. There are meaningful numbers of patients in all 7 countries who want to be individually involved and those individuals tend to prefer lower FI. On the other hand, more interdependent patients are likely to want families involved in many of the countries studied. Thus, individual differences within culture appear to be important in predicting whether a patient desires FI. For this reason, avoiding culture-based assumptions about desired FI during medical decision making is central to providing more effective patient centered care.

Don't Push Your Luck! Educational Family Board (Not Bored) Game for School-Age Children Living with Chronic Conditions

PURPOSE

Children who are living with chronic conditions may be supported in self-care through enjoyable active learning and family social processes. This research focused on development and evaluation of "Don't Push Your Luck!", an educational board game designed to inspire family discussion about chronic conditions, and help affected children learn about self-care choices and consequences.

DESIGN AND METHODS

Mixed-method research was conducted with families from one outpatient Cystic Fibrosis Clinic and four Hemophilia Treatment Centres in Canada and United States (N=72). In phase I, board game prototype and questionnaires were refined with affected boys, siblings, and parents living with hemophilia (n=11), compared with families living with cystic fibrosis (n=11). In phase II, final board game was evaluated with families living with hemophilia (n=50). Data collection included pre-post-game questionnaires on decision-making and Haemo-QoL Index©, and post-game enjoyment. Analysis included descriptive statistics, inferential statistics (non-parametric), and qualitative themes.

RESULTS

Findings revealed this game was an enjoyable and effective resource to engage families in self-care discussions. Key themes included communication, being involved, knowing, decisions and consequences, and being connected. Qualitative and quantitative findings aligned. Statistical significance suggests the game enhanced family engagement to support decision-making skills, as parents identified that the game helped them talk about important topics, and children gained insight regarding family supports and self-care responsibility.

CONCLUSIONS

This board game was an effective, developmentally appropriate family resource to facilitate engagement and conversation about everyday life experiences in preparation for self-care.

PRACTICE IMPLICATIONS

There is promising potential to extend this educational family board game intervention with a greater range of school-age children and families living with chronic conditions.

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.

Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers

PURPOSE

Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance.

METHODS

We administered the survey in 2013-2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression.

RESULTS

Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance.

CONCLUSIONS

The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted.

Decision making in pediatric oncology: Views of parents and physicians in two European countries

BACKGROUND

Decision making is a highly complex task when providing care for seriously ill children. Physicians, parents, and children face many challenges when identifying and selecting from available treatment options.

METHODS

This qualitative interview study explored decision-making processes for children with cancer at different stages in their treatment in Switzerland and Romania.

RESULTS

Thematic analysis of interviews conducted with parents and oncologists identified decision making as a heterogeneous process in both countries. Various decisions were made based on availability and reasonableness of care options. In most cases, at the time of diagnosis, parents were confronted with a "choiceless choice"-that is, there was only one viable option (a standard protocol), and physicians took the lead in making decisions significant for health outcomes. Parents' and sometimes children's role increased during treatment when they had to make decisions regarding research participation and aggressive therapy or palliative care. Framing these results within the previously described Decisional Priority in Pediatric Oncology Model (DPM) highlights family's more prominent position when making elective decisions regarding quality-of-life or medical procedures, which had little effect on health outcomes. The interdependency between oncologists, parents, and children is always present. Communication, sharing of information, and engaging in discussions about preferences, values, and ultimately care goals should be decision making's foundation.

CONCLUSIONS

Patient participation in these processes was reported as sometimes limited, but parents and oncologists should continue to probe patients' abilities and desire to be involved in decision making. Future research should expand the DPM and explore how decisional priority and authority can be shared by oncologists with parents and even patients.

Shared Decision Making in the Care of Children with Developmental and Behavioral Disorders

OBJECTIVE

Shared decision making (SDM) is most needed when there are multiple treatment options and no "right" choice. As with quality and experience of care, frequency of SDM may vary by health condition. The objectives of this study were (1) to compare parent report of SDM between a physical and a behavioral health condition and; (2) to compare parent report of SDM between two different behavioral health conditions.

METHODS

Data on children age 3-17 years with asthma, attention deficit/hyperactivity disorder (ADHD), and/or autism spectrum disorder (ASD) were drawn from the 2009/10 National Survey of Children with Special Health Care Needs. Weighted logistic regression was used to compare a parent-reported, composite measure of SDM. Analyses controlled for sociodemographic factors that may influence experience of SDM.

RESULTS

Compared to parents of children with asthma, parents of children with ADHD were significantly less likely to report experiencing consistent SDM (AOR 0.73). Compared to parents of children with ADHD, those of children with ASD had significantly lower odds of experiencing consistent SDM (AOR 0.59). Those with both ADHD and ASD had the same odds as those with ASD alone of experiencing consistent SDM.

CONCLUSION

Use of SDM is particularly limited in developmental and behavioral conditions, such as ADHD and ASD. These data suggest that challenges to implementing SDM may include disease type, complexity, and use of specialty care. Research to identify specific barriers and facilitators of SDM is needed to inform interventions that will promote SDM in developmental and behavioral conditions.

Relationships of Shared Decision Making with Parental Perceptions of Child Mental Health Functioning and Care

Experts encourage parents and practitioners to engage in shared decision making (SDM) to provide high quality child mental health care. However, little is known regarding SDM among families of children with common mental health conditions. The objectives of this study were to examine associations between parental report of SDM and parental perceptions of (a) receiving child mental health care and (b) child mental health functioning. We analyzed cross-sectional data on children with a common mental health condition (attention-deficit hyperactivity disorder, oppositional-defiant or conduct disorder, anxiety, or depression) from the 2009/2010 National Survey of Children with Special Healthcare Needs (N = 9,434). The primary independent variable was parent-reported SDM, and the dependent variables were parental perception of (a) their child receiving all needed mental health care (b) their children's impairment in school attendance and extracurricular activity participation, and (c) severity of their children's mental health condition. Multivariate logistic and multinomial regression analyses were conducted. Greater parent-reported SDM was associated with parental perceptions of receiving all needed child mental health care and children not having school or extracurricular impairment. Greater SDM was also associated with perceptions of children having a mild mental health condition compared to children having a moderate or severe condition. Findings provide a basis for future longitudinal and intervention studies to examine the benefit of SDM for improving parental perceptions of the quality of child mental health care and mental health functioning among children with common mental health conditions.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England

OBJECTIVES

To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.

STUDY DESIGN

This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.

RESULTS

Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.

CONCLUSIONS

Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Systematic review of approaches to using patient experience data for quality improvement in healthcare settings

OBJECTIVES

Explore how patient-reported experience measures (PREMs) are collected, communicated and used to inform quality improvement (QI) across healthcare settings.

DESIGN

Systematic review.

SETTING

Various primary and secondary care settings, including general practice, and acute and chronic care hospitals.

PARTICIPANTS

A full range of patient populations from (children through to the elderly) and staff (from healthcare practitioners to senior managers).

METHODS

Scientific databases were searched (CINAHL, PsycINFO, MEDLINE and Cochrane Libraries) as was grey literature. Qualitative and quantitative studies describing collection of PREM data and subsequent QI actions in any healthcare setting were included. Risk of bias was assessed using established criteria. Of 5312 initial hits, 32 full texts were screened, and 11 were included.

RESULTS

Patient experience data were most commonly collected through surveys and used to identify small areas of incremental change to services that do not require a change to clinician behaviour (eg, changes to admission processes and producing educational materials). While staff in most studies reported having made effective improvements, authors struggled to identify what those changes were or the impact they had.

CONCLUSIONS

Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient experience.

Shared Decision Making and Treatment Decisions for Young Children With Autism Spectrum Disorder

OBJECTIVE

To describe influences on shared decision making between primary care pediatricians and parents of young children with autism spectrum disorder (ASD).

METHODS

We conducted a qualitative study using key informant interviews with 20 pediatricians of varying experience from 10 primary care practices and 20 English-speaking parents of young children (aged 2-5 years) with a parent-reported diagnosis of ASD. Subjects were recruited through purposive sampling. Interviews were audiotaped, transcribed verbatim, and analyzed using an integrated approach to data analysis. Differences in coding were resolved by consensus. We achieved thematic saturation and ceased recruitment after 20 interviews were completed within each group.

RESULTS

Three primary themes emerged: 1) pediatricians and parents reported knowledge gaps by pediatricians about ASD treatments and community resources as well as ambiguity regarding the pediatrician's role in ASD care; 2) there was little communication between parents and pediatricians about treatment choices; 3) use of complementary and alternative medical treatments created conflict between pediatricians and parents, and as a result, parents may independently pursue treatments, without the benefit of discussing safety and efficacy with pediatricians. Despite these barriers, parents desired increased support and guidance from their pediatricians, including for complementary and alternative medicine.

CONCLUSIONS

Much work is needed to effectively foster shared decision making in the context of ASD treatment decisions in primary care, including pediatrician training in ASD to enhance knowledge about evidence-based and novel treatments, clinical practice guidelines, and community resources.

Parents' Perspectives on Shared Decision Making for Children With Solid Organ Transplants

INTRODUCTION

The Institute of Medicine prioritizes active family and clinician participation in treatment decisions, known as shared decision making (SDM). In this article we report the decision-making experiences for parents of children who had a solid organ transplant.

METHOD

We performed a prospective longitudinal mixed methods study at five major U.S. children's medical centers. Qualitative interview data were obtained at 3 weeks, 3 months, and 6 months after hospital discharge following the child's transplant.

RESULTS

Forty-eight parents participated in the study. Three themes were identified: (a) Parents expect to participate in SDM; (b) parents seek information to support their participation in SDM; and (c) attributes of providers' professional practice facilitates SDM. SDM was facilitated when providers were knowledgeable, transparent, approachable, accessible, dependable, and supportive.

CONCLUSIONS

Parents expect to participate in SDM with their transplant team. Health care providers can intentionally use the six key attributes to engage parents in SDM. The results provide a framework to consider enhancing SDM in other chronic illness populations.

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.