Objective Shared Decision-Making (SDM), an integrative patient-provider communication process emphasizing discussion of scientific evidence and patient/family values, may improve quality care delivery, promote evidence-based practice, and reduce overuse of surgical care. Little is known however regarding SDM in elective surgical practice. The purpose of this systematic review is to synthesize findings of studies evaluating use and outcomes of SDM in elective surgery. Data Sources Pubmed, CochraneCENTRAL, EMBASE, CINAHL, and SCOPUS electronic databases Review Methods We searched for English-language studies (1/1/1990 to 8/9/2015) evaluating use of SDM in elective surgical care. Identified studies were independently screened by two reviewers in stages of title/abstract and full-text review. We abstracted data related to population, study design, clinical dilemma, use of SDM, outcomes, treatment choice, and bias. Results Of 10,929 identified articles, 24 met inclusion criteria. The most common area studied was spine (7/24) followed by joint (5/24) and gynecological surgery (4/24). Twenty studies used decision aids/support tools, including modalities that were multimedia/video (13/20), written (3/20), or personal coaching (4/20). Effect of SDM on preference for surgery were mixed across studies, showing a decrease in surgery (9/24), no difference (8/24), or increase (1/24). SDM tended to improve decision quality (3/3) as well as knowledge/preparation (4/6), while decreasing decision conflict (4/6). Conclusion SDM reduces decision conflict and improves decision quality for patients making choices about elective surgery. While net findings show that SDM may influence patients to choose surgery less often, the impact of SDM on surgical utilization cannot be clearly ascertained.

Objectives (1) Describe trends in the diagnosis of ankyloglossia and the use of lingual frenotomy and (2) analyze patient- and hospital-level factors as compared with the total pediatric discharge population. Study Design National database analysis. Methods We reviewed available data from 1997 to 2012 using the Kids' Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. All weighted pediatric discharges with ankyloglossia, newborn feeding difficulty, or lingual frenotomy were analyzed for variables of sex, payer, zip code median income, hospital ownership, location/teaching status, bed size, region, and children's hospital status. Chi-square analysis with 95% CIs and odds ratio were used to identify differences between the study group and the total database discharge population. Results Diagnosis of ankyloglossia increased each year of publication (every third year)-with 3934, 5430, 7785, 11,397, 19,459, and 32,837 children, respectively, from 1997 to 2012-with the largest increase in the last 6 years. Similarly, frenotomy increased with 1279, 1633, 2538, 3988, 6900, and 12,406 procedures. Compared with the total discharge population, children with ankyloglossia or frenotomy were more often male (63.6% ankyloglossia, 65.3% frenotomy vs 51.2%), privately insured (60.1%, 62.1% vs 43.6%), from a higher median-income zip code (78.1%, 78.2% vs 68.6%), and in Midwest region (29.3%, 32.3% vs 21.7%). Conclusion These pilot data show increases in diagnoses of ankyloglossia and use of frenotomy. There is a preponderance of children who are male, privately insured, or Midwest residents being diagnosed and treated for ankyloglossia. This broad variation may reflect local practice patterns or imply cultural and socioeconomic bias.

Importance-Sleep-disordered breathing (SDB) is prevalent and impacts physical and behavioral health of children. Adenotonsillectomy (AT), the primary treatment, is subject to unexplained variation in utilization which may be reduced by improving physician-patient communication and decision quality for this elective procedure.Objectives-We aimed to learn factors that influence parental experience and decision-making in pediatric SDB and AT surgery.Design-Parents of children with prior SDB evaluation participated in semi-structured interviews. Open-ended questions regarded experiences of having a child with SDB, communication with pediatric clinicians and surgeons, and experiences with AT surgery. Recordings were transcribed and analyzed for emergent themes using grounded theory methodology.Address correspondence to: Emily F Boss, MD, MPH (erudnic2@jhmi.edu), 601 N Caroline St., Baltimore MD. Phone: 410 955 9772. Fax: 410 955 0035. Author Contributions: Emily F Boss, MD, MPH: Dr. Boss conceptualized and designed the study, contributed to analysis, drafted the initial manuscript, revised the manuscript, and approved the final manuscript as submitted. Anne R Links, MS, MHS: Ms. Links carried out analysis and interpretation of the data, drafted the initial manuscript, revised the manuscript, and approved the final manuscript as submitted. Ron Saxton, MS: Mr. Saxton coordinated data collection, drafted the initial manuscript, and approved the final manuscript as submitted. Tina L Cheng, MD, MPH: Dr. Cheng contributed to the conception nd design of the study, revised the manuscript, and approved the final manuscript as submitted. Mary Catherine Beach, MD, MPH: Dr. Beach contributed to the conception and design of the study, revised the manuscript, and approved the final manuscript as submitted All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.Financial Disclosure: Authors have no financial relationships relevant to this article to disclose. Conflict of Interest:Authors have no conflicts of interest to disclose. There was no involvement by sponsors in design, data collection, analysis, drafting of the manuscript, or decision to submit for publication. No honorarium or payment was given to authors to produce this manuscript.Access to data: Dr. Boss and Ms. Links had full access to all the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. HHS Public Access Author Manuscript Author Manuscript Author Manuscript Author ManuscriptSetting-Interviews were conducted at locations convenient for participants and separate from the pediatric clinic.Participants-Parents (N = 11) of children aged 2-17 who had previously been diagnosed or treated for SDB.Main Measures-Themes of parental experiences and treatment decision-making processes with pediatric SDB.Results-Overarching themes related to clinical factors of SDB/AT and clinician interpersonal behaviors/communication. Parents described an urgency that ...

Importance: Tonsillectomy is common in children, but little is known about parental preferences and values concerning this surgery. Social media offers a novel opportunity to evaluate parent understanding and experience of care. Objective: We systematically evaluate posts in a well-known social media site to identify parent perspectives about tonsillectomy in children that may not be apparent in a routine clinical encounter. Design: In this mixed methods analysis, we searched Twitter© for posts (“tweets”) from 2008-2017 written by parents about their child’s tonsillectomy. We applied modified grounded theory to develop a coding taxonomy to classify these tweets. Two reviewers assessed tweets for thematic synthesis and classification. Tweets were quantified, and descriptive statistics were obtained for each theme. Setting: The posts on the social media site www.twitter.com. Participants: A sample of over 700 adult American parents of children who received or will receive a tonsillectomy and posted on Twitter. Main Outcomes and Measures: Themes of parent experiences and perspectives about their child’s tonsillectomy. Results: Of 5801 tweets retrieved, 782 satisfied our inclusion criteria. Tweets fell into overarching themes of 1. procedural concerns (n=549, 70.2%) and 2. attitudes/experiences (n=498, 63.7%). Common tweets related to procedural concerns regarded surgical indication (“sick for months”; n=55,7.0%), recovery [n=227, 29.0%; including child’s attitude (“she is nervous”; n=89, 11.4%) nutrition (“won’t eat”; n=89, 11.4%), and parental experience (“harder on the parents than the kid”;(n=87, 11.1%))]. Common tweets regarding attitudes/experiences included tenor of overall care (“yay for tonsil surgery!”; n=155, 19.8%), and fears/apprehensions (“frankly, I’m terrified”; n=178, 22.8%). Conclusions and Relevance: This analysis provides insight into parent perspectives on pediatric tonsillectomy. Parents commonly tweet concerns about surgery that may not be recognized in routine clinician-parent dialogue. Findings may be used to guide clinicians in educating and counseling parents, and further engaging parents and children in shared decision-making for tonsillectomy.

NA. Laryngoscope, 128:496-501, 2018.

Objective: Unexplained medical terminology impedes clinician/parent communication. We describe jargon use in a pediatric surgical setting. Methods: We evaluated encounters between parents of children with sleep-disordered breathing (SDB; n=64) and otolaryngologists (n=8). Participants completed questionnaires evaluating demographics, clinical features, and parental role in decision-making via a 4-point categorical item. Two coders reviewed consultations for occurrence of clinician and parent utterance of medical jargon. Descriptive statistics established a profile of jargon use, and logistic regression evaluated associations between communication factors with jargon use. Results: Unexplained medical jargon was common (mean total utterances per visit=28.9,SD=19.5,Range=5–100), including SDB-specific jargon (M=8.3,SD=8.8), other medical terminology (M=13.9,SD=12) and contextual terms (M=3.8,SD=4). Parents used jargon a mean of 4.3 times (SD=4.6). Clinicians used more jargon in consults where they perceived parents as having greater involvement in decision-making (OR=3.4,p<0.05) and when parents used more jargon (OR=1.2,p<0.05). Conclusions: Jargon use in pediatric surgical consultations is common and could serve as a barrier to informed or shared parent decision-making. This study provides a foundation for further research into patterns of jargon use across surgical populations. Practice Implications: Results will be integrated into communication training to enhance clinician communication, foster self-awareness in language use, and create strategies to evaluate parental understanding.

IMPORTANCE Despite various barriers identified to early pediatric access to cochlear implantation, barriers to timely access to pediatric hearing aids are not well characterized.OBJECTIVE To identify socioeconomic, demographic, and clinical factors that may be associated with pediatric access to hearing aids. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study included 90 patients aged 1 to 15 years who were referred for auditory brainstem response (ABR) testing and evaluation for hearing aids at a single tertiary care academic medical center from March 2004 to July 2018. Children who did not receive both ABR testing and hearing aids at the same center were excluded from analysis.MAIN OUTCOMES AND MEASURES Associations of insurance type (private vs public), race/ethnicity (white vs other), primary language (English vs other), cause of hearing loss (complex vs not complex), zip code, hearing aid manufacturer, and severity of hearing loss (in decibels) with the duration of intervals from newborn hearing screening to ABR testing, from ABR testing to ordering of hearing aids, and from ABR testing to dispensing of hearing aids. RESULTSOf the 90 patients, mean (SD) age was 5.6 (3.7) years, 56% were female, and 77 (86%) were non-Hispanic. Results of χ 2 tests indicated significant assocations existed between public insurance and race/ethnicity and between public insurance and primary language other than English. Variables associated with the interval from newborn hearing screening to ABR testing included insurance type (mean difference, 7.4 months; 95% CI, 2.6-12.2 months) and race/ethnicity (mean difference, 6.9 months; 95% CI, 2.7-11.1 months). Increased delays between birth and a child's first ABR test were associated with public insurance (mean difference, 6.0 months; 95% CI, 1.8-10.2 months) and race/ethnicity other than white (mean difference, 6.0 months; 95% CI, 2.3-9.7 months). The mean time from birth to initial ABR testing was a mean of 6 months longer for patients from non-English-speaking families than for those from English-speaking families (mean [SD] interval, 14.9 [16.3] months vs 9.0 [8.5] months), although the difference was not statistically significant. Severity of hearing loss was associated with a decrease in the interval from ABR testing to ordering of hearing aids after accounting for other potential barriers (odds ratio, 0.6; 95% CI, 0.4-0.9). Zip code and complexity of the child's medical condition did not appear to be associated with timely access to pediatric hearing aids.CONCLUSIONS AND RELEVANCE This study's findings suggest that insurance type, race/ethnicity, and primary language may be barriers associated with pediatric access to hearing aids, with the greatest difference observed in time to initial ABR testing. Clinical severity of hearing loss appeared to be associated with a significant decrease in time from ABR testing to ordering of hearing aids. Greater efforts to assist parents with ABR testing and coordination of follow-up may help improve access for other at-risk ch...

This SDM framework allows for a more expansive understanding and analysis of how decision making takes place in clinical encounters, including new domains and behaviors not present in existing measures. We hope that this new framework will bring attention to a broader conception of SDM and allow researchers to further explore the new domains and behaviors identified.