Assessment of Parental Choice Predisposition for Tonsillectomy in Children

Shared decision-making is a strategy to improve communication and health care delivery by reducing unwarranted variation and improving quality of treatment decisions, particularly for conditions where evidence supports multiple treatment choices without a single superior option. In such “preference-sensitive” treatment scenarios, shared decision-making promotes a collaborative decision that is consistent with evidence-based practices and patient preferences and values. Obstructive sleep-disordered breathing (OSDB) is a common condition in children for which decisions for surgery with tonsillectomy are often dependent on family preferences. The treatment decisions are considered preference sensitive because of a lack of definitive evidence for a single best treatment.

[..] Choice predisposition is a measure of the strength of a patient’s treatment decision prior to entering a consultation. It reflects not only patient treatment preferences but also the extent to which they are committed to their preference. Previous studies have found that patient predispositions that are strongly polarized for certain treatments are resistant to change. Additionally, for patients with chronic illnesses, such as hepatitis C, choice predispositions are strong predictors of treatment initiation and completion. Certainly, an understanding of patient choice predispositions will improve clinician communication in shared decision-making and perhaps patient health outcomes.

[..] We show that parents are often predisposed to choose tonsillectomy prior to their initial consultation with otolaryngology clinicians. We also show that prior evaluation for OSDB and parent race/ethnicity are associated with predisposition for tonsillectomy. Furthermore, we found that parent predisposition is associated with communication between parents and clinicians and may be associated with a reduced degree of shared decision-making. These findings suggest that the decision for surgery is multifactorial and is not dependent primarily on otolaryngologic evaluation and counseling.

[..] We found that parents predisposed to choose tonsillectomy demonstrated greater knowledge and familiarity with OSDB and tonsillectomy by being more likely to introduce medical jargon during their consultation and scoring higher on the postconsult knowledge measure. These findings suggest that parents more predisposed to tonsillectomy have greater knowledge about the condition and treatment in advance of their consultation with the clinician. Greater knowledge may give parents a greater sense of autonomy regarding their decision for tonsillectomy.

However, parents more predisposed to choose tonsillectomy were less likely to engage in the decision-making process by asking questions during the consultation. It is possible that parents more predisposed to tonsillectomy may perceive they already have adequate information to make a treatment decision for their child. However, this perception of adequate knowledge may hinder honest discussions between clinicians and parents and prevent parents from openly considering alternative treatment options. Previous studies have found that information sources for parents and patients regarding a number of diseases are not always accurate and may not be applicable to a patient’s unique situation. An awareness of parent predisposition for tonsillectomy may allow clinicians to better discern the needs and concerns of parents and more efficiently tailor discussions. The expectation that parents will voluntarily share their choice predisposition and opinions on treatments may be unrealistic. Clinicians may more successfully engage parents by initiating these discussions and eliciting preferences to ensure parents can make the best and most informed decision for their child, aligned with their family values.

[..] The study’s finding that parents of patients who were previously evaluated or treated by their pediatrician for OSDB were more likely to be predisposed to tonsillectomy supports the weight of the primary care clinician relationship and influence on decision-making. Pediatricians play an important role in parental decision-making and are consistently regarded as among the most trusted sources of information by parents. Our prior research interviewing parents about experience with their child’s OSDB suggests that decision-making and treatment suggestions for this condition are often made between the parent and primary care clinician. These interviews also highlighted the concept that the longitudinal nature of their relationship with the pediatrician was a key factor in making decisions for their children. These findings, however, do not minimize the importance of high-quality discussions regarding tonsillectomy between parents and otolaryngologists during consultations. Primary goals for families seeking subspecialty care is to increase confirmation and knowledge about their child’s condition and to align expectations regarding treatment goals. Subspecialty clinicians, such as those in pediatric otolaryngology, may better meet the goals of parents by unequivocally presenting risks and benefits of all treatment options and focusing discussions on treatment benefits to a child’s particular clinical situation as well as the parents’ unique concerns. Understanding parent choice predisposition may allow clinicians to individualize the consultation and prioritize areas of discussion. Moreover, previous studies have found that many pediatricians have varied knowledge regarding sleep disorders, including OSDB. Surgeon content expertise and counseling may help parents better align presurgical expectations with their child’s postsurgical outcomes.

The treatment decision-making process is complex for parents, and personal and familial experiences, cultural practices, and community influences also contribute to their choice predisposition. For example, prior to pediatric otolaryngology consultations, parents often used internet resources and experiences of their family and friends as resources for information regarding their child’s health issue. It is likely that the experiences of family members and friends may also contribute to parent choice predisposition. While the present study’s findings suggest that prior evaluation for OSDB may contribute to parent predisposition, the study was unable to fully explore the influence of other contributors, such as the experiences of family members and friends. Future analyses looking at differences in parent choice predisposition associated with otolaryngology referral patterns may be helpful in addressing the role of pediatricians and other subspecialists in decision-making for pediatric OSDB.”

Full article, Leu GR, Links AR, Ryan MA et al., JAMA Otolaryngology – Head & Neck Surgery 2020.12.30