Tufts University School of Medicine, Boston, Massachusetts.
Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
JAMA Otolaryngol Head Neck Surg. 2021 Mar 1;147(3):263-270. doi: 10.1001/jamaoto.2020.5031.
The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known.
To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication.
DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist.
The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents).
A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34).
In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.
决定是否进行扁桃体切除术来治疗小儿阻塞性睡眠呼吸障碍（OSDB）通常取决于各个家庭。尽管强调了父母和外科医生之间就 OSDB 的扁桃体切除术进行共同决策，但父母在孩子就诊前对手术已经做出决定的程度尚不清楚。
确定父母对 OSDB 扁桃体切除术手术治疗选择倾向的预测因素，并描述其与父母-临床医生沟通的关系。
设计、地点和参与者：在与一家大型学术中心相关的 3 个门诊临床地点（城市门诊中心、郊区场外门诊中心和社区医疗中心）进行的观察性队列研究。通过诊所预约记录确定了 149 名正在接受 OSDB 初始耳鼻喉科咨询的儿童的父母，并认为他们符合参与本研究的条件。在 149 名父母中，有 64 名（42.9%）愿意参加并记录其咨询的志愿者父母被招募。在这 64 名参与者中，有 12 名父母因孩子之前已由专家评估过 OSDB 而被排除在外。
主要结果和措施是治疗选择倾向量表（衡量患者在进入医疗咨询前治疗决策强度的指标），咨询录音中记录的父母沟通行为（提出的实质性问题、引入医学术语、表达治疗偏好以及父母的 OSDB 和腺样体切除术知识量表评分）。
共有 52 名父母参与者纳入最终分析。大多数父母参与者为女性（n=48；92%）；50%（n=26）的父母是非西班牙裔白人，37%（n=19）为黑人，10%（n=5）为西班牙裔/拉丁裔，4%（n=2）的父母自我报告的种族/族裔为“其他”。平均（范围）选择倾向为 6.84（2-10），22 名父母（42%）更倾向于选择扁桃体切除术。更倾向于选择扁桃体切除术的父母在咨询中使用了更多的医学术语（比值比[OR]，3.95；95%置信区间[CI]，1.16-15.15），且不太可能提问（OR，0.22；95%CI，0.05-0.87）。父母对手术选择更大倾向的预测因素是白种人（OR，7.31；95%CI，1.77-39.33）和儿科医生先前对 OSDB 的评估（OR，6.10；95%CI，1.44-33.34）。
在这项针对患有 OSDB 的儿童父母的队列研究中，许多父母在接受初次手术咨询之前就倾向于选择扁桃体切除术治疗，这可能会减少参与度并影响双向沟通。在本队列中，非西班牙裔白人父母和曾由儿科医生评估过 OSDB 的患者的父母更倾向于选择扁桃体切除术。了解父母对手术的选择倾向可以促进在手术咨询期间改善沟通和父母参与度。它还可以帮助将有关睡眠和扁桃体切除术的教育引导至非手术论坛。
