Barriers and Facilitators of Shared Decision-making in Pediatric Otolaryngology

Introduction: Although the benefits of shared decision making (SDM) are well known, it is not routinely practiced in pediatric otolaryngology. The purpose of this study was to identify barriers and facilitators to implementing SDM in pediatric otolaryngology.

Methods: A qualitative research design informed by the Knowledge to Action cycle was used to assess the barriers and facilitators of SDM among pediatric otolaryngologists. The Theoretical Domains Framework (TDF) was used as a guide for data analysis to consider capability, opportunity, and motivation (COM-B) factors. The surgical procedures were tonsillectomy, adenoidectomy and tympanostomy tube placement. Semi-structured interviews of pediatric otolaryngologists across North America were performed. Deductive and inductive coding of interview transcripts according to TDF/COM-B domains were performed by two separate reviewers.

Results: A total of 11 interviews were conducted to achieve data saturation. The four dominant themes were: (1) understanding of SDM criteria (2) social influences (3) environment and (4) applicability in otolaryngology. Theme 1 identified that surgeons perceived SDM as a feature of their practice and discussed treatment options. However, the discussion of patient values and structured interview formats were not commonly employed. Theme 2 demonstrated that a parent’s pre-consult ‘agenda’ influenced their openness to consider other options. Theme 3 outlines the barriers of short appointment times, challenges in the use of support staff, and lack of decision aids. Theme 4 emphasizes the value of SDM for common surgeries where decisions are marked with uncertainty and equipoise. Surgeons believe that parent’s involvement in decision making promoted investment in the decision and reduced likelihood of regret if complications arose later.

Conclusions: Pediatric otolaryngologists strongly support the value of SDM during clinical encounters, particularly to allow parent ownership of decisions regarding treatment. The major barriers were lack of clinical translation of SDM knowledge, social influences, and environmental factors.