For otolaryngology patients, decisions to undergo surgery can be challenging, especially for those considering elective procedures. “Even when surgery is clearly the best option, patients are often concerned about factors surrounding the operation,” explains John J. Chi, MD, MPHS. Increasingly, efforts are being made to increase shared decision-making (SDM), with studies suggesting that SDM can improve clinical outcomes, enhance treatment adherence, and empower patients in their treatment decisions.

An important aspect of SDM is decisional conflict, which has been defined as the difficulties patients face when deciding on care. Recent otolaryngology studies have shown that reports of decisional conflict vary widely, ranging between 13% and 43%. In addition, social distancing policies that were implemented to reduce the spread of COVID-19 during the pandemic may have added an extra layer of uncertainty for patients who are thinking about undergoing an otolaryngologic procedure. This uncertainty can lead to decisional conflict.

Has the Pandemic Added More Uncertainty?

For a study published in JAMA Otolaryngology—Head & Neck Surgery, Dr. Chi and colleagues assessed decisional conflict and concerns in patients scheduled for otolaryngologic surgery during the COVID-19 pandemic. “Our goal was to measure the prevalence of decisional conflict in these patients during the early phases of the pandemic,” Dr. Chi says. The study team also sought to determine associations between patient factors and decisional conflict in those scheduled to undergo otolaryngologic surgery during the pandemic.

The investigators conducted a phone survey from April 22, 2020 to August 31, 2020, and participants were screened for decisional conflict using the validated SURE Questionnaire, a 4-item screening tool in which 1 point is given for a “yes” or 0 points for a “no.” The presence of clinically significant decisional conflict was defined as having a score of 3 or higher on the SURE Questionnaire. Participants were also asked to share their specific concerns about having surgery. Study participants ranged in age from 48-70, with a median age of 60.5 years, and were categorized by race and ethnicity, with 84% of the study group identifying as White at 16% as non-White, a term that collectively referred to Black or African Americans, American Indians or Alaska Natives, Asians, or Pacific Islanders. The authors noted that participants were sampled from multiple subspecialties within otolaryngology.

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Decisional Conflict Affected 1 in 5 Patients

The overall prevalence of decisional conflict was 19% among patients undergoing otolaryngologic surgery during the early months of the COVID-19 pandemic. Decisional conflict was more prevalent among non-White participants than in those who identified as White (OR, 3.0). Non-White patients with no college education who were receiving urgent otolaryngologic surgery had the highest rate of decisional conflict (OR, 10.8).

Several important themes regarding patient-specific concerns were identified in the study (Figure). “Intraoperative and postoperative concerns were the most prevalent patient-specific concerns,” Dr. Chi says. These included fears about anesthesia or worries about achieving successful outcomes, recovery, and wounds and healing. Only 19% of patients cited COVID-19 as a concern, among whom most reported fears about contracting COVID-19 or being uncertain about hospital safety or sanitation. Most patients who were concerned about COVID-19 screened positive for decisional conflict, suggesting the pandemic negatively impacted patient confidence in choosing to have surgery.

Talk to Patient About Their Values & Concerns

The study identified patient populations that are potentially at risk for poor SDM outcomes, but additional research is needed to better understand the impact of factors associated with decisional conflict in people undergoing otolaryngologic surgery. Greater clarity is needed on the role of race and ethnicity in decisional conflict and SDM, according to Dr. Chi. The findings on intraoperative and postoperative concerns indicate that patients may be missing important elements from preoperative discussions with their healthcare providers, he adds. “Clinicians should talk to otolaryngology patients about their values, beliefs, and specific concerns regarding treatment to ensure SDM efforts are optimized,” says Dr. Chi.