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,
,#,**,
* Robert Wood Johnson Clinical Scholars Program
# Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
Departments of Biostatistics
Epidemiology
** Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
|| Department of Family Medicine, Fairfax Family Practice Residency, Virginia Commonwealth University, Richmond, Virginia
¶ George Washington University School of Medicine, Washington, DC
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Methods. We conducted a cross-sectional survey to examine how parents respond to doctor-patient communication styles in 3 clinical vignettes that presented 2 versions of a shared-decision model (SDM) and 1 paternalistic model. Parents were randomly assigned to receive 1 of 3 vignettes. The main predictor variable was the vignette assignment, and the main outcomes were (1) parent proclivity to use antibiotics and (2) parent ratings of care by the physician in the vignette. Using logistic regression, we adjusted for caregivers' age, gender, income, knowledge of antibiotics, decision-making preference, confidence in physician, and length of relationship with personal physician.
Results. Four hundred sixty-six parents met inclusion criteria, with a response rate of 94%. General characteristics were similar across vignette assignment groups. Parents who received the paternalistic-model vignettes were more likely to say that they would use antibiotics than those who received the SDM vignettes (odds ratio: 4.9; 95% confidence interval: 2.3–10.6). This result remained statistically significant after adjustment for potential confounders. In addition, parents in the shared-decision groups were more satisfied (93% and 84%) than those in the paternalistic-model group (76%).
Conclusions. To our knowledge, this is the first study to examine parent interest, acceptance, and satisfaction with the SDM. Our findings suggest that shared decision-making for AOM may lead to less antibiotic usage and higher levels of parental satisfaction. Although more studies are needed to examine how best to incorporate parents in the SDM, our study serves as an example of the potential benefit of this approach in pediatric medicine.
Key Words: shared decision-making • acute otitis media • patient-centered care • doctor-patient communication
Abbreviations: SDM, shared-decision model • AOM, acute otitis media • SNAP, safety-net antibiotic prescription
The practice of medicine is undergoing an evolutionary shift from doctor-centered care to a more patient-centered approach.1–4 To promote patient-centered care, many health care experts and organizations, including the US Institute of Medicine and the Institute for Healthcare Improvement, are encouraging physicians to move toward the shared-decision model (SDM).5 This approach is espoused for many types of situations but is particularly useful when equipoise exists in a clinical situation.
Although American Academy of Pediatrics guidelines provide various options for treating acute otitis media (AOM), it remains a condition for which patients (or caregivers of affected children) and physicians may vary in their beliefs regarding the benefit and risks of treatment with antibiotics.6 AOM is extremely common in children in the United States, accounting for >30 million clinic visits and 10% of all visits to pediatricians.7 Furthermore, in the United States, Australia, and New Zealand, antibiotics are prescribed >98% of the time for AOM, compared with 31% in the Netherlands, resulting in excess of 5 billion US dollars attributed to AOM and 50% of pediatric antibiotic prescriptions.7–11 Recent studies have shown a decrease in overall antibiotic use but a greater use of expensive broad-spectrum agents.12–16
Physicians in the United States and some other Western countries prescribe antibiotics as first-line treatment nearly universally, whereas in some European countries, antipyretics are first-line treatment for young children.17, 18 One of those countries in which recommendations are to first treat with antipyretics is the Netherlands; their level of bacterial resistance is at 
1% compared with 25% in the United States.11
Because of the conflicting evidence regarding the treatment of AOM, combined with the potential economic and public health benefits of reducing antibiotic use, there is now a consensus among experts that some children with nonsevere AOM may be treated appropriately with watchful waiting rather than antibiotics as first-line treatment.19–22 Recent work shows that 63% of parents are comfortable with receiving a safety-net antibiotic prescription (SNAP) and observing their children for 48 hours before starting antibiotics.10 However, parental satisfaction with this technique has seldom been assessed. We found no studies that examined whether the SDM would increase the acceptability of this delayed-prescription technique to parents.10
Our primary objectives were to assess (1) which style of decision-making on the physician's part would most effectively reduce parents' proclivity to use antibiotics for treatment of their child's AOM and (2) parents' satisfaction with different doctor decision-making styles and recommendations. In addition, we examined parents' comfort level with SDM when obtaining care for their children and compared it to their comfort level with SDM when obtaining health care for themselves.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Study Subjects
Individuals were eligible to participate if they (1) were 
18 years of age and (2) had at one time been the primary caregiver of a child <5 years of age. Individuals with the following were excluded: (1) problems reading English; (2) problems with concentration such as dementia or use of medicines that interfered with cognition; (3) extreme pain; or (4) medical conditions requiring acute intervention. Individuals or their accompanying relatives determined whether they met inclusion criteria.
Randomization
Permuted block randomization was used to assign vignettes randomly in blocks of 12 vignettes. Each block consisted of an equal number of random assignments to each vignette that totaled to 12.24 Each parent received a 7-page survey. The pages were identical for all 3 groups with the exception of page 6 (see Appendix for a copy of this page) which described 1 of the 3 different vignettes. Randomized groups then were identified as 1, 2, or 3. All data were initially analyzed and final models were chosen with the data analysts masked to assignments. One author (M.P.) had knowledge of the group's assignments before analysis but did not participate in initial data analysis.
Study Variables
Demographic Characteristics
We collected data regarding general parent characteristics such as age, race, ethnicity, education level, marital status, household income, work outside the home, health insurance status, relationship to child, and the number of children for which the parent had been responsible.
Relationship With the Child's Physician
We assessed the relationship between the parent and their child's physician by asking 2 questions: (1) "How long have you known your child's primary care physician?"; and (2) "How well does your child's physician know you?" The response categories for time frames were <1, 1 to 3, and >3 years. The response categories for degree of familiarity were "not at all," "somewhat," and "very well."
Knowledge Regarding Treatment With Antibiotics
We assessed parents' knowledge of situations warranting the use of antibiotics by their level of agreement with 2 statements: (1) "If your child is diagnosed with a cold, antibiotics will usually be required"; and (2) "If your child is diagnosed with an ear infection, antibiotics will usually be required." Parents were asked to indicate their level of agreement on a 5-point scale: 1, strongly agree; 2, probably agree; 3, not sure; 4, probably disagree; 5, definitely disagree.
Interest in Shared Decision-Making
We examined parents' interest in shared decision-making with 2 validated instruments. The first question ("What role do you want to play in medical decisions about your health?") includes 4 response options.25 Participants are labeled as active if they answer, "The doctor and I make the final decisions together" or "I make all the final decisions." They are labeled as passive if they answer, "The doctor takes the initiative and decides what is best for me" or "The doctor considers some of my ideas but still decides what is best for me." This question was also asked about the role that parents desire to play in the medical decisions about their child's health.
To further examine parents' interest in shared decision-making when visiting their own health care provider, we used 6 items that were most pertinent to our pediatric study from the 26-item Autonomy Preference Index, which measured parents' interest level in participating in medical decisions.26 Each question had 5 possible responses, with a higher score favoring increased interest in shared decision-making; the highest possible score was 30. These 6 questions were also changed to reflect the role the parent's desire plays in their child's health care decisions, asking specific questions about decision-making preference.
The SDM and Clinical Vignettes
We developed 3 different clinical vignettes (full vignettes are shown in the Appendix). All 3 vignettes were identical except for the description at the end of the visit. In each vignette, a mother brings her 2-year-old son to the doctor after the boy's temperature reached 100.2°F (37.9°C) the previous night. She reports that he is eating, playing, and sleeping well but has had a runny nose and cough for 4 days. The doctor in the vignette diagnoses the child with AOM in all 3 vignettes and states, "Until just a few years ago it was very clear how Johnny should be treated; we would place him on antibiotics immediately. Lately, though, with antibiotic resistance, we have been trying to cut down on overusing antibiotics." The doctor goes on to explain that ear infections are not contagious and that in Europe ear infections are seldom treated with antibiotics. Each of the vignettes describes the different options for managing children with AOM: (1) initially treating with antibiotics; (2) strongly leaning against antibiotic usage; or (3) watchful waiting. In the paternalistic or doctor-centered vignette, the doctor acknowledges that there are other ways to treat AOM, but she clearly recommends treating with antibiotics (paternalistic/antibiotic group). The other 2 vignettes were based on criteria regarding the SDM developed by Charles et al,27 with the 4 following characteristics: (1) at a minimum, both the physician and patient are involved in the treatment decision-making process; (2) both the physician and patient share information with each other; (3) both the physician and patient take steps to participate in the decision-making process by expressing treatment preferences; and (4) a treatment decision is made, and both the physician and patient agree on the treatment to implement. In the second vignette, the physician does not give a direct recommendation but instead implements a SNAP (SDM group). In the third vignette, the physician uses a variation of SNAP by recommending acetaminophen (Tylenol) but also gives the mother a prescription for antibiotics that she can start if her child does not improve within 2 to 3 days (Tylenol-SDM group).
Parents' Response to Clinical Vignette
After reading the vignettes, parents were asked to imagine being the parent in the vignette. They were asked to rate their overall satisfaction with the vignette by indicating their level of agreement with the statement, "Overall, I was satisfied with this visit." We grouped responses on this 5-point scale into 3 categories: (1) strongly and probably agree; (2) probably and definitely disagree; and (3) not sure (reference group). We also asked parents to rate the adequacy of information they received by using the question, "How did you feel about the information given to you?" Respondents had 3 choices: (1) perfect amount; (2) too much; and (3) not enough (reference group). Finally, they were asked about their likelihood of using antibiotics for AOM for their child as follows: (1) immediately give the antibiotics; (2) strongly lean against giving antibiotics; or (3) wait 48 hours and reevaluate.
Statistical Analysis
We used descriptive statistics to examine the enrolled sample. We compared baseline characteristics across the 3 vignette assignment groups by using 
2 tests for categorical variables and Kruskal-Wallis and analysis of variance tests for continuous variables. Unless otherwise stated, responses to all questions were on a 5-point Likert scale: 1, strongly agree; 2, probably agree; 3, not sure; 4, probably disagree; 5, definitely disagree.
We used logistic regression for the multivariable analysis. The main predictor variable was vignette assignment, and the main outcomes were (1) parents' proclivity to use antibiotics and (2) parent ratings of care by the physician in the vignette (overall satisfaction and adequacy of information given to the parent). After using bivariate analysis and scatter plots to examine relationships among parent characteristics and the outcomes, we included the following parental characteristics in our final regression models: age, gender, income, knowledge of antibiotics, decision-making preference, confidence in physician, and length of relationship with personal physician. In addition, variance inflation factors were obtained to check for multicollinearity between variables. We conducted all statistical analyses using Stata 8.2 statistical software.24
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Characteristics of the Study Sample
Table 1 displays the general characteristics of each vignette group. The 3 groups were similar with respect to nearly all characteristics except that there was a higher percentage of ethnic minorities in the SDM group without Tylenol than in than the other 2 groups. Consistent with the practice-based research network in which we recruited participants, our sample had a mean age of 45 years and were primarily woman (70%), white (83%), non-Hispanic (95%), insured (95%), married (84%), highly educated (87% had college or higher degree), and of high socioeconomic status (76% had household income greater than $75000).23
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Parents' Decision-Making Preferences
The 6-item Modified Preference Index showed similarities among parents' interest in shared decision-making for both their own health care visits and their child's. The higher the score, the more interest one has in shared decision-making, with a maximum score of 30. All groups had a range of 10 to 30, with an overall mean score of 21.6 for the parents themselves and 22.3 for their child's visits. Seventy-two percent of parents answered the single-item preference for the shared–decision-making measure in a manner consistent with a preference for active involvement in decision-making.
Parent Ratings of Vignette Physician Decision-Making Style
Parents in the paternalistic/antibiotic group were less satisfied with the care depicted in the vignette than those in the 2 SDM groups (Table 2). In fact, 19% of parents in the paternalistic/antibiotic group said they probably or definitely disagreed with the statement, "I was satisfied with this visit." Only 8% of the Tylenol-SDM group and 2% of the SDM group stated that they probably or definitely disagreed with this statement, both of which were statistically significant differences from the paternalistic/antibiotic group (P < .0001).
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Odds of Using Antibiotics
The odds of using antibiotics were 4.9 times higher in the paternalistic/antibiotic group compared with the Tylenol-SDM group (95% confidence interval: 2.3–10.6; P < .0001). In contrast, the SDM group had no statistically significant difference in the odds of using antibiotics compared with the Tylenol-SDM group. After adjustment for potential confounders, the odds of immediately using antibiotics were 7.0 times higher in the paternalistic/antibiotic group (95% confidence interval: 2.7–31.8; P < .0001), whereas there was no statistically significant difference in the odds of using antibiotics between the SDM and Tylenol-SDM groups (Table 3). The adjusted odds of using antibiotics were also statistically significantly higher in parents who were women, those who believed antibiotics would be required before reading the vignettes, and those who had known their personal physician for 1 to 3 years. The adjusted odds of using antibiotics were lower among parents who believed the perfect amount of information was given to them when reading the vignettes (Table 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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Before reading the vignettes, >90% of parents felt that their children diagnosed with AOM would need antibiotics for treatment of AOM. After being given information about 3 different ways to treat AOM through very short vignettes, only 14% said that they would give antibiotics immediately. The reduced proclivity to use antibiotics was most dramatic in parents exposed to clinical vignettes incorporating a SDM. In an intervention study that used a pre/post design with a concurrent control group, Smabrekke et al28 reported 90% usage of antibiotics for AOM at baseline and demonstrated that an educational intervention for doctors, nurses, and patients was successful in reducing the rate of antibiotic use to 74% in community-based practices in Norway, whereas there was no significant change in antibiotic use for AOM in the control practice sites.
The reduction in the proclivity to use antibiotics that we demonstrate in this study is based on clinical vignettes rather than actual behaviors; however, our findings suggest that in addition to education, the shared decision-making approach may help to reduce antibiotic usage for AOM. The results also suggest that parents are not opposed to doctors relaying conflicting evidence and being honest about the uncertainty of how to treat clinical situations such as AOM, as reflected by the high levels of satisfaction reported in the parent groups exposed to the SDM. Several studies show that doctors often overestimate parents' desires to have their children treated with antibiotics.29–31 Use of the SDM, including exchange between doctors and parents regarding their respective concerns, expectations, and preferences for treatment of AOM, might help to improve processes (eg, appropriate use of antibiotics) and outcomes (eg, patient satisfaction) of care for AOM.
Currently, there is much discussion about continuing the shift from doctor-centered care to a more participatory or shared decision model when patients visit their physicians. We believe this is the first study to examine parents' interest in participatory decision-making with their child's physician. We found that parents rated their interest in shared decision-making similarly regardless of whether the treatment was for them or their children. More studies are needed to examine how best to incorporate parents in the SDM. Our study serves as an example of the potential benefit of this approach in pediatric medicine. Although this study was conducted in the United States, the implications for countries such as Sweden, France, Germany, New Zealand, and Australia may be just as important, because their rates of antibiotic usage for AOM and prevalence of penicillin-resistant Streptococcus pneumoniae are both very high.32–35
The study does have some limitations. First, the cross-sectional design does not allow one to draw causal inferences because of the inability to examine temporal relationships between parent knowledge and beliefs and actual behaviors with regard to antibiotic use or interactions with physicians. Second, we used clinical vignettes with children with nonsevere AOM who were 2 years old, and it is possible that under actual conditions with different ages and circumstances, parents might react differently to the physician's decision-making styles. Third, our study sample was somewhat homogenous, with very high education levels and socioeconomic status. However, because individuals from higher socioeconomic status groups generally report higher levels of shared decision-making with physicians, and this study examines the acceptability of the SDM to parents of children under these conditions, it might be considered an ideal situation.36, 37 Fourth, the physician-patient encounters in our vignettes represented a continuum of SDM rather than being strictly paternalistic or autonomous. For example, our Tylenol-SDM vignette does not adhere as strictly to the SDM as the pure SDM vignette. In addition, it is likely that not all parents desire the same approach. We did not have enough power to conduct subgroup analyses for parents with specific demographic or attitudinal characteristics, but one can suspect that parents who labeled themselves as passive on the shared-decision scale might have differed after the vignette education from parents labeled as active. Finally, although our study focused on parents' views of health care decisions for their children, our vignettes and shared-decision measures have only been validated with regard to health care for adults.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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APPENDIX |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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You are meeting Dr Jones for the first time; in the past you have seen his partner. Today your 2-year-old, Johnny, is being seen. Johnny is in day care and for the last 4 days he has had a runny nose and a slight cough. He is sleeping, eating, and playing well but last night his temperature went up to 100.2°F. Johnny is generally very healthy and has been treated with antibiotics only once before for a throat infection
Paternalistic/Antibiotic Group Vignette
Dr Jones: It appears that Johnny has an ear infection, what we doctors call acute otitis media.
Ms Smith: I thought he might have that; he seemed to be pulling at his ear.
Dr Jones: Has he ever had an ear infection before?
Ms Smith: No, he never has but his older sister, Maya, seemed to get them all the time.
Dr Jones: Until just a few years ago it was very clear how Johnny should be treated; we would place him on antibiotics immediately. Lately, though, with antibiotic resistance, we have been trying to cut down on overusing antibiotics.
Ms Smith: Really, that is interesting, as Maya seemed to always be on antibiotics.
Dr Jones: When she was getting treated, that was clearly the norm, but things are always changing in medicine.
Ms Smith: Well, don't we need to treat him so he doesn't get anyone else sick?
Dr Jones: The nice thing about ear infections is that they are not contagious.
Ms Smith: Well, won't Johnny just get sicker if we don't treat him?
Dr Jones: Not necessarily. In fact, in Europe they seldom treat ear infections with antibiotics, and their children seem to do just as well.
Ms Smith: Well, what should we do? I just want to do what is best for Johnny.
Dr Jones: I think we should place him on antibiotics today and he will continue with them for the next 10 days. I do want to let you know, though, that there are 2 other options that other doctors recommend. The first is, we don't treat Johnny with antibiotics yet; instead, you use Tylenol and call me back if you don't see any improvement in 3 to 4 days, or I give you a prescription for antibiotics but you don't fill it unless Johnny seems to be getting worse or shows no improvement in 2 to 3 days.
Ms Smith: Why don't you just treat him now as you recommended?
Dr Jones: That seems most reasonable to me.
SDM Group Vignette
Dr Jones: It appears that little Johnny has an ear infection, what we doctors call acute otitis media.
Ms Smith: I thought he might have that; he seemed to be pulling at his ear.
Dr Jones: Has he ever had an ear infection before?
Ms Smith: No, he never has, but his older sister, Maya, seemed to get them all the time.
Dr Jones: Until just a few years ago, it was very clear how Johnny should be treated; we would place him on antibiotics immediately. Lately, though, with antibiotic resistance, we have been trying to cut down on overusing antibiotics.
Ms Smith: Really, that is interesting, as Maya seemed to always be on antibiotics.
Dr Jones: When she was getting treated, that was clearly the norm, but things are always changing in medicine.
Ms Smith: Well, don't we need to treat him so he doesn't get anyone else sick?
Dr Jones: The nice thing about ear infections is that they are not contagious.
Ms Smith: Well, won't Johnny just get sicker if we don't treat him?
Dr Jones: Not necessarily. In fact, in Europe they seldom treat ear infections with antibiotics, and their children seem to do just as well.
Ms Smith: Well, what should we do? I just want to do what is best for Johnny.
Dr Jones: I think we have 3 very reasonable choices. One, I give you a prescription for antibiotics today and Johnny takes the medicine 3 times a day for 10 days. Option 2, we don't treat Johnny with antibiotics yet; instead, you use Tylenol and call me back if you don't see any improvement in 2 to 3 days. Or option 3, I give you a prescription for antibiotics, but you don't fill it unless Johnny seems to be getting worse or shows no improvement in 2 to 3 days.
Ms Smith: Thanks; I appreciate your giving me the options.
Tylenol-SDM Group Vignette
Dr Jones: It appears that Johnny has an ear infection, what we doctors call acute otitis media.
Ms Smith: I thought he might have that; he seemed to be pulling at his ear.
Dr Jones: Has he ever had an ear infection before?
Ms Smith: No, he never has, but his older sister, Maya, seemed to get them all the time.
Dr Jones: Until just a few years ago, it was very clear how Johnny should be treated; we would place him on antibiotics immediately. Lately, though, with antibiotic resistance, there has been a push to cut down the use of antibiotics.
Ms Smith: Really, that is interesting, as Maya seemed to always be on antibiotics.
Dr Jones: Yeah, that is the old way, but new research shows it is not necessary to start antibiotics for the first few days.
Ms Smith: Well, don't we need to treat him so he doesn't get anyone else sick?
Dr Jones: Not necessarily. In fact, in Europe they seldom treat ear infections with antibiotics, and their children seem to do just as well.
Ms Smith: Well, what should we do? I just want to do what is best for Johnny.
Dr Jones: I think we should place him on Tylenol today and also give you a prescription for antibiotics that you can fill if Johnny doesn't get better in 2 to 3 days. I do want to let you know, though, that there are 2 other options that other doctors recommend. The first is, we treat Johnny today with antibiotics, and the second is we start with Tylenol, and you call me if you are not happy with how he is doing in 2 to 3 days.
Ms Smith: Why don't you just treat him now as you recommended?
Dr Jones: That seems most reasonable to me.
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ACKNOWLEDGMENTS |
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We would like to thank Fairfax Family Practice and Vienna Family Medicine for participating in this study.
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FOOTNOTES |
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Address correspondence to Dan Merenstein, MD, Georgetown University, 3750 Reservoir Rd, 220 Kober Cogan, Washington, DC 20007. E-mail: djm23{at}georgetown.edu
No conflict of interest declared.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIXREFERENCES |
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This article has been cited by other articles:
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  S. Berman Otitis Media, Shared Decision Making, and Enhancing Value in Pediatric Practice Arch Pediatr Adolesc Med, February 1, 2008; 162(2): 186 - 188. [Full Text] [PDF]
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 L. Vernacchio, R. M. Vezina, and A. A. Mitchell Management of Acute Otitis Media by Primary Care Physicians: Trends Since the Release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians Clinical Practice Guideline Pediatrics, August 1, 2007; 120(2): 281 - 287. [Abstract] [Full Text] [PDF]
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E. D. Cox, M. A. Smith, and R. L. Brown Evaluating Deliberation in Pediatric Primary Care Pediatrics, July 1, 2007; 120(1): e68 - e77. [Abstract] [Full Text] [PDF]
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 Parents' Views of Shared Decision-Making in Pediatrics Journal Watch Pediatrics and Adolescent Medicine, December 30, 2005; 2005(1230): 3 - 3. [Full Text]
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 Parents' Views of Shared Decision Making in Pediatrics Journal Watch (General), December 16, 2005; 2005(1216): 4 - 4. [Full Text]
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