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Invited Commentary
Surgery
June 7, 2019

Shared Decision Making in Appendicitis Treatment: Optimized, Standardized, or Usual Communication

Author Affiliations
  • 1S-SPIRE Center, Department of Surgery, Stanford University, Stanford, California
  • 2Associate Editor, JAMA Network Open
JAMA Netw Open. 2019;2(6):e194999. doi:10.1001/jamanetworkopen.2019.4999

Amid considerable interest in nonoperative management of uncomplicated appendicitis, reported failure rates vary, as do rates of complications after appendectomy. Given the risks and benefits associated with both operative and nonoperative management, some authors have suggested that patients themselves may be best at deciding which treatment approach is right for them.1-3 Incorporation of shared decision making into appendicitis treatment algorithms is in keeping with the broader movement to incorporate shared decision making into clinical practice.4

In JAMA Network Open, Minneci et al5 assessed the effects of an optimized, technology-based patient activation tool (PAT) on decision-making and patient-centered outcomes among pediatric patients with acute uncomplicated appendicitis and their caregivers. Rather than comparing communication with an optimized PAT with usual care, the study team followed stakeholder recommendations and compared the PAT with a standardized script that encouraged patient and caregiver participation in treatment decision making. The study found that overall decision-making self-efficacy was very high among both the standardized consultation and PAT groups. At 1 year, the study groups showed no clinically significant differences in decisional self-efficacy, health care satisfaction at discharge, or disability days. The authors concluded that a consultation promoting shared decision making—in the form of either a standardized consultation or a technology-based tool—may inform and prepare caregivers to better participate in their child’s care.

Both groups scored extremely high on all measures of decision-making outcomes and knowledge recall, indicating outstanding comprehension, satisfaction, and self-efficacy. Notably, caregiver decision makers were primarily well educated and English-speaking. Practically, these results also suggest that the standardized scripted surgeon conversation alone provided ample information about both operative and nonoperative management. The authors acknowledge a potential ceiling effect, whereby high proportions of scores near the maximum of instruments’ scales make it difficult to discern clinically meaningful differences. In the real world, however, surgeons do not communicate from a standardized script. Previous research suggests that preoperative counseling often falls short in adequately conveying risks, benefits, and alternatives.6 Outside the setting of a randomized controlled trial, the additional information provided by a technology-based PAT may increase in value to patients and their proxies, in this case parents or guardians.

Although the standardized script and PAT tool contained nearly identical information about risks and benefits of the treatment options, patients and their caregivers in each study arm showed different treatment biases. In the PAT group, 15% of patient-caregiver dyads reported a bias toward nonoperative management, compared with only 3% of patients who received standardized consultation. Regardless, the study found no statistically significant difference in the proportion of patients who chose appendectomy vs nonoperative management between the standardized counseling and PAT groups. Physicians who use shared decision-making techniques in clinical practice must strive for balance when framing treatment options. As evidenced here, patients may continue to look for any clues, no matter how small, from their physician as to which treatment option may be the best.

The authors also found that despite an approximately 35% failure rate of nonoperative management at 1 year—nearly double the 20% failure rate quoted to patients in the standardized consultation and the PAT—nearly all patients who were treated nonoperatively were satisfied with their decision at 1 year. Decision satisfaction did not differ among patients with successful vs unsuccessful nonoperative management. To physicians, this outcome may be somewhat remarkable. However, it is consistent with prior studies demonstrating that some patients who were treated nonoperatively would be willing to choose nonoperative treatment a second time, despite experiencing a recurrence.7 Perhaps recurrence of appendicitis was not as negative an outcome for patients as physicians believe it to be. Alternatively, patients and caregivers may have exhibited a cognitive bias known as choice-supportive bias, whereby a person remembers their choice as better than it actually was simply because it was the one to which they had already committed.8 Through such a lens, it is perhaps less surprising that nearly all patients were satisfied with the decision they made, no matter the outcome.

Finally, the simple fact that patients felt that they had a choice at all may have increased their satisfaction with treatment decision making and the treatment itself. Shared decision making is known to improve patient decision satisfaction and confidence in decisions.9 In the present study, standardized counseling was designed to represent the best available standard care instead of usual care, as usual care does not reliably prioritize patient involvement in decision making for treatment. Thus, both the standardized counseling and PAT interventions emphasized the importance of patient preferences and participation in shared decision making. Given the lack of differences between the groups’ outcomes, the basic presence of shared decision making—rather than the mechanism by which shared decision making was explored—may have been the most important factor in achieving high patient satisfaction, confidence, and self-efficacy in decision making.

Taken together, these data underscore several important lessons. They support the incorporation of shared decision making into all studies that compare operative vs nonoperative management of uncomplicated appendicitis and in real-world practice. They emphasize the importance of presenting patients with unbiased information drawn from the best existing data. Perhaps most importantly, the mechanism by which risks and benefits are communicated and preferences are elicited in shared decision making may matter less than whether such communication occurs at all.

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Article Information

Published: June 7, 2019. doi:10.1001/jamanetworkopen.2019.4999

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Sceats L et al. JAMA Network Open.

Corresponding Author: Arden M. Morris, MD, MPH, Department of Surgery, Stanford University, 300 Pasteur Dr, Room H3680, Stanford, CA 94305 (ammsurg@stanford.edu).

Conflict of Interest Disclosures: Dr Sceats reported grants from the National Institutes of Health Clinical and Translational Science Awards KL2 program outside the submitted work. No other disclosures were reported.

References
1.
Minneci  PC, Mahida  JB, Lodwick  DL,  et al.  Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis.  JAMA Surg. 2016;151(5):408-415. doi:10.1001/jamasurg.2015.4534PubMedGoogle ScholarCrossref
2.
Chhabra  KR, Sacks  GD, Dimick  JB.  Surgical decision making: challenging dogma and incorporating patient preferences.  JAMA. 2017;317(4):357-358. doi:10.1001/jama.2016.18719PubMedGoogle ScholarCrossref
3.
Sceats  LA, Trickey  AW, Morris  AM, Kin  C, Staudenmayer  KL.  Nonoperative management of uncomplicated appendicitis among privately insured patients.  JAMA Surg. 2018;154(2):141-149. doi:10.1001/jamasurg.2018.4282PubMedGoogle ScholarCrossref
4.
Spatz  ES, Krumholz  HM, Moulton  BW.  Prime time for shared decision making.  JAMA. 2017;317(13):1309-1310. doi:10.1001/jama.2017.0616PubMedGoogle ScholarCrossref
5.
Minneci  PC, Cooper  JN, Leonhart  K,  et al.  Effects of a patient activation tool on decision making between surgery and nonoperative management for pediatric appendicitis: a randomized clinical trial.  JAMA Netw Open. 2019;2(6):e195009. doi:10.1001/jamanetworkopen.2019.5009Google Scholar
6.
Chotai  PN, Nollan  R, Huang  EY, Gosain  A.  Surgical informed consent in children: a systematic review.  J Surg Res. 2017;213:191-198. doi:10.1016/j.jss.2017.02.047PubMedGoogle ScholarCrossref
7.
Talan  DA, Saltzman  DJ, Mower  WR,  et al; Olive View–UCLA Appendicitis Study Group.  Antibiotics-first versus surgery for appendicitis: a US pilot randomized controlled trial allowing outpatient antibiotic management.  Ann Emerg Med. 2017;70(1):1-11.e9. doi:10.1016/j.annemergmed.2016.08.446PubMedGoogle ScholarCrossref
8.
Lind  M, Visentini  M, Mäntylä  T, Del Missier  F.  Choice-supportive misremembering: a new taxonomy and review.  Front Psychol. 2017;8:2062. doi:10.3389/fpsyg.2017.02062PubMedGoogle ScholarCrossref
9.
Hauser  K, Koerfer  A, Kuhr  K, Albus  C, Herzig  S, Matthes  J.  Outcome-relevant effects of shared decision making.  Dtsch Arztebl Int. 2015;112(40):665-671. doi:10.3238/arztebl.2015.0665PubMedGoogle Scholar
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