Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis

doi:10.1016/j.acap.2015.03.011

Academic Pediatrics

Volume 15, Issue 6, November–December 2015, Pages 573-583

https://doi.org/10.1016/j.acap.2015.03.011 Get rights and content

Abstract

Background

Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients.

Objectives

To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes.

Data Sources

We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan.

Study Eligibility Criteria

We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes.

Study Appraisal and Synthesis Methods

We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction.

Results

Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD −1.20, 95% CI −2.01 to −0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI −0.04 to 0.78, P = .08).

Limitations

Included studies were heterogeneous in nature, including their conceptions of SDM.

Conclusions and Implications of Key Findings

A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear.

Systematic Review Registration Number

PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).

Section snippets

Study Protocol

We previously published the study protocol as an open access article¹⁵ and registered the systematic review in Prospero (CRD42013004761; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761). We briefly describe the methods herein as well as changes that occurred during the review process.

Changes in the Review Process

The original protocol proposed contacting all primary study authors for verification of extracted data.¹⁵ However, given substantial agreement between data extractors after one round of

Description of Pediatric SDM Interventions

The results of the search, eligibility assessment, and number of references included are outlined in Figure 1. The database search resulted in 1652 references, and the environmental scan resulted in 53 references, all of which we assessed for eligibility. Sixty-one references meeting eligibility criteria were retained for inclusion in the systematic review. Because 11 citations reported results related to 4 unique interventions,14, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 we therefore report on

Summary of Findings

SDM in pediatrics remains poorly defined. In particular, the relative roles of the pediatric patient and their parent have not been clarified. A number of SDM interventions have been developed for pediatrics, but only approximately half of these interventions were formally studied. This may be in part because the environmental scan generated the majority of the included references, many of which were online resources, and thus by their nature were not formally studied. Moreover, less than half

Conclusions

The research enterprise to promote SDM has left children behind. Not only are children often not involved in decisions, but interventions to engage patients and parents are often not rigorously studied. Although a limited evidence base suggests that SDM interventions improve parent knowledge and decisional conflict, further studies are needed to advance the science and practice of SDM in pediatrics.

Acknowledgments

This study was conducted with internal investigator discretionary support at Mayo Clinic. William Brinkman is supported at Cincinnati Children's Hospital Medical Center by award K23MH083027 from the National Institute of Mental Health. The funding sources had no input into the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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: The authors declare that they have no conflict of interest.

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Systematic ReviewShared Decision Making in Pediatrics: A Systematic Review and Meta-analysis