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Patients’ Views of Shared Decision-making and Decisional Conflict in Otolaryngologic Surgery During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the prevalence of decisional conflict for surgical patients during the early phases of the COVID-19 pandemic?

Findings  In this cross-sectional survey study of 182 patients scheduled for otolaryngologic surgery during the pandemic, non-White participants without college education were 10 times more likely to screen positive for decisional conflict compared with college-educated White participants. Concerns about intraoperative and postoperative processes were more prominent than COVID-19 concerns.

Meaning  The results of this survey study suggest the need for health care professionals to converse with patients about patient values, beliefs, and specific concerns about treatment; future studies to elucidate racial health care inequities are warranted.


Importance  A patient’s decision to undergo surgery may be fraught with uncertainty and decisional conflict. The unpredictable nature of the COVID-19 pandemic warrants further study into factors associated with patient decision-making.

Objective  To assess decisional conflict and patient-specific concerns for people undergoing otolaryngologic surgery during the pandemic.

Design, Setting, Participants  This prospective cross-sectional survey study was conducted via telephone from April 22 to August 31, 2020. English-speaking adults scheduled for surgery from a single academic surgical center were invited to participate. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, scheduled for emergent surgery, or had a communication disability were excluded. For race and ethnicity reporting, participants were classified dichotomously as White according to the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention or non-White as a collective term including Black or African American, American Indian or Alaska Native, Asian, or Pacific Islander race and ethnicity.

Exposures  The SURE Questionnaire (sure of myself, understand information, risks/benefits ratio, and encouragement) was used to screen for decisional conflict, with a total score greater than or equal to 3 indicating clinically significant decisional conflict. Participants were asked to share their specific concerns about having surgery.

Main Outcome and Measures  Decisional conflict and patient demographic data were assessed via bivariate analyses, multivariable logistic regression and conjunctive consolidation. Patient-specific concerns were qualitatively analyzed for summative themes.

Results  Of 444 patients screened for eligibility, 182 (40.9%) respondents participated. The median age was 60.5 years (interquartile range, 48-70 years). The racial and ethnic identity of the participants was classified as binary White (84% [153 of 182]) and non-White (16% [29 of 182]). The overall prevalence of decisional conflict was 19% (34 of 182). Decisional conflict was more prevalent among non-White than White participants (proportion difference 18.8%, 95% CI, 0.6%-37.0% and adjusted odds ratio 3.0; 95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non-White patients with no college education receiving urgent surgery (odds ratio, 10.8; 95% CI, 2.6-45.0). Intraoperative and postoperative concerns were the most common themes expressed by participants. There was a clinically significant difference in the proportion of participants who screened positive for decisional conflict (30%) and expressed postoperative concerns than those who screened negative for decisional conflict (17%) (proportion difference, 13%; 95% CI, 1%-25%). Among patients reporting concerns about COVID-19, most screened positive for decisional conflict.

Conclusions and Relevance  Results of this cross-sectional survey study suggest that the COVID-19 pandemic was associated with decisional conflict in patients undergoing otolaryngologic surgery. Consistent discussion of risks and benefits is essential. The role of race and ethnicity in decisional conflict warrants further study.

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Article Information

Accepted for Publication: July 14, 2021.

Published Online: September 9, 2021. doi:10.1001/jamaoto.2021.2230

Corresponding Author: John J. Chi, MD, MPHS, Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Washington University in St Louis, 660 S Euclid Ave, Campus Box 8115, St Louis, MO 63110 (

Author Contributions: Drs Wamkpah and Chi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wamkpah, Piccirillo, Chi.

Acquisition, analysis, or interpretation of data: Wamkpah, Gerndt, Kallogjeri, Chi.

Drafting of the manuscript: Wamkpah, Gerndt.

Critical revision of the manuscript for important intellectual content: Wamkpah, Kallogjeri, Piccirillo, Chi.

Statistical analysis: Wamkpah, Kallogjeri.

Administrative, technical, or material support: Chi.

Supervision: Piccirillo, Chi.

Conflict of Interest Disclosures: Dr Kallogjeri reported receiving personal fees as Statistics Editor for JAMA Otolaryngology-Head & Neck Surgery and owning stock in Potentia Metrics. No other disclosures were reported.

Funding/Support: Research reported in this publication was supported by the National Institute of Deafness and Other Communication Disorders within the National Institutes of Health (NIH) under award 5T32DC000022-30 and by the National Center for Advancing Translational Sciences of the NIH under award UL1TR002345. The use of Research Electronic Data Capture (REDCap) for this project was supported by the Clinical and Translational Science Award grant UL1 TR000448 and Siteman Comprehensive Cancer Center and NCI Cancer Center support grant P30 CA091842.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr Piccirillo is Editor and Dr Kallogjeri is Statistics Editor of JAMA Otolaryngology-Head & Neck Surgery, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: We thank the patients for granting permission to publish this information, and the details about race and ethnicity as collective descriptions were included in verbal phone consent. We thank Drs Joseph Bradley, Gregory Branham, Molly Huston, Randal Paniello, Patrik Pipkorn, Jason Rich, and Emily Spataro (Washington University School of Medicine, St Louis, MO) for access to patients from their practices for recruitment.

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