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Family Risk Communication Preferences in Pediatric Surgery: A Scoping Review

  • Arthega Selvarajan
    Affiliations
    McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
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  • Brandon Arulanandam
    Affiliations
    McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
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  • Elena Guadagno
    Affiliations
    Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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  • Dan Poenaru
    Correspondence
    Corresponding author. Harvey E. Beardmore Division of Pediatric Surgery The Montreal Children's Hospital Room B04.2028, 1001 Decarie Boulevard Montreal, Quebec H4A 3J1, Canada. Tel.: +1 514 412 4498; fax: +1 514 412 4289. .
    Affiliations
    McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada

    Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Open AccessPublished:January 18, 2023DOI:https://doi.org/10.1016/j.jpedsurg.2023.01.027

      Highlights

      • What is currently known about this topic?
      • Good risk communication is essential both in the preoperative shared decision-making process and in postoperative follow-up care in pediatric surgery.
      • What new information is contained in this article?
      • Amongst the various patient-preferred risk communication methods, technology-based communication and written information appear most preferred by families of children undergoing surgery.

      Abstract

      Background

      Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

      Methods

      A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

      Results

      A total of 6,370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

      Conclusion

      Eliciting families’ preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

      Level of Evidence

      Level IV (Scoping Review).

      Keywords

      Abbreviations:

      3D (3-Dimensional), AI (Artificial Intelligence), CASP (Critical Appraisal Skills Programme), DVD (Digital Versatile Disc), ENT (Ear, Nose Throat (Otorhinolaryngology)), JBI (Joanna Briggs Institute), SDM (Shared Decision-making)

      Conflicts of Interest

      None.

      Funding Sources

      Arthega Selvarajan was funded by the McGill University Medical Class of 1964 Summer Research Bursary.
      Dan Poenaru was funded by a Junior Investigator (J1) Salary Award from the Fonds de Recherche du Québec en Santé.

      Introduction

      The importance of effective communication in pediatric surgical practice cannot be overstated. A pediatric surgeon is trained to provide whole-patient-centered care through preoperative, operative and postoperative encounters with the patient; which in this field includes the parent/caregivers alongside the child or adolescent [

      General Surgery Profile. Canadian Medical Association. 2018. Available: https://www.cma.ca/sites/default/files/2019-01/general-surgery-e.pdf1.1.

      ]. However, it has been noted that certain surgical procedures routinely performed in children may not need to be done [
      • Zani-Ruttenstock E.
      • Zani A.
      • Bullman E.
      • Lapidus-Krol E.
      • Pierro A.
      Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital.
      ,
      • Hall N.J.
      • Ron O.
      • Eaton S.
      • Pierro A.
      Surgery for hydrocele in children—an avoidable excess?.
      ,
      • Politoff L.
      • Hadziselimovic F.
      • Herzog B.
      • Jenni P.
      Does hydrocele affect later fertility?.
      ]. In some instances, up to 30% of parents experience uncertainty about the course of action to take (i.e. decisional conflict) and distress or remorse after the decision to have surgery [
      • O’Connor A.M.
      Decisional Conflict Scale.
      ,
      • Lorenzo A.J.
      • Braga L.H.P.
      • Zlateska B.
      • Leslie B.
      • Farhat W.A.
      • Bägli D.J.
      • et al.
      Analysis of decisional conflict among parents who consent to hypospadias repair: single institution prospective study of 100 couples.
      ,
      • Brehaut J.C.
      • O’Connor A.M.
      • Wood T.J.
      • Hack T.F.
      • Siminoff L.
      • Gordon E.
      • et al.
      Decision Regret Scale.
      ,
      • Lorenzo A.J.
      • Pippi Salle J.L.
      • Zlateska B.
      • Koyle M.A.
      • Bägli D.J.
      • Braga L.H.P.
      Decisional regret after distal hypospadias repair: single institution prospective analysis of factors associated with subsequent parental remorse or distress.
      ]. In such cases, shared decision-making (SDM) becomes vital.
      Improvements in patient satisfaction, treatment adherence, quality of life and well-being are observed when clinicians adopt SDM in their practice [
      • Joosten E.A.G.
      • DeFuentes-Merillas L.
      • de Weert G.H.
      • Sensky T.
      • van der Staak C.P.F.
      • de Jong C.A.J.
      Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status.
      ]. Defined as a collaborative treatment decision process, SDM is recognized as an ideal model taking into consideration the patient’s preferences and values, as well as the physician’s clinical expertise with respect to risks, benefits and alternatives to treatment, in order to reach a consensus upon future management plans [
      • Barry M.J.
      • Edgman-Levitan S.
      Shared Decision Making — The Pinnacle of Patient-Centered Care.
      ,
      • Charles C.
      • Gafni A.
      • Whelan T.
      Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango).
      ,
      • Page A.E.
      Safety in surgery: the role of shared decision-making.
      ]. The transmission of risk information is considered to be the cornerstone of SDM, as it can directly influence the patient’s treatment preference.
      Risk communication is defined as the “open, two-way exchange of information and opinion about risk, leading to a better understanding of the risk itself, and promoting better clinical decisions about management [
      • Naik G.
      • Ahmed H.
      • Edwards A.G.K.
      Communicating risk to patients and the public.
      ].” Previous literature has shown the beneficial effects of risk communication with Edwards et al.’s review emphasizing that treatment-specific interventions were associated with larger beneficial effects [
      • Edwards A.
      • Hood K.
      • Matthews E.
      • Russell D.
      • Russell I.
      • Barker J.
      • et al.
      The effectiveness of one-to-one risk communication interventions in health care: a systematic review.
      ,
      • Davis R.E.
      • Dolan G.
      • Thomas S.
      • Atwell C.
      • Mead D.
      • Nehammer S.
      • et al.
      Exploring doctor and patient views about risk communication and shared decision-making in the consultation.
      ] The primary method of delivering risk information is often through verbal discussion.
      However, this sole form of communication may be insufficient as it could result in poor patient retention, omittance of crucial risks and reduced patient recall [
      • Leclercq W.K.
      • Keulers B.J.
      • Houterman S.
      • Veerman M.
      • Legemaate J.
      • Scheltinga M.R.
      A survey of the current practice of the informed consent process in general surgery in the Netherlands.
      ,
      • Pianosi K.
      • Gorodzinsky A.Y.
      • Chorney J.M.
      • Corsten G.
      • Johnson L.B.
      • Hong P.
      Informed Consent in Pediatric Otolaryngology: What Risks and Benefits Do Parents Recall?.
      ]. Additionally, patients may have an even more difficult time adequately comprehending risk information due to the nature of surgical outcomes and actual probabilities of an outcome to occur in their particular case [
      • Timmermans D.
      • Molewijk B.
      • Stiggelbout A.
      • Kievit J.
      Different formats for communicating surgical risks to patients and the effect on choice of treatment.
      ,
      • Mazur D.J.
      • Hickam D.H.
      Patients’ interpretations of probability terms.
      ]. As Al-Taha et al. states, an inadequate understanding of surgical risks can undermine patient autonomy, decrease patient trust in the surgeon, and increase the likelihood of medicolegal action [
      • Al-Taha M.T.
      • Butler M.B.
      • Hong P.
      • Bezuhly M.
      The Effect of Written Information on Recall of Surgical Risks of Primary Cleft Palate Repair: A Randomized Controlled Study.
      ]. This can become particularly precarious in pediatric surgical care, where parents/caregivers assume the challenging role of proxy decision-makers for their children [
      Treatment decisions regarding infants, children and adolescents.
      ]. It is therefore imperative that adjuncts be utilized during risk communication.
      Moreover, the manner in which the surgeon conveys information may strongly affect the patient’s preferences and risk perception of surgery, thus tools such as decision aids were developed to standardize the delivery of information [
      • Stacey D.
      • Légaré F.
      • Lewis K.
      • Barry M.J.
      • Bennett C.L.
      • Eden K.B.
      • et al.
      Decision aids for people facing health treatment or screening decisions.
      ,
      • Kakkilaya V.
      • Groome L.J.
      • Platt D.
      • Kurepa D.
      Use of a visual aid to improve counseling at the threshold of viability.
      ]. Decision aids present quantitative information through optimized percentages, graphs and risk probabilities to help improve SDM [
      • Timmermans D.
      • Molewijk B.
      • Stiggelbout A.
      • Kievit J.
      Different formats for communicating surgical risks to patients and the effect on choice of treatment.
      ]. However, they do not completely address the patient-specific concerns about lifestyle and health care, which could further influence the decision of a patient to proceed with surgery [
      • Jaensson M.
      • Dahlberg K.
      • Nilsson U.
      Factors influencing day surgery patients’ quality of postoperative recovery and satisfaction with recovery: a narrative review.
      ]. Hence, there is a significant need to ascertain a patient's preferences in the context of decision-making [
      • STB Jr.,
      • Bogardus Jr., S.T.
      Perils, Pitfalls, and Possibilities in Talking About Medical Risk.
      ]. The main objective of this scoping review is to detail the patient-preferred methods of risk communication, in order to optimize information exchange in the pediatric surgical field.

      Methods

      We conducted a scoping review of the published literature to broadly look at risk communication preferences in pediatric surgery. The protocol for the study was designed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines (PRISMA-ScR; refer to Supplementary Material A for checklist) and registered with PROSPERO (CRD42020196116), the international registry for systematic reviews [,]. A senior medical librarian (EG) searched the following databases from inception until June 22, 2020: Medline (Ovid), Embase (Ovid), Cochrane (Wiley), Global Health (Ovid), Web of Science (Clarivate Analytics), Africa Wide Information (Ebsco) and Global Index Medicus (WHO), and studies were limited to English or French. The search strategy used variations in text words found in the title, abstract or keyword fields, and relevant subject headings to retrieve articles looking at family or parent communication preferences, and shared decision-making in pediatric surgery (refer to the Supplemental Material B for the full search strategy). Embase conferences were excluded. The PRISMA-S extension was utilized for reporting (refer to Supplementary Material C for full checklist). A grey literature search was conducted separately, employing ProQuest and Google Search. Reference citations from included review articles were also searched. In keeping with the goal of this review to identify various patient-preferred modalities of risk communication, we excluded articles that focused on patient preferences for risk communication but did not mention specific modalities. References found were imported into EndNote X9, where duplicates were removed. Records were imported into the online platform, Rayyan to perform the screening [
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.
      ].
      Two authors (AS and BA) reviewed all titles and abstracts using Rayyan [
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.
      ]. In situations of uncertainty, the reviewers discussed the abstract in question to reach a conclusion. In cases of disagreement, conflicts were resolved by the senior author (DP). A full-text screen was then carried out on all included papers independently by AS and BA, and non-eligible studies were excluded.

      Inclusion and exclusion criteria

      Publications were included if they described a risk communication modality for patients and included some form of patient input, either qualitative or quantitative. All surgical disciplines were included. Studies were excluded if patients were over 18 years of age, if they did not include a risk communication modality, or included a modality but had no reference to patient input. This resulted in the inclusion of multiple study types, categorized mainly as randomized controlled trials, qualitative studies and cross-sectional studies.

      Data Extraction

      Following the full-text screen, all studies were reviewed and data was extracted. For each included publication the following was recorded: author(s), year, study design, country of origin, surgical specialty, surgical procedure, study population, risk communication modality discussed, method of patient input, and type of patient input.

      Quality Assessment

      All included publications were manually assessed for quality and risk of bias using established tools. Cross-sectional studies were assessed using the Joanna Brigg’s Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies [
      • Moola S.
      • Munn Z.
      • Tufanaru C.
      • Aromataris E.
      • Sears K.
      • Sfetic R.
      • et al.
      Chapter 7: Systematic reviews of etiology and risk.
      ], while qualitative studies and randomized controlled trials were assessed using the respective Critical Appraisal Skills Programme (CASP) checklists [

      Critical Appraisal Skills Programme. CASP Checklists. 2018 [cited 25 Aug 2020]. Available: https://casp-uk.net/casp-tools-checklists/30.30.

      ]. Other study designs (i.e. case series and before-after studies) were assessed with Joanna Brigg’s Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. To appropriately assess the included publications, some modifications were made to the CASP checklist for randomized controlled trials. Specifically, for question 4 (i.e. “Were patients, health
      workers and study personnel ‘blind’ to treatment?”) we assessed whether studies single-blinded the researcher/healthcare professional from the modality; while for the open-ended questions (i.e. question 7/8) we utilized the probes suggested in the CASP checklist to enable the application of a Yes/Maybe/No grade to these questions [

      Critical Appraisal Skills Programme. CASP Randomised Controlled Trial Checklist. 2018 [cited 25 Aug 2020]. Available: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Randomised-Controlled-Trial-Checklist-2018_fillable_form.pdf31.31.

      ].

      Results

      As detailed in Fig. 1., a total of 6370 publications were retrieved from the literature search: 6368 from databases and 2 from other sources. Following the exclusion of duplicates, 6027 articles remained for screening. Of these, 5725 studies were removed during the title and abstract screen, leaving 312 articles for the full-text screen. This process excluded an additional 242 publications, thus 70 articles comprised the final set.
      Fig. 1
      Fig. 1PRISMA Flow Diagram [
      • Kakkilaya V.
      • Groome L.J.
      • Platt D.
      • Kurepa D.
      Use of a visual aid to improve counseling at the threshold of viability.
      ].

      General Study Characteristics

      Citing all included studies, Table 1 describes the general characteristics of the reviewed studies. The majority of studies were based in the United States (45.7%), Canada (15.7%) and the United Kingdom (15.7%), with 12 additional countries comprising the remaining studies. Ten surgical specialties were represented, the most frequent being Ear, Nose and Throat Surgery (ENT) (30.0%), followed by general surgery (15.7%) and urology (11.4%).
      Table 1General Study Characteristics.
      Author NameStudy TypeCountrySurgical Specialty
      1Erba et al. 2013[
      • Bresnick J.
      Big data, artificial intelligence.
      ]
      Cross-SectionalItalyNeurosurgery
      2Cegala et al. 2013[

      Nguyen TL, Le Nguyen T, Do TTH. Artificial Intelligence in Healthcare: A New Technology Benefit for Both Patients and Doctors. 2019 Portland International Conference on Management of Engineering and Technology (PICMET). 2019. doi:10.23919/picmet.2019.889388487.

      ]
      Randomized Control TrialUnited StatesNot Reported
      3Noll et al. 2001[
      • Ahuja A.S.
      The impact of artificial intelligence in medicine on the future role of the physician.
      ]
      Cross-SectionalUnited KingdomGeneral surgery
      4Nwomeh et al. 2008[
      • Lin S.Y.
      • Mahoney M.R.
      • Sinsky C.A.
      Ten Ways Artificial Intelligence Will Transform Primary Care.
      ]
      Cross-SectionalUnited StatesGeneral surgery
      5Chang et al. 2020[
      • Erba G.
      • Messina P.
      • Pupillo E.
      • Beghi E.
      Group, Opteff Pediatric. Acceptance of epilepsy surgery in the pediatric age - what the parents think and what the doctors can do.
      ]
      QualitativeSingaporeNot Reported
      6Firdouse et al. 2017[
      • Canty M.J.
      • Breitbart S.
      • Siegel L.
      • Fehlings D.
      • Milo-Manson G.
      • Alotaibi N.M.
      • et al.
      The role of social media in selective dorsal rhizotomy for children: information sharing and social support.
      ]
      Cross-SectionalCanadaMultiple
      7Bergeron et al. 2019[
      • Cegala D.J.
      • Chisolm D.J.
      • Nwomeh B.C.
      A communication skills intervention for parents of pediatric surgery patients.
      ]
      Randomized Control TrialUnited StatesEar, Nose & Throat Surgery
      8Rickard et al. 2018[
      • Noll S.
      • Spitz L.
      • Pierro A.
      Additional medical information: prevalence, source, and benefit to parents.
      ]
      Randomized Control TrialCanadaUrology
      9Tavares et al. 2018[
      • Weidler E.M.
      • Baratz A.
      • Muscarella M.
      • Hern Ez SJ.
      • van Leeuwen K.
      A shared decision-making tool for individuals living with complete androgen insensitivity syndrome.
      ]
      OtherBrazilNeurosurgery
      10Lotto et al. 2019[
      • Nwomeh B.C.
      • Hayes J.
      • Caniano D.A.
      • Upperman J.S.
      • Kelleher K.J.
      A Parental Educational Intervention to Facilitate Informed Consent for Emergency Operations in Children.
      ]
      QualitativeUnited KingdomCardiac surgery
      11Patel et al. 2019[
      • Chawla R.
      • Weidler E.M.
      • Hernandez J.
      • Grimbsy G.
      • van Leeuwen K.
      Utilization of a shared decision-making tool in a female infant with congenital adrenal hyperplasia and genital ambiguity.
      ]
      OtherUnited StatesEar, Nose & Throat Surgery
      12Özveren 2016[
      • Chang C.M.
      • Li Y.
      • Or L.L.
      • Pikkarainen M.
      • Polkki T.
      • Wang W.
      • et al.
      A qualitative study exploring Singaporean parents’ perceptions on preparing their child for surgery.
      ]
      Cross-SectionalTurkeyUrology
      13Binner et al. 2002[
      • Tait A.R.
      • Voepel-Lewis T.
      • Malviya S.
      • Philipson S.J.
      Improving the readability and processability of a pediatric informed consent document: effects on parents’ understanding.
      ]
      Cross-SectionalUnited StatesUrology
      14Kasparian et al. 2017[
      • Bergeron M.
      • Duggins A.
      • Chini B.
      • Ishman S.L.
      Clinical outcomes after shared decision-making tools with families of children with obstructive sleep apnea without tonsillar hypertrophy.
      ]
      Cross-SectionalAustraliaCardiac surgery
      15Adekunle et al. 2020[
      • Rickard M.
      • Brownrigg N.
      • Lorenzo A.J.
      • Easterbrook B.
      • Zizzo K.
      • DeMaria J.E.
      • et al.
      Comparing digital photography via email correspondence (PEC) to traditional telephone communication (TTC) for pediatric urology postoperative patients: a pilot, randomized, controlled trial.
      ]
      Cross-SectionalNigeriaOral and Maxillofacial surgery
      16Nogueira et al. 2009[
      • Lotto R.R.
      • Jones I.D.
      • Guerrero R.
      • Dhannapuneni R.
      • Lotto A.A.
      Congenital cardiac surgery and parental perception of risk: A qualitative study.
      ]
      Cross-SectionalBrazilEar, Nose & Throat Surgery
      17Lopez et al. 2017[
      • Ozveren B.
      Defining the Pathways of Parental Decision-making and Satisfaction Levels About Newborn Circumcision in a Setting Where Traditional Male Circumcision is Prevalent: An Online Survey Study.
      ]
      Cross-SectionalUnited StatesCardiac surgery
      18Korus et al. 2011[
      • Burkell J.
      What are the chances? Evaluating risk and benefit information in consumer health materials.
      ]
      QualitativeCanadaUrology
      19Ko et al. 2007[
      • Rosenfeld E.H.
      • Lopez M.E.
      • Yu Y.R.
      • Justus C.A.
      • Borges M.M.
      • Mathai R.C.
      • et al.
      Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial.
      ]
      OtherUnited StatesEar, Nose & Throat Surgery
      20Kubba 2000[
      • Tavares P.D.A.J.
      • Hamamoto Filho P.T.
      • Ferreira A.S.S.B.S.
      • Avila M.A.G.
      Construction and Validation of Educational Material for Children with Hydrocephalus and Their Informal Caregivers.
      ]
      OtherUnited KingdomGeneral Surgery
      21Weidler et al. 2019[
      • Steadman J.
      • Pretorius C.
      The impact of an online Facebook support group for people with multiple sclerosis on non-active users.
      ]
      OtherUnited StatesUrology
      22Raval et al. 2017[
      • Kasparian N.A.
      • Lieu N.
      • Winlaw D.S.
      • Cole A.
      • Kirk E.
      • Sholler G.F.
      eHealth literacy and preferences for eHealth resources in parents of children with complex CHD.
      ]
      Cross-SectionalUnited StatesGeneral Surgery
      23Hairston et al. 2019[
      • Adekunle A.A.
      • James O.
      • Adeyemo W.L.
      Health Information Seeking Through Social Media and Search Engines by Parents of Children With Orofacial Cleft in Nigeria.
      ]
      QualitativeUnited StatesEar, Nose & Throat Surgery
      24Huestis et al. 2020[
      • Nogueira Jr., J.F.
      • Hermann D.R.
      • Silva M.L.S.
      • Santos F.P.
      • Pignatari S.S.N.
      • Stamm A.C.
      Is the information available on the Web influencing the way parents see ENT surgical procedures?.
      ]
      OtherUnited StatesEar, Nose & Throat Surgery
      25Tait et al. 2005[
      • Erraguntla V.
      De la Huerta I, Vohra S, Abdolell M, Levin AV. Parental comprehension following informed consent for pediatric cataract surgery.
      ]
      Randomized Control TrialUnited StatesNot Reported
      26Nadeau et al. 2010[
      • Lopez C.
      • Hanson C.C.
      • Yorke D.
      • Johnson J.K.
      • Mill M.R.
      • Brown K.J.
      • et al.
      Improving communication with families of patients undergoing pediatric cardiac surgery.
      ]
      Randomized Control TrialUnited StatesEar, Nose & Throat Surgery
      27Chawla et al. 2019[
      • Firdouse M.
      • Wajchendler A.,
      • Koyle M.
      • Fecteau A.
      Checklist to improve informed consent process in pediatric surgery: A pilot study.
      ]
      OtherUnited StatesUrology
      28Moore et al. 2019[
      • Raval M.V.
      • Taylor N.
      • Piper K.
      • Thakore M.
      • Hoff K.
      • Owens S.
      • et al.
      Pediatric Patient and Caregiver Preferences in the Development of a Mobile Health Application for Management of Surgical Colorectal Conditions.
      ]
      Cross-SectionalUnited StatesGeneral Surgery
      29Lee et al. 2019[
      • Hairston T.K.
      • Links A.R.
      • Harris V.
      • Tunkel D.E.
      • Walsh J.
      • Beach M.C.
      • et al.
      Evaluation of Parental Perspectives and Concerns About Pediatric Tonsillectomy in Social Media.
      ]
      OtherUnited StatesOral and Maxillofacial surgery
      30Johnston et al. 2009[
      • Huestis M.J.
      • Kahn C.I.
      • Tracy L.F.
      • Levi J.R.
      Facebook Group Use among Parents of Children with Tracheostomy.
      ]
      OtherCanadaEar, Nose & Throat Surgery
      31Letourneau et al. 2003[
      • Hawley S.T.
      • Zikmund-Fisher B.
      • Ubel P.
      • Jancovic A.
      • Lucas T.
      • Fagerlin A.
      The impact of the format of graphical presentation on health-related knowledge and treatment choices.
      ]
      Cross-SectionalCanadaCraniofacial surgery
      32Newton and Sulman 2016[
      • Beall I.M.S.
      • Golladay G.J.
      • Greenfield M.L.V.H.
      • Hensinger R.N.
      • Biermann J.S.
      Use of the Internet by pediatric orthopaedic outpatients.
      ]
      Cross-SectionalUnited StatesEar, Nose & Throat Surgery
      33Shirley et al. 2015[
      • Nadeau D.P.
      • Rich J.N.
      • Brietzke S.E.
      Informed consent in pediatric surgery: Do parents understand the risks?.
      ]
      Cross-SectionalUnited StatesOrthopedics
      34Ali et al. 2019[
      • Jaime M.
      • Matthew H.
      • Nazrat M.
      • Ying Z.W.
      • Joan H.
      • Caren M.
      • et al.
      Pilot Testing of a Patient Decision Aid for Adolescents with Severe Obesity in US Pediatric Weight Management Programs within the COMPASS Network.
      ]
      Cross - SectionalUnited StatesEar, Nose & Throat Surgery
      35Wellburn et al. 2019[
      • Lee A.Y.
      • Patel N.A.
      • Kurtz K.
      • Edelman M.
      • Koral K.
      • Kamdar D.
      • et al.
      The use of 3D printing in shared decision making for a juvenile aggressive ossifying fibroma in a pediatric patient.
      ]
      Cross - SectionalUnited KingdomOrthopaedics
      36Rosenfeld et al. 2018[
      • Woodward S.
      • Franck L.
      • Wilcox D.
      ]
      RCTUnited StatesGeneral Surgery
      37Beall et al. 2002[
      • Chau D.B.
      • Ciullo S.S.
      • Watson-Smith D.
      • Chun T.H.
      • Kurkchubasche A.G.
      • Luks F.I.
      Patient-centered outcomes research in appendicitis in children: Bridging the knowledge gap.
      ]
      Cross - SectionalUnited StatesOrthopaedics
      38Newton and Sulman et al. 2018[
      • Glynn R.W.
      • O’Duffy F.
      • O’Dwyer T.P.
      • Colreavy M.P.
      • Rowley H.M.
      Patterns of Internet and smartphone use by parents of children attending a pediatric otolaryngology service.
      ]
      Cross - SectionalUnited StatesEar, Nose & Throat Surgery
      39Shah et al. 2006[
      • Johnston J.C.
      • Smith A.D.
      • O’Connor A.
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      The Development and Piloting of a Decision Aid for Parents Considering Sequential Bilateral Cochlear Implantation for Their Child with Hearing Loss.
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      40Lecouturier et al. 2015[
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      Helping Families Make Difficult Choices: Creation and Implementation of a Decision Aid for Neuromuscular Scoliosis Surgery.
      ]
      QualitativeUnited KingdomOphthalmology
      41Care et al. 2018[
      • Price M.
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      • Butow P.
      Communicating risk information: the influence of graphical display format on quantitative information perception-Accuracy, comprehension and preferences.
      ]
      Cross - SectionalUnited KingdomCraniofacial surgery
      42Yang et al. 2018[
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      Assessment of Application-Driven Postoperative Care in the Pediatric Tonsillectomy Population: A Survey-Based Pilot Study.
      ]
      Cross - SectionalChinaGeneral Surgery
      43Staveski et al. 2015[
      • Patel V.A.
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      Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study. Ear,.
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      Cross - SectionalUnited States Study, Conducted in IndiaCardiac Surgery
      44Chan et al. 2020[
      • Tait A.R.
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      The effect of format on parents’ understanding of the risks and benefits of clinical research: a comparison between text, tables, and graphics.
      ]
      QualitativeUnited StatesUrology
      45Clough 2005[
      • Wellburn S.
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      • Bettany-Saltikov J.
      The Information Needs of Adolescent Idiopathic Scoliosis Patients and Their Parents in the UK: An Online Survey.
      ]
      OtherUnited KingdomGeneral Surgery
      46Boss et al. 2017[
      • Shah A.
      • Kuo A.
      • Zurakowski D.
      • Waters P.M.
      Use and satisfaction of the internet in obtaining information on brachial plexus birth palsies and its influence on decision-making.
      ]
      Cross - SectionalUnited StatesEar, Nose & Throat Surgery
      47Adams et al. 2012[
      • Binner S.L.
      • Mastrobattista J.M.
      • Day M.C.
      • Swaim L.S.
      • Monga M.
      Effect of parental education on decision-making about neonatal circumcision.
      ]
      Randomized Control TrialUnited StatesEar, Nose & Throat Surgery
      48Peterlein et al. 2019[
      • Lecouturier J.
      • Clarke M.P.
      • Errington G.
      • Hallowell N.
      • Murtagh M.J.
      • Thomson R.
      Treating childhood intermittent distance exotropia: a qualitative study of decision making.
      ]
      Cross - SectionalGermanyOrthopaedics
      49Fitzpatrick et al. 2011[
      • Yang T.
      • Tan T.
      • Yang J.
      • Pan J.
      • Hu C.
      • Li J.
      • et al.
      The impact of using three-dimensional printed liver models for patient education.
      ]
      QualitativeCanadaEar, Nose & Throat Surgery
      50Byrnes et al. 2003[
      • Clough J.
      Using books to prepare children for surgery.
      ]
      Cross - SectionalUnited StatesPlastic Surgery
      51Aite et al. 2006[
      • Boss E.F.
      • Links A.R.
      • Saxton R.
      • Cheng T.L.
      • Beach M.C.
      Parent Experience of Care and Decision Making for Children Who Snore.
      ]
      Cross - SectionalItalyGeneral Surgery
      52Gkiousias et al. 2016[
      • Peterlein C.D.
      • Bosch M.
      • Timmesfeld N.
      • Fuchs-Winkelmann S.
      Parental internet search in the field of pediatric orthopedics.
      ]
      QualitativeUnited KingdomEar, Nose & Throat Surgery
      53Gorodzinsky et al. 2015[
      • Fitzpatrick E.M.
      • Jacques J.
      • Neuss D.
      Parental perspectives on decision-making and outcomes in pediatric bilateral cochlear implantation.
      ]
      QualitativeCanadaEar, Nose & Throat Surgery
      54Squitieri et al. 2013[
      • Byrnes A.L.
      • Berk N.W.
      • Cooper M.E.
      • Marazita M.L.
      Parental evaluation of informing interviews for cleft lip and/or palate.
      ]
      QualitativeUnited StatesPlastic Surgery
      55Oosthuizen et al. 2012[
      • Ko A.B.
      • Simons J.P.
      • Mandell D.L.
      Introduction of visually oriented information handouts in an academic pediatric otolaryngology practice.
      ]
      Cross - SectionalIrelandEar, Nose & Throat Surgery
      56Glynn et al. 2013[
      • Roncalli J.
      • Perez L.
      • Pathak A.
      • Spinazze L.
      • Mazon S.
      • Lairez O.
      • et al.
      Improvement of Young and Elderly Patient’s Knowledge of Heart Failure After an Educational Session.
      ]
      Cross - SectionalIrelandEar, Nose & Throat Surgery
      57Elkarim et al. 2017[
      • Newton L.
      • Sulman C.
      A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.
      ]
      QualitativeCanadaNeurosurgery
      58Sjoberg et al. 2015[
      • Care H.
      • Dalton L.
      • Johnson D.
      The Value of a Photobook in Informing Families About the Cosmetic Results of Surgery in Craniosynostosis.
      ]
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      • Newton L.
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      Use of text messaging to improve patient experience and communication with pediatric tonsillectomy patients.
      ]
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      • Aite L.
      • Zaccara A.
      • Trucchi A.
      • Nahom A.
      • Iacobelli B.
      • Bagolan P.
      Parents’ informational needs at the birth of a baby with a surgically correctable anomaly.
      ]
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      • Yang J.Y.
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      • Park J.H.
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      The Effects of Tonsillectomy Education Using Smartphone Text Message for Mothers and Children Undergoing Tonsillectomy: A Randomized Controlled Trial.
      ]
      Cross - SectionalUnited StatesEar, Nose & Throat Surgery
      62Bellew et al. 2002[
      • Kubba H.
      An evidence-based patient information leaflet about otitis media with effusion.
      ]
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      Interactive web-based format vs conventional brochure material for information transfer to children and parents: a randomized controlled trial regarding preoperative information.
      ]
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      Examination of bariatric surgery Facebook support groups: a content analysis.
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      It IS worth the effort: Patient knowledge of reproductive aspects of inflammatory bowel disease improves dramatically after a single group education session.
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      • Korus M.
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      ]
      Other (Case - Series)CanadaOphthalmology
      Most studies focused on the parents/caregivers as the study population for communication modality preferences (74.3%), while 20.0% focused on the family as a unit (including both caregivers and children). Two publications (2.9%) studied children/adolescents as the main population, while the primary population for the remaining two studies was unclear/not reported. Eleven publications reported randomized controlled trials, 16 qualitative studies, 32 cross-sectional studies, and the remaining 11 included a mix of other study designs.

      Risk Communication Modalities

      As seen in Fig. 2. , 35 papers discussed technological modalities, 38 studied written communication, 21 evaluated verbal communication, 12 reported visual forms of communication, 5 addressed decision aids, and 6 focused on other modalities - with some discussing multiple modalities. Amongst the studies, technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods.
      Fig. 2
      Fig. 2Breakdown of risk communication modalities.
      Patient preferences for risk communication modalities were reported by either testing a specific modality and soliciting feedback (40 studies), directly asking patients’ for their preferred modalities (25 studies) or reporting a mix of both patient tested and suggested modalities (5 studies).

      Comparison of Tested Modalities

      The most frequently tested modalities were hybrid written/visual tools, such as instructional cards or leaflets (11 studies), informed consent tools such as checklists (7 studies) and decision aids (5 studies).
      Among studies testing a visual modality, 2 evaluated the use of 3D anatomical models among patients during consultations. Both studies found an improved level of understanding among patient families with the model. Another 2 articles evaluated the importance of pictures within the clinical consultation, both finding that the pictorial delivery of information was informative and effective.
      The 5 articles which evaluated decision aids all noted improved patient family comprehension of treatment options and better perceptions of shared decision-making. Three of the 5 articles noticed lower decisional conflict and better certainty about the treatment plan with the use of a decision aid.
      All technology-based modalities included in our review reported an increased patient understanding of surgical risk information. Three publications noted that messaging services reduced patient anxiety associated with the surgery. Studies that tested websites observed an increase in satisfaction with information transfer, whereas social media modalities were focused on education and testimonial transfer of knowledge. Notably, although the internet was widely utilized by patients, all patients still preferred to ultimately discuss surgical risk information with their respective surgical teams.
      Out of the 20 articles testing written modalities, 11 noted that patients believed hybrid material, i.e. a combination of pictures and written material, were the most useful for comprehensively understanding the surgical process.

      Comparison of Suggested Modalities

      Multiple studies explored patients’ opinions for the most effective risk communication modalities. Out of all the studies, patients primarily chose healthcare professionals (11 studies), the internet (9 studies) and experience-based forums/support groups (8 studies) as their preferred form of risk communication. Twenty-four studies noted patients to prefer verbal forms of communication which included communications with healthcare professionals (11 studies), discussions in support groups (8 studies) and talks with family/friends (5 studies). Out of 25 studies in which patients suggested technological platforms as optimal risk communication tools, the patients mainly preferred either the internet/Google (9 studies) or specific videos/DVDs (5 studies). Twelve studies reported written modalities as a preferred risk communication method, with 5 studies favoring a list of complications as the preferred modality. Finally, only 4 studies noted pictures/photos as a preferred component of risk communication.

      Study Quality

      The results of the risk of bias assessment for the included studies is summarized in Fig. 3a - 3c. The study quality of the randomized controlled trials and qualitative studies was generally high, whereas the quality of the cross-sectional studies was mixed, ranging from high to low. The lower scores of the cross-sectional studies were due mainly to the JBI checklist criterion #3, as many studies had no comparator group, and #5-6, as many studies did not describe or employ strategies to mitigate potential confounders [
      • Moola S.
      • Munn Z.
      • Tufanaru C.
      • Aromataris E.
      • Sears K.
      • Sfetic R.
      • et al.
      Chapter 7: Systematic reviews of etiology and risk.
      ]. Among the qualitative studies, 10 out of 17 had unclear bias associated with the researcher’s participation in the study. As observed in Fig. 3a, 8 out of 11 randomized control studies were identified to have a high or unclear risk of bias with respect to intervention blinding. This was due to the inherent nature of risk communication modality dissemination, where generally the researchers and health care professionals were aware of the intervention being utilized, and hence were not blinded.
      Fig. 3
      Fig. 3Critical Appraisal results for included studies.

      Discussion

      With the current shift towards patient-centered care, the task of detailing the preferences of patients with respect to risk communication becomes paramount - confirming the need for this scoping review [
      • Laine C.
      • Davidoff F.
      Patient-centered medicine. A professional evolution.
      ]. As noted in Fig. 4, the review identified that a majority of studies originated from three countries: United States, Canada and the United Kingdom. This is in keeping with the literature, and is understandable given that the primary languages explored within this review are English or French [
      • Lu C.
      • Li X.
      • Yang K.
      Trends in Shared Decision-Making Studies From 2009 to 2018: A Bibliometric Analysis.
      ].
      Fig. 4
      Fig. 4Prevalence of countries in risk communication studies.
      The review identified a paucity of studies investigating risk communication preferences of the entire family unit, with most publications addressing only the parents’/caregivers' preferences. The importance of including the children’s voices in the communication process has been previously stressed by the literature [
      • Kain Z.N.
      • MacLaren J.E.
      • Hammell C.
      • Novoa C.
      • Fortier M.A.
      • Huszti H.
      • et al.
      Healthcare provider-child-parent communication in the preoperative surgical setting.
      ,
      • Rackley S.
      • Bostwick J.M.
      The pediatric surgeon-patient relationship.
      ]. Furthermore, it has been reported that a large number of children undergoing elective surgery have developed maladaptive postoperative behavioral changes, such as nightmares and separation anxiety [
      • Kain Z.N.
      • Caldwell-Andrews A.A.
      • Maranets I.
      • McClain B.
      • Gaal D.
      • Mayes L.C.
      • et al.
      Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.
      ,
      • Kain Z.N.
      Postoperative maladaptive behavioral changes in children: incidence, risks factors and interventions.
      ]. Children may benefit from being increasingly engaged and reassured within preoperative consultations. Hence, soliciting their preferences for risk communication is essential.

      Preferred Modality by Surgical Specialty

      As seen in Fig. 5a and 5b, our study indicated that a majority of articles came from the ENT specialty, followed by general surgery and urology respectively. It has been noted that an increased prevalence of elective same-day surgeries are performed in the aforementioned three specialties [

      I. Orfanos, K. Kyriazia, D. Orfanou, J. Anastasopoulos, K. Athanasakis. A Paediatric Day Surgery Unit: Costs and Outcomes. Available: https://www.iaas-med.com/files/Journal/24.4/24_4_ORFANOS.pdf38.38.

      ]. Moreover, previous literature identifies the need for increased patient-centered surgical decision-making, specifically with respect to elective same-day surgeries [
      • Ankuda C.K.
      • Block S.D.
      • Cooper Z.
      • Correll D.J.
      • Hepner D.L.
      • Lasic M.
      • et al.
      Measuring critical deficits in shared decision making before elective surgery.
      ]. Contributing to this knowledge gap, our findings emphasize the importance of patient preferences with respect to risk communication media in elective day surgeries. With a majority of risk communication studies pertaining to the ENT specialty, the increase in technology-based modalities in that specialty is hardly surprising. Interestingly, patients in the other specialties appear to prefer written risk communication modalities.
      Fig. 5
      Fig. 5Risk communication methods in relation to surgical specialties.

      Tested Risk Communication Modalities

      Visual Modalities

      On review of the included studies, Tait et al. deemed pictographs superior to tables and text for improving patient understanding - a finding supported by the literature [
      • Price M.
      • Cameron R.
      • Butow P.
      Communicating risk information: the influence of graphical display format on quantitative information perception-Accuracy, comprehension and preferences.
      ,
      • Burkell J.
      What are the chances? Evaluating risk and benefit information in consumer health materials.
      ,
      • Hawley S.T.
      • Zikmund-Fisher B.
      • Ubel P.
      • Jancovic A.
      • Lucas T.
      • Fagerlin A.
      The impact of the format of graphical presentation on health-related knowledge and treatment choices.
      ,
      • Tait A.R.
      • Voepel-Lewis T.
      • Zikmund-Fisher B.J.
      • Fagerlin A.
      The effect of format on parents’ understanding of the risks and benefits of clinical research: a comparison between text, tables, and graphics.
      ]. Pictures were found to be useful in both the preoperative and postoperative settings. Care et al. demonstrated that the use of a photobook comparing patients with craniosynostosis preoperatively and postoperatively was rated highly among patients considering surgery as a treatment; they found that it helped patients decide whether to proceed with surgery [
      • Care H.
      • Dalton L.
      • Johnson D.
      The Value of a Photobook in Informing Families About the Cosmetic Results of Surgery in Craniosynostosis.
      ]. This is consistent with several other articles in this review which also suggest that patients appreciate seeing before-and-after photos when considering surgery [
      • Korus M.
      • Stinson J.N.
      • Pool R.
      • Williams A.
      • Kagan S.
      Exploring the information needs of adolescents and their parents throughout the kidney transplant continuum.
      ,
      • Letourneau N.
      • Neufeld S.
      • Drummond J.
      • Barnfather A.
      Deciding on surgery: supporting parents of infants with craniosynostosis.
      ,
      • Chan K.H.
      • Panoch J.
      • Carroll A.
      • Wiehe S.
      • Cain M.P.
      • Frankel R.
      Knowledge gaps and information seeking by parents about hypospadias.
      ,
      • Sjoberg C.
      • Amhliden H.
      • Nygren J.M.
      • Arvidsson S.
      • Svedberg P.
      The perspective of children on factors influencing their participation in perioperative care.
      ].

      Verbal Modality

      Only one paper in our review tested a verbal modality of risk communication, noting significant anecdotal misconceptions amongst families whose children presented to the ER with suspected appendicitis [
      • Chau D.B.
      • Ciullo S.S.
      • Watson-Smith D.
      • Chun T.H.
      • Kurkchubasche A.G.
      • Luks F.I.
      Patient-centered outcomes research in appendicitis in children: Bridging the knowledge gap.
      ]. In line with other studies, the authors confirmed that patient knowledge acquisition was enhanced via verbal educational sessions [
      • Roncalli J.
      • Perez L.
      • Pathak A.
      • Spinazze L.
      • Mazon S.
      • Lairez O.
      • et al.
      Improvement of Young and Elderly Patient’s Knowledge of Heart Failure After an Educational Session.
      ,
      • Mountifield R.
      • Andrews J.M.
      • Bampton P.
      It IS worth the effort: Patient knowledge of reproductive aspects of inflammatory bowel disease improves dramatically after a single group education session.
      ,
      • Ronco M.
      • Iona L.
      • Fabbro C.
      • Bulfone G.
      • Palese A.
      Patient education outcomes in surgery: a systematic review from 2004 to 2010.
      ].

      Technological Modalities

      The included studies that evaluated the internet as a risk communication modality reported that it was remarkably helpful in terms of patient education and understanding [
      • Beall I.M.S.
      • Golladay G.J.
      • Greenfield M.L.V.H.
      • Hensinger R.N.
      • Biermann J.S.
      Use of the Internet by pediatric orthopaedic outpatients.
      ,
      • Glynn R.W.
      • O’Duffy F.
      • O’Dwyer T.P.
      • Colreavy M.P.
      • Rowley H.M.
      Patterns of Internet and smartphone use by parents of children attending a pediatric otolaryngology service.
      ]. However, in spite of the internet's ability to answer specific questions, it has also inadvertently led to an increase in questions requiring medical professionals' attention [
      • Beall I.M.S.
      • Golladay G.J.
      • Greenfield M.L.V.H.
      • Hensinger R.N.
      • Biermann J.S.
      Use of the Internet by pediatric orthopaedic outpatients.
      ,
      • Glynn R.W.
      • O’Duffy F.
      • O’Dwyer T.P.
      • Colreavy M.P.
      • Rowley H.M.
      Patterns of Internet and smartphone use by parents of children attending a pediatric otolaryngology service.
      ,
      • Loof G.
      • Liljeberg C.
      • Eksborg S.
      • Lonnqvist P.A.
      Interactive web-based format vs conventional brochure material for information transfer to children and parents: a randomized controlled trial regarding preoperative information.
      ]. This highlights the increasing online information-seeking behavior of patients, while also emphasizing the importance of physicians acknowledging it as a given aid to risk communication and inviting further discussion with patients [
      • Beall I.M.S.
      • Golladay G.J.
      • Greenfield M.L.V.H.
      • Hensinger R.N.
      • Biermann J.S.
      Use of the Internet by pediatric orthopaedic outpatients.
      ,
      • Glynn R.W.
      • O’Duffy F.
      • O’Dwyer T.P.
      • Colreavy M.P.
      • Rowley H.M.
      Patterns of Internet and smartphone use by parents of children attending a pediatric otolaryngology service.
      ,
      • Loof G.
      • Liljeberg C.
      • Eksborg S.
      • Lonnqvist P.A.
      Interactive web-based format vs conventional brochure material for information transfer to children and parents: a randomized controlled trial regarding preoperative information.
      ,
      • Tan S.S.-L.
      • Goonawardene N.
      Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review.
      ].
      Several included studies have evaluated the importance of messaging services (i.e. emails and text messages) for clarifying surgical risks [
      • Newton L.
      • Sulman C.
      A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.
      ,
      • Newton L.
      • Sulman C.
      Use of text messaging to improve patient experience and communication with pediatric tonsillectomy patients.
      ,
      • Yang J.Y.
      • Lee H.
      • Zhang Y.
      • Lee J.U.
      • Park J.H.
      • Yun E.K.
      The Effects of Tonsillectomy Education Using Smartphone Text Message for Mothers and Children Undergoing Tonsillectomy: A Randomized Controlled Trial.
      ]. Real-time messaging features were noted to provide timely information regarding pain management, with a reduction of postoperative negative outcomes noted (i.e. increased visits to ED, improper management) [
      • Newton L.
      • Sulman C.
      A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.
      ,
      • Newton L.
      • Sulman C.
      Use of text messaging to improve patient experience and communication with pediatric tonsillectomy patients.
      ,
      • Yang J.Y.
      • Lee H.
      • Zhang Y.
      • Lee J.U.
      • Park J.H.
      • Yun E.K.
      The Effects of Tonsillectomy Education Using Smartphone Text Message for Mothers and Children Undergoing Tonsillectomy: A Randomized Controlled Trial.
      ]. In keeping with the literature, these publications cited messaging services as an adjunct means for helping families manage their own healthcare, and ultimately reduce their anxiety [
      • Newton L.
      • Sulman C.
      A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients.
      ,
      • Newton L.
      • Sulman C.
      Use of text messaging to improve patient experience and communication with pediatric tonsillectomy patients.
      ,
      • Yang J.Y.
      • Lee H.
      • Zhang Y.
      • Lee J.U.
      • Park J.H.
      • Yun E.K.
      The Effects of Tonsillectomy Education Using Smartphone Text Message for Mothers and Children Undergoing Tonsillectomy: A Randomized Controlled Trial.
      ,
      • Lu K.
      • Marino N.E.
      • Russell D.
      • Singareddy A.
      • Zhang D.
      • Hardi A.
      • et al.
      Use of Short Message Service and Smartphone Applications in the Management of Surgical Patients: A Systematic Review.
      ].
      Regarding the benefits of social media platforms, such as Facebook, Twitter and YouTube, several included studies have systematically analyzed and categorized the data found on these respective sources [
      • Elkarim G.A.
      • Alotaibi N.M.
      • Samuel N.
      • Wang S.
      • Ibrahim G.M.
      • Fallah A.
      • et al.
      Social media networking in pediatric hydrocephalus: a point-prevalence analysis of utilization.
      ,
      • Canty M.J.
      • Breitbart S.
      • Siegel L.
      • Fehlings D.
      • Milo-Manson G.
      • Alotaibi N.M.
      • et al.
      The role of social media in selective dorsal rhizotomy for children: information sharing and social support.
      ,
      • Sorensen J.A.
      • Pusz M.D.
      • Brietzke S.E.
      YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery.
      ]. These studies reported that YouTube was utilized by patients for either specific medical information or experience-based testimonial videos [
      • Elkarim G.A.
      • Alotaibi N.M.
      • Samuel N.
      • Wang S.
      • Ibrahim G.M.
      • Fallah A.
      • et al.
      Social media networking in pediatric hydrocephalus: a point-prevalence analysis of utilization.
      ,
      • Canty M.J.
      • Breitbart S.
      • Siegel L.
      • Fehlings D.
      • Milo-Manson G.
      • Alotaibi N.M.
      • et al.
      The role of social media in selective dorsal rhizotomy for children: information sharing and social support.
      ,
      • Sorensen J.A.
      • Pusz M.D.
      • Brietzke S.E.
      YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery.
      ]. They highlighted the benefit of Facebook as a space for emotional support through the building of patient support groups [
      • Elkarim G.A.
      • Alotaibi N.M.
      • Samuel N.
      • Wang S.
      • Ibrahim G.M.
      • Fallah A.
      • et al.
      Social media networking in pediatric hydrocephalus: a point-prevalence analysis of utilization.
      ,
      • Canty M.J.
      • Breitbart S.
      • Siegel L.
      • Fehlings D.
      • Milo-Manson G.
      • Alotaibi N.M.
      • et al.
      The role of social media in selective dorsal rhizotomy for children: information sharing and social support.
      ,
      • Sorensen J.A.
      • Pusz M.D.
      • Brietzke S.E.
      YouTube as an information source for pediatric adenotonsillectomy and ear tube surgery.
      ,
      • Koball A.M.
      • Jester D.J.
      • Domoff S.E.
      • Kallies K.J.
      • Grothe K.B.
      • Kothari S.N.
      Examination of bariatric surgery Facebook support groups: a content analysis.
      ,
      • Steadman J.
      • Pretorius C.
      The impact of an online Facebook support group for people with multiple sclerosis on non-active users.
      ].

      Written Modalities

      Among the 20 publications that tested written risk communication modalities, 7 were focused on the modalities used during the informed consent process. Interestingly, when employing a surgeon checklist to facilitate the transfer of surgical risk information, overall patient’s anxiety levels did not improve [
      • Firdouse M.
      • Wajchendler A.,
      • Koyle M.
      • Fecteau A.
      Checklist to improve informed consent process in pediatric surgery: A pilot study.
      ], and often patients overestimated their comprehension levels of risk information [
      • Erraguntla V.
      De la Huerta I, Vohra S, Abdolell M, Levin AV. Parental comprehension following informed consent for pediatric cataract surgery.
      ]. Even when the patients were given a standardized consent form, Woodward et al. maintained that it was only useful if the patients took the time to thoroughly read it through - which was not always the case, since patients either did not recall many risks or did not comprehensively understand all the points on the form [
      • Woodward S.
      • Franck L.
      • Wilcox D.
      ]. Both Weidler et al. and Chawla et al. evaluated the importance of the patient checklist in the consent form process, and noted that they both achieved the goal to improve confidence in decisions that were not known to exist prior to the utilization of the checklist [
      • Weidler E.M.
      • Baratz A.
      • Muscarella M.
      • Hern Ez SJ.
      • van Leeuwen K.
      A shared decision-making tool for individuals living with complete androgen insensitivity syndrome.
      ,
      • Chawla R.
      • Weidler E.M.
      • Hernandez J.
      • Grimbsy G.
      • van Leeuwen K.
      Utilization of a shared decision-making tool in a female infant with congenital adrenal hyperplasia and genital ambiguity.
      ]. However, Tait et al. and Rosenfeld et al. highlighted the importance of creating a clearer modified checklist. In both publications, when respective modifications were made to a checklist, a marked increase in understanding was noted [
      • Tait A.R.
      • Voepel-Lewis T.
      • Malviya S.
      • Philipson S.J.
      Improving the readability and processability of a pediatric informed consent document: effects on parents’ understanding.
      ,
      • Rosenfeld E.H.
      • Lopez M.E.
      • Yu Y.R.
      • Justus C.A.
      • Borges M.M.
      • Mathai R.C.
      • et al.
      Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial.
      ].
      As for hybrid forms of risk communication (e.g. including both text and pictures), most of the included studies highlighted an overall increased comprehension of risks [
      • Tavares P.D.A.J.
      • Hamamoto Filho P.T.
      • Ferreira A.S.S.B.S.
      • Avila M.A.G.
      Construction and Validation of Educational Material for Children with Hydrocephalus and Their Informal Caregivers.
      ,
      • Patel V.A.
      • Harounian J.A.
      • Carr M.M.
      Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study. Ear,.
      ,
      • Binner S.L.
      • Mastrobattista J.M.
      • Day M.C.
      • Swaim L.S.
      • Monga M.
      Effect of parental education on decision-making about neonatal circumcision.
      ,
      • Ko A.B.
      • Simons J.P.
      • Mandell D.L.
      Introduction of visually oriented information handouts in an academic pediatric otolaryngology practice.
      ,
      • Kubba H.
      An evidence-based patient information leaflet about otitis media with effusion.
      ,
      • Staveski S.L.
      • Zhelva B.
      • Paul R.
      • Conway R.
      • Carlson A.
      • Soma G.
      • et al.
      Pediatric cardiac surgery Parent Education Discharge Instruction (PEDI) program: a pilot study.
      ,
      • Adams M.T.
      • Chen B.
      • Makowski R.
      • Bevans S.
      • Boseley M.
      Multimedia approach to preoperative adenotonsillectomy counseling.
      ,
      • Oosthuizen J.C.
      • Burns P.
      • Timon C.
      The changing face of informed surgical consent.
      ,
      • Bellew M.
      • Atkinson K.R.
      • Dixon G.
      • Yates A.
      The introduction of a paediatric anaesthesia information leaflet: an audit of its impact on parental anxiety and satisfaction.
      ,
      • Landier M.
      • Villemagne T.
      • Le Touze A.
      • Braïk K.
      • Meignan P.
      • Cook A.R.
      • et al.
      The position of a written document in preoperative information for pediatric surgery: A randomized controlled trial on parental anxiety, knowledge, and satisfaction.
      ,
      • Humphris G.M.
      • O’Neill P.
      • Field E.A.
      Knowledge of wisdom tooth removal: influence of an information leaflet and validation of a questionnaire.
      ], with only two of eleven studies noting it had minimal to no impact on the decision-making process [
      • Binner S.L.
      • Mastrobattista J.M.
      • Day M.C.
      • Swaim L.S.
      • Monga M.
      Effect of parental education on decision-making about neonatal circumcision.
      ,
      • Oosthuizen J.C.
      • Burns P.
      • Timon C.
      The changing face of informed surgical consent.
      ]. For instance, two studies claimed that a reduced number of phone calls were made to the hospital postoperatively [
      • Patel V.A.
      • Harounian J.A.
      • Carr M.M.
      Decreasing Telephone Calls for Tympanostomy Tube Otorrhea: A Pilot Study. Ear,.
      ,
      • Ko A.B.
      • Simons J.P.
      • Mandell D.L.
      Introduction of visually oriented information handouts in an academic pediatric otolaryngology practice.
      ], another two studies claimed an improved transfer of knowledge [
      • Landier M.
      • Villemagne T.
      • Le Touze A.
      • Braïk K.
      • Meignan P.
      • Cook A.R.
      • et al.
      The position of a written document in preoperative information for pediatric surgery: A randomized controlled trial on parental anxiety, knowledge, and satisfaction.
      ,
      • Humphris G.M.
      • O’Neill P.
      • Field E.A.
      Knowledge of wisdom tooth removal: influence of an information leaflet and validation of a questionnaire.
      ], while five studies stressed the importance of the leaflet to adequately comprehending the risks, benefits and alternatives to surgery [
      • Tavares P.D.A.J.
      • Hamamoto Filho P.T.
      • Ferreira A.S.S.B.S.
      • Avila M.A.G.
      Construction and Validation of Educational Material for Children with Hydrocephalus and Their Informal Caregivers.
      ,
      • Kubba H.
      An evidence-based patient information leaflet about otitis media with effusion.
      ,
      • Staveski S.L.
      • Zhelva B.
      • Paul R.
      • Conway R.
      • Carlson A.
      • Soma G.
      • et al.
      Pediatric cardiac surgery Parent Education Discharge Instruction (PEDI) program: a pilot study.
      ,
      • Adams M.T.
      • Chen B.
      • Makowski R.
      • Bevans S.
      • Boseley M.
      Multimedia approach to preoperative adenotonsillectomy counseling.
      ,
      • Bellew M.
      • Atkinson K.R.
      • Dixon G.
      • Yates A.
      The introduction of a paediatric anaesthesia information leaflet: an audit of its impact on parental anxiety and satisfaction.
      ].

      Suggested Modalities

      Previous literature has noted technology to be an ever-evolving mode of risk communication, with some suggesting the use of technology as less effective, whereas others praising the incorporation of technology in consultations [
      • Koball A.M.
      • Jester D.J.
      • Domoff S.E.
      • Kallies K.J.
      • Grothe K.B.
      • Kothari S.N.
      Examination of bariatric surgery Facebook support groups: a content analysis.
      ,
      • Proude E.M.
      • Shourie S.
      • Conigrave K.M.
      • Wutzke S.E.
      • Ward J.E.
      • Haber P.S.
      Do elective surgery patients use the internet to look for information about their condition?.
      ,
      • De Martino I.
      • D’Apolito R.
      • McLawhorn A.S.
      • Fehring K.A.
      • Sculco P.K.
      • Gasparini G.
      Social media for patients: benefits and drawbacks.
      ]. Based on our review, there has been a shift towards utilizing technology-based platforms for risk communication from earlier written/pictorial models. This includes the utilization of websites, social media platforms, slide decks, videos and DVDs, app/games and messaging services. With easily accessible information and support available on technological platforms for patients, this shift is not surprising. Notably however, although the internet was: (a) widely utilized by patients, (b) increased patient comprehension and (c) provided useful information, patients still preferred to ultimately discuss surgical risk information with their respective surgical team/healthcare professional. With technology rapidly advancing within medicine, the possibility of emerging artificial intelligence (AI) replacing medical professionals has been widely debated in the literature - with AI being hailed as the key to increased quality, productivity, and accuracy [
      • Bresnick J.
      Big data, artificial intelligence.
      ,

      Nguyen TL, Le Nguyen T, Do TTH. Artificial Intelligence in Healthcare: A New Technology Benefit for Both Patients and Doctors. 2019 Portland International Conference on Management of Engineering and Technology (PICMET). 2019. doi:10.23919/picmet.2019.889388487.

      ,
      • Ahuja A.S.
      The impact of artificial intelligence in medicine on the future role of the physician.
      ]. Based on the findings of this review and existing literature, it is more likely that AI will exist rather as an agent to streamline logistic processes, leaving more time for physicians to participate in crucially needed risk communication [
      • Ahuja A.S.
      The impact of artificial intelligence in medicine on the future role of the physician.
      ,
      • Lin S.Y.
      • Mahoney M.R.
      • Sinsky C.A.
      Ten Ways Artificial Intelligence Will Transform Primary Care.
      ].

      Limitations and Gaps

      Although this review highlights the different patient-preferred modalities within the various pediatric surgical subspecialties, it cannot make a generalized claim for the most preferred modality in pediatric surgery. This is in part due to the lack of equal representation from the various subspecialties included in this review, and the different modalities chosen by each patient population within each surgical subspecialty. Indeed, the main limitation of this review lies in the heterogeneity of the included studies, with a high variability in terms of setting, context and intervention dissemination. This made it difficult to perform comparative analyses amongst the articles, leading to a generalization of risk communication categories, reduced quality assessments and difficulty in identifying associations. Another inherent limitation to the scoping review was the limitation placed on languages, with the review solely examining articles written in English or French. This inherently excludes a majority of countries, which may also explain the prevalence of the aforementioned countries (i.e. United States, Canada and United Kingdom) in the included studies. Moreover, not all included articles took note of the demographic characteristics of the patient population, and hence this review cannot conclude that the aforementioned preferences are in accordance with all population groups’ preferences. Finally, another identified limitation was the lack of standardized outcome measures used to evaluate patient preference in relation to risk communication. However, our review was able to address this limitation by defining patient preference as: (a) the solicitation of patient feedback after testing a modality, or (b) the interpretation of suggestions provided by patients.
      Our review has also highlighted the domains that require further investigation relative to SDM in the pediatric surgical field. For instance, in accordance with others, our review noted that there is still little experimental evidence whether the graphical representation of information was preferred by patients over numerical representation [
      • Timmermans D.
      • Molewijk B.
      • Stiggelbout A.
      • Kievit J.
      Different formats for communicating surgical risks to patients and the effect on choice of treatment.
      ]. Furthermore, our review solely focused on identifying correlations amongst patient-preferred modalities within specific surgical specialties. Further investigation within distinct patient populations must be conducted to confirm the findings of this review.

      Conclusion

      Eliciting patients’ preferences for risk communication methods is of utmost importance in pediatric surgical care. We have shown that different risk communication media appear best suited for specific surgical domains. Although this review does not validate specific patient-preferred modalities based on demographic characteristics, social determinants, and age, it highlights the need to develop standardized patient-reported outcome measures to clarify patient preference. Ultimately, the review emphasizes the importance of developing personalized up-to-date risk communication tools in pediatric surgery, and learning through them what patients and families expect and prefer in their communication with the healthcare team.

      Uncited References

      • Gorodzinsky A.Y.
      • Hong P.
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      • Hong P.
      Pediatric otoplasty and informed consent: do information handouts improve parental risk recall?.
      .

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