Project CONNECTS (Communication and Outcomes that eNhaNce Equity in Childhood Tonsillectomy and Sleep)

PROJECT SUMMARY/ABSTRACT
We evaluate the influence of patient race/ethnicity and surgeon bias on communication and outcomes for
children with obstructive sleep-disordered breathing (OSDB). OSDB occurs in up to 20% of children and
impacts physical health, behavior, and learning. The primary treatment is tonsillectomy, with or without
adenoidectomy, which is the most common major surgical procedure performed in U.S. children. Children
who are Black or Hispanic have increased prevalence of OSDB, poorer sleep outcomes, and more
complications of surgery. Clinician implicit bias may be an important contributor to these disparities, as
evolving evidence shows that bias negatively impacts patient relationships, care delivery, and outcomes for
vulnerable populations. We have previously shown that surgeons inconsistently offer alternatives to surgery
and rarely elicit family preferences when speaking to parents, and that they are less likely to explore emotions
of minority families. These findings, coupled with known disparities in OSDB clinical outcomes, highlight the
critical problem that surgeon implicit attitudes toward minority families may influence communication,
decision-making, and ultimately outcomes for children with OSDB. Our long-term goal is to improve equity,
healthcare quality, and outcomes for children with OSDB. The overall objective of this application is to develop
a comprehensive profile of the complex social and interpersonal dynamics that may affect treatment decisions
and cause disparate patient outcomes for minority children. To do so, we will establish across three institutions
a repository of audio-recorded encounters between a large, diverse cohort of surgical clinicians and parents
of children undergoing OSDB consultations. We will first evaluate the influence of clinician implicit bias and
patient race/ethnicity on surgeon parent-communication and quality and equity of OSDB care. We will
quantitatively code communication behaviors (patient-centeredness, emotional responsiveness, and shared
decision-making) of parents and clinicians occurring during child OSDB consultations and test for differences
between high and low implicit bias clinicians, by patient race and ethnicity. We will also examine differences
in parent trust in clinician, decision regret, and clinical outcomes, and assess whether communication
behaviors mediate observed disparities in these patients and parent reported OSDB outcomes. We will then
interview a subset of Black, Hispanic, and White parents and high and low bias clinicians to understand the
potential influence of race, ethnicity, and bias on communication, and learn patient-centered solutions to
improve communication. Using a stimulated recall qualitative approach, participants listen to audiotapes of
their own clinical encounters and directly comment on salient elements of communication that occurred.
Findings from this research will directly inform development of interventions to mitigate surgeon bias, promote
culturally competent communication, and improve outcomes for children with OSDB.

Grant Number: 5R01HL166504-03
NIH Institute/Center: NIH
Principal Investigator: Emily Boss