INTRODUCTION
Over the next 15 years, it is estimated that the number of persons with cataract in the U.S. will double1,2 and that the demand for cataract surgery will increase concomitantly.3 With growing recognition of the importance of patient-centered care,4 it is critical to understand the varied preferences patients have as they navigate complex medical decisions, for example, choosing to undergo cataract surgery. A 2004 study from Austria that evaluated patient preferences for decision-making in cataract surgery found that a majority (61%) preferred a physician-dominated process.5 However, that study, conducted in a different sociocultural context over a decade ago, may not reflect current American preferences; moreover, that study did not assess preferences for family involvement in the decision-making process. In our study, using national survey data from the U.S., we evaluated medical decision-making preferences among older adults who had recently undergone cataract surgery and assessed whether preferences varied by sociodemographics. A nuanced understanding of the preferred modes of decision-making may help cataract surgeons to further empower and engage patients in the health care process.
PARTICIPANTS AND METHODS
The National Health and Aging Trends Study (NHATS) is a population-based study of U.S. Medicare beneficiaries age 65 and older. In 2012, NHATS included an Engagement in Healthcare (EH) Module in which respondents were asked, “thinking about your [doctor/family and close friends], do you prefer to make decisions: without much advice from them, get their advice and then make decisions, make decisions together, or leave decisions up to them?”
Our study included respondents who participated in the EH module, reported having cataract surgery in the prior 24 months, and were able to complete the survey without help from a proxy. We used the Fisher exact test to examine differences in decision-making preferences by sociodemographic and economic characteristics. Data were analyzed using STATA/MP version 15. The University of Michigan institutional review board deemed this study exempt because it consisted of secondary analyses of publicly available data.
RESULTS
The study included 213 respondents, a majority of whom were white (71.4%), female (65.7%), and between 75-84 years old (50.2%) (Table 1). Most respondents from all sociodemographic groups preferred shared decision-making with doctors and family, citing a preference for “considering advice and then making decisions” or “making decisions together” (Table 2).
Table 1.
Characteristics of Study Sample
| N (%) (N=213) |
|
|---|---|
| Total | 213 (100%) |
| Age, years | |
| 65–74 | 66 (31.0%) |
| 75–84 | 107 (50.2%) |
| 85+ | 40 (18.8%) |
| Sex | |
| Male | 73 (34.3%) |
| Female | 140 (65.7%) |
| Marital Status | |
| Married | 103 (48.4%) |
| Unmarried | 110 (51.6%) |
| Race/Ethnicity | |
| White | 152 (71.4%) |
| Black | 47 (22.1%) |
| Hispanic | 8 (3.7%) |
| Other | 6 (2.8%) |
| Education | |
| <High School Degree | 50 (23.5%) |
| High School Degree | 67 (31.4%) |
| >High School Degree | 96 (45.1%) |
| Income | |
| 1st tercile | 73 (34.3%) |
| 2nd tercile | 68 (31.9%) |
| 3rd tercile | 72 (33.8%) |
Table 2.
Summary Statistics of Study Sample
| Doctor’s Role in Healthcare Decision Making | Family’s Role in Healthcare Decision Making | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Make Decisions without Much Advice |
Get Their Advice and then Decide |
Make Decisions Together |
Leave Decisions Up to Them |
Total | P-value | Make Decisions without Much Advice |
Get Their Advice and then Decide |
Make Decisions Together |
Leave Decisions Up to Them |
Total | P-value | |
| Total, N (%) | 24 (11.3%) | 88 (41.3%) | 70 (32.9%) | 31 (14.6%) | 213 | 85 (39.9%) | 66 (31.0%) | 57 (26.8%) | 5 (2.4%) | 213 | ||
| Age, years, N (%) | 0.089* | 0.993 | ||||||||||
| 65-74 | 5 (7.6%) | 29 (43.9%) | 27 (40.9%) | 5 (7.6%) | 66 | 27 (40.9%) | 21 (31.8%) | 16 (24.2%) | 2 (3.0%) | 66 | ||
| 75-84 | 12 (11.2%) | 44 (41.1%) | 35 (32.7%) | 16 (15.0%) | 107 | 43 (40.2%) | 32 (29.9%) | 30 (28.0%) | 2 (1.9%) | 107 | ||
| 85+ | 7 (17.5%) | 15 (37.5%) | 8 (20.0%) | 10 (25.0%) | 40 | 15 (37.5%) | 13 (32.5%) | 11 (27.5%) | 5 (2.4%) | 40 | ||
| Sex, N (%) | 0.238 | 0.646 | ||||||||||
| Male | 5 (6.9%) | 27 (37.0%) | 28 (38.4%) | 13 (17.8%) | 73 | 29 (39.7%) | 23 (31.5%) | 18 (24.7%) | 3 (4.1%) | 73 | ||
| Female | 19 (13.6%) | 61 (43.6%) | 42 (30.0%) | 18 (12.9%) | 140 | 56 (40.0%) | 43 (30.7%) | 37 (27.9%) | 2 (1.4%) | 140 | ||
| Marital Status, N (%) | 0.201 | 0.042* | ||||||||||
| Married | 9 (8.7%) | 50 (48.5%) | 31 (30.1%) | 13 (2.6%) | 103 | 33 (32.0%) | 32 (31.1%) | 34 (33.0%) | 4 (3.9%) | 103 | ||
| Unmarried | 15 (13.6%) | 38 (34.6%) | 39 (35.5%) | 18 (16.4%) | 110 | 52 (47.3%) | 34 (30.9%) | 23 (20.9%) | 1 (0.9%) | 110 | ||
| Race/Ethnicity, N (%) | 0.273 | 0.519 | ||||||||||
| White | 17 (11.2%) | 66 (43.4%) | 49 (32.2%) | 20 (13.2%) | 152 | 61 (40.1%) | 49 (32.2%) | 39 (25.7%) | 3 (2.0%) | 152 | ||
| Black | 3 (6.4%) | 17 (36.2%) | 19 (40.4%) | 8 (17.0%) | 47 | 18 (38.3%) | 14 (29.8%) | 14 (29.8%) | 1 (2.1%) | 47 | ||
| Hispanic | 3 (37.5%) | 3 (37.5%) | 1 (12.5%) | 1 (12.5%) | 8 | 2 (25.0%) | 3 (37.5%) | 2 (25.0%) | 1 (12.5%) | 8 | ||
| Other | 1 (16.7%) | 2 (33.3%) | 1 (16.7%) | 2 (33.3%) | 6 | 4 (66.7%) | 0 (0.0%) | 2 (33.3%) | 0 (0.0%) | 6 | ||
| Education, N (%) | ||||||||||||
| <High School Degree | 7 (14.0%) | 13 (26.0%) | 15 (30.0%) | 15 (30.0%) | 50 | 0.009* | 18 (36.0%) | 14 (28.0%) | 15 (30.0%) | 3 (6.0%) | 50 | 0.619 |
| High School Degree | 9 (13.4%) | 27 (40.3%) | 26 (38.8%) | 5 (7.5%) | 67 | 29 (43.3%) | 19 (28.4%) | 18 (26.9%) | 1 (1.5%) | 67 | ||
| >High School Degree | 8 (8.3%) | 48 (50.0%) | 29 (30.2%) | 11 (11.5%) | 96 | 38 (39.6%) | 33 (34.4%) | 24 (25.0%) | 1 (1.0%) | 96 | ||
| Income, N (%) | 0.482 | 0.617 | ||||||||||
| 1st quartile | 12 (16.4%) | 24 (32.9%) | 25 (34.3%) | 12 (16.4%) | 73 | 34 (46.6%) | 20 (27.4%) | 18 (24.7%) | 1 (1.4%) | 73 | ||
| 2nd quartile | 6 (8.8%) | 30 (44.1%) | 21 (30.9%) | 11 (16.2%) | 68 | 22 (32.4%) | 25 (36.8%) | 20 (29.4%) | 1 (1.5%) | 68 | ||
| 3rd quartile | 6 (8.3%) | 34 (47.2%) | 24 (33.3%) | 8 (11.1%) | 72 | 29 (40.3%) | 21 (29.2%) | 19 (26.4%) | 3 (4.2%) | 72 | ||
statistically significant
Level of education (p=.009) and marital status (p=.04) were significantly associated with differences in medical decision-making preferences. A greater proportion of respondents who did not complete high-school preferred to “leave decisions up to [the doctor]” compared to those with education beyond high-school (30.0% vs 11.5%). Respondents with education beyond high-school more frequently preferred to “get [doctors’] advice and then make decisions” or “make decisions without much advice from [doctors]” compared to those who did not complete high-school (58.3% vs 40.0%). Unmarried respondents preferred to “make decisions without much advice from [family]” more frequently than those who were married (47.3% vs 32.0%), whereas a greater proportion of married respondents preferred to “make decisions together with their [families]” (33.0% vs 20.9%). There were no differences by sex, race/ethnicity, or income.
DISCUSSION
This study of older adults who underwent recent cataract surgery suggests a preference toward shared decision-making with patients, doctors, and family. In a study from 2004, Kiss et al. reported that 44% preferred the physician alone to make decisions about cataract surgery, whereas in our study only 15% noted this preference. The discrepancy between studies may reflect a difference in patient populations and study designs, as well as a shift from physician-centered to patient-centered care over time.6 It is also important to note that we found considerable variation in older adults’ preferences, which underscores the importance of understanding the expectations and needs of individual patients.
Our study is limited because it relied on survey data, which is susceptible to recall and desirability biases. Also, the survey did not specifically ask about decision-making related to cataract surgery, though all included participants reported having cataract surgery in the prior 24 months. This study makes an important contribution to our understanding of medical decision-making preferences among older adults in the U.S. who chose to have cataract surgery and may help to promote patient satisfaction and the delivery of patient-centered eye care to an aging population.
Acknowledgments
Funding information: This research was supported by an ASCRS Foundation Research Grant to JRE and the National Eye Institute (K23 EY027848) to JRE.
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