From Compliance to Concordance in Orthodontic Treatment - Development of a Patient Decision Aid for Children considering Fixed Orthodontic Appliance Treatment

ABSTRACT Background: Concordance involves a process of agreement or shared decision-making between patients and healthcare providers. Concordance was introduced to replace the term compliance, which has connotations of a paternalistic doctor-patient relationship. Previous systematic reviews in healthcare have identified the importance of the patient-clinician relationship to achieve concordance. They have also suggested the use of patient decision aids (PDAs) to improve involvement of patients in their own healthcare choices. Patients and parents need sufficient information and discussion before they decide whether to proceed with orthodontic treatment which can last up to 2 years. Recent studies in orthodontics have noted that enhancing the relationship between the orthodontist and patient through effective communication and encouraging patient participation in choosing the best treatment alternative is essential for successful orthodontic treatment. Aim: The aim of the study was to investigate any shifts in emphasis from compliance to concordance within the orthodontic literature, then develop and carry out an initial evaluation of a decision aid for young people and parents considering whether to have fixed orthodontic appliance treatment or not. Objectives: 1. To conduct a systematic review of the orthodontic literature to identify the factors associated with concordance and compliance with orthodontic treatment and to establish the degree to which the shift has been reflected in the literature. This review will inform the development of the PDA. 2. To use a child-centred approach to develop a Patient Decision Aid for children and parents considering fixed orthodontic appliance treatment to facilitate shared decision-making and improve patient-clinician interaction. 3. To undertake an initial evaluation of the PDA in reducing decisional conflict, increasing knowledge and meeting expectations. Methods: A systematic review of the literature involving different databases was carried out to investigate factors that are important to patients for inclusion in the PDA. The PDA was developed based on the Ottawa Decision Support Framework (ODSF) through the workbook produced by O’Connor and Jacobsen (2003). This involves two separate steps; qualitative interviews and formation of expert groups. The qualitative study involved interviews with orthodontic patients aged 12 to 16 years old and their parents attending the Orthodontic Department of Charles Clifford Dental Hospital, and formation of expert groups of patients and clinicians to develop and review the PDA. Finally, a pilot evaluation study was conducted to investigate the impact of the PDA on decisional conflict, knowledge and expectations of orthodontic treatment. Thirty young people aged 12-16 years and 30 parents participated in this pre- post-PDA evaluation study. Results: No studies of concordance with orthodontic treatment were found, however, the factor that appeared to be most important to patients was the orthodontist-patient interaction and comprehensive discussions about treatment options and outcomes. A PDA was then developed based on the ODSF. The pilot evaluation of the PDA revealed that the decisional conflict of young people and their parents reduced by nearly 50% after exposure to the PDA. Participants felt more informed, clearer in their values, and more certain about their choice. In addition, the PDA increased participants’ knowledge regarding duration of the treatment and the frequency of orthodontic appointments. However, the current PDA showed a limited effect on patients’ and parents’ expectations about orthodontic treatment. Conclusions: Orthodontic research has failed to embrace the shift from compliance to concordance. The systematic review revealed the importance of the orthodontist-patient relationship for patients. The developed PDA was found to have a significant effect in reducing decisional conflict, increasing knowledge, although it has a limited effect on expectations about orthodontic treatment. The use of the PDA with patients and parents considering orthodontic treatment has the potential to facilitate shared decision-making, although, further research is needed on its effect on patients’ persistence with choice. Also, further research on orthodontists’ views about PDAs and its influence on orthodontist-patient interaction is required.