Patient preference and satisfaction in decision-making process.

To the Editor:

Sir: Dr. Hwang et al. (1) have conducted a prospective study investigating the satisfaction of patients those who involved in the decision-making process for choosing an individualized anesthesia method for surgery. In the study, patients those who involved in the decision-making process were satisfied and felt being respected; the majority of patients preferred a collaborative role, indicating that patient-centered and -oriented care will improve the management outcomes in clinical practice. In addition, the authors have found that most patients expressed a preference for assuming an active role in the decision-making process for future medical care. I would like to add up and raise useful information along with some issues concerning patient-centered care model in the present letter. My first question is whether Dr. Hwang et al. (1) did sub-analysis investigating any potential moderators affecting on the change between patients' preference preferred decision-making role in current and future anesthesia (presented at Table 4); those moderators would be very useful to meet and predict the patients' needs in clinical practice. The second point is about anesthetic methods preferred by the patients presented at Table 3; were there any interesting clinical factors addressing such difference by operation region? This point should be intriguing since clinicians may reflect such differences in proposing and choosing treatment strategy in communicating with their patients, leading to better collaboration with patients in their management.

The awareness and interest of patients' perspectives and self-reports have drastically increased, in particular, in the management of their illness such as treatment choice today. The consumer movement in numerous areas at this contemporary civilized-society has been dramatically increasing over and over, especially, medical providers are one of the most influenced one by such new waves (2). Indeed interactive communication and active collaboration between clinicians and patients as standing on equal position may put patients onto better understanding and cooperation on specific medical process and procedure, which will ultimately involve patients themselves in the clinical decision-making process, with the clear expectations of better therapies and improved outcomes.

In fact, the recent interest by the US Food and Drug Administration (US FDA) in patient-reported outcomes (PROs) in the process of developing and testing new medications such as antipsychotics, has also prompted more driving force for such research (2). There has been an emerging evidence that patients' preference on choice of treatment strategy (3), certain medication or formulation (4), or specific medico-surgical procedures (1, 5), may improve treatment outcomes (3, 6) and compliance (7), should reduce safety issues (8), or even promote improvement and development of medical devices (9). Even in psychiatry field, it has been also very evident that active involvement of patients in the decision-making process substantially broadens the concept of recovery by giving a right to patients for being active participants as well as delivering a straightforward message that successful treatment in mental illness is not only a symptomatic improvement but also restoration of functional status (2). Interestingly ethnic difference was found in seeking health care information source and own reliance, indicating a need of cross-cultural studies since these differences may substantially impact on interaction between clinicians and patients. A recent study (10) found that Koreans were significantly more likely to perceive higher usefulness in mass media and direct-to-consumer advertising sources than were Western population. Koreans showed a trend toward less use of available information sources, particularly less use of printed materials in drug information seeking. This is also very important in patient-centered care since the deviated information seeking behaviour or limited resources potentially leading to improper understanding on the medical information provided by third party (not health professionals or authority) can desperately distort or worsen cooperation and interaction between clinicians and patients.

Despite a positive impact of such patients' active participation in decision-making process, the expansion of this concept should be mandatory for future research topics (i.e., methodological aspects, economic impact such as medical expense, psychosocial effects, dyadic approach, health policy, long-term effect, more various dimensions of patient involvement, etc). Additionally, family involvement (11) and health policy under full understanding of health authorities should be also integrated into this patient-centered care model for complete settlement of it in clinical practice since insurance reimbursement system is critically involved in success of any kind of medico-surgical procedure today across the world; family involvement can also crucially (positively or negatively) impact on the patients' attitude and cooperation with health professionals. Conclusively, modern health care clearly requires health professionals to be more attentive and respectful to individual patients' preferences as well as trying to provide better patient-centered care (12).

The Author Response:

We appreciate important questions and comments related to our manuscript titled "Patient Preference and Satisfaction with Their Involvement in the Selection of an Anesthetic Method for Surgery" (1). The following information should answer your questions. First, 78/179 collaborative role patients selected active role in the decision-making process for their future anesthesia. The majority of them said "it was a very interesting and satisfactory experience, and if I get the chance for future anesthesia, I want to select an anesthetic method by myself".

And, 2/31 passive role patients who had suffered from several attempts for regional anesthesia selected active role for their future anesthesia with some complaints. About these changes, we think that the experience of involvement in decision-making itself may be an important potential moderators affecting on the change between patients' preference preferred decision-making role in current and future anesthesia.

Second, regarding preferred anesthetic methods, the preference tended to be affected by past anesthetic experience, especially in complications. In patients of lower extremities, the patients experienced spinal anesthesia who had suffered from several trials for anesthesia, tingling sensation, or difficulty of urination after anesthesia selected general anesthesia. In patients of upper extremities, the patients who had remembered their fear about needling into the neck or a stress by nerve stimulation selected general anesthesia. Whereas, regional anesthesias were selected by the patients who had had complications of general anesthesia such as throat pain due to intubation and late awakening. Thus, clinicians should be aware that each patient has so many different thoughts and past experience about anesthesia, and fully communicate with the patients about the thoughts and experience for their involvement in the decision-making.