The decisional conflict was calculated from the total scores, which were calculated from the five subscales: uncertainty, informed, values clarity, support, and effective decision making. The subscale of uncertainty measured the degree of patient’s uncertainty in decision-making. The subscales of informed, values clarity, and support considered patient’s factors that lead uncertainty and represent the feelings of being uninformed, the clarity of personal values, and feelings of being unsupported, respectively. The subscale of effective decision showed the combination of informed selectable choice, patient response value, and patient’s satisfaction. Total scores of < 25 and ≥ 37.5 were associated with decision implementation and decision delay or indecision. In this study, the mean scores of decisional conflict scale in pre-surgery was 21.8, a relatively low score compared to previous reports, including patients who underwent chemotherapy for cancer [7] and treatment for asthma [10]. The total scores of DCS were lower than 25 at any of the three time points and were considered to be feasible for invasive treatment.
Patient anxiety for surgical morbidity and mortality enforced uncertainty of decision making in patients with elective thoracic surgeries. Besides studying the decisional conflict before surgery, we examined the DCS score change over time after surgery. The DCS score after surgery was supposed to be affected by the post-operative complications, which would strengthen remorse for decision-making of surgical treatment and unselecting potential alternative options. The decision support for interventional treatment could ameliorate decisional conflict [11]. Therefore, we expected that a patient’s own experience of surgery may reduce the DCS score. The scores post-surgery before discharge and at 3 months after surgery were gradually decreased, although the differences did not show any statistical significance. Of the subscores of DCS, the effective decision subscores that show patient dissatisfaction of selected treatment significantly decreased after surgery (Table 1). The effective decision subscores were not related to post-operative complications in this series of patients. At 3 months after surgery, the most QOL scores at that time were more related to the total scores, especially effective with the decision subscores of DCS.
In this study, the thoracic surgeries were performed for lung tumors, lung diseases, mediastinum diseases, and chest wall tumors. In recent years, VATS have been performed worldwide. In this analysis, 88% of the performed thoracic surgeries were VATS. The pain scores at discharge were significantly lower in patients who underwent VATS than in those who underwent thoracotomy. At 3 months after surgery, analysis of DCS showed that patient satisfaction was significantly related to most of the patient symptoms. In contrast with our expectations, pain after surgery was not related to patient satisfaction. Although patients who underwent thoracotomy experienced more pain than those who underwent VATS, the irrelevant relationship between pain and patient satisfaction may cause the nonsignificant impact of differences in surgical approach between VATS and thoracotomy on patient satisfaction.
The effective decision subscale of DCS represents patient satisfaction. In pulmonary resection, there were some reports regarding patient satisfaction. Barlesi and colleagues examined the patient satisfaction by self-administered questionnaires with different deliberation of medical information to patients and reported difficult interpretation of satisfaction assessment [12]. Pompili and colleagues reported that patient satisfaction was different among centers of thoracic surgery units, mainly due to physician-related scales: technical skill, interpersonal skills, availability, and information provision [13]. In our study, factors directly addressed to the ability of medical staff and institutions potentially related to patient satisfaction were not planned to be examined because there were no related items in the DCS questionnaire. However, the informed and support subscores in the DCS represented patient’s acceptance of medical information and support related to the ability of medical staff and institutions. In this study, among the subscores in the DCS, the support subscore indicated the lowest values and the informed subscore was similar to the total score (Table 1). Therefore, in our study, the medical staff and institution ability was considered insignificant in patient decisional conflict.
The limitation of this study was that several patients in the study period were excluded from the analysis because of thier missing data. There was no difference between the patients included in this analysis and those not analyzed in the study period in terms of age, sex, comorbidities, and approach of surgery. However, the most patients with lung malignant tumors were included in this analysis. Therefore, the DCS values of the included patients were presumed to be higher than the corresponding of the background population. In the univariate analysis, the DCS scores of individuals with malignant lung tumors did not decrease over time. Relatively many patients with malignant lung tumors in this analysis might have affected the result of DCS, especially at 3 months after surgery.