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\begin{document}

\title{Shared Decision Making in Adult Strabismus Care}



\author[1]{Ala Paduca}%
\author[1]{Corina Cardaniuc}%
\author[2]{Per Olof Lundmark}%
\author[2]{Jan Richard Bruenech}%
\author[1]{Eugeniu Beschieru}%
\affil[1]{Nicolae Testemiceanu State Medical and Pharmaceutical University}%
\affil[2]{University of South-Eastern Norway}%


\vspace{-1em}



  
  \date{May 28, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: In order to involve patients in collaborative decisions
(SDM), they need to know the treatment options and determine the
patient's preferences from the doctors. This process is a must to be
evaluated in the Republic of Moldova. Objective: The study's aim was to
evaluate Shared Decision Making in adult strabismus care from both
patients' and physicians' perspectives. Material and methods: A
prospective, transversal study was conducted. Sixty nine adult
strabismus patients and their attending physician were asked to fill out
the SDM-9 and SDM-9-DOC questionnaires related to their perception of
SDM during the entire period of strabismus treatment. After treatment,
patients were asked to describe their satisfaction level. Results: All
the participants completed the questionnaire (mean age  =  29.7  \selectlanguage{ngerman}± \selectlanguage{english} 6.9
years, 49.3\% female and 50.7\% male). The mean SDM-Q-9 score among the
patients was 78.42\% (IQR = 75.6--82.2\%). The mean SDM-Q-Doc score was
86.7\% (IQR 84.4--88.9\%). The SDM-Q-Doc values were consistently higher
than the SDM-Q-9 values (average difference of 6.7\%). Female and yang
patients reported a lower SDM score. Pearson correlation test revealed a
positive significant correlation between both SDM-Q-9 score and patient
satisfaction t (69)= .28, p .02. Conclusions: Our research pointed out
blanks in assessing patient information needs as the main obstacles to
SDM. Doctors are more confident in their belief that the information
provided as well as deliberations and the shared decision process are
performed at a high level compared to patients' expectations. These
findings can serve as a springboard to further improve communication and
SDM between patients and physicians, thereby raising patient
satisfaction.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Introduction}

Adult strabismus is a very complex, multi-dimensional disease which has
a serious impact on sightseeing, self-perception, self-esteem and the
social interactions of the patient\textsuperscript{1}. Important
treatment options, including optical correction, prism prescription,
correction, various surgical approaches and botox injections all of them
are significant, each with the individual advantages and
disadvantages\textsuperscript{2}. Therefore, the choice of therapy
requires a careful examination, where the available scientific data, the
experience of the clinician as well as the characteristics and
preferences of the individual patient are balanced and together
determine the decision\textsuperscript{3}. However, all treatment
options, including the option not to operate, should always have their
advantages and disadvantages to make space for the patient's
preferences.

In the meantime, it has been recognized that these principles are
difficult to apply in daily clinical practice\textsuperscript{4.,5} To
begin with, the clinicians' expertise may be restricted due to the
absence of treatment experience or inaccessibility of certain treatment
methods in hospital. Secondly, it is doubtful to what extent the
patient's individual preferences are recognized as an ethical
imperative, and to what extent the patients are actually actively
involved\textsuperscript{4,5}. In this context, collaborative decision
making (SDM) is seen as a model for clinical
practice\textsuperscript{6.} and was defined by Weston WW. in 2001 as
being one of the key components of patient-centered care
\textsuperscript{7}. Interest in patient participation in SDM has
increased in recent years\textsuperscript{8}, which represents a shift
from the paternalistic healthcare model to a person-centered health care
approach. This patient-physician alliance results in empowering patients
to develop their autonomy \textsuperscript{9,10} and in finding better
healthcare choices. According to Stiggelbout AM et al. (2012), this
approach brings more benefits in healthcare and fewer variations in
practice.\textsuperscript{11}

Gartner et al. (2018) in a literature search identified 16 existing
patient profiles related to SDM \textsuperscript{12}. A general
nine-point decision-making questionnaire is one of the most commonly
used tools to assess the extent to which doctors involve patients in the
decision-making process. It consists of versions of the patient
(SDM-Q-9) and the doctor (SDM-Q-Doc), which can be used to evaluate the
patient's involvement in decision-making process from two points of
view\textsuperscript{13,14}. It is often used in various clinical
situations, including primary and special care \textsuperscript{15}.
Since 2009 it has been translated into many languages, including
Romanian\textsuperscript{13}.\textsuperscript{16.}

Although SDM has become a priority of health policy in many European
countries in the past two decades\textsuperscript{17}, there are no
studies on the involvement of patients in medical decisions in the
Republic of Moldova.

Our goal was to examine the involvement of patients and physicians in
the SDM process in the treatment of strabismus; the correlation between
patient satisfaction and postsurgical outcome.

\textbf{Methods}

This study was implemented in the Republic of Moldova Republican
Clinical Hospital from January 2017 to July 2019. Among the participants
were adult patients with manifest strabismus who needed a surgical
correction and, where more than one techniques was enforceable (simetry
surgery, asimetric surgery, ajustable stitch) and their doctor. Patients
were enrolled in this study if they met the following criteria: (1) 18
years and older, (2) a confirmed diagnosis of manifest strabismus
through orthoptic examination, and (3) Romanian communicative skills and
presented the written agreemnet. The exclusion criteria were as follows:
(1) severe cognitive impairment and (2) study involvement disapproval.
The patients were informed about the study by their healthcare provider.
They were thoroughly informed and assured that refusing to participate
would not affect their treatment in any way.

This study was conducted in accordance with the principles of the
Helsinki Declaration. Board of Directors for Medical Ethics, State
University of Medicine and Pharmacy '' Nicolae Testemitanu'' approved
the study.

All patients underwent a detailed ocular examination and orthoptic
evaluation before being subjected to strabismus surgery.

Before the study, patients basic demographic data on age, gender,
diagnosis and number of consulation needed to reach a joint patient -
doctor decision were registered. After the final consultation the
patients completed the SDM-Q-9 questionnaire. In this previously
approved questionnaire, the SDM level is assessed subjectively by
evaluating the nine phases of the decision-making process from the
patient's perspective on a 6-point Likert scale ranging from 0 (not at
all) to 5 (fully applicable). The doctor also filled out the SDM-Q-Doc
questionnaire immediately after the consultation. This questionnaire was
developed to measure the behavior of SDM from a doctor's perspective and
addresses the same problems as SDM-Q-9 for patients\textsuperscript{14}.
Romanian version had good internal consistency with 0.96 as the Cronbach
\selectlanguage{greek}α \selectlanguage{english}coefficient \textsuperscript{18}.

After treatment, patients were asked to rate their satisfaction with the
surgical outcome as excellent, good, fair, and bad using the Face-Q
scale (a 4-point scale)\textsuperscript{19}. Fig. 1

\textbf{Statistical Analyses}

The SDM-Q-9 and SDM-Q-Doc scores (which were between 0 and 45) were
transformed into percentages to make simple the results exposition (0\%
= no SDM behavior; 100\% = ideal SDM behavior). This conversion into
percentages is close to the other researches on this
topic\textsuperscript{13, 20} Multiplication of the score by 20/9.

It was applied a detailed analysis using the Statistical Package for
Social Sciences, Version 26 (IBM SPSS Inc.). Descriptive statistics were
expressed as mean and standard deviation (SD) or median with a range or
inter-quartile range (IQR). A Pearson test was conducted to evaluate the
correlation among variables and a paired sample t test to compare two
questionnares score. Therefore the statistical significance was defined
as p \textless{}0.05

\subsubsection*{Results}

{\label{results}}

Sixty nine patients took part in the study with mean age  of 29.7  \selectlanguage{ngerman}±
\selectlanguage{english} 6.9 years (ranged between 18-68 years old). ( 48 patients- 18-30 years,
31-40 - 13 patients, 41-50 - 5 patients, 51-60 -2 patients and 1 patient
- 60-70 years old ). Female represented 49.3\%, male -50.7\%. Fifthy
four (78.3\%) patients were diagnosed with esotropia and 15 (21.7\%)
with exotropia.

The mean SDM-Q-9 score among the patients was 78.42\% (IQR =
75.6\selectlanguage{english}-82.2\%). The SDM-Q-9 score ranged between 100\selectlanguage{english}-90\% was not assigned
by any patient, 90\selectlanguage{english}-80\% was given by 35 (50.7\%) patients and 80-70\% by
29 (42\%) patients, and 70\selectlanguage{english}-60\% by 5 (7.2\%) patients. All the SDM-Q-9
had an average score of 3.9. Table 1.

Mean SDM-Q-Doc score was 86.7\% (IQR 84.4--88.9\%). Six questionnaires
(8.7\%) had a score ranging between 100\selectlanguage{english}-90\%, and the remaining (91.3\%)
a score ranging between 90-80\%. All SDM-Q-Doc issues showed an average
score of 4.3. Table 1

The SDM-Q-Doc values were systematically higher than the SDM-Q-9 values
(average difference 6.7\%).

The postoperative patient satisfaction was reated as excellent by 12
(17.4\%) patients, good by 27 (39.1\%) , fair by 24 (34.8\%) and poor by
6 patients (8.7\%). Figure 1

A paired-sample t-test was carried out to establish the differences
among SDM-Q-9 and SDM-Q-DOC scores of the patient and doctor. The test
revealed a significant difference between the total score for SDM-Q-9
(M=78.4; SD=4.82) and for SDM-Doc (M=86.8; SD =2.23 at t (68) 13.7, p
\textless{} .001) as well as for first item score, fifth, sixth,
seventh, eighth and ninth items scores. A significant difference between
the general decision of patients and practitioners on other points was
not established. Table 2

Pearson's test revealed a low negative correlation between patient's
gender and SDMQ-9 score r (68)= - .12, p .31 and patient's age and
SDM-Q-9 score r (68)= - .23, p .61. Females and yang patients reported a
lower SDM-Q-9 score. Table 3. Pearson test revealed a positive
significant correlation between SDM-Q-9 score and patient satisfaction t
(69)= .28, p .02.

In 15 (21.4\%) cases 2 consultations were required before the shared
decision was reached, in 27 (38.6\%) cases -3, in 25 (35.7\%) cases -4
and in 2 (2.9\%) cases -5 consultations. We also reveald a positive
significant correlation between patient age and number of consultations
t (69)= .45, p = .00.

\textbf{Discussion}

SDM comprises three main elements: the exchange of information (personal
and medical) between the patient and the doctor, the discussion on
diagnostic and treatment options and the building of
consensus\textsuperscript{20, 21} .

In our study, we have identified concerns among patients about the SDM
process related to the enough information delivery to take a decision
about patient preferences. It was reported that the doctor has not
always rated adequately or met their informational needs. This research
showed relatively low scores to SDM-Q-9 items 5 (patients' information),
6 (patients' preference), 7 (weighing options), and 8 (shared decision).
This means that doctors should actively invite patients to share their
goals, expectations, and concerns to prevent misdiagnosis of patient
preferences \textsuperscript{22}, and that treatment decisions are
currently limited to informing the patient, as found in previous
studies\textsuperscript{23}. Our study showed that identifying and
considering patient preferences is not common in treatment yet and that
women's responses are lower than men's responses. Most patients
indicated that their doctor had not informed them about all strabismus
management options and that they would prefer to receive more
information about the treatment (3.36 points). As a consequence Tamaris
et al. raised the question of whether patients can really participate if
they do not know all the options.\textsuperscript{24}. Our study showed
that some patients believe that their doctors had not evaluated the
level of information that they wanted to receive. In contrast, the
doctor found that the information provided to patients was sufficient,
and that the consultation process and joint decision-making process were
satisfactory (overall score SDM-Q-Doc 4.0). This raises a question
(concern) about the possible lack of knowledge of health workers about
what is actually a general decision-making process and how it should be
carried out.

Charles CA et al. (2003) have shown that doctors do not always give
recommendations on which treatment option they consider to be
preferable.\textsuperscript{25} The other authors have found that when
developing a recommendation, many doctors do not disclose their personal
opinions about optimal treatment, but, instead, focus on providing
information about the risks and benefits of each option, with the
patient choosing. \textsuperscript{26-28}.

One of the main components of SDM is determining patient values and
preferences for different treatment options \textsuperscript{29,30.}.
Anyway, not all the doctors are ready to discuss patients' values and
needs; otherwise, some feel like their clinical experience will be
compromised if the patient disagrees with their recommendations.
Therefore, this choice sometimes may not be the best one for the
patient, after considering his values and needs.\textsuperscript{22}. If
patients disagree with the treatment recommendations, this may be due to
a mismatch between their preferences and the perception of these
preferences by doctors. Benbassat J et al. (1998) revealed that doctors'
conclusions about patient values and preferences are often inaccurate,
even for doctors with more clinical experience and a longer relationship
between doctor and patient \textsuperscript{31}. It is not astonishing,
that Tamarisa et al. concluded that many patients got serious problems
in SDM \textsuperscript{24}. The relatively low scores given by patients
in our study regarding the shared decision process could be because
there was no clear equipoise toward one of the existing treatment
methods or there was time absence. The fact that SDM is a time consuming
process has also been mentioned by other authors\textsuperscript{29}.
Some patients need more time to assimilate and become aware of the
information received from the doctor. Our study revealed a mean of 3.2
consultations required before a shared ``patient- doctor'' decision was
reached. Young patients required fewer consultations compared to adults,
which could be explained by their desire to regain the phisical
appearance, to imorove the quality of life as soon as possible. Elder
patients needed more time to decide. Furthermore, our results suggest
that the higher the SDM score, which means higher patient involvement in
their healthcare process, the higher is their satisfaction with the
provided care. This fact demonstrates once more that by providing
recommendations and performing the treatment in concordance with a
patient's preferences, the healthcare and research agenda may become
truly patient centered.

This study has some limits. Firstly, the small number of the
participants limits generalization to all patients and physicians
involved in strabismus nursing. Only one physician was involved in the
study. A more representative sample of doctors, or a sample of doctors
and patients from multiple regions, may produce different results than
the one we received.

\textbf{Conclusion}

Our research pointed out blanks in assessing patient information needs
as the main obstacles to SDM. Doctors are more confident in their belief
that the information provided as well as deliberations and the shared
decision process are performed at a high level compared to patients'
expectations. These findings can serve as a springboard to further
improve communication and SDM between patients and physicians, thereby
raising patient satisfaction.

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\emph{Table 1 SDM-Q-9 and SDM-Doc Description}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM-Q-9 description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM-Q-9 description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM-Q-9 description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM-Q-9 description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM - Doc description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM - Doc description\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
SDM - Doc description\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Item\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Minimum -\\
Maximum Score\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mean\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Std. Deviation\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Minimum -\\
Maximum Score\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mean\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Std. Deviation\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,55\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,53\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,03\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,19\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,46\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,17\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,38\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,23\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,42\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,20\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,40\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 -5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,20\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,40\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,14\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,39\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 - 4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3,19\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,49\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,00\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3,70\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,58\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,94\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,23\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 - 4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3,36\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,51\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,00\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2 - 4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3,41\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,52\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,58\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,49\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Q 9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4 - 5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,54\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,50\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5 -5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5,00\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
,00\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\emph{Table 2. Paired score SDM-Q-9 and SDM-Doc}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired items\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired items\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired Differences\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired Differences\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired Differences\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Paired Differences\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
t\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Sig. (2-tailed)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Mean\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Std. Deviation\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
95\% CI of the Difference\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
95\% CI of the Difference\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Lower\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Upper\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I made clear to my patient that a decision needs to be made - My doctor
made clear that a decision needs to be made.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,52\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,58\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,66\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,38\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-7,42\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I wanted to know exactly from my patient how he/she wants to be involved
in making the decision - My doctor wanted to know exactly how I want to
be involved in making the decision\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,014\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,58\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,15\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,12\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,21\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,84\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I told my patient that there are different options for treating his/her
medical condition - My doctor told me that there are different options
for treating my medical condition\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,03\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,15\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,09\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,47\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,64\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I precisely explained the advantages and disadvantages of the treatment
options to my patient - My doctor precisely explained the advantages and
disadvantages of the treatment options\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,06\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,18\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,06\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-,94\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,35\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I helped my patient understand all the information - My doctor helped me
understand all the information.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,81\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,55\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,68\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,94\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12,26\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
I asked my patient which treatment option he/she prefers - My doctor
asked me which treatment option I prefer\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,25\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,58\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,11\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,39\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17,87\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
My patient and I thoroughly weighed the different treatment options - My
doctor and I thoroughly weighed the different treatment options\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,64\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,76\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10,31\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 8\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
My patient and I selected a treatment option together. - My doctor and I
thoroughly weighed the different treatment options\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,22\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,70\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,05\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,39\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14,36\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Pair 9\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
My patient and I reached an agreement on how to proceed - My doctor and
I reached an agreement on how to proceed\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,46\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,50\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,34\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,58\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7,67\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
,000\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note: df -68

\emph{Table 3. Correlations among variables}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& 1 & 2 & 3 & 4\tabularnewline
Age & & & &\tabularnewline
Gender (F) & -,19 & & &\tabularnewline
SDM-Q-9 score & -,23 & -,12 & &\tabularnewline
Postoperative satisfaction & ,29\textsuperscript{*} & -,13 &
,28\textsuperscript{*} &\tabularnewline
\bottomrule
\end{longtable}

Note. N= 69, * p\textless{} .05;

\textbf{Hosted file}

\verb`Fig 1 Postsurgical  patients satisfaction.docx`  available at \url{https://authorea.com/users/342222/articles/469058-shared-decision-making-in-adult-strabismus-care}

\selectlanguage{english}
\FloatBarrier
\end{document}

