PROJECT SUMMARY/ABSTRACT Obstructive sleep-disordered breathing (OSDB) occurs in up to 20% of children and impacts physical, behavioral, and neurocognitive health. The primary treatment for OSDB in children is tonsillectomy, with or without adenoidectomy, which is the most common major surgical procedure performed in U.S. children. Tonsillectomy is a `preference-sensitive' procedure, as some children experience resolution of symptoms without treatment. As such, clinicians are encouraged to use shared decision-making to ensure parents make the right treatment choice for their child. Effective communication is paramount to incorporate family values into decisions about surgery. Children who are black, Hispanic, or low-income have increased prevalence of OSDB, worse sleep outcomes, and more complications of surgery. Although clinical and environmental determinants contribute to these disparities, negative attitudes of clinicians also contribute to poor care delivery and outcomes, particularly for vulnerable populations. We have previously shown that surgeons rarely elicit family preferences when speaking to parents, and that they more commonly make directive recommendations to minority families. These findings suggest that surgeons may harbor biases that influence treatment decisions and potentially lead to disparities in outcomes. Our long-term goal is to improve equity, healthcare quality, and outcomes for children with OSDB. The overall objective of this application is to develop a comprehensive profile of the complex interpersonal dynamics, including potential surgeon bias, parent trust, and surgeon-parent communication that may affect treatment decisions and cause disparate patient outcomes for minority children. To accomplish this objective, we will establish a repository of audio-recorded visits between surgeons and parents of children undergoing surgical consult for OSDB and embed these recordings within a longitudinal cohort. We will first evaluate how surgeon-parent communication impacts patient and family outcomes. We will code communication from audio-recorded patient visits and evaluate communication quality as defined by patient-centeredness, emotional responsiveness, language complexity, and shared decision-making. We will then evaluate the association of communication with clinical and parent- reported outcomes including postoperative revisits, knowledge, trust, and decision regret. Next, we will learn what parents perceive as `good' communication through stimulated recall interviews where parents hear their recently recorded consultations as stimulus to evaluate preferences for dialogue and impact on treatment decisions. Finally, we will assess the influence of parent race/ethnicity and implicit surgeon bias on outcomes, and learn whether `good' communication mediates any observed disparities. Findings from this research will inform development of interventions that elucidate surgeon bias and promote culturally competent communicati...