Informed consent recall and comprehension in orthodontics: Traditional vs improved readability and processability methods

Patient-provider communication during consultations for elective dental procedures: A scoping review

INTRODUCTION

Patient-provider communication (PPC) is a critical component of patient-centered care. Original studies have examined specific factors related to PPC during consultations for elective dental procedures, but this evidence has yet to be comprehensively summarized. This scoping review aimed to understand better the extent and depth of the available literature regarding factors that influence PPC during consultations for elective dental procedures.

METHODS

The authors considered electronically available, English-language, original research published since 1990 assessing communication during consultations for elective dental procedures. Four electronic databases, Google Scholar, and reference lists of inclusions were searched until August 2023. No quality assessment was completed. Two independent researchers assessed article eligibility. Data were charted with a narrative review approach.

RESULTS

A total of 37 studies were included. The most popular discipline studied was orthodontics. Prospective cohorts and cross-sectional were the most common study designs. Information recall, patient satisfaction, and patient comprehension were the most common outcome measures. Most studies employed questionnaires, surveys, or interviews for data collection. Nineteen factors related to PPC during elective dental consultations were identified and categorized into information delivery (4), patient-related (9), and provider-related factors (6).

CONCLUSIONS

This scoping review is the first to present a list of evidence-supported factors related to PPC in elective dental consultations. Identifying these factors is an important first step to better understanding their influence on PPC and designing interventions targeting those that may be modifiable. PPC during elective dental consultations is a dynamic, ongoing process. Several recommendations emerged that may help improve PPC, including appropriate information delivery, patient engagement, providing adequate time, and educating ourselves on approaches to PPC.

Why do patients transition between orthodontic appliances? A qualitative analysis of patient decision-making

OBJECTIVES

To gain an in-depth understanding of patients' decision-making processes when choosing to transition to a different orthodontic appliance (OA).

METHODS

This was a retrospective qualitative study using one-on-one in-depth semi-structured interviews. Patients were recruited through purposive convenience sampling. Participants who had elected to transition from and to one of these OAs: metal brackets, tooth-coloured brackets, or clear aligners before the end of treatment were recruited. Recruitment ceased when data saturation was achieved. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Twenty-three adult participants (12 males, 11 females) with their ages ranging from 18 to 52 years were interviewed. The analysis of the data revealed that participants perceived two reasons for the transition: (1) insufficient initial information and (2) evolving life circumstances and personal style. Data analysis of participants who expressed a notable discrepancy between their expectations and the reality of the OA they chose revolved around three themes: (a) health benefits and threats, (b) personal control, and (c) financial considerations. Data analysis of participants who described transitioning between OAs due to changes in personal circumstances and style, revealed two themes: (a) change in personal values and motivations and (b) change in social and psychological influence.

CONCLUSIONS

This qualitative study highlighted the complex multifactorial nature of patient decision-making when choosing and transitioning OAs. Orthodontists can benefit from understanding these factors to engage in thorough patient-centered counselling, provide tailored treatment recommendations, and optimize the choice of appliances.

A Comparison of Instructions for Use Documents and Manufacturer Produced Administration Videos for Biological Products

OBJECTIVES

To compare Instructions for Use (IFU) and Manufacturer Produced Administration Videos (MPAV) for biological products to describe if they are highly similar or different. To identify differences between the two that may lead to medication errors and to point out possible solutions to optimize safety.

METHODS

We screened 139 biological products having both an IFU and a MPAV. Differences between the IFU and MPAV of each biological product were noted and categorized by importance and how likely it would cause harm to patients. Strategies were discussed based on differences observed.

RESULTS

Of the products screened, 51 had an IFU and a MPAV available for evaluation. They were primarily made to support the use of auto-injectors (n = 25) and pre-filled syringes (n = 19). Of this group, we found that 11 had no differences between the IFU and MPAV, while the other 40 had at least one or more identifiable differences. Differences were stratified into the following sub-categories from most to least prevalent: word choice differences, supplementary information, missing information, and unaligned directions. We looked at the distribution of differences per biological product and found an average of two differences per MPAV (IQR 1-3).

CONCLUSION

We suggest that when sponsors create or update MPAVs, to focus on aligning critical content between the respective IFU and MPAV. We believe that it is possible for MPAVs to potentially reduce medication errors as a non-text-based media form and that care should be taken to avoid substantial differences in critical content between the IFU and MPAV.

Compliance with retainer wear using audiovisual integration and reminder: a randomized clinical trial

Active audiovisual representation of instructions ensures vibrant knowledge acquisition and improves acquaintance needed for self-care with retainer wear. The aim of this trial is to assess the impact of audiovisual instructions with additional weekly electronic reminder messages on improving adherence to instructed wear time of Hawley retainer, periodontal outcomes, and participants' experiences. Fifty-two participants (mean age 26.1 y) planned for removable retention, were randomly assigned to two parallel groups to receive either (1) audiovisual instructions with an additional weekly reminder, or (2) verbal instructions alone. Each participant received a Hawley retainer equipped with a TheraMon microsensor and was instructed to wear it for 22 h daily. Participants were monitored for adherence to the wear time after 3 (T1) and 6 months (T2), and had their periodontal health and experiences assessed at T2. Overall, the mean objectively measured daily wear time at T1 was 14.9 (± 4.9 h), and 14.3 (± 5.4 h) at T2. After 3 months, no significant differences were found between the groups (p = 0.065), however, a significant difference favoring better compliance with wear instructions was observed in the audiovisual group after 6 months (p = 0.033). A non-significant difference was observed between both groups regarding the gingival (p = 0.165) and plaque index scores (p = 0.173). Participants' experiences were similar in both groups, except for satisfaction with the way of delivering instructions, being favorably reported in the audiovisual group. Audiovisual instructions with weekly reminders seem to have a significant effect on patient compliance in the longer term.Trial registration: TCTR20230220002.

What is the best method to ensure informed consent is valid for orthodontic treatment? A trial to assess long-term recall and comprehension

Design Single-blind randomised controlled trial.Intervention Patient and parent pairs were randomly assigned via a random number generator to Group A or B. Both groups were given ten minutes to read a modified consent document. Group A (rehearsal) were given printouts that showed images of four core and four custom risks with handwritten descriptions of each risk and consequences. Group B were given an audio-visual presentation instead (PowerPoint). Interviews of each group were completed immediately after the informed consent and at six-month follow-up to assess recall and comprehension of information provided.Case selection Patients aged 11-18 years old and their parents attending for comprehensive orthodontic treatment at Ohio State University graduate orthodontic clinic. All subjects needed to be able to communicate in English, have no developmental disabilities or urgent medical conditions and neither the patients or parents or subjects' siblings were to have had orthodontic treatment in the last five years.Data analysis 1) Exploratory analysis to test for differences in demographics and anxiety between the two groups; 2) Multiple linear regression analysis was used to assess percentage of accurate responses at baseline and six months and the change between the two different groups, with differing baseline characteristics (p <0.05 was considered statistically significant); and 3) Intra- and inter-rater reliability was assessed using intra-class correlation.Results There were no significant differences in information retention and understanding between the two methods at six-month follow-up. For both groups, recall was significantly lower six months following consent-taking. Specific domains whereby information recall and comprehension are poor include: treatment method, risks, resorption and discomfort.Conclusions There is no superior method of consent-taking to ensure patients' and parents' information retention in the months following commencement of treatment. However, the study highlighted that current consent practices which are considered 'best practice' may be deficient.

Rehearsal's effect on long-term recall and comprehension of orthodontic informed consent

INTRODUCTION

The purpose of this study was to determine if written rehearsal of informed consent improved 6-month recall and comprehension compared with the current best practices.

METHODS

A consultation was provided and subjects read the modified informed consent document. They were randomized to group A (received the core and up to 4 custom elements of treatment, wrote what each image displayed) or group B (presentation of the 18 elements with core elements chunked at the end followed by up to 4 custom elements). Interviews recording knowledge recall/comprehension occurred immediately and after months later.

RESULTS

Overall, no significant differences in baseline or 6-month follow-up scores were found between groups. Initially, group A outperformed group B in some core domains. There were no significant differences between groups in the change of scores from initial to follow-up. Follow-up scores were significantly lower than baseline scores (P <0.05). Higher initial scores were associated with larger drops at follow-up. A decrease in knowledge >20% was common.

CONCLUSIONS

Overall the methods are comparable at baseline and 6-months. Initial content retention was roughly 60+%, with 6%-9% deterioration. For areas of treatment methods, risk, discomfort, and resorption at 6-months, the current processes failed the patient and left the practitioner vulnerable to risk management issues. Results support the rehearsal method with immediate feedback for misunderstandings as the preferred method for informed consent.

The effectiveness of interventions to increase patient involvement in decision-making in orthodontics: A systematic review

OBJECTIVES

To examine the effectiveness of interventions that aim to increase patient involvement in treatment decisions in orthodontic, orthognathic and cleft treatment, based on patient-reported outcomes and patient knowledge.

DESIGN

Systematic review.

DATA SOURCES

OVID databases (MEDLINE, EMBASE and EBM reviews), CENTRAL, WHO's International Clinical Trials Registry Platform and reference lists of included studies.

DATA SELECTION

Studies were selected by two reviewers independently and in duplicate based on pre-defined eligibility criteria: Population: People considering or undergoing orthodontic, orthognathic or cleft treatment. Intervention: Any intervention that aims to increase patient involvement in decision-making. Outcomes: Patient-reported outcomes and patient knowledge. Studies: All experimental studies published in English from January 2000 to October 2019 were eligible.

DATA EXTRACTION

Standardised data extraction of study information and assessment of risk of bias using the Cochrane Risk of Bias Tool for RCTs and ROBINS-I for non-randomised studies of interventions.

DATA SYNTHESIS

13 randomised controlled trials were included. Due to heterogeneity in the studies, a narrative synthesis was undertaken. The majority (n=11) of studies involved orthodontic patients, with one study of cleft patients and one study of orthognathic and orthodontic patients. Six included studies reported significant differences between intervention and control groups with improved patient knowledge or better patient-reported outcomes.

CONCLUSIONS

A variety of different interventions and outcome measures were used making data synthesis challenging. There is some evidence that interventions to increase patient involvement in decision-making can improve patient-reported outcomes and patient knowledge.

Informed consent challenges and strategies: A qualitative study of the orthodontists' perspective

OBJECTIVE

To identify the barriers and strategies perceived by orthodontists when obtaining consent from their adult patients concerning patients' comprehension or recollection of treatment information.

SETTINGS AND SAMPLE POPULATION

The sample comprised 12 orthodontists working in 8 different cities in Alberta, Canada.

METHODS

An exploratory investigation using qualitative inquiry was conducted. Participants were recruited through a combination of purposive, maximum variation and snowball sampling. Data were collected through audio-recorded, semi-structured interviews until saturation was reached. Then, data were analysed using thematic analysis. Quality and credibility were achieved by employing member checks, memo writing and analyst triangulation strategies.

RESULTS

Two major themes were identified, with subthemes: (1) Challenges that may interfere with patients' comprehension and recollection of treatment information (i. patients' internal barriers, ii. patients' external barriers and iii. financial barriers); and (2) strategies to optimize information delivery and communication (i. tailoring the content to be delivered, ii. communication fashion, iii. communication timing and iv. being accommodative).

CONCLUSION

The participants reported barriers that may be overlooked in the daily routine of orthodontic practices. Information is provided that may guide orthodontists to overcome or minimize these challenges, increase patient comprehension and improve the quality of informed consent processes.

Review of the Content and Quality of Mobile Applications About Alzheimer's Disease and Related Dementias

This study reviewed the content of mobile applications (apps) providing Alzheimer's disease or related dementias (ADRD) information and assessed quality of the apps. Characteristics, content, and technical aspects of 36 apps in the U.S. Google Play Store and App Store were coded, and quality of the apps was evaluated using the Mobile Application Rating Scale. Caregiving (62.1%) and disease management (55.6%) content was frequently provided. Few apps had an app community (8.3%) or a reminder function (8.3%). Overall, quality of the apps was acceptable; apps by health care-related developers had higher quality scores than those by non-health care-related developers. This analysis showed that ADRD-related apps provide a range of content and have potential to benefit caregivers, individuals with ADRD, health care providers, and the general public. Collaboration of ADRD experts and technology experts is needed to provide evidence-based information using effective technical functions that make apps to meet users' needs.

A Novel assessment tool monitoring the level of patient anxiety during third molar surgery procedure

The authors hypothesized that an audio-visual presentation providing information regarding the removal of an impacted mandibular third molar would reduce patient anxiety.

Aim& objectives

A clinical trial was performed to assess the level of patient anxiety during third molar surgery by using a new induction program and comparing the results amongst two groups that were the verbally informed and the audio-visual informed groups.

Materials and methods

the clinical trial included the patients who required surgical removal of an impacted third molar and fulfilled the predetermined criteria. The patients were divided into two groups - group 1 (no. = 20) the audio visual informed group and group 2(no. = 20) the verbally informed group. For both the groups the HR was recorded beat by beat using HR sensor (polar H1 UK) connected to an ActiGraph WGT3X- 3T USA. Also the modified dental analogue scale(MDAS) was used to subjectively record the anxiety during the surgery.

Results

The HR reading were statistically significant for the following surgical stages; drilling, suturing and upon leaving the clinic. The audio-visual informed group had lower self-reported anxiety scores than did the verbally informed group.

Conclusion

These results suggested that providing an audio-visual presentation about the surgical procedures in our routine clinical practice could aid in alleviating anxiety which would thereby reduce surgical complications.

Evaluation of the effectiveness of a tailored mobile application in increasing the duration of wear of thermoplastic retainers: a randomized controlled trial

Background

The ‘My Retainers’ mobile application is a patient-informed intervention designed to enhance removable retainer wear and associated patient experiences during the retention phase.

Objectives

To evaluate the effect of receiving the ‘My Retainers’ application on objectively assessed thermoplastic retainer (TPR) wear time, stability, periodontal outcomes, patient experiences, and knowledge related to retainers.

Materials and methods

Eighty-four participants planned for removable retention with TPRs were assigned either to receive the ‘My Retainers’ application or to control not receiving electronic reminders during the 3-month period. Randomization was based on computer-generated random numbers and allocation was concealed using opaque, sealed envelopes. The primary outcome was objectively assessed retainer wear recorded using an embedded TheraMon® micro-electronic sensor. Secondary outcomes, including irregularity of the maxillary and mandibular incisors, plaque levels, bleeding on probing and probing depth, were assessed at baseline and 3-month follow-up; and analysed using a series of mixed models. Experiences and knowledge related to orthodontic retainers were recorded using questionnaires. The outcome assessor was blinded when possible.

Results

Receipt of the mobile application resulted in slightly higher median wear time (0.91 hours/day); however, this difference was not statistically significant (P = 0.56; 95% confidence interval [CI]: −2.19, 4.01). No significant differences were found between the treatment groups in terms of stability (P = 0.92; 95% CI: −0.03, 0.04), plaque levels (P = 0.44; 95% CI: −0.07, 0.03), bleeding on probing (P = 0.61; 95% CI: −0.05, 0.03) and probing depth (P = 0.79; 95% CI: −0.09, 0.07). Furthermore, similar levels of patient experiences (P = 0.94) and knowledge related to retainers (P = 0.26) were found. However, marginally better levels of knowledge were identified in the intervention group. No harms were observed.

Limitations

A relatively short follow-up period with the study confined to a single-center in a university-based hospital.

Conclusions

Provision of the bespoke ‘My Retainers’ application did not lead to an improvement in adherence with TPR wear over a 3-month follow-up period. Further refinement and research are required to develop and investigate means of enhancing adherence levels.

Clinical registration

NCT03224481.

What information do patients recall from the third molar surgical consultation?

The aim of this study was to determine whether the use of a professionally prepared educational video on third molar extraction enhances comprehension and retention of general and informed consent information. A prospective cohort study of adult patients undergoing consultation followed by extraction of third molars in the Oral and Maxillofacial Surgery Clinic, University of Illinois at Chicago was completed. At the initial consultation, the subjects viewed an educational video and received specific verbal individual information about their case. A written examination (group 1) was then completed; a subgroup of the subjects (group 2) was selected randomly to complete the same examination at the next visit prior to the procedure. The primary predictor variable was utilization of the video. The primary outcome variable was comprehension of information regarding third molars, assessed by examination scores. The secondary outcome variable was retention of the information, assessed by repeat examination scores. One hundred adults (34 male, 66 female; group 1) completed the examination at least once; 54 (19 male, 35 female) completed both examinations (group 2). Correct responses ranged from 64% to 100% in group 1 and from 37% to 100% in group 2. In group 2, all questions answered incorrectly at the first visit were answered correctly at the second visit, without any additional information being provided. Patient comprehension and retention of pertinent pre-surgical information is poor, despite use of an educational video to supplement the usual verbal consultation. These results confirm those of prior studies and may have medico-legal implications regarding the informed consent process for third molar surgery.

Facilitating Informed Permission/Assent/Consent in Pediatric Clinical Trials

Individuals approached to participate in human subjects research, irrespective of age, must be completely apprised of the study, and researchers must ensure that the information is understood to the fullest extent possible, prior to decision making. However, evolving regulatory and institutional requirements have led to permission/assent/consent (PAC) forms that are unnecessarily complex, serving only to exacerbate the challenges associated with communicating this important information to prospective participants. At greatest risk are children and other individuals with low literacy, limited English proficiency, and diminished mental capacity, populations all too often neglected in clinical research. This paper examines various strategies that have been evaluated to facilitate informed PAC, drawing on experiences across a broad array of populations whose needs overlap with those of children. These strategies range from simplifying PAC forms for readability and creating multimedia PAC delivery tools to actively engaging participants on their understanding of PAC elements by leveraging testing, rewards, and third-party communications. Notably, the findings from strategies that have been explored in more than one setting are uniformly mixed with respect to their ability to improve comprehension, underscoring the challenges that persist in designing, implementing, and objectively examining strategies intended to facilitate informed PAC. However, these studies do serve to highlight efforts that may reduce anxiety around, and increase the satisfaction of participants with, the PAC process. Ultimately, accommodating a diverse participant pool will require the consideration, and continual refinement, of various PAC strategies along with the engagement of team members who are intimately familiar with these populations.

Improving quality of the informed consent process: Developing an easy-to-read, multimodal, patient-centered format in a real-world setting

OBJECTIVE

To develop a patient-centered informed consent and assessment tool written at a 6th grade-level that is multimodal, affordable, transportable, and readily modifiable for protocol updates.

METHODS

This quality improvement initiative was performed in two phases on an actively-recruiting study at a pediatric diabetes clinic. In phase I, 38 volunteers underwent the standard-paper consent process, a comprehension assessment and provided feedback. Using feedback and the structure of the Plan-Do-Study-Act cycle a multimodal consent and assessment were developed. In phase II, volunteers were randomized to the standard (n = 25) or the multimodal consent (n = 25) and all completed the same comprehension assessment via touch-screen tablet. Primary outcomes were comparison of the individual and total comprehension assessment scores.

RESULTS

Total comprehension scores were higher in the multimodal versus the standard consent group (p <  0.001) and on the elements of benefits (p <  0.001), risks (p <  0.001), volunteerism (p <  0.012), results (p <  0.001), confidentiality (p <  0.004) and privacy (p < 0.001).

CONCLUSION

A multimodal consent and assessment presented sequentially on a touch-screen tablet were patient-centered enhancements to standard consent.

PRACTICE IMPLICATIONS

Multimodal standardization of delivery with improved readability may strengthen the informed consent process.

Valid consent and orthodontic treatment

Valid patient consent is a legal and ethical principle that is fundamental to healthcare provision. Oral health practitioners (OHPs) must understand the principles that need to be addressed to ensure that the consent given by a patient is valid. Failure to obtain consent may result in a negligence claim or a complaint of professional misconduct against the OHP. Orthodontic treatment is mostly elective but is not without risk to the patient. Obtaining and maintaining valid consent for orthodontic treatment presents additional challenges in comparison with other dental procedures as the treatment lasts over a longer time and is most commonly performed in adolescents. In addition, prospective patients need to be informed regarding ‘lifelong’ management in the retention phase to minimise the risk of relapse. The present paper outlines the principles of valid consent with particular regard to orthodontic treatment in the adolescent patient. OHPs must ensure that they are satisfied that the competent patient has the capacity to voluntarily consent. Clinicians must also recognise that valid consent is not a one-off ‘tick the box’ procedural exercise but an ongoing process of effective information sharing in light of changing laws and an ever-changing scientific evidence base within a patient-centred model of healthcare.

Preferences Related to the Use of Mobile Apps as Dental Patient Educational Aids: A Pilot Study

PURPOSE

Numerous patient education apps have been developed to explain dental treatment. The purpose of this study was to assess perceptions and preferences regarding the use of apps in dental settings.

MATERIALS AND METHODS

Four patient education apps describing fixed partial dentures were demonstrated to participants (N = 25). Questions about each app were asked using a semi-structured interview format to assess participants' opinions about each app's content, images, features, and use. Sessions were analyzed via note-based methods for thematic coding.

RESULTS

Participants believed that apps should be used in conjunction with a dentist's explanation about a procedure. They desired an app that could be tailored for scope of content. Participants favored esthetic images of teeth that did not show structural anatomy, such as tooth roots, and preferred interactive features.

CONCLUSIONS

Patient education apps may be a valuable tool to enhance patient-provider communication in dental settings. Participants exhibited varying preferences for different features among the apps and expressed the desire for an app that could be personalized to each patient. Additional research is needed to assess whether the use of apps improves oral health literacy and informed consent among patients.

The role of informed consent in patient complaints: Reducing hidden health system costs and improving patient engagement through shared decision making

INTRODUCTION

Patient complaints about physicians are strongly associated with malpractice risk. Physicians at high risk for lawsuits tend to have poor communication skills and are more commonly the subject of patient complaints about communication issues. If a malpractice action does not arise, patient complaints nonetheless represent significant prelitigation transaction costs for the healthcare system that have not been previously quantified. Informed consent complaints represent a unique constellation of clinical communication skills clearly tied to malpractice risk. The goal of this study was to measure institutional resource consumption allocated to informed consent (IC) complaints, which are both costly and preventable.

METHODS

We compared IC complaints to other complaints about medical care in a single medical center in the United States, estimating the absolute and relative burden of IC deficiencies within this healthcare system.

RESULTS

Resource consumption for the resolution of IC complaints far exceeded their proportional representation of complaints, representing half of all complaints, while disproportionately absorbing two-thirds of staff time devoted to complaint resolution.

CONCLUSIONS

Complaint resolution represents an unrecognized remediable cost and an underappreciated opportunity for reducing waste in healthcare. We suggest that healthcare systems can reduce costs and elevate their patient-centered care practices by improving patient-provider communication during medical decision making via engagement strategies such as shared decision making.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

A classification of errors in lay comprehension of medical documents

Emphasis on participatory medicine requires that patients and consumers participate in tasks traditionally reserved for healthcare providers. This includes reading and comprehending medical documents, often but not necessarily in the context of interacting with Personal Health Records (PHRs). Research suggests that while giving patients access to medical documents has many benefits (e.g., improved patient-provider communication), lay people often have difficulty understanding medical information. Informatics can address the problem by developing tools that support comprehension; this requires in-depth understanding of the nature and causes of errors that lay people make when comprehending clinical documents. The objective of this study was to develop a classification scheme of comprehension errors, based on lay individuals' retellings of two documents containing clinical text: a description of a clinical trial and a typical office visit note. While not comprehensive, the scheme can serve as a foundation of further development of a taxonomy of patients' comprehension errors. Eighty participants, all healthy volunteers, read and retold two medical documents. A data-driven content analysis procedure was used to extract and classify retelling errors. The resulting hierarchical classification scheme contains nine categories and 23 subcategories. The most common error made by the participants involved incorrectly recalling brand names of medications. Other common errors included misunderstanding clinical concepts, misreporting the objective of a clinical research study and physician's findings during a patient's visit, and confusing and misspelling clinical terms. A combination of informatics support and health education is likely to improve the accuracy of lay comprehension of medical documents.

Are informed consent forms for organ transplantation and donation too difficult to read?

Informed consent for organ transplantation and donation is an ethical obligation, legally required, and considered as part of the Patient's Rights Condition of Medicare Participation for hospitals. National policy-makers recommend that informed consent forms and patient education materials be written at a low reading level (5th-8th grade level) to facilitate patient comprehension. We assessed reading levels of informed consent forms (CFs) for adult organ transplant recipients and living organ donors across US transplant centers. CFs were analyzed using three measures of reading level: Lexile Measure, Flesch-Kincaid Grade Level, and the Gunning Fog Index. Of active transplant centers contacted (N=209), 75 (36%) sent a total of 332 CFs. CFs were written, on average, at the college level, which is a considerably higher reading level than the standards set by policy-makers. CF reading levels were negatively correlated with transplant center volume (r=-0.119; p<0.03). CFs for intestine transplantation and for evaluation/listing were the easiest to read, while consent forms for liver transplantation/donation and pre-transplant agreements were the most difficult to read. Reducing CFs' reading level may help to increase patient comprehension for adequate informed consent.

Transplant center provision of education and culturally and linguistically competent care: a national study

Although transplant centers are required to educate patients about kidney transplantation (KT) and living donation (LD), little is known about the educational format, and cultural and linguistic competence necessary for patients to make informed treatment decisions. This study surveyed US transplant administrators about education provided concerning KT and LD and culturally and linguistically competent care. Transplant administrators were invited to participate in an anonymous Internet-based survey about education format, education providers, promoting LD, culturally and linguistically competent care and center characteristics. Most (61%) transplant administrators contacted (N = 280/461) completed the survey. Most administrators (91%) reported that their center provides any type of formal education in their pre-KT evaluation. Education was mostly provided by: nurses (97%), social workers (72%) and surgeons (55%), and predominantly as one-on-one (80%) versus group discussions (60%). Education was primarily delivered through written materials (93%). Written educational materials in Spanish (86%) and the provision of interpreters (82%) were emphasized over educational sessions in Spanish (39%), or employing bilingual (51%) and bicultural staff (39%). Half (55%) promoted LD as the best option. Transplant centers need to take greater efforts to consistently provide appropriate education, promote LD, and provide culturally and linguistically competent care to ensure effective communication with all patients.

Experiences of families with a child, adolescent, or young adult with neurofibromatosis type 1 and plexiform neurofibroma evaluated for clinical trials participation at the National Cancer Institute

BACKGROUND

With increasing knowledge of the molecular pathways contributing to the progression of neurofibromatosis type 1 (NF1)-related plexiform neurofibroma (PN), the number of clinical trials for PNs has increased. However, little is known about the experiences of families with children with NF1 participating in clinical trials.

METHOD

A 47-item anonymous survey, designed to assess experiences in research, was sent to parents with a child with NF1 and PNs who was evaluated at the National Cancer Institute (NCI) for a clinical trial.

RESULTS

Sixty-four (85%) parents completed the paper or online questionnaire. Fifty-nine percent of the children were male; 44% were 11 years or older upon enrollment. Most parents reported understanding the purpose of the study, possible side effects, and their right to withdraw. Of respondents whose child had participated in a placebo-controlled trial, 100% said they understood the reason for the placebo at least somewhat. Seventy-four percent felt that study participation helped their child; most would "definitely" or "probably" participate in a future study, including a placebo-controlled trial, and particularly those assessing cognitive functioning or pain. Overall satisfaction with participation was high and correlated with fewer transportation problems, fewer study-related financial difficulties, and fewer school problems for the child (ps<.05).

CONCLUSIONS

Most parents of children with NF1 who participated in research at the NCI reported a positive impact and would participate in future studies. Respondents identified several areas for improvement. This report may help plan future studies to optimize experiences of children and their families enrolled in clinical trials.