Computer-based tutorial to enhance the quality and efficiency of the informed-consent process for cataract surgery

The Impact of a Computer-Based Interactive Informed Consent for Surgery on Decision Conflict

PURPOSE

Informed consent for surgery can address the legal aspects of care while also being simple, informative, and empathic. We developed interactive informed consents and compared them with standard printed informed consents asking: (1) are there any factors associated with lower decision conflict or greater patient-rated clinician empathy including consent format? (2) Are there any factors associated with rating the consent process as informative, comfortable, and satisfying including consent format?

METHODS

Ninety-four adult patients accepted an offer of surgery from one of three hand surgeons to address one of six common hand surgery diagnoses: carpal tunnel release, cubital tunnel release, trigger finger release, plate and screw fixation of a distal radius fracture, removal of a benign mass, including a ganglion cyst, and Dupuytren contracture release. Fifty-three patients were randomized to complete an interactive consent, and 41, a standard written consent. Symptoms of anxiety, depression, and unhelpful thoughts were measured. Patients completed the Decision Conflict Scale and the Jefferson Scale of Patient's Perceptions of Physician Empathy and rated the consent as informative, comfortable, and satisfactory on a scale of 0-10.

RESULTS

Greater decisional conflict was slightly associated with greater patient unhelpful thoughts about symptoms and was not associated with consent format. A higher rating of comfort with the consent process was slightly associated with patient choice to proceed with surgical treatment, but not with consent format. Accounting for potential confounding in multivariable analysis, a higher rating of the consent process as informative was slightly associated with patient preference for surgical over nonsurgical treatment, CONCLUSIONS: The observation that an interactive consent form was not related to decision conflict or other aspects of patient experience suggests that such tools may not have much weight relative to the interaction between patient and clinician.

CLINICAL RELEVANCE

Efforts to improve informed consent may need to focus on the dialog between patient and surgeon rather than how information is presented.

The use of e-consent in surgery and application to neurosurgery: a systematic review and meta-analysis

INTRODUCTION

The integration of novel electronic informed consent platforms in healthcare has undergone significant growth over the last decade. Adoption of uniform, accessible, and robust electronic online consenting applications is likely to enhance the informed consent process and improve the patient experience and has the potential to reduce medico-legal ramifications of inadequate consent. A systematic review and meta-analysis was conducted to evaluate the utility of novel electronic means of informed consent in surgical patients and discuss its application to neurosurgical cohorts.

METHODS

A review of randomised controlled trials, non-randomised studies of health interventions, and single group pre-post design studies in accordance with the PRISMA statement. Random effects modelling was used to estimate pooled proportions of study outcomes. Patient satisfaction with the informed consent process and patients' gain in knowledge were compared for electronic technologies versus non-electronic instruments. A sub-group analysis was conducted to compare the utility of electronic technologies in neurosurgical cohorts relative to other surgical patients in the context of patient satisfaction and knowledge gain.

RESULTS

Of 1042 screened abstracts, 63 studies were included: 44 randomised controlled trials (n = 4985), 4 non-randomised studies of health interventions (n = 387), and 15 single group pre-post design studies (n = 872). Meta-analysis showed that electronic technologies significantly enhanced patient satisfaction with the informed consent process (P < 0.00001) and patients' gain in knowledge (P < 0.00001) compared to standard non-electronic practices. Sub-group analysis demonstrated that neurosurgical patient knowledge was significantly enhanced with electronic technologies when compared to other surgical patients (P = 0.009), but there was no difference in patient satisfaction between neurosurgical cohorts and other surgical patients with respect to electronic technologies (P = 0.78).

CONCLUSIONS

Novel electronic technologies can enhance patient satisfaction and increase patients' gain in knowledge of their surgical procedures. Electronic patient education tools can significantly enhance patient knowledge for neurosurgical patients. If used appropriately, these modalities can shorten and/or improve the consent discussion, streamlining the surgical process and improving satisfaction for neurosurgical patients.

Effect of an educational video about ERAS on reducing preoperative anxiety and promoting recovery

Video propaganda is reported effectively improving patients' understanding of operation. However, whether a video introducing patients' most concerns can reduce preoperative anxiety and promote recovery stays unsealed. In this study, we investigated the effects of complementary therapy of educational video during preoperative visit. The results showed that thirty-five (23.2%) parents in Group Control were diagnosed as anxiety according to SAS, and nineteen (12.3%) patients were diagnosed after video intervention. The APAIs anxiety score and APAIs information score in Group Video were lower than those in Group Control. Compared with Group Control, video visit helped to increase the first-attempt pass rate of the knowledge retention exam and solve the patient's most worried concerns, and decrease incidence of emergence agitation, total cost of hospitalization and length of hospital stay. Moreover, video visit improved satisfaction degrees of patients and their main family members. Briefly, our study demonstrated video visit can improve patients' knowledge of anesthesia and decrease their preoperative anxiety, which may represent an important complementary therapy to routine preoperative visits.

Digital technology in informed consent for surgery: systematic review

BACKGROUND

Informed consent is an ethical and legal requirement in healthcare and supports patient autonomy to make informed choices about their own care. This review explores the impact of digital technology for informed consent in surgery.

METHODS

A systematic search of EBSCOhost (MEDLINE/CINAHL), Embase, Cochrane Central Register of Controlled Trials and Web of Science was performed in November 2021. All RCTs comparing outcomes of both digital and non-digital (standard) consent in surgery were included. Each included study underwent an evaluation of methodological quality using the Cochrane risk of bias (2.0) tool. Outcomes assessed included comprehension, level of satisfaction and anxiety, and feasibility of digital interventions in practice.

RESULTS

A total of 40 studies, across 13 countries and 15 surgical specialties were included in this analysis. Digital consent interventions used active patient participation and passive patient participation in 15 and 25 studies respectively. Digital consent had a positive effect on early comprehension in 21 of 30 (70 per cent) studies and delayed comprehension in 9 of 20 (45 per cent) studies. Only 16 of 38 (42 per cent) studies assessed all four elements of informed consent: general information, risks, benefits, and alternatives. Most studies showed no difference in satisfaction or anxiety. A minority of studies reported on feasibility of digital technology in practice.

CONCLUSION

Digital technologies in informed consent for surgery were found to have a positive effect on early comprehension, without any negative effect on satisfaction or anxiety. It is recommended that future studies explore the feasibility of these applications for vulnerable patient groups and busy surgical practice.

An evaluation of the efficacy of a supplemental computer-based tutorial to enhance the informed consent process for cataract surgery: an exploratory randomized clinical study

Background

To assess whether informing patients with a computer-based tutorial in addition to standard informed consent influences the patient’s attitude towards surgery and increases patient’s knowledge.

Methods

In this prospective, exploratory, randomized clinical study, patients scheduled for their first eye cataract surgery were randomly allocated to two groups, receiving standard face-to-face informed consent (control group) or additionally using an interactive computer-based tool (CatInfo) containing an audiovisual presentation about cataract and its treatment (study group). Cataract-related knowledge and decisional confidence (decisional conflict scale (DCS)) were assessed as well as one-month postoperatively decisional regret (decision regret scale (DRS)) and willingness to exchange face-to-face discussion time for the use of such a tool.

Results

The study comprised 134 patients, 64 patients in the study group and 70 in the control group. Patients in the study group answered more questions correctly, 16.3 ± 2.0 (median 16.5, 11.0–19.0) versus 15.5 ± 1.9 (median 16.0, 8.0–19.0; p = 0.01). Patients showed a high decisional confidence with a study group mean DCS score of 92.4 ± 9.8 (median 96.9, 65.6–100) and control group score of 91.6 ± 10.9 (median 95.3, 43.3–100; p = 0.52). Mean DRS score in the study group was 2.5 ± 8.0 (median 0, 0–40) and 4.3 ± 12.5 (median 0, 0–75) in the control group (p = 0.14). Of study group patients 23 (67.6%) were willing to trade time, on average 158 ± 180 s (median 120 s, 45–900). Satisfaction with the tool was high with a mean of 9.1 ± 1.3 out of 10 (median 9.7, 5.0–10).

Conclusions

Cataract-related knowledge was generally good, with slightly higher scores in the study group. In both groups, decisional confidence was high and regret after surgery was low. A tendency towards slightly higher decisional confidence and lower regret was found in the study group, although these differences were not statistically significant. Additional use of an interactive computer-based tool may prove useful in the informed consent process in a high-volume cataract outpatient setting.

Trial registration

ClinicalTrials.gov, NCT04975126. Retrospectively registered – July 23, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02652-z.

Graphic narrative based informed consent for bronchoscopy improves satisfaction in patients after lung-transplantation: A randomized controlled trial

OBJECTIVE

This study investigated the effects of supplementing standard informed consent (IC) with a graphic narrative on patient satisfaction, periprocedural anxiety and experience.

METHODS

Patients due to undergo first conscious surveillance bronchoscopy following lung transplantation were randomized to receive IC with (intervention group) or without (control group) a graphic narrative illustrating the procedure. The primary endpoint was overall patient satisfaction with the IC. Key secondary endpoints were change in state anxiety level, as measured by State Trait Anxiety Inventory, and a questionnaire assessing satisfaction with IC and adverse experience during bronchoscopy (judged by patient and examiners).

RESULTS

Sixty patients were randomized, and 59 patients were included in the analysis (30 intervention-group; 29 control-group). Overall patient satisfaction was higher in the intervention group 9.5 (²⁵Q-⁷⁵Q: 8.6-9.8) vs. 8.6 (²⁵Q-⁷⁵Q: 8.1-9.2), p = 0.028). Change in state anxiety level (before vs after informed consent) was similar between the groups. There were no significant differences in adverse experience during bronchoscopy.

CONCLUSION

Addition of a graphic narrative illustrating bronchoscopy improved patient satisfaction with IC but did not influence anxiety before and adverse experience during the procedure.

PRACTICE IMPLICATIONS

Supplementing the IC process with a procedure-specific graphic narrative may be a simple tool to improve patient satisfaction.

Improving Surgical Informed Consent: Unanswered Questions

Objective

This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice.

Summary Background

Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further?

Methods

A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost.

Results

There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost.

Conclusions

No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Impact of Preoperative Video Education for Cataract Surgery on Patient Learning Outcomes

Purpose

To assess the effect of an educational video on 1) patient knowledge about cataract surgery, 2) patient perception of preoperative assessment visit quality, 3) face-to-face time with the surgeon, and 4) choices regarding premium intraocular lenses (IOLs) or laser-assisted cataract surgery (LACS).

Setting

Eye clinic in an academic medical center.

Design

Prospective survey of patients who randomly viewed or did not view an educational video.

Methods

Patients of three cataract surgeons completed a survey during cataract surgery preoperative visits. One group viewed an educational video about cataract surgery, while the other did not. All patients received their surgeon’s typical preoperative counseling.

Results

A total of 101 patients were surveyed. Out of 101 patients, 58 viewed the educational video. Patients who viewed the video exhibited stronger learning outcomes; in particular, patients who viewed the video scored higher on cataract surgery educational assessments than those who did not (83% vs 76%, p=0.032), particularly on the assessment of postoperative visual expectations (98% vs 80%, p=0.003). Differences in educational assessment scores between groups were not affected by which surgeon patients saw (p=0.807). Patients who watched the video were more likely to agree their surgeon provided quality explanations (93% vs 74% strongly agreed, p=0.025) and trended toward greater perception the surgeon spent enough time with them (p=0.067). Video education did not affect face-to-face surgeon time with patients (p=0.212) or choices of multifocal IOLs (p=0.795), toric IOLs (p=0.321), or LACS (p=0.940).

Conclusion

Video education during preoperative cataract surgery assessments improved patient understanding of cataract surgery and perception of preoperative visits. Video education is easily integrated into preoperative visits and can enhance the preoperative experience.

Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: An Updated Systematic Review

Background. Patient comprehension is fundamental to valid informed consent. Current practices often result in inadequate patient comprehension. Purpose. An updated review to evaluate the characteristics and outcomes of interventions to improve patient comprehension in clinical informed consent. Data Sources. Systematic searches of MEDLINE and EMBASE (2008-2018). Study Selection. We included randomized and nonrandomized controlled trials evaluating interventions to improve patient comprehension in clinical informed consent. Data Extraction. Reviewers independently abstracted data using a standardized form, comparing all results and resolving disagreements by consensus. Data Synthesis. Fifty-two studies of 60 interventions met inclusion criteria. Compared with standard informed consent, a statistically significant improvement in patient comprehension was seen with 43% (6/14) of written interventions, 56% (15/27) of audiovisual interventions, 67% (2/3) of multicomponent interventions, 85% (11/13) of interactive digital interventions, and 100% (3/3) of verbal discussion with test/feedback or teach-back interventions. Eighty-five percent of studies (44/52) evaluated patients' understanding of risks, 69% (41/52) general knowledge about the procedure, 35% (18/52) understanding of benefits, and 31% (16/52) understanding of alternatives. Participants' education level was reported heterogeneously, and only 8% (4/52) of studies examined effects according to health literacy. Most studies (79%, 41/52) did not specify participants' race/ethnicity. Limitations. Variation in interventions and outcome measures precluded conduct of a meta-analysis or calculation of mean effect size. Control group processes were variable and inconsistently characterized. Nearly half of studies (44%, 23/52) had a high risk of bias for the patient comprehension outcome. Conclusions. Interventions to improve patient comprehension in informed consent are heterogeneous. Interactive interventions, particularly with test/feedback or teach-back components, appear superior. Future research should emphasize all key elements of informed consent and explore effects among vulnerable populations.

A randomized, controlled trial of video supplementation on the cataract surgery informed consent process

PURPOSE

To assess the effects of the American Academy of Ophthalmology's 2015 patient education video on patient information retention and anxiety preoperatively, on the day of surgery and postoperatively.

METHODS

This is a prospective, surgeon-blinded randomized controlled trial at the University of Chicago Medical Center. Ninety-one patients with a diagnosis of first-eye cataract were randomized into either a video or control group. Subjects in both groups received face-to-face discussion with the surgeon and an informational brochure at the preoperative evaluation. Participants in the video group then viewed a four-minute educational video at the preoperative evaluation and on the day of surgery. Both groups completed an information retention quiz and a state anxiety assessment at the preoperative visit, on the day of surgery, and on the postoperative week one visit. Subject understanding of cataract surgery was measured using a twelve-question multiple choice quiz. State anxiety was measured by State Trait Anxiety Inventory-Y1 survey score.

RESULTS

Participants in the video group did not score significantly higher on the information retention quiz compared with the control group at the preoperative evaluation (8.7 ± 2.4 vs 7.7 ± 2.5, P = 0.07), but did so on the day of surgery (11.2 ± 0.8 vs 8.4 ± 1.7, P < 0.001) and postoperative week 1 visit (10.8 ± 1.5 vs 9.0 ± 2.0, P < 0.001). Subjects in the video group were significantly less anxious on the day of surgery (26.4 ± 5.1 vs 41.1 ± 10.3, P < 0.001).

CONCLUSIONS

Video supplementation to the traditional informed consent process demonstrated an improvement in patient understanding of cataract surgery at multiple timepoints and decreased anxiety on the day of surgery.

Developing, Implementing, and Evaluating a Multimedia Patient Decision Aid Program to Reform the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Protocol for Quality Improvement

Background

Informed consent has considerable clinical, ethical, and legal implications for patient safety and liability. Little information is available about the use of multimedia patient decision aids (PtDA) in the consent process for therapeutic invasive procedures such as the peripherally inserted central venous catheter (PICC). In addition, none of the available studies have designed their multimedia PtDAs based on the Agency for Healthcare Research and Quality’s (AHRQ) comprehensive guide for informed consent.

Objective

This paper describes a patient-centered, systematic, multidisciplinary approach to develop, implement, and alpha test a multimedia PtDA to reform the informed consent process of a PICC for patients in 10 acute and intensive care units.

Methods

The development, implementation, and evaluation processes of the PtDA followed the phases in the Multimedia Production Framework: preproduction, production, and postproduction. Within this framework, we applied the criteria for judging the quality of PtDAs, the AHRQ’s Health Literacy Universal Precautions Toolkit, and the AHRQ’s Patient Education Materials Assessment Tool Guide. The methodology was guided by the Interprofessional Shared Decision-Making Model and the AHRQ’s Making Informed Consent an Informed Choice guide. In the preproduction phase, we (1) reviewed the current consent form; (2) observed 18 consent processes; (3) surveyed the vascular access team (N=6 nurses) about their perception of the current process; (4) surveyed 30 patients for knowledge recall and retention, overall satisfaction, and attitude toward using a multimedia PtDA; and (5) wrote and reviewed the script for the multimedia program. The production phase focused on filming the PtDA in English and Spanish languages. The postproduction phase included integrating the multimedia programs into the care processes, developing a modified workflow for the consent process, and alpha testing of the English and Spanish PtDAs by (1) a group of 5 patients for clarity and understandability of the information; (2) nurses using the AHRQ’s Patient Education Materials Assessment Tool Audio and Video; and (3) by the multidisciplinary change team.

Results

Based on the alpha testing, patients indicated that the content was easy to follow and read; nurses provided positive feedback, and their comments were mainly related to the changes in the workflow in the consent process of the PICC after using the PtDA; and the multidisciplinary change team suggested edits related to changing a few scenes. The final multimedia program consisted of 7 min and 37 s demonstrating detailed information about the PICC.

Conclusions

A systematic development of PtDAs for nonurgent invasive procedures may eliminate many limitations of the conventional consent process by ensuring comprehensive, standardized, and easy-to-comprehend information and providing sufficient time for the patients to reflect on the information. To be effective, PtDAs should follow a systematic, patient-centered, evidence-based, and rigorous approach in the development, implementation, and evaluation processes.

International Registered Report Identifier (IRRID)

RR1-10.2196/10709

Informed consent in refractive surgery: in-person vs telemedicine approach

Purpose

The aim of this study was to compare the quality of consent process in refractive surgery between patients who had a preoperative consent discussion with the surgeon using a telemedicine approach and those who had a face-to-face discussion.

Methods

Patients treated between January and December 2017 (8,184 laser vision correction [LVC] and 3,754 refractive lens exchange [RLE] patients) that attended day 1 and 1-month postoperative visit were retrospectively reviewed. Preoperative consent preparation included a consultation with an optometrist, observation of an educational video, and written information. Patients then selected either a face-to-face appointment with their surgeon (in-clinic group) or a telemedicine appointment (remote group) for their consent discussion, according to their preference. Patient experience questionnaire and clinical data were included in a multivariate model to explore factors associated with consent quality.

Results

Prior to surgery, 80.1% of LVC and 47.9% of RLE patients selected remote consent. Of all LVC patients, 97.5% of in-clinic and 98.3% of remote patients responded that they were adequately consented for surgery (P=0.04). Similar percentages in the RLE group were 97.6% for in-clinic and 97.9% for remote patients (P=0.47). In a multivariate model, the major predictor of patient's satisfaction with the consent process was postoperative satisfaction with visual acuity, responsible for 80.4% of variance explained by the model. Other significant contributors were postoperative visual phenomena and dry eyes, difficulty with night driving, close-up and distance vision, postoperative uncorrected distance visual acuity, change in corrected distance visual acuity, and satisfaction with the surgeon's approach. The type of consent (remote or in-clinic) had no impact on patient's perception of consent quality in the regression model.

Conclusion

The majority of patients opted for telemedicine-assisted consent. Those who chose it were equally satisfied as those who had a face-to-face meeting with their surgeon. Dissatisfaction with surgical outcome was the major factor affecting patient's perception of consent quality, regardless of the method of their consent.

Effect of a Multimedia Patient Decision Aid to Supplement the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Pre-Post Quasi-Experimental Study

Background

Informed consent is a complex process to help patients engage in care processes and reach the best treatment decisions. There are many limitations to the conventional consent process that is based on oral discussion of information related to treatment procedures by the health care provider. A conclusive body of research supports the effectiveness of multimedia patient decision aids (PtDAs) in the consent process in terms of patient satisfaction, increased knowledge about the procedure, reduced anxiety level, and higher engagement in the decision making. Little information is available about the effectiveness of multimedia PtDAs in the consent process of invasive therapeutic procedures such as the peripherally inserted central venous catheter (PICC).

Objective

The objective of this study was to examine the effectiveness of a multimedia PtDA in supplementing the consent process of the PICC for patients in 10 acute and intensive care units in terms of knowledge recall, knowledge retention, satisfaction with the consent process, and satisfaction with the PICC multimedia PtDA.

Methods

This pre-post quasi-experimental study included 130 patients for whom a PICC was ordered. Patients in the control group (n=65) received the conventional consent process for the PICC, while those in the intervention group (n=65) received the multimedia PtDA to support the consent process of a PICC. All patients were surveyed for knowledge recall and retention about the procedure and satisfaction with the consent process. Patients in the intervention group were also surveyed for their satisfaction with the multimedia PtDA.

Results

Compared with the control group, patients in the intervention group scored around 2 points higher on knowledge recall (t₁₂₅=4.9, P<.001) and knowledge retention (t₁₂₆=4.8, P<.001). All patients in the intervention group were highly satisfied with the multimedia PtDA, with a mean score of >4.5 out of 5 on all items. Items with the highest mean scores were related to the effect of the multimedia PtDA on knowledge retention (mean 4.9 [SD 0.2]), patient readiness to learn (mean 4.8 [SD 0.5]), complete understanding of the procedure-related complications (mean 4.8 [SD 0.4]), and patient role in maintaining the safety of the PICC (mean 4.8 [SD 0.5]). Patients in the two groups were highly satisfied with the consent process. However, 15% (10/65) patients in the control group reported that the following information was omitted from the discussion: patient and provider roles in the safety of the PICC, other treatment options, and common side effects. Furthermore, 2 patients commented that they were not ready to engage in the discussion.

Conclusions

The multimedia PtDA is an effective standardized, structured, self-paced learning tool to supplement the consent process of the PICC and improve patient satisfaction with the process, knowledge recall, and knowledge retention.

Efficiency of video-presented information about excimer laser treatment on ametropic patients' knowledge and satisfaction with the informed consent process

PURPOSE

To evaluate whether the presentation of a video within the informed consent consultation affects patient knowledge about refractive excimer laser treatment, satisfaction with the informed consent process, anxiety in respect to the planned surgery, and the consultation duration.

SETTING

Tertiary referral center, Lucerne, Switzerland.

DESIGN

Single-center, randomized controlled trial.

METHODS

Consenting eligible patients were randomly assigned to receive either a conventional face-to-face consultation (conventional group) or a conventional consultation with additional video-assisted information (interventional group). Knowledge and satisfaction with the informed consent process and anxiety regarding surgery were assessed. Differences between groups were tested with Wilcoxon-Mann-Whitney, Chi-square, and Student t tests.

RESULTS

The study comprised 113 patients (58 in the conventional group and 55 in the interventional group). There was no difference in terms of knowledge with 22/25 points (interquartile range [IQR], 3) in the conventional group versus 22/25 points (IQR, 2) in the interventional group (P = .957), satisfaction with the informed consent ("very satisfied": 47/58 versus 45/55; P = .915) and anxiety toward surgery with a median 8 (IQR, 4) versus median 9 (IQR, 3; P = .159). In the interventional group, however, the total consultation time was significantly lower than in the conventional group (-4.96 minutes; 95% CI, -9.50 to -0.43; P = .032).

CONCLUSION

Compared with a conventional consultation, video-assistance slightly reduced the total consultation time while maintaining patient knowledge, satisfaction with the informed consent process, and anxiety regarding the surgery on equal levels. Video-assistance could increase efficiency of clinical management on a double-digit percentage at an equal running cost compared with a conventional consultation.

Patient education strategies in cataract surgery: A systematic review

OBJECTIVE

To systematically review the comparative effectiveness of patient education strategies in cataract surgery.

METHODS

A comprehensive literature search of five electronic databases was conducted for randomized controlled trials (RCTs) studying the efficacy of educational interventions for cataract surgery patients. Peer-reviewed articles published in English were considered for inclusion without restriction limits on publication date. General study characteristics, measurement methodologies, and outcome measures were narratively synthesized. Quality appraisal was conducted using the Oxford quality rating system (for individual studies) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines (for bodies of evidence).

RESULTS

Sixteen RCTs were compiled for qualitative review. We identified 21 distinct patient outcomes, four (19%) with a multi-study evidence base: knowledge of cataracts/cataract surgery, knowledge of postoperative care, proficiency in postoperative care, and anxiety. Targeted interventions significantly increased educational efficacy in 11 (69%) studies, but there were consistent improvements only for patient understanding of cataracts/cataract surgery and postoperative care. Quality of evidence was poor for all outcomes examined in multiple studies, as well as for deciding to undergo cataract surgery (measured in one study). Cross-study examination revealed appreciable clinical and methodological heterogeneity.

CONCLUSIONS

Targeted interventions fostered patients' understanding of cataract surgery and postoperative care. Additional high-quality studies are needed to determine appropriate educational strategies that improve other clinical, performance, and humanistic outcomes.

Refractive Surgery: Malpractice Litigation Outcomes

PURPOSE

To review data on malpractice claims related to refractive surgery to identify common allegations and injuries and financial outcomes.

METHODS

The WestlawNext database was reviewed for all malpractice lawsuits/settlements related to refractive eye surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes.

RESULTS

A total of 167 cases met the inclusion criteria, of which 108 cases (64.7%) were found to be favorable and 59 cases (35.3%) unfavorable to the defendant. A total of 141 cases were tried by a jury with 108 cases (76.4%) favorable and 33 cases (23.6%) unfavorable to the defendant. Laser in situ keratomileusis was performed in 127 cases (76%). The most common allegations were negligence in treatment or surgery in 127 cases (76%) and lack of informed consent in 83 cases (49.7%). For all cases, the need for future surgery (P = 0.0001) and surgery resulting in keratoconus (P = 0.05) were more likely to favor the plaintiff. In jury verdict decisions, cases in which failure to diagnose a preoperative condition was alleged favored the defendant (P = 0.03), whereas machine malfunction (P = 0.05) favored the plaintiff. After adjustment for inflation, the overall mean award was $1,287,872. Jury verdicts and settlements led to mean awards of $1,604,801 and $826,883, respectively.

CONCLUSIONS

Malpractice litigation in refractive surgery tends to favor the defendant. However, large awards and settlements were given in cases that were favorable to the plaintiff. The need for future surgery and surgery leading to keratoconus increased the chance of an unfavorable outcome.

Surgical Informed Consent Process in Neurosurgery

The doctrine of informed consent, as opposed to medical paternalism, is intended to facilitate patient autonomy by allowing patient participation in the medical decision-making process. However, regrettably, the surgical informed consent (SIC) process is invariably underestimated and reduced to a documentary procedure to protect physicians from legal liability. Moreover, residents are rarely trained in the clinical and communicative skills required for the SIC process. Accordingly, to increase professional awareness of the SIC process, a brief history and introduction to the current elements of SIC, the obstacles to patient autonomy and SIC, benefits and drawbacks of SIC, planning of an optimal SIC process, and its application to cases of an unruptured intracranial aneurysm are all presented. Optimal informed consent process can provide patients with a good comprehension of their disease and treatment, augmented autonomy, a strong therapeutic alliance with their doctors, and psychological defenses for coping with stressful surgical circumstances.

Educational and interactive informed consent process for treatment of unruptured intracranial aneurysms

OBJECTIVE

For patients with unruptured intracranial aneurysms (UIAs), the information transfer that precedes informed consent needs to be in-depth and detailed, as most patients with a UIA have no symptoms, yet the risks related to treatment are relatively high. Thus, in this study an educational and interactive program was proposed for patients with UIAs to improve the informed consent process and assess the level of comprehension.

METHODS

A total of 110 patients with UIAs underwent the proposed educational and interactive informed consent (EIIC) process and were enrolled in this study. The EIIC process combines patient education using information booklets, a cartoon book, a video, an initial physician-patient interview, answering a questionnaire, a second physician-patient interview based on the questionnaire results, and finally consent. After the first physician-patient interview that provides the patient with specific information, including his or her angiographic characteristics, medical condition, and recommended treatment, the patient is requested to answer a questionnaire composed of 3 parts: demographic information, including the patient's age, sex, and years of education; 13 medical questions to assess the patient's knowledge about his or her UIA; and an evaluation of the usefulness of the educational resources. The control group consisted of 65 patients from 3 other tertiary university hospitals where the EIIC process was not used.

RESULTS

The questionnaire scores of the EIIC group ranged from 7 to 13 (mean ± SD: 11.9 ± 1.3) and were significantly higher than those for the controls (10.2 ± 1.9, p < 0.001). The better comprehension of the patients in the EIIC group was remarkable as they were significantly older than those in the control group (62.7 ± 8.3 years vs 55.9 ± 10.5 years, respectively; p < 0.001). For both the EIIC group and the control group, a Pearson correlation analysis revealed a positive correlation (r = 0.232 for the EIIC group, r = 0.603 for controls) between the years of education and the questionnaire score (p = 0.015 for the EIIC group, p < 0.001 for the controls), whereas no correlation was found between the patient age and the questionnaire score. For the EIIC group, the verbal information from the attending physician was selected by 90 patients (81.8%) as the most useful and informative educational method, while the most effective reinforcement of this verbal communication was the video (n = 86; 78.2%), information booklets (n = 16; 14.5%), the Internet (n = 7; 6.4%), and the cartoon book (n = 1; 0.9%).

CONCLUSIONS

The proposed standardized EIIC process resulted in good patient comprehension about UIAs. The verbal information from the attending physician was the most informative, and the video was the most effective reinforcement of the verbal communication. The patient level of comprehension was shown to be correlated with years of education.

Informed consent in dental care and research for the older adult population: A systematic review

BACKGROUND

Ethics in health care and research is based on the fundamental principle of informed consent. However, informed consent in geriatric dentistry is not well documented. Poor health, cognitive decline, and the passive nature of many geriatric patients complicate this issue.

METHODS

The authors completed this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors searched the PubMed (MEDLINE), Web of Science, PsycINFO, and Cochrane Library databases. The authors included studies if they involved participants 65 years or older and discussed topics related to informed consent beyond obtaining consent for health care. The authors explored informed consent issues in dentistry and other biomedical care and research.

RESULTS

The authors included 80 full-text articles on the basis of the inclusion criteria. Of these studies, 33 were conducted in the United States, 29 addressed consent issues in patients with cognitive impairment, 29 were conducted in patients with medical conditions, and only 3 involved consent related to dental care or research.

CONCLUSIONS

Informed consent is a neglected topic in geriatric dental care and research. Substantial knowledge gaps exist between the understanding and implementation of consent procedures. Additional research in this area could help address contemporary consent issues typically encountered by dental practitioners and to increase active participation from the geriatric population in dental care and research.

PRACTICAL IMPLICATIONS

This review is the first attempt, to the authors' knowledge, to identify informed consent issues comprehensively in geriatric dentistry. There is limited information in the informed consent literature covering key concepts applicable to geriatric dentistry. Addressing these gaps could assist dental health care professionals in managing complex ethical issues associated with geriatric dental patients.

Role of the treating surgeon in the consent process for elective refractive surgery

Purpose

To compare patient’s perception of consent quality, clinical and quality-of-life outcomes after laser vision correction (LVC) and refractive lens exchange (RLE) between patients who met their treating surgeon prior to the day of surgery (PDOS) or on the day of surgery (DOS).

Design

Retrospective, comparative case series.

Setting

Optical Express, Glasgow, UK.

Methods

Patients treated between October 2015 and June 2016 (3972 LVC and 979 RLE patients) who attended 1-day and 1-month postoperative aftercare and answered a questionnaire were included in this study. All patients had a thorough preoperative discussion with an optometrist, watched a video consent, and were provided with written information. Patients then had a verbal discussion with their treating surgeon either PDOS or on the DOS, according to patient preference. Preoperative and 1-month postoperative visual acuity, refraction, preoperative, 1-day and 1-month postoperative questionnaire were compared between DOS and PDOS patients. Multivariate regression model was developed to find factors associated with patient’s perception of consent quality.

Results

Preoperatively, 8.0% of LVC and 17.1% of RLE patients elected to meet their surgeon ahead of the surgery day. In the LVC group, 97.5% of DOS and 97.2% of PDOS patients indicated they were properly consented for surgery (P=0.77). In the RLE group, 97.0% of DOS and 97.0% of PDOS patients stated their consent process for surgery was adequate (P=0.98). There was no statistically significant difference between DOS and PDOS patients in most of the postoperative clinical or questionnaire outcomes. Factors predictive of patient’s satisfaction with consent quality were postoperative satisfaction with vision (46.7% of explained variance), difficulties with night driving, close-up vision or outdoor/sports activities (25.4%), visual phenomena (12.2%), dry eyes (7.5%), and patient’s satisfaction with surgeon’s care (8.2%).

Conclusion

Perception of quality of consent was comparable between patients that elected to meet the surgeon PDOS, and those who did not.

Use of Multimedia Technology in the Doctor-Patient Relationship for Obtaining Patient Informed Consent

Patient informed consent for surgery or for high-risk methods of treatment or diagnosis means that unlawful breach of the patient's personal interests is avoided and the patient accepts the risk of surgery and takes the brunt of it. Patient awareness - their knowledge of the condition and circumstances of continued therapeutic procedure, including offered and available methods of treatment and their possible complications - constitutes a particular aspect of the informed-consent process. The rapid development of technologies and methods of treatment may cause communication problems between the doctor and the patient regarding the scope and method of patient education prior to surgery. The use of multimedia technology (e.g., videos of surgical procedures, computer animation, and graphics), in addition to media used in preoperative patient education, may be a factor in improving the quality of the informed consent process. Studies conducted in clinical centers show that with use of multimedia technology, patients remember more of the information presented. The use of new technology also makes it possible to reduce the difference in the amount of information assimilated by patients with different levels of education. The use of media is a way to improve the quality of preoperative patient education and, at the same time, a step towards their further empowerment in the healing process.

Assessing a narrated white board animation as part of the consent process for intravenous fluorescein angiography: a randomized educational study

OBJECTIVE

To determine if a narrated white board animation (nWBA) video as part of the consent process for intravenous fluorescein angiography (IVFA) improves patient comprehension compared with a standard consent process.

DESIGN

Prospective, randomized study.

PARTICIPANTS

Patients undergoing an initial IVFA investigation.

METHODS

Three groups of 26 patients (N = 78) naïve to the IVFA procedure were included. Groups 1 and 2 consisted of patients undergoing IVFA for diagnostic purposes. Group 1 received the IVFA information via standard physician-patient interaction to obtain standard consent. Group 2 received IVFA information by watching an nWBA explaining the purpose, method, and risks of the diagnostic test to obtain informed consent. Group 3 comprised patients who were not scheduled to undergo IVFA. This group was exposed to both the standard and nWBA consent. All groups completed a 6-question knowledge quiz to assess retained information and a survey to reflect on the consent experience.

RESULTS

Participants receiving information via standard physician-patient interaction to obtain informed consent had a lower mean knowledge score (4.38 out of 6; 73%) than participants receiving the information to obtain consent via nWBA (5.04 out of 6, 84%; P = 0.023). Of participants receiving both forms of information (group 3) to obtain informed consent, 73% preferred the nWBA to the standard consent process.

CONCLUSIONS

Participants receiving consent information for an IVFA diagnostic test via nWBA have better knowledge retention regarding the IVFA procedure and preferred this medium compared with participants receiving the standard physician-patient interaction for obtaining consent. Incorporation of multimedia into the informed consent process should be explored for other diagnostic tests.