Effects of presentation method on the understanding of informed consent

Visual supplementation is an effective tool in cataract surgery counselling by eye-care practitioners

BACKGROUND

Informed consent constitutes an important aspect of eye care. However, patients often experience difficulties understanding and retaining information presented to them during consultations. This study investigates the efficacy of pictorial aids in supplementing preoperative counselling of patients undergoing cataract surgery.

METHODS

Patients attending routine pre-cataract surgery counselling were randomized to receive either a standard verbal consultation (control) or a verbal consultation with a digitalized pictorial aid illustrating key surgical steps (intervention). Patients were assessed after the consultation on their knowledge, satisfaction, anxiety and preparedness using an anonymous questionnaire.

RESULTS

Seventy-six patients were recruited and randomized into the control and intervention groups. The intervention group attained better Knowledge Scores (control: 5 [2-6] vs. intervention: 6 [6]), and more patients "strongly agreed" that they were more prepared (control: 78.9% vs. intervention: 97.4%, P=0.028). A higher proportion of patients in the control group either "disagreed" or "neither disagree nor agreed (neutral)" that they were less worried (control: 15.8% vs. intervention: 0.0%, Fisher's Exact Test P=0.025). Although the consultation duration was shorter in the intervention group (21±4mins vs. 27±6mins, P<0.001), the use of digital pictorial aids during consultation resulted in more effective counselling with increased patient knowledge, easier decision-making process and reduced patient anxiety.

CONCLUSION

Pictorial aids add to the repository of tools available to eye-care practitioners and are low-cost, easy to implement, and can effectively augment existing preoperative counselling processes to ensure accurate and effective preoperative counselling of patients.

The effect of an information video on preoperative anxiety level before percutaneous nephrolithotomy procedure: A prospective, randomized trial

INTRODUCTION

We aimed to show the effect of patient information videos on preoperative anxiety before performing the percutaneous nephrolithotomy (PCNL ) for kidney stones.

METHODS

This study was designed as a randomized, controlled trial with patients scheduled for PCNL operation for kidney stones. Demographic information, such as age, gender, and American Society of Anesthesiologists (ASA) score, were collected. State-Trait Anxiety Inventory (ST AI) was used to measure anxiety levels. Before informing the patients, anxiety levels were evaluated using the ST AI-state (pre-information ST AI-S) and ST AI-trait (ST AI-T). Patients were randomly divided into two groups: both groups received written and verbal information, while the "video" group was also shown a video of a PCNL procedure. The post-information anxiety levels of both groups were evaluated using ST AI-S (post-information).

RESULTS

A total of 109 patients were included in the study and 50 patients were included in each group after nine patients were excluded. The participants in the two groups were similar in terms of gender distribution, mean age, and pre-information ST AI-S scores. Post-information ST AI-S scores were statistically significantly lower in the video group (p=0.02). There was no significant difference between post-information and pre-information ST AI-S scores in the no-video group (p=0.86), whereas a significant decrease was found in post-information ST AI-S scores in the video group (p<0.01).

CONCLUSIONS

In addition to written and verbal information before PCNL operations, informative videos are an inexpensive, effective method to reduce preoperative anxiety levels. Video-based briefing may be routinely used in addition to preoperative verbal and written information.

Improving oncology first-in-human and Window of opportunity informed consent forms through participant feedback

BACKGROUND

Although patient advocates have developed templates for standard consent forms, evaluating patient preferences for first in human (FIH) and window of opportunity (Window) trial consent forms is critical due to their unique risks. FIH trials are the initial use of a novel compound in study participants. In contrast, Window trials give an investigational agent over a fixed duration to treatment naïve patients in the time between diagnosis and standard of care (SOC) surgery. Our goal was to determine the patient-preferred presentation of important information in consent forms for these trials.

METHODS

The study consisted of two phases: (1) analyses of oncology FIH and Window consents; (2) interviews of trial participants. FIH consent forms were analyzed for the location(s) of information stating that the study drug has not been tested in humans (FIH information); Window consents were analyzed for the location(s) of information stating the trial may delay SOC surgery (delay information). Participants were asked about their preferred placement of the information in their own trial's consent form. The location of information in the consent forms was compared to the participants' suggestions for placement.

RESULTS

34 [17 FIH; 17 Window] of 42(81%) cancer patients approached participated. 25 consents [20 FIH; 5 Window] were analyzed. 19/20 FIH consent forms included FIH information, and 4/5 Window consent forms included delay information. 19/20(95%) FIH consent forms contained FIH information in the risks section 12/17(71%) patients preferred the same. Fourteen (82%) patients wanted FIH information in the purpose, but only 5(25%) consents mentioned it there. 9/17(53%) Window patients preferred delay information to be located early in the consent, before the "Risks" section.  3/5(60%) consents did this.

CONCLUSIONS

Designing consents that reflect patient preferences more accurately is essential for ethical informed consent; however, a one-size fits all approach will not accurately capture patient preferences. We found that preferences differed for FIH and Window trial consents, though for both, patients preferred key risk information early in the consent. Next steps include determining if FIH and Window consent templates improve understanding.

A Multifaceted Strategy to Enhance Glaucoma Knowledge and Reduce Anxiety in the Uyghur Population of Rural China

Purpose. The aim of the study is to assess the impact of a multifaceted education strategy for Uyghur patients with glaucoma on their anxiety, satisfaction, and comprehension of disease information in rural China. Methods. This study recruited 100 patients who were randomized into two groups: the control group that received a conventional consultation and the intervention group that received a multifaceted education approach. Information comprehension was evaluated using a 15-item questionnaire. A 6-item State-Trait Anxiety Inventory (STAI-6) score was used to assess patient anxiety levels. Satisfaction was evaluated on the day of discharge. Results. After education, patients in the intervention group scored significantly higher than those in the control group on their knowledge of glaucoma ( $p\le 0.001$ ). Education level, family history of glaucoma, and number of glaucoma clinic visits were independently associated with baseline scores (p = 0.038, 0.002, and 0.017, respectively). The age was negatively correlated with scores ( $p\le 0.001$ ) after education. The STAI-6 score of the intervention group was 28.50 ± 5.13, which was significantly lower than that of the control group (32.50 ± 6.47, p = 0.001). Income levels were negatively correlated and the duration of glaucoma was positively correlated with STAI-6 scores ( $p\le 0.001$ and $p=0.003$ , respectively). Overall satisfaction was significantly higher in the intervention group ( $p\le 0.001$ ). The knowledge score was positively correlated with overall satisfaction and follow-up probability (both $p\le 0.001$ ). The STAI-6 score was negatively correlated with overall satisfaction and follow-up probability ( $p=0.017$ and 0.006, respectively). Conclusions. This new multifaceted educational strategy can enhance patients’ knowledge of glaucoma, reduce their anxiety, and improve their satisfaction. ClinicalTrials.gov (No. 2100050926)

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 Video Education on Patient Knowledge, Anxiety, and Satisfaction in Selective Laser Trabeculoplasty: A Pilot Study

PRéCIS:: In patients undergoing selective laser trabeculoplasty, preoperative video education did not improve patient knowledge regarding the procedure, decrease anxiety, or increase satisfaction, as these metrics were already favorable across all patients in this study.

PURPOSE

To assess the effect of an educational video on patient knowledge, anxiety, and satisfaction at a selective laser trabeculoplasty (SLT) procedure visit.

MATERIALS AND METHODS

This is a prospective, randomized trial. Patients at a single academic medical center completed a survey at their procedure visit for SLT; patients were randomized to view an educational video or no video before survey administration. Knowledge was assessed with a 10-item questionnaire. The 6-item State-Trait Anxiety Inventory scale (STAI-6) assessed anxiety (score >40 defined significant anxiety). Perceptions of visit quality were assessed using a Likert scale.

RESULTS

Twenty-two patients were randomized into video (n=11) and control (n=11) groups. No difference in knowledge was observed between groups (83.6% control vs. 82.7% video group, P=0.635). No patient had significant anxiety (STAI-6 range, 20 to 40, average 29) and scores were similar between groups (P=0.385). Overall, patients had positive perceptions of visit quality, and there was no significant difference between groups (P=0.999).

CONCLUSION

Patients undergoing SLT had high levels of knowledge, low levels of anxiety, and high levels of satisfaction. In this clinical setting, an educational video seemed to have no additional benefit on these metrics and thus, may be omitted. Further research may be directed toward optimizing patient education regarding SLT, particularly in settings with poor health literacy, limited resources, or limited access to glaucoma specialists.

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.

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.

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.

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.

A randomized trial of multimedia-facilitated informed consent for cataract surgery

Objective

The aim of this study was to evaluate the value and role of patient’s education videos in the informed consent process for patients undergoing preoperative assessment of cataracts.

Design

The study is a single-center prospective randomized controlled trial.

Subjects, participants, and/or controls

Participants enrolled in this study were specifically those undergoing first-time phacoemulsification cataract surgery with the placement of a monofocal lens implant.

Participants and methods

Subjects were randomized to either face-to-face surgeon-informed consent with a preceding education video or face-to-face surgeon-informed consent alone.

Main outcome measures

The main outcome measures assessed were time to complete the informed consent process, patient’s satisfaction, and patient’s comprehension.

Results

The video and control groups were similar in satisfaction (4.67±0.104 video vs. 4.53±0.133 control; P=0.43) and comprehension (79.4%±2.82% video vs. 79.3%±3.39% control; P=0.99). Counseling time was statistically significantly different (117.5±10.9 seconds video versus 241.6±13.0 seconds control; P<0.0001).

Conclusion

Use of a patient’s education video for cataract surgery was associated with reduced physician counseling time yet similar comprehension and patient-reported satisfaction when compared with traditional counseling methods.

A novel metadata management model to capture consent for record linkage in longitudinal research studies

Background: Informed consent is an important feature of longitudinal research studies as it enables the linking of the baseline participant information with administrative data. The lack of standardized models to capture consent elements can lead to substantial challenges. A structured approach to capturing consent-related metadata can address these. Objectives: a) Explore the state-of-the-art for recording consent; b) Identify key elements of consent required for record linkage; and c) Create and evaluate a novel metadata management model to capture consent-related metadata. Methods: The main methodological components of our work were: a) a systematic literature review and qualitative analysis of consent forms; b) the development and evaluation of a novel metadata model. Discussion: We qualitatively analyzed 61 manuscripts and 30 consent forms. We extracted data elements related to obtaining consent for linkage. We created a novel metadata management model for consent and evaluated it by comparison with the existing standards and by iteratively applying it to case studies. Conclusion: The developed model can facilitate the standardized recording of consent for linkage in longitudinal research studies and enable the linkage of external participant data. Furthermore, it can provide a structured way of recording consent-related metadata and facilitate the harmonization and streamlining of processes.

Video-Assisted Informed Consent for Cataract Surgery: A Randomized Controlled Trial

Purpose. To investigate whether adding video assistance to traditional verbal informed consent advisement improved satisfaction among cataract surgery patients. Methods. This trial enrolled 80 Chinese patients with age-related cataracts scheduled to undergo unilateral phacoemulsification surgery. Patients were randomized into two groups: the video group watched video explaining cataract-related consent information and rewatched specific segments of the video at their own discretion, before receiving traditional verbal consent advisement; the control group did not watch the video. Outcomes included patient satisfaction, refusal to consent, time to complete the consent process, and comprehension measured by a ten-item questionnaire. Results. All 80 enrolled patients signed informed consent forms. Compared with the control group, members of the video group exhibited greater satisfaction (65% versus 86%, p = 0.035) and required less time to complete the consent process (12.3 ± 6.7 min versus 5.6 ± 5.4 min, p < 0.001), while also evincing levels of comprehension commensurate with those reported for patients who did not watch the video (accuracy rate, 77.5% versus 80.2%, p = 0.386). Conclusion. The video-assisted informed consent process had a positive impact on patients' cataract surgery experiences. Additional research is needed to optimize patients' comprehension of the video.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy

Background

Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion.

Methods

This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed.

Results

Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension.

Conclusions

Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.

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.

A pragmatic randomized trial comparing tablet computer informed consent to traditional paper-based methods for an osteoporosis study

Objective

Methods to improve informed consent efficiency and effectiveness are needed for pragmatic clinical trials. We compared informed consent using a tablet computer to a paper approach to assess comprehension and satisfaction of patients and clinic staff for a future osteoporosis clinical trial.

Methods

Nine community-based practices identified and recruited patients to compare the informed consent processes (tablet vs. paper) in a mock osteoporosis clinical trial. The tablet informed consent included an animation summarizing the trial, complete informed consent document, and questions to assess and reinforce comprehension of the study. Participants were women age ≥55 years with ≥1 year of alendronate use. We surveyed participants to assess comprehension and satisfaction and office staff for satisfaction and perceived time demands.

Results

The nine practices enrolled 33 participants. There was not a significant difference in comprehension between the tablet vs. paper informed consent [mean (SD) tablet: 12.2 (1.0) vs. paper: 11.4 (1.7)]. Office staff preferred the tablet to the paper informed consent for identifying potential study participants (two-sided t-test p = 0.02) despite an increased perceived time spent to complete the tablet process [tablet: 28.3 min (SD 16.3) vs. paper: 19.0 min (SD 6.9); p = 0.08].

Conclusions

Although, there were no significant differences in participant satisfaction and comprehension with the tablet informed consent compared to a paper informed consent, patients and office staff trended towards greater satisfaction with the tablet informed consent. Larger studies are needed to further evaluate the utility of electronic informed consent in pragmatic clinical trials.

The effect of multimedia interventions on the informed consent process for cataract surgery in rural South India

Context:

The provision of ocular surgical interventions for poorer, less educated populations is increasing as a result of increased globalization and outreach. However, these populations still have trouble understanding surgical concepts and are not always fully informed decision makers.

Aims:

We aimed to test the effect that a multimedia addition to a traditional verbal informed consent would have on patient comprehension of relatively difficult cataract surgical concepts.

Settings and Design:

We conducted a randomized controlled trial with relatively uneducated patients reporting to a private surgical hospital in Chennai, India. 47 patients were placed into the intervention group and 50 patients were placed into the control group.

Materials and Methods:

The intervention group was presented with a scripted verbal informed consent as well as a 3-fold pamphlet and a presentation with a 3-dimensional model of the eye. The control group was only presented with a scripted verbal informed consent. The two groups were tested using an 11 item “True/False/I don’t know” quiz directly before the informed consent, directly after the informed consent, and one-day postoperatively.

Statistical Analysis Used:

Scores on the quiz were compared across groups and time-points using paired t-tests.

Results:

Patients in the both groups showed a significant improvement in scores between pre- and post-informed consent quizzes (P value on the order of 10^-6) and the improvement in scores was significantly greater in the intervention group than the control group (P value on the order of 10^-16). There was no significant difference observed in either group with regards to the change in scores between post-informed consent and post-operative quizzes.

Conclusion:

Multimedia aids in addition to a standard informed consent process are effective in improving patient comprehension even for patients with low literacy and limited knowledge of surgical interventions.

Patient education and recall regarding postsplenectomy immunizations

BACKGROUND

The purpose of this study was to determine the rates of initial vaccinations after splenectomy for trauma, assess the effectiveness of patient education on reimmunizations, and evaluate patients' utilization of their knowledge regarding immunization after discharge.

METHODS

From June 1996-December 2011, 144 patients underwent splenectomy after traumatic injury. A telephone survey was completed in 100 of 144 splenectomized patients (69%) at a mean of 7.9 y after their splenectomy. Questions were directed to determine the quality of patients' recall of the implications of splenectomy, the need for vaccinations, and the quality of the health information administered. Research electronic data capture tool was used for collecting data, and data were analyzed with Stata 11.2.

RESULTS

Only 27% of participants recall receiving education on postsplenectomy vaccination and 41% of those patients rated their education as poor or minimal. Ninety-one percent of patients indicated that they would like more information in the form of a brochure. Our overall initial vaccination rates among patients who had splenectomy from 1996-2011 were 76%, 75%, and 68% for Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenza type b, respectively. Since 2004, 95% of those who had splenectomy between 2004 and 2007 received all three vaccines. Since 2008, our institution has maintained 100% initial vaccination rates for all three vaccines. The revaccination rates in this group of patients (from 1996-2007) were 39% and 15% for pneumococcal and meningococcal vaccines, respectively.

CONCLUSIONS

Patients had poor recall of the information provided during hospitalization for splenectomy. There were low revaccination rates in our patient cohort. Specific educational and vaccination surveillance strategies are required to improve vaccination rates.

Evaluating the application of research-based guidance to the design of an emergency preparedness leaflet

Guidelines for the design of emergency communications were derived from primary research and interrogation of the literature. The guidelines were used to re-design a nuclear emergency preparedness leaflet routinely distributed to households in the local area. Pre-test measures of memory for, and self-reported understanding of, nuclear safety information were collected. The findings revealed high levels of non-receipt of the leaflet, and among those who did receive it, memory for safety advice was poor. Subjective evaluations of the trial leaflet suggested that it was preferred and judged easier to understand than the original. Objective measures of memory for the two leaflets were also recorded, once after the study period, and again one week or four weeks later. Memory for the advice was better, at all time periods, when participants studied the trial leaflet. The findings showcase evaluation of emergency preparedness literature and suggest that extant research findings can be applied to the design of communications to improve memory and understandability.

STATEMENT OF RELEVANCE

Studies are described that showcase the use of research-based guidelines to design emergency communications and provide both subjective and objective data to support designing emergency communications in this way. In addition, the research evaluates the effectiveness of emergency preparedness leaflets that are routinely distributed to households. This work is of relevance to academics interested in risk communication and to practitioners involved in civil protection and emergency preparedness.

Informed consent in otolaryngologic surgery: case scenario from a nigerian specialist hospital

Informed consent is a foundational concept necessary for ethical conduct of clinical research and practice. It is a technical tool that shifts the autonomy to decide whether a medical procedure should be performed-from the doctor to the patient. However there is an ongoing discussion in bioethical circles on the level of comprehension of the informed consent process by the patients and research participants. We present this case vignette and the discussion afterwards to explore the question of to what extent a patient comprehends the information given to him/her before a surgical procedure is carried out. In other words, the question being asked here is how informed is informed consent in the context of oto-laryngological practice.

The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study

BACKGROUND

Historically, the preoperative consultation has consisted of a discussion between patient and surgeon. There is a growing literature describing efforts to integrate multimedia into surgical patient education. This study aimed to assess the efficacy of an educational video tutorial on early learning of information specific to patients undergoing shoulder arthroscopy when it was used as an adjunct to the standard preoperative consultation.

METHODS

This study was a surgeon-blinded, randomized controlled trial involving 40 consecutive patients requiring shoulder arthroscopy. After a preoperative consultation with an orthopaedic surgeon, patients were randomized in a 1:1 ratio to either a control group or a treatment group. The treatment group viewed a 10-minute video, which covered the expected preoperative, intraoperative, and postoperative experience. Immediately afterward, both groups completed a questionnaire measuring satisfaction and recall of information received. All patients completed a second questionnaire at the first postoperative visit that assessed overall satisfaction with their experience.

RESULTS

Thirty-four patients were available for follow-up. The video group (N = 15) answered 87% of the knowledge questions correctly, whereas the control group (N = 19) answered only 56% (P = .000). There was stronger agreement in the video group that the preoperative consultation contained an appropriate amount of information (P = .039). Postoperatively, there was agreement that the video was an effective preparation tool for all stages of the surgical experience. However, there was no difference between the groups in satisfaction with their overall surgical experience.

CONCLUSIONS

Video can enhance patients' operative experiences and improve their retained knowledge when it is used as an adjunct to the preoperative consultation.

LEVEL OF EVIDENCE

Basic science, education methodology study, devices to improve learning.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented, for example, on the Internet or on DVD) are one such method. We updated a 2008 review of the effects of these interventions for informed consent for trial participation.

OBJECTIVES

To assess the effects of audio-visual information interventions regarding informed consent compared with standard information or placebo audio-visual interventions regarding informed consent for potential clinical trial participants, in terms of their understanding, satisfaction, willingness to participate, and anxiety or other psychological distress.

SEARCH METHODS

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 6, 2012; MEDLINE (OvidSP) (1946 to 13 June 2012); EMBASE (OvidSP) (1947 to 12 June 2012); PsycINFO (OvidSP) (1806 to June week 1 2012); CINAHL (EbscoHOST) (1981 to 27 June 2012); Current Contents (OvidSP) (1993 Week 27 to 2012 Week 26); and ERIC (Proquest) (searched 27 June 2012). We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or verbal information), with standard forms of information provision or placebo audio-visual information, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to consider participating in a real or hypothetical clinical study. (In the earlier version of this review we only included studies evaluating informed consent interventions for real studies).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. We synthesised the findings using meta-analysis, where possible, and narrative synthesis of results. We assessed the risk of bias of individual studies and considered the impact of the quality of the overall evidence on the strength of the results.

MAIN RESULTS

We included 16 studies involving data from 1884 participants. Nine studies included participants considering real clinical trials, and eight included participants considering hypothetical clinical trials, with one including both. All studies were conducted in high-income countries.There is still much uncertainty about the effect of audio-visual informed consent interventions on a range of patient outcomes. However, when considered across comparisons, we found low to very low quality evidence that such interventions may slightly improve knowledge or understanding of the parent trial, but may make little or no difference to rate of participation or willingness to participate. Audio-visual presentation of informed consent may improve participant satisfaction with the consent information provided. However its effect on satisfaction with other aspects of the process is not clear. There is insufficient evidence to draw conclusions about anxiety arising from audio-visual informed consent. We found conflicting, very low quality evidence about whether audio-visual interventions took more or less time to administer. No study measured researcher satisfaction with the informed consent process, nor ease of use.The evidence from real clinical trials was rated as low quality for most outcomes, and for hypothetical studies, very low. We note, however, that this was in large part due to poor study reporting, the hypothetical nature of some studies and low participant numbers, rather than inconsistent results between studies or confirmed poor trial quality. We do not believe that any studies were funded by organisations with a vested interest in the results.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions as a tool for helping to enhance the informed consent process for people considering participating in clinical trials remains largely unclear, although trends are emerging with regard to improvements in knowledge and satisfaction. Many relevant outcomes have not been evaluated in randomised trials. Triallists should continue to explore innovative methods of providing information to potential trial participants during the informed consent process, mindful of the range of outcomes that the intervention should be designed to achieve, and balancing the resource implications of intervention development and delivery against the purported benefits of any intervention.More trials, adhering to CONSORT standards, and conducted in settings and populations underserved in this review, i.e. low- and middle-income countries and people with low literacy, would strengthen the results of this review and broaden its applicability. Assessing process measures, such as time taken to administer the intervention and researcher satisfaction, would inform the implementation of audio-visual consent materials.

Pre-operative considerations in aesthetic facial surgery

This article reviews the common pitfalls in the complex process of pre-operative assessment for facial plastic surgery. Legal guidelines and best practice are discussed, and attention is directed mainly towards the consenting and psychological issues surrounding this area of surgery.

Opportunities for shared decision making in kidney transplantation

Health researchers and policy-makers increasingly urge both patient and clinician engagement in shared decision making (SDM) to promote patient-centered care. Although SDM has been examined in numerous clinical settings, it has received little attention in solid organ transplantation. This paper describes the application of SDM to the kidney transplantation context. Several distinctive features of kidney transplantation present challenges to SDM including fragmented patient-provider relationships, the time-sensitive and unpredictable nature of deceased organ offers, decision-making processes by transplant providers serving as both organ guardians (given the organ scarcity) versus advocates for specific patients seeking transplantation, variable clinical practices and policies among transplant centers, and patients' potentially compromised cognitive status and literacy levels. We describe potential barriers to and opportunities for SDM, and posit that SDM is feasible, warranting encouragement in kidney transplantation. We propose strategies to promote and overcome obstacles to SDM in kidney transplantation. We contend that engagement in SDM can be facilitated by re-organization of clinical care, communication and education of providers and patients.

Correlates of lower comprehension of informed consent among participants enrolled in a cohort study in Pune, India

BACKGROUND

Optimum comprehension of informed consent by research participants is essential yet challenging. This study explored correlates of lower comprehension of informed consent among 1334 participants of a cohort study aimed at estimating HIV incidence in Pune, India.

METHODS

As part of the informed consent process, a structured comprehension tool was administered to study participants. Participants scoring ≥90% were categorised into the 'optimal comprehension group', whilst those scoring 80-89% were categorised into the 'lower comprehension group'. Data were analysed to identify sociodemographic and behavioural correlates of lower consent comprehension.

RESULTS

The mean ± SD comprehension score was 94.4 ± 5.00%. Information pertaining to study-related risks was not comprehended by 61.7% of participants. HIV-negative men (adjusted OR [AOR] = 4.36, 95% CI 1.71-11.05) or HIV-negative women (AOR = 13.54, 95% CI 6.42-28.55), illiteracy (AOR= 1.65, 95% CI 1.19-2.30), those with a history of multiple partners (AOR = 1.73, 95% CI 1.12-2.66) and those never using condoms (AOR = 1.35, 95% CI 1.01-1.82) were more likely to have lower consent comprehension.

CONCLUSIONS

We recommend exploration of domains of lower consent comprehension using a validated consent comprehension tool. Improved education in these specific domains would optimise consent comprehension among research participants.

Informed consent in trauma: does written information improve patient recall of risks? A prospective randomised study

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery. 121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process. Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was improved in the group receiving written and verbal information and 90% of patients in both groups expressed a preference for both written and verbal information compared to verbal information alone. Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients.

Pilot study demonstrating effectiveness of targeted education to improve informed consent understanding in AIDS clinical trials

Assessing and improving informed consent understanding is equally important as obtaining consent from participants in clinical trial research, but developing interventions to target gaps in participants' informed consent understanding remains a challenge. We used a randomized controlled study design to pilot test an educational intervention to improve actual informed consent understanding of new enrollees in the Adult AIDS Clinical Trial Group (AACTG). Questionnaires were administered to 24 enrollees to assess their baseline understanding on eight elements of informed consent associated with AIDS clinical trials. Enrollees who scored 18/21(85%) or less were randomly assigned to in-person, targeted education (intervention), or delayed education (control). Two follow-up assessments were administered. Repeated measures ANOVA was performed to determine intervention effectiveness in improving actual informed consent understanding over time. Actual understanding improved at the immediate post-intervention time point with a significant score difference of 2.5 when comparing the intervention and delayed groups. In addition, there was a significant score difference of 3.2 when comparing baseline to three-month follow-up for the two groups, suggesting a statistically significant intervention effect to improve actual understanding of the basic elements of informed consent. The findings demonstrated that one-time targeted education can improve actual informed consent understanding one week after the intervention, but retention of these concepts may require periodic monitoring to ensure comprehension throughout the course of a clinical trial.

Patient expectation and satisfaction after macular hole surgery

PURPOSE

To assess patient expectation, visual improvement, and patient satisfaction after macular hole surgery.

METHODS

Fifty-three consecutive patients completed a self-administered questionnaire after macular hole surgery. Responses for expectation of visual improvement before surgery and subjective visual assessment after surgery were scored from 0 to 10 (0 = no improvement in vision, 10 = full improvement). Visual acuity was measured using Snellen charts and converted to logMAR equivalent for statistical analysis. Wilcoxon and Mann-Whitney U tests were performed using the Minitab statistical software program; p < 0.05 was considered significant.

RESULTS

Thirty-eight (71%) patients were satisfied with the outcome, 14 (26%) were not, and 1 was uncertain. Both satisfied and dissatisfied patients had no difference in baseline preoperative best-corrected visual acuity (BCVA; 6/60 and 6/60, respectively). There was also no significant difference in median postoperative BCVA between both groups (6/24 and 6/29, respectively, p = 0.6). In satisfied patients, median vision expectation score of 6 was equally similar to the median subjective postoperative vision improvement score of 6, p = 0.7. However, in dissatisfied patients, median vision expectation score (8) was significantly higher than median postoperative subjective vision improvement score (1), p = 0.0001. The commonest reason for dissatisfaction was perceived visual reduction (7/14 patients).

CONCLUSIONS

In the dissatisfied patients, expectation was significantly higher, and subjective assessment of vision after surgery was lower than in satisfied patients, although they had similar improvement in BCVA. Visual acuity and patient satisfaction are not always directly correlated. An important factor in patient satisfaction is expectation.

A review of surgical informed consent: past, present, and future. A quest to help patients make better decisions

Background

Informed consent (IC) is a process requiring a competent doctor, adequate transfer of information, and consent of the patient. It is not just a signature on a piece of paper. Current consent processes in surgery are probably outdated and may require major changes to adjust them to modern day legislation. A literature search may provide an opportunity for enhancing the quality of the surgical IC (SIC) process.

Methods

Relevant English literature obtained from PubMed, Picarta, PsycINFO, and Google between 1993 and 2009 was reviewed.

Results

The body of literature with respect to SIC is slim and of moderate quality. The SIC process is an underestimated part of surgery and neither surgeons nor patients sufficiently realize its importance. Surgeons are not specifically trained and lack the competence to guide patients through a legally correct SIC process. Computerized programs can support the SIC process significantly but are rarely used for this purpose.

Conclusions

IC should be integrated into our surgical practice. Unfortunately, a big gap exists between the theoretical/legal best practice and the daily practice of IC. An optimally informed patient will have more realistic expectations regarding a surgical procedure and its associated risks. Well-informed patients will be more satisfied and file fewer legal claims. The use of interactive computer-based programs provides opportunities to improve the SIC process.

The effect of a visual aid on the comprehension of cataract surgery in a rural, indigent South Indian population

PURPOSE

To determine whether a visual aid improves the understanding and retention of information presented during informed consent for rural, indigent patients presenting for cataract surgery.

MATERIALS AND METHODS

This was a randomized, unmasked, interventional study. We recruited patients who presented to the Hande Surgical Hospital in Chennai, India, for cataract surgery. Patients were randomized into two groups: verbal consent alone (group A) and verbal consent plus a poster (group B). Both groups completed an 11-question true/false quiz immediately before and after informed consent and one day after surgery.

RESULTS

A total of 60 patients were recruited for the study, with 30 randomly assigned to each group; 23 patients from group A and 17 from group B completed the study. Informed consent improved patient scores in both groups; however, group B had significantly higher mean scores on postoperative day 1 (7.4 vs 8.7, P = 0.005) and significantly greater improvement in mean scores from pre-informed consent to postoperative day 1 (1.3 vs 3.6, P = 0.002).

CONCLUSIONS

Informed consent improves patient understanding of cataract surgery. Using a visual aid during informed consent for cataract surgery improves understanding and retention of information more than verbal consent alone in a rural South Indian population.

The influence of informed consent content on study participants' contraceptive knowledge and concerns

Little is known about how the information presented in the informed consent process influences study outcomes among participants. This study examines the influence of informed consent content on reported baseline contraceptive knowledge and concerns among two groups of HIV-serodiscordant and seroconcordant HIV-positive couples enrolled in research projects at an HIV research center in Lusaka, Zambia. We found significant differences in the reporting of contraceptive knowledge and concerns between couples viewing consent materials that included detailed information about contraception and those viewing consent materials that lacked the detailed information. We conclude that the design of informed consent materials should strike a balance between ensuring that participants give truly informed consent and educating participants in ways that do not compromise the assessment of the impact of behavioral interventions.

Developing communication in informed consent

Changes within the NHS have established perioperative practitioners, as well as other healthcare professionals, in roles that include obtaining informed consent. Practitioners involved in these roles require highly developed communication skills (Church 2008a). This article examines the philosophy of risk communication and explores the often complex skill of communication in informed consent.

Comparison of group counseling with individual counseling in the comprehension of informed consent: a randomized controlled trial

Background

Studies on different methods to supplement the traditional informed consent process have generated conflicting results. This study was designed to evaluate whether participants who received group counseling prior to administration of informed consent understood the key components of the study and the consent better than those who received individual counseling, based on the hypothesis that group counseling would foster discussion among potential participants and enhance their understanding of the informed consent.

Methods

Parents of children participating in a trial of nutritional supplementation were randomized to receive either group counseling or individual counseling prior to administration of the informed consent. To assess the participant's comprehension, a structured questionnaire was administered approximately 48-72 hours afterwards by interviewers who were blinded to the allocation group of the respondents.

Results

A total of 128 parents were recruited and follow up was established with 118 (90.2%) for the study. All respondents were aware of their child's participation in a research study and the details of sample collection. However, their understanding of study purpose, randomization and withdrawal was poor. There was no difference in comprehension of key elements of the informed consent between the intervention and control arm.

Conclusions

The results suggest that the group counseling might not influence the overall comprehension of the informed consent process. Further research is required to devise better ways of improving participants' understanding of randomization in clinical trials.

Trial Registration

Clinical Trial Registry - India (CTRI): CTRI/2009/091/000612

Best practice updates for informed consent and patient education in weight loss surgery

To update evidence-based best practice guidelines for obtaining informed consent from weight loss surgery (WLS) patients, with an emphasis on appropriate content and communications approaches that might enhance patient understanding of the information, we performed a systematic search of English-language literature published between April 2004 and May 2007 in MEDLINE and the Cochrane database. Keywords included WLS and informed consent, comprehension, health literacy, and patient education; and WLS and outcomes, risk, patient safety management, and effectiveness. Recommendations are based on the most current literature and the consensus of the expert panel; they were graded according to systems used in established evidence-based models. We identified over 120 titles, 38 of which were reviewed in detail. Evidence suggests that WLS outcomes, including long-term rates of relapse, vary by procedure. For some weight loss surgeries, long-term outcomes may not be known. Risks also vary by patient and provider characteristics. Informed consent should incorporate realistic projections of the short- and long-term risks, benefits, and consequences of surgery, as well as alternatives to WLS. For consent to be informed, the education process should continue until the patient demonstrates comprehension of all relevant material and concepts. Confirmation of comprehension can protect patients engaged in the process of consent for WLS. Future research should focus on the outcomes and consequences of WLS, and different approaches that facilitate patient understanding of, and decision making about, WLS.

Assessing and Improving Research Participants' Understanding of Risk: Potential Lessons from the Literature on Physician-Patient Risk Communication

Evidence that lay people frequently misinterpret risk raises concerns for the ethical conduct of human research, which requires adequate disclosure, understanding, and appreciation of risk information. Review of the risk communication research literature suggests new directions for empirical research on human research ethics: Investigation is needed on how to best assess and improve potential and enrolled subjects' understanding of risk information. Preferences regarding the presentation of risk information and the effects of alternative presentation formats and decision aids on knowledge, trust, satisfaction, risk/benefit analysis, and perceptions of respectful treatment should be studied. Research is also needed on the effects of payment for research participation, the order in which study information is presented, and having one's own physician present risk information.

Understanding and retention of the informed consent process among parents in rural northern Ghana

Background

The individual informed consent model remains critical to the ethical conduct and regulation of research involving human beings. Parental informed consent process in a rural setting of northern Ghana was studied to describe comprehension and retention among parents as part of the evaluation of the existing informed consent process.

Methods

The study involved 270 female parents who gave consent for their children to participate in a prospective cohort study that evaluated immune correlates of protection against childhood malaria in northern Ghana. A semi-structured interview with questions based on the informed consent themes was administered. Parents were interviewed on their comprehension and retention of the process and also on ways to improve upon the existing process.

Results

The average parental age was 33.3 years (range 18–62), married women constituted a majority (91.9%), Christians (71.9%), farmers (62.2%) and those with no formal education (53.7%). Only 3% had ever taken part in a research and 54% had at least one relation ever participate in a research. About 90% of parents knew their children were involved in a research study that was not related to medical care, and 66% said the study procedures were thoroughly explained to them. Approximately, 70% recalled the study involved direct benefits compared with 20% for direct risks. The majority (95%) understood study participation was completely voluntary but only 21% recalled they could withdraw from the study without giving reasons. Younger parents had more consistent comprehension than older ones. Maternal reasons for allowing their children to take part in the research were free medical care (36.5%), better medical care (18.8%), general benefits (29.4%), contribution to research in the area (8.8%) and benefit to the community (1.8%). Parental suggestions for improving the consent process included devoting more time for explanations (46.9%), use of the local languages (15.9%) and obtaining consent at home (10.3%).

Conclusion

Significant but varied comprehension of the informed consent process exists among parents who participate in research activities in northern Ghana and it appears the existing practices are fairly effective in informing research participants in the study area.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented for example on the Internet, DVD, or video cassette) are one such method.

OBJECTIVES

To assess the effects of providing audio-visual information alone, or in conjunction with standard forms of information provision, to potential clinical trial participants in the informed consent process, in terms of their satisfaction, understanding and recall of information about the study, level of anxiety and their decision whether or not to participate.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (searched 20 June 2006); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 2, 2006; MEDLINE (Ovid) (1966 to June week 1 2006); EMBASE (Ovid) (1988 to 2006 week 24); and other databases. We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or oral information as usually employed in the particular service setting), with standard forms of information provision alone, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to participate in a real (not hypothetical) clinical study.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. Due to heterogeneity no meta-analysis was possible; we present the findings in a narrative review.

MAIN RESULTS

We included 4 trials involving data from 511 people. Studies were set in the USA and Canada. Three were randomised controlled trials (RCTs) and the fourth a quasi-randomised trial. Their quality was mixed and results should be interpreted with caution. Considerable uncertainty remains about the effects of audio-visual interventions, compared with standard forms of information provision (such as written or oral information normally used in the particular setting), for use in the process of obtaining informed consent for clinical trials. Audio-visual interventions did not consistently increase participants' levels of knowledge/understanding (assessed in four studies), although one study showed better retention of knowledge amongst intervention recipients. An audio-visual intervention may transiently increase people's willingness to participate in trials (one study), but this was not sustained at two to four weeks post-intervention. Perceived worth of the trial did not appear to be influenced by an audio-visual intervention (one study), but another study suggested that the quality of information disclosed may be enhanced by an audio-visual intervention. Many relevant outcomes including harms were not measured. The heterogeneity in results may reflect the differences in intervention design, content and delivery, the populations studied and the diverse methods of outcome assessment in included studies.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions for people considering participating in clinical trials remains unclear. Evidence is mixed as to whether audio-visual interventions enhance people's knowledge of the trial they are considering entering, and/or the health condition the trial is designed to address; one study showed improved retention of knowledge amongst intervention recipients. The intervention may also have small positive effects on the quality of information disclosed, and may increase willingness to participate in the short-term; however the evidence is weak. There were no data for several primary outcomes, including harms. In the absence of clear results, triallists should continue to explore innovative methods of providing information to potential trial participants. Further research should take the form of high-quality randomised controlled trials, with clear reporting of methods. Studies should conduct content assessment of audio-visual and other innovative interventions for people of differing levels of understanding and education; also for different age and cultural groups. Researchers should assess systematically the effects of different intervention components and delivery characteristics, and should involve consumers in intervention development. Studies should assess additional outcomes relevant to individuals' decisional capacity, using validated tools, including satisfaction; anxiety; and adherence to the subsequent trial protocol.

Standards in consent for cataract surgery

Consent forms for cataract surgery performed at Burnley General Hospital (BGH) and Blackburn Royal Infirmary (BRI) from October 4 to December 7, 2004, were prospectively reviewed to ensure that the East Lancashire Hospital's National Health Service (NHS) Trust Policy on consent to treatment and Department of Health (DoH) guidelines were being followed when seeking consent for cataract surgery. A set of 22 criteria derived as standards were formulated from the reference guide published by the DoH and from the East Lancashire trust policy document for consent to treatment. Each consent form was measured against these standards. Cases were randomly selected between BRI and BGH prospectively. All consent forms completed by physicians involved in formulating the standards were excluded. The review showed the NHS Trust Policy and DoH guidelines were largely followed when seeking consent for cataract surgery. However, certain areas were found to be deficient. If a health professional fails to obtain proper consent and the patient suffers harm as a result of treatment, it may be a factor in a claim of negligence against that health professional. Subsequent recommendations may include simple solutions that can be implemented to improve clinical practice when obtaining informed consent.