Internet based patient education improves informed consent for elective orthopaedic surgery: a randomized controlled trial

Beyond the Signature: Informed Consent from a Legal Perspective and Its Implications for Plastic Surgery

SUMMARY

Informed consent is the principal tool that bridges the gap between clinical practice and our society's ethical ideals. The intricacies of informed consent, however, are frequently misunderstood, and its effective implementation can be challenging in practice. The continuous stream of innovations, wide array of procedures, and other characteristics inherent to the practice of plastic surgery compound the challenges of implementing informed consent. Unfortunately, there remains a dearth of literature to provide a comprehensive overview of informed consent as it relates to plastic surgery. In this article, the authors highlight the history, legal components, and challenges of informed consent within plastic surgery and offer recommendations on how to approach them. A deeper understanding of informed consent helps enhance patient care, mitigates unnecessary malpractice risk, and leads to better physician-patient relationships.

Sustainable surgical practices: A comprehensive approach to reducing environmental impact

This paper presents a comprehensive overview of the environmental impact of surgical procedures and highlights potential strategies to reduce the associated greenhouse gas emissions. We discuss procurement, waste management, and energy consumption, providing examples of successful interventions in each area. We also emphasize the importance of adopting the Green Theatre Checklist as a useful tool for clinicians aiming to implement sustainable surgical practices.

Varicose Vein Education and Informed coNsent (VVEIN) Study: A Randomized Controlled Pilot Feasibility Study

BACKGROUND

The primary aim of this study was to assess the feasibility of introducing a digital health education tool (dHET) for varicose vein surgery.

METHODS

This randomized, feasibility study allocated 40 patients, into dHET (n = 20) or standard consent (SC) (n = 20) groups. Primary outcomes were related to feasibility. Secondary outcomes were knowledge recall, anxiety, and satisfaction.

RESULTS

Recruitment and retention rates were 100% and 97.5%, respectively. Acceptability was also rated high, confirming feasibility. There was also no evidence of a difference between groups for early knowledge recall (14 [12-17] vs. 14 [11-16]; P = 0.72) or delayed (at 2 weeks) knowledge recall (15 [13-16] vs. 15 [13-16]; P = 0.89). The dHET module took significantly longer to complete compared to SC (13 min [12-18] vs. 9 min [8-12]; P < 0.01). However, the control group asked significantly more questions about the intended procedure (P = 0.03). There was no evidence of a difference between groups for patient anxiety or satisfaction.

CONCLUSIONS

This trial shows that the addition of a dHET is feasible and noninferior to SC. Digital consent provides a unique opportunity to promote patient education and autonomy for better shared decision making. It also offers better documentation of the consent process.

Prehabilitation: The underutilised weapon for chronic pain management

Objective

Prehabilitation encompasses preparatory clinical intervention(s) delivered during the period between diagnosis and treatment commencement. Despite widespread successful usage preoperatively, psychological prehabilitation is neglected in outpatient chronic pain management. Although pain management waitlists are associated with treatment attrition and psychological and physical decline, this time window is underutilised in preventing escalation. Waitlists present an under-explored opportunity to 'prehabilitate' patients waiting for treatment. This topical review aimed to: (1) examine the effectiveness of psychological prehabilitation for pain services; (2) evaluate the psychological and physical decline associated with waiting for pain management; (3) highlight key psychological prehabilitative targets for increasing treatment engagement; (4) promote pain management psychological prehabilitation within personalised pain medicine, building recommendations for future interventions.

Methods

Studies regarding the impact of waitlists and prehabilitation for chronic pain were reviewed.

Results

Findings demonstrated that the psychological constructs of patient expectations, health locus of control, self-efficacy and pain catastrophizing dynamically influence attrition, treatment engagement and outcomes while waiting. These constructs are amenable to change, emphasising their potential utility within a targeted waitlist intervention.

Conclusions

Prehabilitating chronic pain patients towards treatment engagement could circumvent cycles of failed treatment seeking, preventing psychological and physical decline, and reducing healthcare utilisation. Utilising the waitlist to identify psychosocial risk factors (external health locus of control, low self-efficacy and high pain catastrophizing) would identify who requires additional support to prevent increased risk of treatment failure, enhancing personalised care before prescribed treatment is accessed. This review cements the urgent need for pain services to engage proactively with prehabilitation innovation.

Assessing the Efficacy of an AI-Powered Chatbot (ChatGPT) in Providing Information on Orthopedic Surgeries: A Comparative Study With Expert Opinion

Background The use of artificial intelligence (AI) as a tool for patient care has continued to rapidly expand. The technology has proven its utility in various applications across several specialties in a variety of applications. However, its practicality in orthopedics remains widely unknown. This study seeks to determine if the open-access software Chat Generative Pre-Trained Transformer (ChatGPT) can be a reliable source of data for patients. Questions/purposes This study aims to determine: (1) Is the open-access AI software ChatGPT capable of accurately answering commonly posed patient questions? (2) Will there be a significant difference in agreement among the study experts in the answers generated by ChatGPT? Methods A standard list of questions for six different procedures across six subspecialties is posed to ChatGPT. The procedures chosen were anterior cruciate ligament (ACL) reconstruction, microdiscectomy, total hip arthroplasty (THA), rotator cuff repair, carpal tunnel release, and ankle fracture open reduction and internal fixation. The generated answers are then compared to expert opinion using a Likert scale based on the agreement of the aforementioned experts. Results On a three-point Likert scale with 1 being disagree and 3 being agree, the mean score across all subspecialties is 2.43, indicating at least partial agreement with expert opinion. There was no significant difference in the Likert scale mean across the six subspecialties surveyed (p = 0.177). Conclusions This study shows promise in using ChatGPT as an aid in answering patient questions regarding their surgical procedures. This opens doors for the use of the software by patients for understanding and increased shared decision-making with their surgeons. However, studies with larger participation groups are necessary to ensure accuracy on a larger and broader scale as well as studies involving specific application of AI within surgeon's practice.

Using Google web search to analyze and evaluate the application of ChatGPT in femoroacetabular impingement syndrome

Background

Chat Generative Pre-trained Transformer (ChatGPT) is a new machine learning tool that allows patients to access health information online, specifically compared to Google, the most commonly used search engine in the United States. Patients can use ChatGPT to better understand medical issues. This study compared the two search engines based on: (i) frequently asked questions (FAQs) about Femoroacetabular Impingement Syndrome (FAI), (ii) the corresponding answers to these FAQs, and (iii) the most FAQs yielding a numerical response.

Purpose

To assess the suitability of ChatGPT as an online health information resource for patients by replicating their internet searches.

Study design

Cross-sectional study.

Methods

The same keywords were used to search the 10 most common questions about FAI on both Google and ChatGPT. The responses from both search engines were recorded and analyzed.

Results

Of the 20 questions, 8 (40%) were similar. Among the 10 questions searched on Google, 7 were provided by a medical practice. For numerical questions, there was a notable difference in answers between Google and ChatGPT for 3 out of the top 5 most common questions (60%). Expert evaluation indicated that 67.5% of experts were satisfied or highly satisfied with the accuracy of ChatGPT's descriptions of both conservative and surgical treatment options for FAI. Additionally, 62.5% of experts were satisfied or highly satisfied with the safety of the information provided. Regarding the etiology of FAI, including cam and pincer impingements, 52.5% of experts expressed satisfaction or high satisfaction with ChatGPT's explanations. Overall, 62.5% of experts affirmed that ChatGPT could serve effectively as a reliable medical resource for initial information retrieval.

Conclusion

This study confirms that ChatGPT, despite being a new tool, shows significant potential as a supplementary resource for health information on FAI. Expert evaluations commend its capacity to provide accurate and comprehensive responses, valued by medical professionals for relevance and safety. Nonetheless, continuous improvements in its medical content's depth and precision are recommended for ongoing reliability. While ChatGPT offers a promising alternative to traditional search engines, meticulous validation is imperative before it can be fully embraced as a trusted medical resource.

Readability and Quality of Online Patient Education Materials Concerning Posterior Cruciate Ligament Reconstruction

Objective This study aimed to assess the quality of online patient educational materials regarding posterior cruciate ligament (PCL) reconstruction. Methods We performed a search of the top-50 results on Google® (terms: "posterior cruciate ligament reconstruction," "PCL reconstruction," "posterior cruciate ligament surgery," and "PCL surgery") and subsequently filtered to rule out duplicated/inaccessible websites or those containing only videos (67 websites included). Readability was assessed using six formulas: Flesch-Kincaid Reading Ease (FRE), Flesch-Kincaid Grade Level (FKG), Gunning Fog Score (GF), Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index (CLI), Automated Readability Index (ARI); quality was assessed using the JAMA benchmark criteria and recording the presence of the HONcode seal. Results The mean FRE was 49.3 (SD 11.2) and the mean FKG level was 8.09. These results were confirmed by the other readability formulae (average: GF 8.9; SMOG Index 7.3; CLI 14.7; ARI 6.5). A HONcode seal was available for 7.4 % of websites. The average JAMA score was 1.3. Conclusion The reading level of online patient materials concerning PCL reconstruction is too high for the average reader, requiring high comprehension skills. Practice implications Online medical information has been shown to influence patient healthcare decision processes. Patient-oriented educational materials should be clear and easy to understand.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Assessing ChatGPT's orthopedic in-service training exam performance and applicability in the field

BACKGROUND

ChatGPT has gained widespread attention for its ability to understand and provide human-like responses to inputs. However, few works have focused on its use in Orthopedics. This study assessed ChatGPT's performance on the Orthopedic In-Service Training Exam (OITE) and evaluated its decision-making process to determine whether adoption as a resource in the field is practical.

METHODS

ChatGPT's performance on three OITE exams was evaluated through inputting multiple choice questions. Questions were classified by their orthopedic subject area. Yearly, OITE technical reports were used to gauge scores against resident physicians. ChatGPT's rationales were compared with testmaker explanations using six different groups denoting answer accuracy and logic consistency. Variables were analyzed using contingency table construction and Chi-squared analyses.

RESULTS

Of 635 questions, 360 were useable as inputs (56.7%). ChatGPT-3.5 scored 55.8%, 47.7%, and 54% for the years 2020, 2021, and 2022, respectively. Of 190 correct outputs, 179 provided a consistent logic (94.2%). Of 170 incorrect outputs, 133 provided an inconsistent logic (78.2%). Significant associations were found between test topic and correct answer (p = 0.011), and type of logic used and tested topic (p =  < 0.001). Basic Science and Sports had adjusted residuals greater than 1.96. Basic Science and correct, no logic; Basic Science and incorrect, inconsistent logic; Sports and correct, no logic; and Sports and incorrect, inconsistent logic; had adjusted residuals greater than 1.96.

CONCLUSIONS

Based on annual OITE technical reports for resident physicians, ChatGPT-3.5 performed around the PGY-1 level. When answering correctly, it displayed congruent reasoning with testmakers. When answering incorrectly, it exhibited some understanding of the correct answer. It outperformed in Basic Science and Sports, likely due to its ability to output rote facts. These findings suggest that it lacks the fundamental capabilities to be a comprehensive tool in Orthopedic Surgery in its current form.

LEVEL OF EVIDENCE

II.

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.

Varicose Vein Education and Informed coNsent (VVEIN) study: a randomised controlled pilot feasibility study

INTRODUCTION

Doctors have a legal requirement and duty of care to ensure patients are enabled to make an informed decision about their treatment, including discussion of the benefits, risks and alternatives to a procedure. A patient-centred approach to consent has been firmly established in Ireland, and fundamental to this is the ability to engage in a dialogue that offers comprehensible information to patients. Telemedicine has revolutionised the way we can deliver care to patients in the modern era of computers, tablets, and smartphones, and its use has been rapidly expanded. Novel digital strategies to improve the informed consent process for surgical procedures have been increasingly under investigation over the last 10-15 years and may offer a low cost, accessible and tailored solution to consent for surgical interventions. Within vascular surgery, superficial venous interventions have been associated with a high number medicolegal claims and also represents an area within the specialty with rapidly evolving technology and techniques. The ability to communicate comprehensible information to patients has never been greater. Thus, the author's aim is to explore whether it is feasible and acceptable to deliver a digital health education intervention to patients undergoing endovenous thermal ablation (EVTA) to supplement the consent process.

METHODS

This is a prospective, single centre, randomised controlled, feasibility trial recruiting patients with chronic venous disease deemed suitable to undergo EVTA. Patients will be randomised to receive either standard consent (SC) or a newly developed digital health education tool (dHET). The primary outcome is feasibility; assessing the recruitment and retention rate of participants and assessing acceptability of the intervention. Secondary outcomes include knowledge retention, anxiety and satisfaction. This feasibility trial is designed to recruit 40 patients, which will allow for a moderate dropout rate. This pilot study will inform the authors of the appropriateness of an adequately powered multicentre trial.

DISCUSSION

To examine the role of a digital consent solution for EVTA. This may improve and standardise the consent dialogue with patients and may have the potential to reduce claims related to poor consent processes and disclosure of risks.

ETHICAL COMMITTEE REFERENCE

Ethical approval has been sought and received from both the Bon Secours Hospital and RCSI (202109017), on 14 May 2021 and 10 October 2021, respectively.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05261412 , registered on 1 March 2022.

How an Automated Patient Education Module Improves Patient Outcomes and Informs Quality-of-Care Measures for Providers Within a Minimally Invasive Aesthetic Practice

I conducted a quality improvement project to determine whether providing patient education before consultation and treatment would help meet the needs of aesthetic patients and providers. The project objective was to create an automated patient education module that provided consistent, accurate information to each patient who viewed it and would give the providers additional time to treat the patient and generate revenue. Before and during the 6-week study period, I administered three surveys and reviewed electronic health records metrics indicating patient check-in and check-out times and facility revenue. I used descriptive statistics to examine the demographics of the patients included in the study. I analyzed check-in and check-out times and facility revenue by conducting two-tailed Mann-Whitney U tests. There were a total of 201 patient visits in the 6-week period before the study and a total of 316 patient visits during the study period. Most patients were White, married women, 50- to 59-years-old, with at least some college education. The most common treatments administered were neurotoxin and dermal filler injections. After implementing the preappointment education, I found a significant reduction in the length of patient appointments (p < .001) and a significant increase in facility revenue (p < .037). I concluded that after implementing the education program, patient understanding about the intended treatment was improved. To better correlate how preappointment automated education impacts the amount of time the provider spends with patients and influences practice revenue, I recommend conducting a longer study with a greater number of patients.

Social Media, Misinformation, and Online Patient Education in Emergency General Surgical Procedures

INTRODUCTION

Patients use the internet to learn about diagnoses and treatment options. These sources vary in quality and accuracy of medical information. Thus, utilization of social media may lead to misinformation regarding treatment for patients in need of emergent general surgery procedures.

METHODS

YouTube was searched with keywords "cholecystectomy," "cholecystitis," and "gallbladder surgery" and "appendectomy," "appendicitis," and "appendix surgery." For each procedure, the 100 videos with the greatest views were reviewed. Videos were assessed by four surgical trainees using validated instruments, DISCERN and the Patient Education Materials Assessment Tool (PEMAT), and Likert scales for patient education and misinformation. After appendectomy or cholecystectomy, patients completed a survey assessing use of social media preoperatively.

RESULTS

The median DISCERN score was 28.0 of 75. The median PEMAT scores were 66.7% for understandability and 0% for actionability. Nearly half (49%) of videos provided no patient education and only 22% provided moderate or more. More than a third (35%) of videos contained misinformation. Doctors, medical education, and healthcare systems published videos with less misinformation, whereas patients, health/wellness groups published more misinformation (P < 0.001). Videos discoverable with colloquial terms "appendix surgery" and "gallbladder surgery" were more likely to contain misinformation (45.3%) compared to 20.5% of videos with misinformation discoverable using medical search terms only (P < 0.001).

CONCLUSIONS

There is a range of video quality online with most videos of poor quality and provide little patient education. Understanding information available to patients online can tailor surgeon-patient discussions to combat misinformation and improve the informed consent process for patients.

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.

The role of digital health interventions to improve health literacy in surgical patients: a narrative review in arthroplasty

BACKGROUND

Arthroplasty is a high-volume but costly treatment option for advanced osteoarthritis. Health literacy and patient education are modifiable factors that can improve patient outcomes in arthroplasty. Digital technologies show potential as an instrument for providing patients with reliable information. This narrative review aimed to identify the current evidence for how effective digital health interventions (DHIs) are in targeting health literacy and related constructs (including knowledge, decision-making and self-efficacy) in arthroplasty.

METHODS

Six databases were searched for published studies comprising health literacy and related constructs, arthroplasty, and DHIs. The main outcome measure was health literacy. Two reviewer-authors independently screened studies according to predefined inclusion criteria and performed data extraction. Data was analysed and summarized in tabular and narrative form.

RESULTS

Two thousand seven-hundred and sixty-four titles and abstracts were screened. One hundred and sixty-seven papers underwent full-text analysis. No studies used health literacy as an outcome measure; therefore, the outcome measure was broadened to include its constructs, and the full-text analysis was repeated. Thirteen studies were included. No study following a structured design for their DHI. Eleven studies demonstrated participant improvement in constructs of health literacy, including knowledge, decision-making and self-management.

CONCLUSION

Current evidence suggests digital technology may provide new means of educating patients and improving aspects of their health literacy. More research digital technology with a structured approach, framework and standardized measures is required. Well-designed digital technology may become a useful adjunct to future patient care.

The impact of a digital joint school educational programme on post-operative outcomes following lower limb arthroplasty: a retrospective comparative cohort study

Background

As part of an ongoing service improvement project, a digital ‘joint school’ (DJS) was developed to provide education and support to patients undergoing total hip (THR) and total knee (TKR) replacement surgery. The DJS allowed patients to access personalised care plans and educational resources using web-enabled devices, from being listed for surgery until 12 months post-operation. The aim of this study was to compare a cohort of patients enrolled into the DJS with a cohort of patients from the same NHS trust who received a standard ‘non-digital’ package of education and support in terms of Health-Related Quality of Life (HRQoL), functional outcomes and hospital length of stay (LoS).

Methods

A retrospective comparative cohort study of all patients undergoing primary TKR/THR at a single NHS trust between 1st Jan 2018 and 31st Dec 2019 (n = 2406) was undertaken. The DJS was offered to all patients attending the clinics of early adopting surgeons and the remaining surgeons offered their patient’s standard written and verbal information. This allowed comparison between patients that received the DJS (n = 595) and those that received standard care (n = 1811). For each patient, demographic data, LoS and patient reported outcome measures (EQ-5D-3L, Oxford hip/knee scores (OKS/OHS)) were obtained. Polynomial regressions, adjusting for age, sex, Charlson Comorbidity Index (CCI) and pre-operative OKS/OHS or EQ-5D, were used to compare the outcomes for patients receiving DJS and those receiving standard care.

Findings

Patients that used the DJS had greater improvements in their EQ-5D, and OKS/OHS compared to patients receiving standard care for both TKR and THR (EQ-5D difference: TKR coefficient estimate (est) = 0.070 (95%CI 0.004 to 0.135); THR est = 0.114 (95%CI 0.061 to 0.166)) and OKS/OHS difference: TKR est = 5.016 (95%CI 2.211 to 7.820); THR est = 4.106 (95%CI 2.257 to 5.955)). The DJS had a statistically significant reduction on LoS for patients who underwent THR but not TKR.

Conclusion

The use of a DJS was associated with improved functional outcomes when compared to a standard ‘non-digital’ method. The improvements between pre-operative and post-operative outcomes in EQ-5D and OKS/OHS were higher for patients using the DJS. Furthermore, THR patients also had a shorter LoS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07989-1.

The Effect of an Informative Video upon Anxiety and Stress in Patients Requiring an Oral Biopsy: A Randomized Controlled Study

OBJECTIVE

The use of multimedia tools improves patient understanding of surgical procedures, reduces anxiety and increases satisfaction. The present study evaluates the impact of an audiovisual intervention (video) upon anxiety and stress in patients requiring an oral biopsy.

MATERIAL AND METHODS

A prospective randomized clinical trial was carried out in patients requiring an oral biopsy. The control group (n = 60) received verbal standard information while the experimental group (n = 60) received information in the form of a video. The following data were recorded: gender, age, educational level and hemodynamic parameters (blood pressure, heart rate and blood oxygen saturation). The following questionnaires were used to assess anxiety and stress before and after the biopsy procedure: Corah's Modified Dental Anxiety Scale (MDAS), the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The final study sample consisted of 120 patients, of which 65.8% were women and 34.2% men, with a mean age of 40.5 ± 15.3 years. At the end of the study, the experimental group presented a significantly lower MDAS score than the control group (p = 0.041). The STAI score also showed a significant decrease with respect to the control group at the end of the study (p = 0.012). There were no statistically significant changes in the hemodynamic parameters in either group.

CONCLUSIONS

The video constituted a useful and easy tool for reducing anxiety among patients requiring an oral biopsy.

Applications of Digital Health Technologies in Knee Osteoarthritis: A Narrative Review (Preprint)

Background

With the increasing adoption of high-speed internet and mobile technologies by older adults, digital health is a promising modality to enhance clinical care for people with knee osteoarthritis (KOA), including those with knee replacement (KR).

Objective

This study aimed to summarize the current use, cost-effectiveness, and patient and clinician perspectives of digital health for intervention delivery in KOA and KR.

Methods

In this narrative review, search terms such as mobile health, smartphone, mobile application, mobile technology, ehealth, text message, internet, knee osteoarthritis, total knee arthroplasty, and knee replacement were used in the PubMed and Embase databases between October 2018 and February 2021. The search was limited to original articles published in the English language within the past 10 years. In total, 91 studies were included.

Results

Digital health technologies such as websites, mobile apps, telephone calls, SMS text messaging, social media, videoconferencing, and custom multi-technology systems have been used to deliver interventions in KOA and KR populations. Overall, there was significant heterogeneity in the types and applications of digital health used in these populations. Digital patient education improved disease-related knowledge, especially when used as an adjunct to traditional methods of patient education for both KOA and KR. Digital health that incorporated person-specific motivational messages, biofeedback, or patient monitoring was more successful at improving physical activity than self-directed digital interventions for both KOA and KR. Many digital exercise interventions were found to be as effective as in-person physical therapy for people with KOA. Many digital exercise interventions for KR incorporated both in-person and web-based treatments (blended format), communication with clinicians, and multi-technology systems and were successful in improving knee range of motion and self-reported symptoms and reducing the length of hospital stays. All digital interventions that incorporated cognitive behavioral therapy or similar psychological interventions showed significant improvements in knee pain, function, and psychological health when compared with no treatment or traditional treatments for both KOA and KR. Although limited in number, studies have indicated that digital health may be cost-effective for these populations, especially when travel costs are considered. Finally, although patients with KOA and KR and clinicians had positive views on digital health, concerns related to privacy and security and concerns related to logistics and training were raised by patients and clinicians, respectively.

Conclusions

For people with KOA and KR, many studies found digital health to be as effective as traditional treatments for patient education, physical activity, and exercise interventions. All digital interventions that incorporated cognitive behavioral therapy or similar psychological treatments were reported to result in significant improvements in patients with KOA and KR when compared with no treatment or traditional treatments. Overall, technologies that were blended and incorporated communication with clinicians, as well as biofeedback or patient monitoring, showed favorable outcomes.

Gamifying health literacy: how can digital technology optimize patient outcomes in surgery?

The digital age is entrenched in our society, with constant innovation driving change in the way clinicians and patients manage their health concerns. Health literacy is emerging as an important modifiable factor that can affect clinical and patient outcomes, yet traditional forms of patient education have shown mixed results. Digital media and technologies, the concept of gamification as a means to improve patient health literacy, and its potential for misuse will be explored in this review, in the context of a digital, gamified tool that could support patients along their surgical journey.

A Randomized Controlled Trial of Decision Aids for Upper-Extremity Conditions

PURPOSE

Decision aids (DAs) are tools designed to correct misconceptions, help people weigh the pros and cons of each option, and choose an option consistent with their values. This randomized controlled trial tested the difference in decision regret between patients who reviewed a DA at the end of the visit and those who did not. Secondary study questions addressed differences in pain self-efficacy, pain intensity, satisfaction, physical function, and treatment choice.

METHODS

We enrolled 147 patients who visited an orthopedic upper-extremity surgeon for a condition that could be treated surgically or nonsurgically. We randomized 76 of these patients to review a DA as part of the visit (52%). At baseline, we measured results using the Pain Self-Efficacy short form, PROMIS Physical Function computer adaptive test, pain intensity on an 11-point ordinal scale, and satisfaction with the visit on an 11-point ordinal scale, as well as whether patients understood all received information and felt adequately educated to decide (no/yes), and choice of surgery, injection, or another treatment. Four to six weeks later, the survey by phone consisted of the PROMIS Physical Function computer adaptive test, pain intensity, satisfaction with the visit, the sense of a well-informed decision, and the Decision Regret Scale. We assessed factors independently associated with each measure.

RESULTS

People who reviewed a DA had significantly less decision regret 4 to 6 weeks after the visit compared with those who did not. High pain self-efficacy was associated with lower likelihood to choose surgery during the initial visit, better physical function rates, and lower reported pain.

CONCLUSIONS

Decision aids reduce decision regret, which suggests that they help people organize their thoughts and make decisions more consistent with their values.

CLINICAL RELEVANCE

Hand surgeons can consider the use of DAs as a method for improving the quality of shared decisions.

The Quality of Web Sites' Health Information on Minimal Invasive Repair of Pectus Excavatum Using the DISCERN Instrument

INTRODUCTION

 The Internet is a frequently used tool for patients with pectus excavatum (PE) to get information about symptoms and treatment options. In addition, it is used by both health care providers as a marketing tool and support group systems. The Internet health information varies in precision, quality, and reliability. The study purpose was to determine the quality of information on the PE Web sites using the DISCERN instrument, including information about operation and potential complications after a Nuss bar procedure.

MATERIALS AND METHODS

 Four search engines, Google, Yahoo, Ask, and Bing, were used to explore seven key terms concerning PE. Search language was English. The DISCERN quality instrument was used to evaluate the Web sites. Also, information on possible complications was scored per Web site.

RESULTS

 A total of 560 Web sites were assessed in March 2019. Excluded were 139 Web sites. There were 333 duplicates, leaving 88 unique Web sites. Of these, 58.1% were hospital-related information Web sites, 28.4% medical information Web sites, and 3.4% patient forum sites. Interactive multimedia was used on 21.6% of the sites. Pain postoperatively was mentioned on 64.8% of the sites, while only 9.1% mentioned the mortality risk of the surgical correction of PE for Nuss bar placement. The quality of the unique Web sites showed a mean DISCERN score of 42.5 (standard deviation 12.2). Medical information Web sites, encyclopedia, and government-sponsored sites had higher DISCERN scores. Hospital-related information sites, medical companies, and lay persons' sites, had lower total scores.

CONCLUSION

 The overall quality of PE Web sites is low to moderate, with serious shortcomings.

Effects of Information Architecture on the Effectiveness and User Experience of Web-Based Patient Education in Middle-Aged and Older Adults: Online Randomized Experiment

Background

Web-based patient education is increasingly offered to improve patients’ ability to learn, remember, and apply health information. Efficient organization, display, and structural design, that is, information architecture (IA), can support patients’ ability to independently use web-based patient education. However, the role of IA in the context of web-based patient education has not been examined systematically.

Objective

To support intervention designers in making informed choices that enhance patients’ learning, this paper describes a randomized experiment on the effects of IA on the effectiveness, use, and user experience of a patient education website and examines the theoretical mechanisms that explain these effects.

Methods

Middle-aged and older adults with self-reported hip or knee joint complaints were recruited to use and evaluate 1 of 3 patient education websites containing information on total joint replacement surgery. Each website contained the same textual content based on an existing leaflet but differed in the employed IA design (tunnel, hierarchical, or matrix design). Participants rated the websites on satisfaction, engagement, control, relevance, trust, and novelty and completed an objective knowledge test. Analyses of variance and structural equation modeling were used to examine the effects of IA and construct a theoretical model.

Results

We included 215 participants in our analysis. IA did not affect knowledge gain (P=.36) or overall satisfaction (P=.07) directly. However, tunnel (mean 3.22, SD 0.67) and matrix (mean 3.17, SD 0.69) architectures were found to provide more emotional support compared with hierarchical architectures (mean 2.86, SD 0.60; P=.002). Furthermore, increased perceptions of personal relevance in the tunnel IA (β=.18) were found to improve satisfaction (β=.17) indirectly. Increased perceptions of active control in the matrix IA (β=.11) also improved satisfaction (β=.27) indirectly. The final model of the IA effects explained 74.3% of the variance in satisfaction and 6.8% of the variance in knowledge and achieved excellent fit (χ²_17,215=14.7; P=.62; root mean square error of approximation=0.000; 95% CI [0.000-0.053]; comparative fit index=1.00; standardized root mean square residual=0.044).

Conclusions

IA has small but notable effects on users’ experiences with web-based health education interventions. Web-based patient education designers can employ tunnel IA designs to guide users through sequentially ordered content or matrix IA to offer users more control over navigation. Both improve user satisfaction by increasing user perceptions of relevance (tunnel) and active control (matrix). Although additional research is needed, hierarchical IA designs are currently not recommended, as hierarchical content is perceived as less supportive, engaging, and relevant, which may diminish the use and, in turn, the effect of the educational intervention.

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.

A patient satisfaction survey investigating pre- and post-operative information provision in lower limb surgery

Background

Planned lower limb surgery is common, with over 90,000 hip replacements, 95,000 knee replacements and 15,000 anterior cruciate ligament reconstructions performed in the UK each year. These procedures are primarily indicated to treat osteoarthritis, sporting injuries and trauma. Patient satisfaction is an important element of healthcare provision, which is usually measured by functional outcomes but influenced by other factors. Few studies have assessed patients’ views on the information given to them pertaining surgery and patients are infrequently consulted when designing leaflets and information packs, which can lead to confusion during the recovery period and poor long-term outcomes. Furthermore, previous studies have not directly asked patients what resources they would prefer, or which format would suit them best. This project aimed to assess if patients were satisfied with the information they received around their operations and to identify potential improvements.

Methods

Set in a National Health Service (NHS) run major trauma centre in the West Midlands, a multiple choice and free-text answer survey was administered to patients who used the orthopaedic service over the course of 1 month. Surveys were designed in Qualtrics and administered face-to-face on paper. Thematic content analysis was performed on the results.

Results

Eighty patients completed the survey, of which 88.8% of patients were satisfied with the information they received. Discussions with surgeons were the most useful resource and 53% of patients requested more internet resources. Post-operative patients were statistically more likely to be dissatisfied with information provision than pre-operative patients. Over 20% of the study population requested more information on post-operative pain and recovery timelines.

Conclusions

Although patients were satisfied in general, areas for change were identified. Suggested resources took the form of webpages and mobile platforms. These resources could contain educational videos, patient experience blogs or interactive recovery timelines, to be of benefit to patients. These suggestions may enable NHS Trusts to “get into the digital age”, however, more research on patient satisfaction around information provision and the impact it has on recovery and decision making is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03761-w.

Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources

INTRODUCTION

Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources.

METHODS

Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison.

RESULTS

Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003).

CONCLUSIONS

Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

Enhancing Trauma Patient Experience Through Education and Engagement: Development of a Mobile Application

The purpose was to determine the utility of an open access mobile device application (App: http://bit.ly/traumaapp) to improve patient education and engagement.

Use of a custom website by orthopaedic sports medicine surgical patients: If you build it, will they come?

BACKGROUND

Internet use is nearly ubiquitous, and orthopaedic patients are increasingly utilizing the Internet for medical information. The quality of resources available to patients is variable, and patients may benefit from physician guidance. A recent study showed only 11% of orthopaedic trauma patients accessed a custom-designed website developed by a physician. The purpose of this study was to determine whether orthopaedic sports medicine patients would use a custom-designed website and what factors would be associated with website use.

METHODS

A prospective study was conducted of patients undergoing eight common orthopaedic sports medicine procedures from April 2017 to December 2017.108 patients were enrolled and provided access to the website that allowed tracking of each patient's website use. The sports medicine cohort was compared to a previously published trauma cohort using the same methodology in a similar population at the same institution. The custom-designed website was replicated from the previous trauma study, but with the patient information now focused on sports medicine conditions and procedures. Patients' access to the website, tracking of website use, data collection, and analysis was identical to the previous trauma cohort. Bivariate and multivariate analyses were performed to determine which patient factors were associated with website use.

RESULTS

33 orthopaedic sports medicine patients (31%) accessed the website, and of those, 96% found the website helpful or very helpful. Orthopaedic sports medicine patients were nearly 3 times more likely to use the designated website than orthopaedic trauma patients (31% vs. 11%; p = 0.0004). Higher education predicted website use (p = 0.006). Age, gender, race, employment status, and household income were not predictive of use (p = 0.49, 0.27, 0.23, 0.15, 0.58; respectively). Anterior cruciate ligament (ACL) reconstruction was associated with website use as compared to meniscus and cartilage surgery (42% vs. 20%; p = 0.037). Nominal logistic regression analysis confirmed higher level of education (p = 0.00001) and ACL reconstruction (p = 0.0005) independently predicted website use.

CONCLUSION

Orthopaedic sports medicine surgical patients are more likely to use a custom-designed informational website than orthopaedic trauma patients. However, only 31% of sports medicine patients accessed the website. Inherent differences between groups may account for the differences in website use. Higher level of education is predictive of website use, as is ACL reconstruction for knee surgery patients. Physicians should work to direct patients to high quality Internet resources given the vast amount of potentially unreliable information available.

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.

Feasibility, Acceptability, and Preliminary Impacts of Web-Based Patient Education on Patients With Schizophrenia Spectrum Disorder: Quasi-Experimental Cluster Study

BACKGROUND

Web-based interventions are promising tools for increasing the understanding of illness and treatment among patients with serious mental disorders.

OBJECTIVE

This study aimed to test the feasibility and acceptability of a Web-based patient education intervention using a quasi-experimental cluster design to report feedback on patient education sessions and the website used and to report preliminary evidence of the intervention's impact on patients with schizophrenia spectrum disorder.

METHODS

A single-blind, parallel, quasi-experimental cluster study over a 6-month period comparing Web-based education (n=33) with a nonequivalent control group (treatment as usual, n=24) for people with schizophrenia spectrum disorder was conducted. Participants (N=57) were recruited from one psychiatric hospital (6 wards). Feasibility was assessed by participants' commitment (refusal rate, dropout rate) to the study. Acceptability was assessed as participants' commitment to the intervention. Patient education sessions and website feedback were assessed by the patients and health care professionals. The preliminary impact of the sessions on patients' self-efficacy, self-esteem, illness cognition, and knowledge level was measured at baseline and follow-ups (8 weeks, 6 months) with self-rated questionnaires.

RESULTS

The refusal rate among patients was high with no statistically significant difference (69% [74/107] in the intervention group, 76% [76/100] in the control group; P=.21). The same result was found for the dropout rates (48% [16/33] vs 58% [14/24]; P=.46). The acceptability of the intervention was good; 31 participants out of 33 (94%) completed all five sessions. Feedback on the intervention was mainly positive; three out of four subscales of session were rated above the midpoint of 4.0. Feedback on the website was also positive, with a grade of good for content (69%, 20/29 patients; 75%, 21/28 professionals), layout (62%, 18/29 patients; 61%, 17/28 professionals), and usability (62%, 18/29 patients; and 68%, 19/28 professionals). The patients using the intervention had significantly higher scores 6 months after the sessions in self-efficacy (baseline mean 26.12, SD 5.64 vs 6-month mean 29.24, SD 6.05; P=.003) and regarding knowledge level about schizophrenia (mean 11.39, SD 4.65 vs 6-month mean 15.06, SD 5.26; P=.002), and lower scores in the subscale of helplessness in illness cognition (mean 2.26, SD 0.96 vs 6-month mean 1.85, SD 0.59; P=.03). Differences from the control group were not significant. No differences were found in patients' self-esteem or other subscales in illness cognition.

CONCLUSIONS

The patients were reluctant to participate in the study and tended to drop out before the follow-ups. Once they had participated, their acceptance of the intervention was high. A more effective recruitment strategy and monitoring method will be needed in future studies. To assess the impact of the intervention, a more rigorous study design with an adequately powered sample size will be used in cooperation with outpatient mental health services.

Sources of information used by patients prior to elective surgery: a scoping review

OBJECTIVE

To describe the range and nature of available research regarding sources of information that patients access to inform their decisions about elective surgery.

DESIGN

Scoping review.

DATA SOURCES

Peer-reviewed studies published until February 2019 from the six scientific literature databases were searched and included in the study: Medline, PubMed, CINAHL, Academic Search Premier, EMBASE and SCOPUS. Web searches for grey literature were conducted in Google, South Australia Department of Health, Commonwealth Department of Health (Australia) and My Aged Care from the Department of Social Services (Australia).

ELIGIBILITY CRITERIA

Studies with a focus on elective surgery information sources oriented to patients were eligible for inclusion. Only studies written in English were sought and no publication date or study restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Included literature was described by National Health and Medical Council hierarchy of evidence, and data were extracted on country and year of publication, type of literature, who provided it and any information on end users. Information sources were categorised by type and how information was presented.

RESULTS

A pool of 1039 articles was reduced to 26 after screening for duplicates and non-relevant studies. Face-to-face exchanges were the most likely source of information prior to elective surgery (59.3%), printed information (55.6%) followed by e-learning (51.9%) and multimedia (14.8%). The face-to-face category included information provided by the physician/general practitioners/specialists, and family and friends. Printed information included brochures and pamphlets, e-learning consisted of internet sites or videos and the use of multimedia included different mixed media format.

CONCLUSION

There is considerable variability regarding the types of information patients use in their decision to undergo elective surgery. The most common source of health information (face-to-face interaction with medical personnel) raises the question that the information provided could be incomplete and/or biased, and dependent on what their health provider knew or chose to tell them.

Assessment of American Cleft Palate-Craniofacial Association-Approved Teams' Websites for Patient-Oriented Content and Readability

OBJECTIVE

Informed decision-making relies on available information, including online resources. We evaluated the content and readability of websites published by American Cleft Palate-Craniofacial Association (ACPA)-approved cleft lip and/or palate (CLP) teams in the United States.

DESIGN

Team websites were reviewed, and teams with no accessible website or <30 sentences of content were excluded. Website content was scored by presence/absence of 20 variables derived from ACPA approval standards. Readability was evaluated with 8 scales. Readability was then compared to American Medical Association (AMA) recommendations. The relationship between website content and readability was assessed.

MAIN OUTCOME MEASURE(S)

Content and readability of team websites.

RESULTS

From 167 reviewed teams, 47 (28.1%) had nonfunctional links, 17 (10.2%) had no accessible website, and 39 (23.4%) had <30 sentences. The average content score for all 111 team websites included was 14.5 (2.6) of 20. The combined average reading level across all scales (10.7 [1.9]) exceeded the AMA-recommended sixth-grade reading level; this finding held true for each individual website. Children's Hospital-affiliated teams (n = 86) had a significantly higher content score (14.8 vs 13.5; P = .03) and better readability as evidenced by lower reading grade level (10.5 vs 11.4; P = .04). On linear regression, a higher content score significantly predicted better readability (β = -0.226; P < .001).

CONCLUSIONS

Websites published by ACPA-approved CLP teams vary in accessibility and content and exceed the recommended reading level. These findings could inform future efforts to improve patient-oriented resources.

Digital vs face-to-face information provision in patient counselling for prenatal screening: A noninferiority randomized controlled trial

Objective

To evaluate face‐to‐face information provision in patient counselling for prenatal screening compared with two forms of digital information provision, namely, noninteractive instructional video or interactive video.

Method

We performed a prospective, noninferiority, cluster‐randomized controlled trial comparing face‐to‐face (usual care) with two forms of digital information provision (intervention) in counselling for prenatal screening. This study was performed in the Amsterdam UMC, the Netherlands, in 2017, and included women in the first trimester of pregnancy. Main outcomes were knowledge gained by the patient and counselling duration. We performed a noninferiority analysis.

Results

One hundred forty‐one women were included, randomized, and analysed. The baseline characteristics were comparable. The intervention group was noninferior compared with the control group regarding the level of satisfaction. The knowledge grade difference was higher after using intervention, and the duration was significantly longer in the face‐to‐face group at 23 minutes versus 16 minutes. The addition of interaction with the video made no difference in any of the outcomes.

Conclusion

Adding an instructional video to patient counselling is of added value to improve patient's knowledge and shorten time consumption of the counsellor, therefore possibly saving costs. But this form of counselling maintains the same level of satisfaction.

What is already known about this topic?

Counselling for prenatal screening is a complex process containing education, information, and evaluation in order to make a well‐considered decision.

Counselling for prenatal screening has an increase in interdoctor variation and unpredictable time consumption.

What does this study add?

Digital information provision added to face‐to‐face counselling shortens the counsellors' time significantly without decreasing satisfaction and even improving knowledge.

Shortening the counsellors' time consumption can be a very cost‐effective way of saving time or increasing atient care.

Adding interactivity to patient information provision does not improve knowledge or satisfaction.

Web-Based Patient Education in Orthopedics: Systematic Review

Background

Patients with orthopedic conditions frequently use the internet to find health information. Patient education that is distributed online may form an easily accessible, time- and cost-effective alternative to education delivered through traditional channels such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of Web-based educational interventions exists.

Objective

The objective of this systematic review was to examine the effects of Web-based patient education interventions for adult orthopedic patients and to compare its effectiveness with generic health information websites and traditional forms of patient education.

Methods

CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus, and Web of Science were searched covering the period from 1995 to 2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the internet to the adult orthopedic population and assessed its effects in a controlled or observational trial.

Results

A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after Web-based patient education. Seven trials reported increased satisfaction and good evaluations of Web-based patient education. No compelling evidence exists for an effect of Web-based patient education on anxiety, health attitudes and behavior, or clinical outcomes.

Conclusions

Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopedic patient population as most trials included considerably younger, higher-educated, and internet-savvy participants only.

Educational video-assisted versus conventional informed consent for trauma-related debridement surgery: a parallel group randomized controlled trial

BACKGROUND

We investigated whether, in the emergency department (ED), educational video-assisted informed consent is superior to the conventional consent process, to inform trauma patients undergoing surgery about the procedure, benefits, risks, alternatives, and postoperative care.

METHODS

We conducted a prospective randomized controlled trial, with superiority study design. All trauma patients scheduled to receive trauma-related debridement surgery in the ED of Kaohsiung Medical University Hospital were included. Patients were assigned to one of two education protocols. Participants in the intervention group watched an educational video illustrating informed consent information, whereas those in the control group read an informed consent document. The primary outcome was knowledge scores and the secondary outcome was assessment of patient satisfaction. A multivariable regression model, with predefined covariates, was used to analyze differences in knowledge scores and patient satisfaction levels between the groups.

RESULTS

A total of 142 patients were enrolled, with 70 and 72 assigned to the intervention and control groups, respectively. Mean knowledge scores were higher in the intervention (72.57 ± 16.21 (SD)) than in the control (61.67 ± 18.39) group. By multivariate analysis, the intervention group had significantly greater differences in knowledge scores (coefficient: 7.646, 95% CI: 3.381-11.911). Age, injury severity score, and baseline knowledge score significantly affected the differences in knowledge scores. Significant improvements were observed in patients' perception of statements addressing comprehension of the information provided, helpfulness of the supplied information for decision making, and satisfaction with the informed consent process. Multivariate analysis showed significant correlations between video education and patient satisfaction.

CONCLUSIONS

Both the educational approach and severity of injury may have an impact on patient understanding during the informed consent process in an emergency environment. Video-assisted informed consent may improve the understanding of surgery and satisfaction with the informed consent process for trauma patients in the ED. Institutions should develop structured methods and other strategies to better inform trauma patients, facilitate treatment decisions, and improve patient satisfaction.

TRIAL REGISTRATION

The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

Enhancing the Radiologist-Patient Relationship through Improved Communication: A Quantitative Readability Analysis in Spine Radiology

BACKGROUND AND PURPOSE

More than 75 million Americans have less than adequate health literacy skills according to the National Center for Education Statistics. Readability scores are used as a measure of how well populations read and understand patient education materials. The purpose of this study was to assess the readability of Web sites dedicated to patient education for radiologic spine imaging and interventions.

MATERIALS AND METHODS

Eleven search terms relevant to radiologic spine imaging were searched on the public Internet, and the top 10 links for each term were collected and analyzed to determine readability scores by using 10 well-validated quantitative readability assessments from patient-centered education Web sites. The search terms included the following: x-ray spine, CT spine, MR imaging spine, lumbar puncture, kyphoplasty, vertebroplasty, discogram, myelogram, cervical spine, thoracic spine, and lumbar spine.

RESULTS

Collectively, the 110 articles were written at an 11.3 grade level (grade range, 7.1-16.9). None of the articles were written at the American Medical Association and National Institutes of Health recommended 3rd-to-7th grade reading levels. The vertebroplasty articles were written at a statistically significant (P < .05) more advanced level than the articles for x-ray spine, CT spine, and MR imaging spine.

CONCLUSIONS

Increasing use of the Internet to obtain health information has made it imperative that on-line patient education be written for easy comprehension by the average American. However, given the discordance between readability scores of the articles and the American Medical Association and National Institutes of Health recommended guidelines, it is likely that many patients do not fully benefit from these resources.

Radiology Online Patient Education Materials Provided by Major University Hospitals: Do They Conform to NIH and AMA Guidelines?

AIMS

The internet creates opportunities for Americans to access medical information about imaging tests and modalities to guide them in their medical decision-making. Owing to health literacy variations in the general population, the American Medical Association and National Institutes of Health recommend patient education resources to be written between the third and seventh grade levels. Our purpose is to quantitatively assess the readability levels of online radiology educational materials, written for the public, in 20 major university hospitals.

MATERIALS AND METHODS

In September and October 2016, we identified 20 major university hospitals with radiology residency-affiliated hospital systems. On each hospital׳s website, we downloaded all radiology-related articles written for patient use. A total of 375 articles were analyzed for readability level using 9 quantitative readability scales that are well validated in the medical literature.

RESULTS

The 375 articles from 20 hospital systems were collectively written at an 11.4 ± 3.0 grade level (range: 8.4-17.1). Only 11 (2.9%) articles were written at the recommended third to seventh grade levels. Overall, 126 (33.6%) were written above a full high-school reading level. University of Washington Medical Center׳s articles were the most readable with a reading level corresponding to 7.9 ± 0.9.

CONCLUSIONS

The vast majority of websites at major academic hospitals with radiology residencies designed to provide patients with information about imaging were written above the nationally recommended health literacy guidelines to meet the needs of the average American. This may limit the benefit that patients can derive from these educational materials.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.

OBJECTIVES

To assess the effects of decision aids in people facing treatment or screening decisions.

SEARCH METHODS

Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.

SELECTION CRITERIA

We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.

MAIN RESULTS

We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.

AUTHORS' CONCLUSIONS

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia

BACKGROUND

In a review and meta-analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion-focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect.

OBJECTIVES

To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review.

SELECTION CRITERIA

We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery.

DATA COLLECTION AND ANALYSIS

One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion.Where possible we used random-effects meta-analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta-analysis we performed a narrative review.

MAIN RESULTS

Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty-one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta-analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD -0.20, 95% confidence interval (CI) -0.35 to -0.06), length of stay (mean difference -0.52 days, 95% CI -0.82 to -0.22) and negative affect (SMD -0.35, 95% CI -0.54 to -0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached.Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as 'low' because of the high level of heterogeneity in meta-analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta-analysis, so we rated the quality of evidence as `very low'.

AUTHORS' CONCLUSIONS

The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well-conducted and clearly reported research.