Educating Patients About Anesthesia: A Systematic Review of Randomized Controlled Trials of Media-Based Interventions

Anna Lee, MPH, PhD, Po Tong Chui, Tony Gin, MBChB, MD, FANZCA, FRCA
MBBS, FANZCA, FHKCA, MHA,

and

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China

In this systematic review, we compared the effectiveness of media-based patient education about anesthesia. Fifteen randomized controlled trials (n 1506) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, CINAHL, PSYCINFO, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were anxiety, knowledge, and patient satisfaction. Anxiety levels before anesthesia were less intense in subjects receiving the video and printed information compared with those receiving no intervention (weighted mean difference of 3; 95% confidence interval [95%CI], 15 Spielbergers State and Trait Anxiety Inventory). Patients in the video group were more likely to answer all

knowledge questions correctly compared with patients with no intervention (relative risk of 6.64; 95%CI, 2.05 21.52). The level of knowledge about pain management was higher in the video group compared with patients with no intervention (weighted mean difference of 17%; 95%CI, 9 25). However, the level of patient satisfaction with the intervention (expectation versus actual anesthetic experience) was similar between the groups (relative risk of 1.06; 95%CI, 0.931.22). This systematic review supports the use of video and printed information about general process and risks of anesthesia for patient education before surgery. (Anesth Analg 2003;96:1424 31)

he preanesthetic consultation serves as a forum for patient education (1). The most common concerns about anesthesia include pain, death, intraoperative awareness, and postoperative nausea and vomiting (2 4), with the incidence of preoperative anxiety in adults ranging from 11% to 80% (5). Patients need general information about anesthesia and specific information relating to their condition and their personal concerns. By providing information about anesthesia, misconceptions can be dispelled and patients feel more reassured. If much of this information about the general process and risks of anesthesia can

Support was provided solely from institutional and/or departmental sources. Presented in part at the scientific meeting of The Australian and New Zealand College of Anaesthetists, Brisbane, May 1115, 2002. Accepted for publication December 27, 2002. Address correspondence to Dr. Anna Lee, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China. Address e-mail to annalee@cuhk.edu.hk. DOI: 10.1213/01.ANE.0000055806.93400.93

be provided before the preoperative consultation, anesthesiologists can then focus on the specific needs of the individual in order to obtained informed consent. Because there is an increasing trend toward shorter times between hospital admission and surgery, there has been a need to develop methods to optimize patient preparation. The role of media, such as videos and printed information about anesthesia, has been the subject of many randomized controlled trials (RCTs) (6 20) but the results are conflicting because of differences in trial methodology, media-based intervention, and instruments used to measure outcomes. Therefore, we undertook a qualitative and quantitative systematic review of RCTs of media-based interventions for educating patients about anesthesia. Our objectives were to examine whether the media were effective in decreasing patient anxiety, increasing patient knowledge, and satisfaction.

Methods
Information Retrieval
We did a systematic search on electronic databases (MEDLINE 1966 May 2002, EMBASE 1988 May 2002,
2003 by the International Anesthesia Research Society 0003-2999/03

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PSYCINFO 1984 May 2002, CINAHL 1982May 2002, Cochrane Central Register of Controlled Trials). The electronic search strategy included the following medical subject heading terms and text words which were combined: anesthesia, patient education, preoperative care, anxiety, video, and information. Additional reports were identified from reference lists of retrieved reports, review articles, and observational studies of educating patients about anesthesia. We contacted authors of RCTs (6 8,11,12,15) for further published and unpublished trials that had not been identified in our original search. There was no language restriction.

resolved by discussion, or advice was sought from a third party (TG).

Quality Assessment
The quality of the eligible trials was assessed independently. The level of allocation concealment, defined as the process used to prevent the foreknowledge of group assignment in an RCT, was graded as A (adequate), B (unclear), or C (inadequate), as previously described (25). Blinding, losses to follow-up, and reasons for trial exclusion from the systematic review were recorded.

Eligibility of Articles
Reports of RCTs that examined the effect of media (video, pamphlets, booklets, audiotapes, Internet) designed to give general information about general or regional anesthesia and/or pain management were included in this systematic review. Trials with either a control group (no intervention or an intervention with nonmedical content) or another type of media-based intervention arm were included. We did not consider trials that compared various levels of risk disclosure (21,22).

Statistical Analysis
In one RCT (15), there were two treatment arms: Operating Room Tour and video (treatment A) and Operating Room Tour, video and role-play (treatment B). For this systematic review, we compared treatment A with the control (Operating Room Tour) (15). The DerSimonian and Laird random-effects model was used to combine data for both continuous and dichotomous outcomes, because the treatment and conditions in these studies were expected to have some heterogeneity. This model incorporates both between-study (different treatment effects) and within-study (sampling error) variability and is more conservative than a fixed-effects model (26). The random-effects model has been recommended as the approach for metaanalysis and is more realistic than the fixed-effects model (26). The pooled relative risk (RR) and 95% confidence intervals (95%CI) were calculated for dichotomous data. The weighted mean difference (WMD) method was used to pool continuous data. Before and after anxiety scores were used, with a correlation of 0.80 (15) to calculate the mean difference in scores for each arm of the trials before a WMD was estimated (27). Heterogeneity was analyzed by using the Q-statistic with a threshold for the P value of 0.10. If there was significant heterogeneity, the data were not pooled and reasons for heterogeneity were sought. Sensitivity analyses according to quality of RCTs and funnel plot to detect bias were not performed, because there were too few trials. All metaanalyses were performed by using Arcus Quickstat software (version 1.2; Addison Wesley Longman Ltd., Cambridge, UK).

Outcome Measures
The outcomes collected were anxiety, patient knowledge, and patient satisfaction with the intervention. Anxiety was measured by using reliable and valid instruments (Spielbergers State and Trait Anxiety Inventory, Visual Analog Scale, Amsterdam Preoperative Anxiety and Information Scale, Yale Preoperative Anxiety Scale, Childrens Global Mood Score) (8,15,23,24). The level of patient knowledge was assessed by the Standard Anesthesia Learning Test (23) or scores from multiitem (unvalidated) knowledge questionnaires. We used the specific definition of patient satisfaction that was used in each individual trial because none of the RCTs had used validated and reliable patient satisfaction instruments.

Data Extraction
The selection of trials for inclusion in the systematic review was performed independently by the reviewers (AL and PC) after using the search strategy described above. Trials were examined for duplicate data. Data were abstracted independently by AL and PC by using a standardized data collection form. There was no attempt to blind the reviewers (AL and PC) to the authors or results of the relevant trials. Details of study population, intervention, and definition of patient satisfaction were collected. Where appropriate, the primary author of an RCT was contacted for clarification of data. Discrepancies were

Results
Included and Excluded Trials
Twenty-seven trials were initially considered for inclusion, but after consideration, 12 were excluded. Reasons for exclusions were observational studies

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(3,28 34),1 no media-based intervention used (35), no relevant comparison arm (36), and no relevant outcome measure reported (37). No additional trials were identified after contacting the authors of RCTs included in this systematic review. Table 1 shows the 15 RCTs (n 1506) of video and/or printed information for patient education about anesthesia included in this systematic review. There were no trials using audiotapes or the Internet. The interventions included basic information about general anesthesia (nine RCTs) (6,8 11,14,15,19,20), regional anesthesia (two RCTs) (7,13), and the use of patient-controlled analgesia and/or pain management (four RCTs) (12,16 18). Interventions were given at a preadmission clinic (6 8,11,15), a day before surgery (14,17,20), or on the day of surgery (9,16,18,19).

Quality of Trials
Adequate allocation concealment was found in four RCTs (9,12,13,15). Inadequate allocation concealment was found in two RCTs (10,18). There were two double-blinded RCTs (9,15) and four single-blinded RCTs (6,8,14,17).

Outcome Measures
Anxiety. This outcome was measured in eight RCTs. Although the full-version Spielberger State and Trait Anxiety Inventory was used in four RCTs (11,13 15), before and after state anxiety (transient situation) levels were measured in three RCTs (11,13,15). Combining these 3 trials showed that state anxiety (transient situational) levels before anesthesia were decreased in subjects receiving the video and/or printed information compared with those receiving no intervention (WMD of 3; 95%CI, 15) (Fig. 1). When the analysis was limited to trials involving parents of children undergoing surgery (11,15), the reduction in state anxiety levels in the video group was significant compared with the control group (WMD of 2; 95%CI, 0 5). There was no reduction in state anxiety levels when a pamphlet and video group was compared with a pamphlet-only group (WMD of 1.00; 95%CI, 0.53 2.53) (19). In one trial, when pre- and postintervention trait anxiety (stable, dispositional) levels were measured, there was no change between the groups (13). When an abbreviated version of the Spielbergers State and Trait Anxiety Inventory was used, there was no significant difference between the video and control group in state and trait anxiety scores after adjusting for baseline measurements (9).
1 Griffith KE, Foster WE, Lacour T, et al. Effect of multimedia preoperative information on patient knowledge and anxiety prior to ambulatory surgery [abstract]. Anesth Analg 1994;81:A27.

Because there were various methods of measuring anxiety in children, we did not attempt to pool the results. Margolis et al. (8) found no significant difference in childrens anxiety (as measured by Global Mood Score) between the groups in the preoperative holding area, operating room, and during anesthetic induction. Parents of children in the intervention group reported lower anxiety levels (visual analog scale 4.5 3.7) than the control group (visual analog scale 5.8 5.0) but this difference was not significant (8). Similarly, there was no significant difference in childrens anxiety (as measured by an observational visual analog scale and Yale Preoperative Anxiety Scale by a blinded assessor) between control and video groups after the intervention, in the preoperative holding area and during induction (15). In contrast, parents in the video group were significantly less anxious (Amsterdam Preoperative Anxiety Scale) than parents in the control group (P 0.0001) (11). Using a visual analog scale, patients in the pamphlet group were less anxious about pain management compared with a control group (P 0.01) (17). Patient Knowledge. There was no standard method of measuring the level of patient knowledge. The Standard Anesthesia Learning Test was used in one RCT (11) to assess the factual knowledge of anesthesia procedures and risks. There was a significant increase in knowledge scores in the video group compared with the control group (P 0.02) (11). A metaanalysis of 2 RCTs (9,14) showed that patients in the video group were more likely to answer all knowledge questions correctly compared with patients with no intervention (RR of 6.64; 95%CI, 2.0521.52). The video intervention was most effective in educating patients about risks of anesthesia (RR of 7.12; 95%CI, 3.70 10.07) than the process of anesthesia (RR of 1.27; 95%CI, 1.10 1.34) after adjusting for preintervention state and trait anxiety levels (9). After adjusting for previous anesthesia experience and preoperative state and trait anxiety scores, patients in the video group were more likely to identify misconceptions about anesthesia correctly than patients who did not have the video intervention (RR of 3.15; 95%CI, 1.94 4.29) (9). The level of knowledge about pain management, as measured by the percentage of correct responses to a knowledge questionnaire, was higher in the video group compared with patients with no intervention (WMD of 17%; 95%CI, 9 25) (12,18). Parents of children who had previously been exposed to pain management had significantly less improvement in knowledge scores after viewing the video than those with no previous exposure (12). In another trial, the mean score for understanding the use of patient-controlled analgesia device and pain management was higher in the pamphlet group than in the control group who had received instructions from a physician (16). For example, control patients were 3 times more likely to

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believe that they could overdose themselves with patient-controlled analgesia than patients in the video group (RR of 2.80; 95%CI, 1.117.09) (16). Klafta and Klock (7) found that more patients in the video group were able to identify neuraxial analgesia as a potential method of postoperative pain relief (P 0.02). Courtney (10) found that an anesthetic booklet was valuable because patients had a better understanding of what a premedication would do and how long after an anesthetic to wait before driving. Although more patients in the booklet group knew what procedures to take if they were not feeling well before outpatient surgery than patients in the control group, neither group knew that an anesthesiologist was a specialist doctor or what they did during anesthesia (10). Zvara et al. (6) concluded that the video intervention was not effective, because there were no significant differences in the proportion of correct responses found between groups for questions about the process of anesthesia. Patient Satisfaction. Patient satisfaction with the media was not well defined in any of the RCTs and was not measured using validated questionnaires. More patients in the video group believed that it helped them prepare for surgery than patients in the control group (92% versus 74%, P 0.01) (20). In another RCT (6), 85% of patients who viewed a video found it to be helpful compared with 42% of control patients who thought it might be helpful (P 0.01). The results were not pooled because there was statistical heterogeneity (Q statistic of 11.43, P 0.01), probably because of the style of video presentation [general narration (6) versus personal narration (20)]. When patient satisfaction with media-based intervention was defined as the expected versus actual experience in the operating room, there was no difference between the intervention and nonintervention groups (RR of 1.06; 95%CI, 0.931.22) (8,14,20). More parents in the interactive book group than parents in the control group believed that they had received enough information (82% versus 65%, P 0.05) (8). There was no difference in the proportion of patients who wanted more detailed information than what was given (69% video group versus 84% control group, P 0.07) (20). Also, there was no difference in the level of patient satisfaction with knowledge of perioperative events or knowledge about anesthetic practice between booklet and control groups (10).

Discussion
Reducing patient anxiety has been defined as one of the principles of conducting a preanesthetic consultation (1). This systematic review has shown that there was a significant reduction in state anxiety levels attributable to media-based patient education before anesthesia. However, this reduction was smallat most,

a change in five points. An important clinical change in state-anxiety levels has been defined as 1 standard deviation (10 points) using the Spielbergers state anxiety self-administered questionnaire (score 20 80) (21). Therefore, the clinical significance of this finding is debatable. Quantitative and qualitative analysis of pediatric trials suggest that media-based interventions can decrease anxiety for parents but not for the children who are patients. Only one RCT in this systematic review measured the association between anxiety and recovery (17). Not surprisingly, there was no association because these outcomes are influenced by other factors, such as socioeconomic issues or individual surgical practices (17). The postoperative quality of recovery is probably a more useful outcome to use for assessing the effectiveness of an education intervention (38). In a recent trial, a significant correlation was found between increased anxiety and reduced quality of recovery (39). Patients with preoperative state anxiety are nearly 3 times more likely to have postoperative anxiety (odds ratio 2.65; 95%CI, 1.70 4.14), which in turn is associated with moderate-to-intense postoperative pain (odd ratio 2.62; 95%CI, 1.773.88) (40). The optimal duration and timing of media to educate patients about anesthesia are unclear, because there were insufficient trials for a sensitivity analysis to be done. Half of the trials in this systematic review included interventions given on the day before or on the day of surgery. Arellano et al. (41) showed a small reduction in state anxiety scores when patients were seen by an anesthesiologist immediately before surgery compared with those seen at an outpatient clinic one week before surgery or at the time of admission to the hospital. The logistics of providing media-based interventions close to the time of anesthesia should be weighed against giving patients sufficient time to cope with and reflect on the information gained. Patients vary considerably in the amount of information they think appropriate and this varies within individuals over time (21). Providing detailed information about risks of complications of general anesthesia on the night before surgery did not increase patients levels of anxiety (22). Miller et al. (23) suggested that parents of pediatric surgery patients experience greater levels of anxiety and need for information than do adults who are undergoing surgery themselves. The main benefit from video and written information was an increased level of patient knowledge about risks and the process of anesthesia and pain management. The benefits of explaining the risks of anesthesia include satisfying responsibility and understanding in parents of healthy pediatric patients (42). Identification of subgroups of patients who would benefit most from media-based interventions is a challenge. Greenberg et al. (12) found that parents of children with less educational experience and who had not been

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Table 1. Characteristics of 15 Randomized, Controlled Trials of the Use of Video and Printed Information for Patient Education Before Anesthesia Study Gaskey, 1987 (US) (n 40) (14) Timmons and Bower, 1993 (US) (n 109) (16) Zvara et al. 1996 (US) (n 178) (6) Courtney, 1997 (NZ) (n 140) (10) Margolis et al., 1998 (US) (n 102) (8) Quality Unclear allocation concealment; single blinding Unclear allocation concealment; no blinding Unclear allocation concealment; single blinding Inadequate allocation concealment; no blinding Unclear allocation concealment; single blinding

Done and Lee, 1998 (Aust) (n 127) (9) Kain et al., 1998 (US) (n 73) (15)

Adequate allocation concealment; double blinding Adequate allocation concealment; double blinding

Cassady et al., 1999 (US) (n 85) (11) Bondy et al., 1999 (US) (n 134) (13) Greenberg et al., 1999 (US) (n 100) (12) Knoerl et al., 1999 (US) (n 76) (18) Klafta and Klock, 2000 (US) (n 101) (7) Lam et al., 2001 (HK) (n 60) (17) Zuwala and Barber, 2001 (US) (n 80) (19)

Unclear allocation concealment; no blinding Adequate allocation concealment; no blinding Adequate allocation concealment; no blinding Inadequate allocation concealment; no blinding Unclear allocation concealment; no blinding Unclear allocation concealment; single blinding Unclear allocation concealment; no blinding

Roth-Isigkeit et al., 2002 (Germany) (n 101) (20)

Unclear allocation concealment; no blinding

US United States, STAI State-Trait Anxiety Inventory, NZ New Zealand, Aust Australia, SALT Standard Anesthesia Learning Test, APAIS The Amsterdam Preoperative Anxiety and Information Scale, HK Hong Kong.

exposed to pain management gained the most benefit from a video intervention. Factual knowledge of anesthesia can improve compliance with perioperative instructions and facilitate informed consent (11). None of the trials in this systematic review examined the impact of

media-based intervention on patient compliance with perioperative instructions. Despite being given detailed oral and written instructions, patients were noncompliant with fasting instructions (2%), took medications contrary to advice (7%), and intended to drive home after ambulatory surgery (4%) (43).

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Table 1. (Continued) Intervention 16-min video about general anesthesia viewed 1 d before surgery; control: none Pamphlet about use of patient-controlled analgesia and pain management given 2 h before surgery; control: none 10-min video about general anesthesia viewed at a preadmission visit; control: none Your Anesthesia booklet sent in the mail before hospital admission; control: none Interactive childrens book Pat the Bunny given at a preadmission visit (13 d before surgery); control: coloring book with no medical content Outcomes measured Postintervention STAI state and anxiety scores, 15 questions assessing knowledge, patient satisfaction (expectation versus actual experience in operating theatre) Knowledge score on the understanding of the use of patientcontrolled analgesia and pain management 6 questions assessing knowledge, satisfaction with knowledge gained 6 questions assessing knowledge, satisfaction with the knowledge on the type of anesthesia, risks, and postoperative pain Childrens anxiety measured by Global Mood Score in the preoperative holding area, operating room entry, and mask application Parents anxiety measured by visual analog scale Parents satisfaction on whether they had received enough information; expectation versus actual experience Knowledge-based questions (% correct for process, risk, and misconception), 8-item preintervention and postintervention STAI state and trait scores Preintervention and postintervention parent STAI state and trait, childs anxiety by visual analog scale, and Yale Preoperative Anxiety Scale Parents preintervention and postintervention SALT (knowledge-based validated questionnaire), STAI state, APAIS anxiety Preintervention and postintervention STAI state and trait scores 30 knowledge-based questions (% correct), also stratified by education level and previous pain management history 6 knowledge-based questions Postintervention self-assessment of knowledge, ability to identify neuraxial analgesia as a method of postoperative pain relief Postintervention visual analog scale anxiety measurement Preintervention and postintervention STAI

7-min video About Your General Anesthetic viewed on the day of surgery; control: none Animated video A Hospital Trip with Dr. Bip viewed at a preadmission visit (110 d before surgery) plus 10-min tour of operating theatres; control: 10-min tour of operating theatres 22-min video Your Childs Anesthesia viewed at a preadmission visit (1 wk before surgery); control: video with no medical content Pamphlets and 10-min video about regional anesthesia mailed 3 wk before surgery; control: none 19-min video about pain management of children; control: none 11-min video about the use of patient-controlled analgesia viewed on the day of surgery; control: none 12-min video about regional anesthesia viewed at a preadmission visit; control: none Pamphlet about patient-controlled analgesia given at a routine preanesthetic visit; control: none 2-min video about child mask induction viewed on day of surgery and pamphlet about expected events during perioperative period; control: pamphlet about expected events during perioperative period 8-min video about expected events during the perioperative period for patients undergoing elective cardiac surgery viewed on the night before surgery; control: video with no medical content

Patient satisfaction (helpfulness of video in preparing for surgery, actual versus expected experience, enough information)

Patient noncompliance may result in cancellation of surgery or unanticipated perioperative complications. Therefore, the use of media, together with reinforcement by an anesthesiologist, may have an important role in increasing patient compliance with perioperative instructions.

Patient satisfaction is a complex psychological phenomenon and should be assessed by multiitem questionnaires that have been shown to be reliable and valid. A limitation in this systematic review was that the included trials relied on single-item rating for patient satisfaction without established validity and

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Figure 1. Metaanalysis of trials (11,13,15). The effect of video and printed information on state anxiety levels (measured by Spielbergers State and Trait Anxiety Inventory) before anesthesia. Data are weighted mean difference with 95% confidence intervals (CIs).

reliability properties. We found no significant difference between intervention groups in expected versus actual experience in the operating room. The question of how helpful a video is in preparing patients before anesthesia seems to depend on the style of video presentation (20). A video presentation from a patients perspective allows other patients to take a more active role in the perioperative situation because this process of identification induces a higher degree of anticipatory coping (20). Patients want both procedural and sensory information (44) which may partly explain the heterogeneity observed between the two trials assessing the usefulness of a video intervention (6,20). The applicability of the results of this quantitative systematic review was limited to video and/or printed information interventions and there was no direct comparison between the two methods. Although the World Wide Web is becoming an important source of medical information, preliminary evidence suggests that the quality of information for patients is unreliable and poor (45). Other methods, such as CD-ROM programs, may be more comprehensive in content and satisfy a broader range of educational needs but are probably more expensive to develop than videos and printed information (46). A recent survey showed that patients most preferred to learn about anesthesia by individual instruction by staff, followed by video, written materials, and the Internet (30). However, the most cost-effective and practical method of delivering patient education remains to be addressed. The quality of trials in this systematic review was fair. Only 4 of 15 trials in this review had adequate allocation concealment. Compared with trials with adequate allocation concealment, trials with unclear allocation concealment have been shown to exaggerate the treatment effect by 30% (25). Therefore, it is possible that the presence of publication bias and the

quality of trials included in this review may be overestimating any beneficial effects of media-based interventions. We did not formally assess publication bias using the method of Egger et al. (47) because there were few trials with dichotomous outcomes for metaanalysis. Effective patient education requires good communication skills, consideration to adult learning and teaching principles, and selecting the media to suit the individual patients needs (48). Written information is successful in a proportion of the population because it requires basic literacy skills as well as the motivation to read the material provided (49). In comparison, videos are useful in that patients learn by seeing a demonstration of perioperative processes. Overall, this systematic review supports the use of video and printed information about general process and risks of anesthesia for patient education before surgery. These interventions were associated with increased patient knowledge (an important component of an informed patient consent) and a small reduction in anxiety levels. However, there was no effect on patient satisfaction. Future trials are needed to address which medium is more effective and its impact on patient compliance with perioperative instructions.

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