Abstract
Purpose:
To assess the effects of the American Academy of Ophthalmology’s 2015 patient education video on patient information retention and anxiety preoperatively, on the day of surgery and postoperatively.
Methods:
This is a prospective, surgeon-blinded randomized controlled trial at the University of Chicago Medical Center. Ninety-one patients with a diagnosis of first-eye cataract were randomized into either a video or control group. Subjects in both groups received face-to-face discussion with the surgeon and an informational brochure at the preoperative evaluation. Participants in the video group then viewed a four-minute educational video at the preoperative evaluation and on the day of surgery. Both groups completed an information retention quiz and a state anxiety assessment at the preoperative visit, on the day of surgery, and on the postoperative week one visit. Subject understanding of cataract surgery was measured using a twelve-question multiple choice quiz. State anxiety was measured by State Trait Anxiety Inventory-Y1 survey score.
Results:
Participants in the video group did not score significantly higher on the information retention quiz compared to the control group at the preoperative evaluation (8.7±2.4 vs 7.7±2.5, P = 0.07), but did so on the day of surgery (11.2±0.8 vs 8.4±1.7, P < 0.001) and postoperative week one visit (10.8±1.5 vs 9.0±2.0, P < 0.001). Subjects in the video group were significantly less anxious on the day of surgery (26.4±5.1 vs 41.1±10.3, P < 0.001).
Conclusions:
Video supplementation to the traditional informed consent process demonstrated animprovement in patient understanding of cataract surgery at multiple time points and decreased anxiety on day of surgery.
Keywords: informed consent for cataract surgery, patient education, video supplementation
Introduction
Cataract surgery is the most commonly performed ophthalmologic surgery in the U.S. with approximately 3 million surgeries performed annually. [1]. Ideally, the patient and physician should have a personalized discussion regarding the procedure, benefits, risks, alternatives and expected outcomes of cataract surgery. Effective informed consent helps patients make educated healthcare decisions and also lowers the risk of malpractice litigation [2–4]. Despite the success rate of cataract surgery, ophthalmic malpractice cases have still been on the rise with inadequate informed consent cited as a primary or secondary cause in more than 90% of cases [1, 5, 6].
Previous studies have shown information retention regarding common ophthalmic surgeries to range from approximately 40 to 70%, suggesting that the informed consent process may benefit from further improvements [5, 7]. While face-to-face education of patients by surgeons remains the standard of care, many surgeons have supplemented this process with patient education brochures that explain cataract surgery using diagrams and easily understood language. The American Academy of Ophthalmology (AAO) and several other organizations have published patient education materials in this regard to further educate patients. However, the efficacy of these documents can be suboptimal due to a variety of reasons, including difficulty understanding the material due to poor functional literacy.
Recently, the possible benefits of using audiovisual or interactive multimedia in the informed consent process have been gaining traction [5, 8–11]. However, there are concerns that video supplementation may worsen anxiety and uncertainties in the decision making process [12]. We therefore aimed to study the efficacy of the 2015 AAO cataract surgery patient education video in regards to information retained and overall anxiety pertaining to cataract surgery in the context of the informed consent process. There has been one prior study that demonstrated the effectiveness of a 13-minute AAO patient education video [9]. We are specifically interested in the 2015 version of this video because it is up to date and significantly condensed with a runtime of four minutes. Furthermore, we sought to examine the effects of video supplementation throughout the surgical process: preoperatively, on the day of surgery and postoperatively. To the best of our knowledge, this is the first study that has examined the impact of video supplementation on information retention and patient anxiety with these three distinct timepoints.
Methods
Eligibility Criteria
This single-center, prospective, surgeon-blinded randomized controlled trial included patients who were scheduled for first-eye cataract surgery. All patients age 40 years or older with a diagnosis of cataract at the University of Chicago between January 2017 and June 2018 were eligible for this study. Patients were excluded if they had previous cataract surgery, had a spouse who had undergone previous cataract surgery, had a history of dementia or other cognitive impairment documented in the medical record, or had worked in the healthcare industry. Patients with a history of depression or anxiety were not excluded from the study because we are interested in the effect of the video on these patients as part of the broader clinical population. A review of the medical history of the patients included in our study indicates that there were comparatively equal numbers of patients that had a medical diagnosis of depression and/or anxiety in both groups. Eligible subjects were diagnosed with visually significant cataracts during clinical visits with the principal investigator (KMR) and were enrolled after consenting to participate in the study.
Video
The video shown to patients was a four-minute presentation explaining phacoemulsification cataract surgery with monofocal lens replacement released by the AAO in 2015 and available for purchase on its website. The video begins by discussing the diagnosis of cataract and its symptoms. Then, it explains the basic steps of cataract surgery including the incision, phacoemulsification and placement of the intraocular lens using animation and narration. The end of the video describes the prognosis without cataract surgery, expected outcomes of cataract surgery, risks of cataract surgery and possible visual side effects of an intraocular lens.
Procedures
Patients who were considering cataract surgery were randomized into two groups using a random number generator. Both groups had a face-to-face informed consent discussion with the surgeon (KMR) and were given an educational brochure at this time (Figure A1). This brochure was estimated to be a 9th-grade reading level by the Flesch-Kincaid readability test and was printed in large sixteen-point font [13]. The surgeon did not use a script to verbally educate patients but rather performed his routine verbal discussion in order to better simulate standard clinical practice. Patients were then introduced to the coinvestigators (MHZ and EMB) who oversaw the rest of the study process. The video group watched the 2015 AAO cataract surgery educational video at this time while the control group received no multimedia supplementation. The video was shown on a laptop in a private room with only the patient and coinvestigator present. The majority of patients were dilated at the time of viewing.
Immediately after the face-to-face discussion with or without video supplementation, patients in both groups completed an information retention quiz (Figure A2) under supervision of the coinvestigators. Consultation with people, electronic devices or paper material was not permitted. Patients were then asked to complete a state anxiety, a trait anxiety survey and a health literacy survey (Figure A3). All surveys were in printed paper format and completed manually. Since vision is necessary to see the video and read the quiz, steps were taken to limit visual acuity as a potential confounder. In addition to randomizing the patients, the video was shown full-screen on a fifteen-inch laptop with audio narration at the patient’s preferred volume. If patients had difficulty reading due to cataract and/or eye dilation, the coinvestigators read the text aloud for the subject. Subjects were verbally asked for their educational status during this preoperative appointment. Patients in both groups received the same amount of face-to-face time with the coinvestigators to complete all forms (15–20 minutes). The video group did not receive any additional counseling from the primary investigator or coinvestigators.
The information retention quiz is a previously validated instrument consisting of 12 multiple choice questions [9]. This quiz assesses knowledge on topics such as risk factors for developing cataracts and, risks and benefits of, and alternatives to cataract surgery (Figure A2). The State Trait Anxiety Inventory (STAI) is a survey composed of two forms: Y1 which measures state anxiety and Y2 which measures trait anxiety [14]. State anxiety refers to how a person is feeling at the moment, whereas trait anxiety is defined as how one feels generally, on a day to day basis [15]. Both forms are composed of 40 questions with each response measured on a four-point Likert scale. Scores for the STAI-Y1 and STAI-Y2 survey range from 20 (minimal anxiety) to 80 (maximal anxiety). STAI-Y1 was used to assess anxiety at three distinct time points: preoperatively, on the day of surgery and postoperatively. STAI-Y2 was administered at the preoperative evaluation to measure trait anxiety as a baseline characteristic for all subjects. The Medical Term Recognition Test (METER) includes 40 medical words and 40 nonwords (Figure A3). Each subject is asked to mark only words they recognize as actual words and skip words they do not recognize or are unsure about. The METER was scored as the total number of words correctly recognized. Scores for the METER survey range from 0 (minimal health literacy) to 40 (maximal health literacy) [16]. All other exams and tests were done as indicated per medical care.
All surgeries were performed by the primary investigator. On the day of surgery, the video group watched the educational video prior to pharmacological dilation. No other part of the informed consent process was repeated on the day of surgery. The information retention quiz and state anxiety surveys were administered to both groups prior to dilation on the day of surgery and then again at the postoperative week one appointment.
Statistical Methods
A power calculation was performed with the following parameters: α = 0.05, β = 0.1, the standard deviation was 1.3 for the experimental group and 1.6 for the control group and δ = 1.5-point difference on the information retention quiz. The standard deviations and delta parameters were derived from prior work done by Shukla, et al. in 2012 using the same information retention quiz. The necessary calculated sample size was 42 with 21 in each arm.
A Chi-squared test was used to assess inter-group differences in baseline characteristics and responses to individual questions on the information retention quiz. Aggregate scores on the information quiz, STAI-Y1 and STAI-Y2 surveys were non-normally distributed and assessed by Wilcoxon rank-sum tests. Subgroup analysis was performed by age, education and health literacy and effect sizes were compared by Hedge’s g statistic. Correlations between preoperative visual acuity and retention scores were assessed with Pearson correlation coefficient testing. A threshold of P < 0.05 was considered statistically significant. A Bonferroni correction was applied to all assessments that required multiple comparisons. All statistical tests were two-sided. All analyses were performed with RStudio, Version 1.0.153 (RStudio Team, Boston MA).
Results
A total of 91 patients were recruited to participate in the study and randomized into two groups: 46 patients underwent patient-surgeon discussion plus written brochure and 45 patients underwent patient-surgeon discussion, written brochure and educational video supplementation. We report the results of 40 patients (87%) in the control group and 39 patients (87%) in the video group who underwent surgery and were included in our analysis. Baseline characteristics were similar in the control and video groups (Table 1). Two video group patients did not complete the surveys on their day of surgery, resulting in 40 control group and 37 video group patients in the day of surgery analysis. Two control group patients did not complete the postoperative surveys, leaving 38 control group and 37 video group patients in the postoperative analysis.
Table 1.
Baseline demographics for the video and control groups
| Video group (n = 39) | Control group (n = 40) | P value | |
|---|---|---|---|
| Age (yrs) | 66±8 | 68±10 | 0.49 |
| Male (n) | 15 (41%) | 13 (34%) | 0.75 |
| Health literacy | 36±6 | 36±8 | 0.72 |
| Education level (yrs) | 13±3 | 14±4 | 0.53 |
| Trait anxiety | 29±8 | 31±9 | 0.23 |
| Time to surgery (days) | 69±81 | 49±62 | 0.22 |
Health literacy measured by METER score. Trait anxiety (a person’s general tendency towards anxiety) measured by STAI-Y2 score. Data are mean ± standard deviation, unless otherwise indicated.
Information Retention
The video group scored 1-point better on the information retention quiz compared to the control group at the preoperative evaluation (8.7±2.4 vs 7.7±2.5, P = 0.07), but this finding was not statistically significant. Significant differences were noted on the day of surgery (11.2±0.8 vs 8.4±1.7, P < 0.001) and on the postoperative week one visit (10.8±1.5 vs 9.0±2.0, P < 0.001) (Table 2).
Table 2.
Information retention scores and state anxiety levels in the video and control groups at preoperative, day of surgery, and postoperative timepoints
| Video group | Control group | P value | |
|---|---|---|---|
| Retention score | |||
| Preoperative | 8.7±2.4 | 7.7±2.5 | 0.07 |
| Day of Surgery | 11.2±0.8 | 8.4±1.7 | <0.001 |
| Postoperative | 10.8±1.5 | 9.0±2.0 | <0.001 |
| State anxiety | |||
| Preoperative | 28.1±9.5 | 28.7±11.0 | 0.98 |
| Day of Surgery | 26.4±5.1 | 41.1±10.3 | <0.001 |
| Postoperative | 26.9±6.5 | 29.4±7.9 | 0.09 |
State anxiety (anxiety concerning the current situation) measured by STAI-Y1 score. Data are mean ± standard deviation, unless otherwise indicated.
A per-question analysis identified a distinct set of questions that were answered correctly more often by the video group when compared to the control group. Questions 3, 5, 6, 10 and 12 were answered correctly at a significantly higher rate by patients who watched the educational video at one or more timepoints (Table A1). A statistically significant difference was observed with questions 5 and 6 at two timepoints.
Subgroup analyses by age, years of education and health literacy were performed at all three time points. A trend was noted for effect size (ES) being larger for older, low-education, and low-health literacy subgroups at all three timepoints as compared to younger, high-education, and high-health literacy subgroups (Table 3) though this was not statistically significant (Table A2). The only exception was the preoperative health literacy analysis where the video had a greater effect on high-health literacy patients. The video had a significant effect on the day of surgery information retention for high-health literacy subjects (ES = 2.6, P < 0.001) but not for low-health literacy subjects despite a larger ES (ES = 3.7, P = 0.024). The same paradox was observed postoperatively (Table 3). Both are due to an insufficient sample size of 9 patients (3 video, 6 control) in the low-health literacy subgroup. The video improved postoperative information retention significantly in the low-education subgroup (ES = 2.5, P < 0.001) but not in the high-education subgroup (ES = 1.3, P = 0.030). No ES was significantly different by age.
Table 3.
Information retention scores for video and control groups at preoperative, day of surgery and postoperative timepoints stratified by age, years of education and health literacy level
| Retention Score | ||||
|---|---|---|---|---|
| Preoperative | Video Group | Control Group | Difference | P value |
| Older | 8.5 (n=11) | 7.5 (n=20) | 1.1 | 0.29 |
| Younger | 8.8 (n=28) | 7.9 (n=20) | 0.9 | 0.27 |
| High Education | 9.6 (n=21) | 9.0 (n=21) | 0.6 | 0.61 |
| Low Education | 7.6 (n=18) | 6.2 (n=18) | 1.4 | 0.06 |
| High Health Literacy | 9.0 (n=35) | 8.1 (n=34) | 0.9 | 0.11 |
| Low Health Literacy | 5.6 (n=4) | 5.2 (n=6) | 0.6 | 0.91 |
| Day of Surgery | ||||
| Older | 11.0 (n=10) | 8.2 (n=20) | 2.8 | <0.001 |
| Younger | 11.2 (n=27) | 8.6 (n=20) | 2.7 | <0.001 |
| High Education | 11.1 (n=20) | 9.0 (n=21) | 2.0 | <0.001 |
| Low Education | 11.3 (n=17) | 7.6 (n=18) | 3.7 | <0.001 |
| High Health Literacy | 11.2 (n=34) | 8.6 (n=34) | 2.6 | <0.001 |
| Low Health Literacy | 11.0 (n=3) | 7.3 (n=6) | 3.7 | 0.024 |
| Postoperative | ||||
| Older | 11.0 (n=10) | 8.6 (n=20) | 2.4 | 0.003 |
| Younger | 10.9 (n=27) | 9.4 (n=18) | 1.4 | 0.008 |
| High Education | 11.0 (n=20) | 9.8 (n=20) | 1.3 | 0.030 |
| Low Education | 10.8 (n=17) | 8.3 (n=17) | 2.5 | <0.001 |
| High Health Literacy | 10.9 (n=34) | 9.1 (n=32) | 1.8 | <0.001 |
| Low Health Literacy | 11.3 (n=3) | 8.5 (n=6) | 2.8 | 0.024 |
One patient in the control group with missing education status was excluded from education sub-groups. Subgroup analysis was performed by older (age ≥ 70) versus younger (age < 70), high-education (postsecondary education, years of school > 12) versus low-education (no postsecondary education, years of school ≤ 12) and high-health literacy (METER score ≥ 35) versus low-health literacy (METER score < 35). This cutoff was chosen for health literacy because previous literature demarcated a METER score of 35 as an appropriate cutoff for functional health literacy.16 Bonferroni correction was applied, with a threshold of P < 0.017 considered statistically significant.
In both groups, preoperative LogMAR visual acuity in the better eye had no statistically significant association with preoperative retention scores (control group r = −0.20, P = 0.23) (video group r = −0.15, P = 0.37).
Anxiety
State anxiety as measured by STAI Y-1 was not significantly different between the two groups at the preoperative evaluation or postoperative visit (Table 2). However, on the day of surgery, subjects in the video group reported a lower level of anxiety than the non-video group (P < 0.001).
No differences in the subgroup analysis was found at the preoperative timepoint (Table 4). The video helped high-health literacy subjects feel less anxious on the day of surgery (ES = −14.8, P < 0.001) whereas no statistically significant effect was observed for low-health literacy patients (ES = −13.3, P = 0.15). As discussed previously, we believe this is due to small sample size because the similar effect sizes suggest this is not a clinically significant difference. Subgroup analysis showed that neither the age nor education level of subjects modulated the effect of video supplementation.
Table 4.
State anxiety levels for video and control groups at preoperative, day of surgery and postoperative timepoints stratified by age, years of education and health literacy level
| State Anxiety | ||||
|---|---|---|---|---|
| Preoperative | Video group | Control group | Difference | P value |
| Older | 25.7 (n=11) | 25.6 (n=20) | 0.2 | 0.49 |
| Younger | 29.9 (n=28) | 30.6 (n=20) | −0.7 | 0.41 |
| High Education | 30.9 (n=21) | 24.6 (n=21) | 6.3 | 0.19 |
| Low Education | 26.2 (n=18) | 31.7 (n=18) | −5.5 | 0.21 |
| High Health Literacy | 28.7 (n=35) | 25.7 (n=34) | 3.0 | 0.48 |
| Low Health Literacy | 28.8 (n=4) | 41.5 (n=6) | −12.8 | 0.11 |
| Day of Surgery | ||||
| Older | 26.3 (n=10) | 39.5 (n=20) | −13.2 | 0.009 |
| Younger | 26.4 (n=27) | 42.8 (n=20) | −16.4 | <0.001 |
| High Education | 26.8 (n=20) | 39.5 (n=21) | −12.7 | <0.001 |
| Low Education | 25.8 (n=17) | 43.1 (n=18) | −17.3 | <0.001 |
| High Health Literacy | 26.2 (n=34) | 41.0 (n=34) | −14.8 | <0.001 |
| Low Health Literacy | 28.7 (n=3) | 42.0 (n=6) | −13.3 | 0.15 |
| Postoperative | ||||
| Older | 26.2 (n=10) | 28.7 (n=20) | −2.5 | 0.86 |
| Younger | 27.2 (n=27) | 30.1 (n=18) | −2.9 | 0.06 |
| High Education | 27.4 (n=20) | 26.9 (n=20) | 0.5 | 0.94 |
| Low Education | 26.3 (n=17) | 31.2 (n=17) | −4.9 | 0.019 |
| High Health Literacy | 26.9 (n=34) | 29.2 (n=32) | −2.3 | 0.18 |
| Low Health Literacy | 26.7 (n=3) | 30.2 (n=6) | −3.5 | 0.30 |
One patient in the control group with missing education status was excluded from education sub-groups. State anxiety (anxiety concerning the current situation) measured by STAI-Y1 score. Subgroup analysis was performed by older (age ≥ 70) versus younger (age < 70), high-education (postsecondary education, years of school > 12) versus low-education (no postsecondary education, years of school ≤ 12) and high-health literacy (METER score ≥ 35) versus low-health literacy (METER score < 35). This cutoff was chosen for health literacy because previous literature demarcated a METER score of 35 as an appropriate cutoff for functional health literacy.16 Bonferroni correction was applied, with a threshold of P < 0.017 considered statistically significant.
Discussion
In recent years, video supplementation has been found to improve patient experience and satisfaction for various surgical procedures outside of ophthalmology [17–19]. In the ophthalmic literature, patient retention of verbal and written information related to cataract surgery complications has been previously demonstrated to be poor on the day of surgery [20]. Our study examined the efficacy of the 2015 AAO cataract surgery patient education video when used as a complementary tool for the informed consent process in regards to both information retention and patient anxiety at multiple time points.
The results of our study suggest that video supplementation improved patients’ understanding of cataract surgery on the day of surgery. It also remained higher one week after surgery, which has not been previously demonstrated and is especially important. After surgery, patients must understand proper postoperative care and be aware of potential postoperative complications. The video group did not score significantly higher than the control group preoperatively. This could be due to several reasons. First, many patients were dilated prior to watching the video which may have limited the effectiveness of the first viewing. Also, it is possible that patients did not have enough time to digest and understand the video prior to taking the quiz since it was administered during the same preoperative appointment shortly after watching the video. Lastly, this finding could simply represent a false negative result since it was on the borderline of statistical significance (P = 0.07).
In the per-question analysis, question 6 was answered correctly by the video group at a significantly higher rate than the control group on the day of surgery and the postoperative visit (Table A1). Question 5 showed a similar pattern on the day of surgery and at the postoperative visit. These questions relate to how cataract surgery is performed and when it is appropriate to consider cataract surgery, respectively. Significant improvements on questions 3, 10 and 12 were demonstrated on the day of surgery. Question 3 asked about risk factors for cataract development and questions 10 and 12 asked about the rates of complications or worsening of vision after surgery. These trends suggest that the control group overestimated the frequency of poor surgical outcomes that were corrected by the video.
In addition to assessing information retention, we also assessed anxiety. With every intervention that can provide benefit to the patient, providers must also monitor for unintended negative effects. One theoretical concern of video supplementation is possible worsening of patient anxiety due to further emphasis of potential complications. In this study, we found that watching the video helped educate patients without adding unnecessary stress or feelings of discomfort. On the day of surgery when patients were most anxious, watching the video alleviated anxiety (Table 2).
Per our subgroup analysis, identified trends suggest that older, low-education, and low-health literacy populations may receive more benefit than younger, high-education and high-health literacy populations from viewing the video at all timepoints. One notable exception was the health literacy analysis where the low-health literacy video group and control group had the two lowest mean retention scores of any subgroup (Table 3). However, low-health literacy subjects who saw the video improved their retention score to 11.0 by the day of surgery while those who did not scored an average of 7.3. This suggests that the second video viewing on the day of surgery is especially beneficial to low-health literacy patients. In addition, low-health literacy patients may need more time with the educational material, so the video’s effect on score was seen at the day of surgery timepoint and not the preoperative timepoint.
When obtaining informed consent, practitioners should be motivated to educate patients in such a manner that their functional health literacy level (FHLL) is at an adequate level prior to signing the consent form. Patients with higher education levels may naturally have a high FHLL and therefore surgeons should be particularly interested in improving FHLL in lower education patients in the perioperative period. We noted a trend that patients with low-education levels in the video group scored higher than their counterparts in the control group, indicating that viewing the video improved FHLL in patients with lower education. Also, the video’s effect size was consistently greater in the low-education subgroup than the high-education subgroup (preoperative ES = 1.4 vs 0.6, day of surgery ES = 3.7 vs 2.0, postoperative ES = 2.5 vs 1.3). Patients with a high-education level in both groups scored high on the preoperative surveys, suggesting that the traditional verbal and written education process is sufficient and multimedia supplementation may have minimal additional value. The video may have greater educational value in participants without postsecondary education since it provides information primarily in visual and audio form where there is less reliance on reading comprehension.
One limitation of this study is that we did not assess patient satisfaction in the video group with a validated instrument. Given the additional time to watch the video, we could have studied whether patients in the video group felt that the time spent to watch the video was worthwhile. Moreover, practitioners may feel that the additional time required to watch the video may negatively impact clinic workflow and it is unclear if showing the video twice would be clinically feasible. One solution may be to have ancillary staff show patients a multimedia video during the wait time between initial workup and physician examination and then proceed with the customary verbal and written patient education process.
Another weakness of this study is the fact that the discussion with the surgeon and perusal of the brochure was not standardized, though this is more representative of actual clinical practice. As would be expected in customary clinical practice, patients had varying levels of questions in regards to cataract surgery. All patient questions were answered during the face-to-face discussion, including questions regarding to risks, benefits and alternatives to surgery. It is possible that information relevant to quiz questions came up during discussion with some patients but not others. Also, while all patients were handed the educational brochure, we did not require patients to read it prior to survey administration.
Another limitation was while we excluded patients who were healthcare workers or whose spouses had undergone cataract surgery, we could not account for other family members or friends who may have positively or negatively impacted patients’ information retention or anxiety, especially after the initial visit. In addition, patient retention scores may have been positively or negatively impacted from exposure to other multimedia information about cataract surgery that is available on the internet. We also limited this study to first-eye cataract surgery patients as we did not want experiences from prior cataract surgery to affect retention and anxiety scores. Future studies may choose to assess whether video supplementation is useful for second-eye cataract surgery patients as well.
Whereas previous studies have shown the ability of multimedia supplementation to improve patient education prior to cataract surgery, we believe that the novelty of our study lies in assessing information retention and anxiety levels preoperatively through the day of surgery and then postoperatively [5, 9, 11]. None of these studies tested the effects of video supplementation at multiple timepoints [5, 9, 11]. Of these three studies, only Tipotsch-Maca, et al. examined effects on anxiety and found no difference with multimedia supplementation. While previous studies show an immediate improvement in retention scores, our study is the first to demonstrate a sustained improvement in patient understanding after multimedia supplementation. Furthermore, while a previous edition of the AAO’s patient education video was examined by Shukla, et al., our study uses a video that is more recent and a quarter of the length with a runtime of four minutes [9]. The AAO’s 2015 video is shown here to be effective yet short, allowing for easier integration into a clinic’s workflow. In addition, this study is also the first randomized controlled trial to demonstrate the ability of video supplementation to be particularly effective in improving FHLL in patients at high risk of being improperly consented and making uninformed medical decisions, namely patients without postsecondary education and those with poor health literacy. Lastly, to the best of our knowledge, our results are the first to support the notion that video supplementation can reduce patient anxiety on the day of surgery.
In conclusion, the 2015 AAO patient education video, which is part of a commercially available package, is a useful supplementary tool that can be used by cataract surgeons to improve information retention at multiple timepoints and decrease patient anxiety on the day of surgery. Surgeons may consider using this video to supplement and customize their individual informed consent processes to better serve the needs of their cataract surgery patients.
Supplementary Material
Fig A1 Informational brochure provided to video and control groups at the preoperative visit, with size scaled down 75%.
Fig A2 Twelve-question multiple-choice information retention quiz [9].
Fig A3 Medical Term Recognition Test (METER) administered to assess health literacy [16].
Funding:
This study was funded by The University of Chicago Pritzker School of Medicine, Chicago, IL, USA. The sponsor or funding organization had no role in the design or conduct of this research.
Table A1.
Absolute count and percentage of subjects in the video and control groups who correctly answered information retention questions at preoperative, day of surgery and postoperative timepoints
| Preoperative visit | Day of surgery | Postoperative visit | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Video group | Control group | P value | Video group | Control group | P value | Video group | Control group | P value | |
| % | % | % | % | % | % | ||||
| Q1 | 97.5% | 100.0% | 0.32 | 100.0% | 100.0% | − | 97.3% | 94.7% | 0.57 |
| Q2 | 92.5% | 97.4% | 0.98 | 97.3% | 95.0% | 0.60 | 100.0% | 100.0% | − |
| Q3 | 37.5% | 53.9% | 0.21 | 97.3% | 50.0% | <0.001 | 78.4% | 47.4% | 0.006 |
| Q4 | 85.0% | 92.3% | 0.69 | 94.6% | 95.0% | 0.94 | 94.6% | 97.4% | 0.54 |
| Q5 | 67.5% | 51.3% | 0.08 | 86.5% | 45.0% | <0.001 | 97.3% | 60.5% | <0.001 |
| Q6 | 62.5% | 33.3% | 0.005 | 67.6% | 27.5% | <0.001 | 83.8% | 47.4% | 0.001 |
| Q7 | 66.5% | 56.4% | 0.021 | 97.3% | 85.0% | 0.06 | 94.6% | 86.8% | 0.25 |
| Q8 | 60.0% | 64.1% | 0.93 | 97.3% | 90.0% | 0.19 | 94.6% | 73.7% | 0.014 |
| Q9 | 62.5% | 56.4% | 0.41 | 91.9% | 67.5% | 0.008 | 91.9% | 81.6% | 0.19 |
| Q10 | 70.0% | 61.5% | 0.27 | 94.6% | 50.0% | <0.001 | 78.4% | 60.5% | 0.09 |
| Q11 | 60.0% | 53.9% | 0.42 | 91.9% | 80.0% | 0.14 | 91.9% | 81.6% | 0.19 |
| Q12 | 75.0% | 66.7% | 0.24 | 100.0% | 52.5% | <0.001 | 86.5% | 68.4% | 0.06 |
Bonferroni correction was applied, with a threshold of P < 0.004 considered statistically significant.
Table A2.
Effect size of video supplementation after stratification by age, health literacy and subgroups.
| Retention Score | |||
|---|---|---|---|
| Preoperative | Hedge’s g | Lower bound | Upper bound |
| Older | 0.37 | −0.40 | 1.15 |
| Younger | 0.38 | −0.22 | 0.97 |
| High Education | 0.27 | −0.35 | 0.90 |
| Low Education | 0.60 | −0.09 | 1.30 |
| High Health Literacy | 0.40 | −0.09 | 0.88 |
| Low Health Literacy | 0.24 | −1.25 | 1.74 |
| Day of Surgery | |||
| Older | 1.76 | 0.84 | 2.68 |
| Younger | 2.05 | 1.32 | 2.79 |
| High Education | 1.39 | 0.69 | 2.09 |
| Low Education | 3.24 | 2.19 | 4.28 |
| High Health Literacy | 1.88 | 1.30 | 2.46 |
| Low Health Literacy | 2.82 | 0.53 | 5.12 |
| Postoperative | |||
| Older | 1.26 | 0.40 | 2.12 |
| Younger | 0.87 | 0.23 | 1.51 |
| High Education | 0.75 | 0.09 | 1.41 |
| Low Education | 1.52 | 0.73 | 2.31 |
| High Health Literacy | 0.98 | 0.46 | 1.50 |
| Low Health Literacy | 2.33 | 0.21 | 4.45 |
Effect size is reported as Hedge’s g with 95% confidence interval.
Footnotes
Conflict of interest: The authors declare that they have no conflict of interest.
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent: Informed consent was obtained from all individual participants included in the study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Fig A1 Informational brochure provided to video and control groups at the preoperative visit, with size scaled down 75%.
Fig A2 Twelve-question multiple-choice information retention quiz [9].
Fig A3 Medical Term Recognition Test (METER) administered to assess health literacy [16].