The value of a routine interview as the preanesthetic visit and preoperative preparation technique has been called into question, and an increasing number of studies have addressed the effectiveness of media-based interventions (1–4). In this context, patient satisfaction and information gain are important variables in the comparison of different methods for conducting the preanesthetic visit.
This is the first study to compare face-to-face interview, brochure plus interview, and documentary video plus interview with regard to preoperative preparation for anesthesia in elective surgical patients. For this purpose, patient satisfaction and information gain were tested (5–9) for each technique of conducting the preanesthetic visit with a specially developed written questionnaire (10–14).
After we received approval from the institutional ethics committee and informed consent from the patients, all adult patients were included who were scheduled to undergo elective surgery with general anesthesia with a single anesthesia provider and who required intubation of the trachea and mechanical ventilation during a 3-mo period in the year 2000. Patients were excluded when a postoperative stay in the intensive care unit was expected, when repeated general anesthesia had been performed in the previous 6 mo, if the ASA classification was more than III, and when there were pronounced cognitive and/or speech barriers (if a patient was not oriented to person, time, or place or if he/she had any difficulties in speaking fluently, e.g., because of language problems, dementia, or laryngectomy). The study was conducted as a randomized, prospective trial.
To evaluate patient satisfaction and information gain after different methods of conducting the preanesthetic visit, a special questionnaire was developed and validated after a pretest (published elsewhere) (15). The questions on patient satisfaction were assessed on a six-point scale, and those on information gain were assessed on a multiple-choice basis. The questionnaire was to be answered the day before surgery after the preanesthetic interview but before the administration of any premedication. Patients were randomly allocated to one of the three techniques by a computer-generated procedure with initially equal group sizes. If allocated to the interview technique, the patient was seen by an anesthesiologist in the routine preanesthetic visit. If allocated to brochure and interview, the patient received the brochure “General Anesthesia: An Information Guide” (16) and was asked to read the booklet before the preanesthetic visit. If allocated to video and interview, the patient was shown the documentary video (Videorecording Leroudier, Ginsheim, Germany) on portable video equipment presented by a medical student before the preanesthetic visit. Afterward, each patient received a questionnaire and was asked to answer all questions without assistance from anyone.
The preanesthetic visit by an anesthesiologist is of major importance for informing the patient adequately about anesthesia and is required before any elective surgery (informed consent). Therefore, the brochure or video techniques can be conducted only in combination with an interview. The anesthesiologist explained to each patient individually the perioperative course of anesthesia. The brochure “General Anesthesia: An Information Guide” is a 30-page booklet that describes the course of anesthesia. All explanations are illustrated and can be easily understood. A 6-min documentary video was produced for this study which presented the topics of the brochure “General Anesthesia: An Information Guide,” as well as the guidelines of the German Society of Anesthesiology and Intensive Medicine. The video shows the standard perioperative course of anesthesia: preanesthetic visit by the anesthesiologist, premedication medicine and fasting, transport to the operating room, IV cannulation, oxygen mask, anesthesia induction, tracheal intubation and mechanical ventilation, maintenance of anesthesia, extubation, recovery room and monitoring, nausea and vomiting, and postoperative pain therapy. All patients received the same type of information; this was ensured by the anesthesiologists in the interview and by the video, which was based on the contents of the written brochure.
The questionnaire consists of two parts. Part 1 contains five specific questions and one global question on patient satisfaction with the preanesthetic visit, expressed as antonymic pairs of statements. The degree of patient satisfaction can be expressed on a six-point scale. The questions on patient satisfaction were as follows: 1) the preanesthetic visit took place under time pressure; 2) the explanations could be understood easily; 3) some of my questions were not answered during the preanesthetic visit; 4) after the preanesthetic visit, I was informed about the procedure of anesthesia; 5) the form of the preanesthetic visit should have been clearer; and 6) I was content with the preanesthetic visit.
The second part of the questionnaire consists of six specific questions on information gain with the technique. They are expressed as multiple-choice questions with four response possibilities from which the appropriate one has to be marked in a tick box. The questions on information gain are as follows: 1) What is an anesthesiologist (answers: A nurse? A doctor [correct answer]? A medical technician? I don’t know/I cannot remember)? 2) Where is the anesthesiologist staying during your operation (answers: He is with me all the time to check my vital signs [correct answer]. He leaves the operating room as the surgeon is monitoring the anesthesia. He is looking after several patients at a time. I don’t know/I cannot remember)? 3) How do you breathe during general anesthesia (answers: I am mechanically ventilated by a tube [correct answer]. I am breathing normally. During surgery I don’t need to breathe. I don’t know/I cannot remember)? 4) What do you know about strong pain after surgery (answers: Severe pain can be prevented [correct answer]. Severe pain is a necessary part of recovery. Severe pain has to be endured. I don’t know/I cannot remember)? 5) What is true about the duration of anesthesia (answers: The duration of anesthesia is determined before surgery and cannot be altered thereafter. The duration of anesthesia can be prolonged as desired during surgery [correct answer]. The duration of anesthesia cannot be predicted or be influenced. I don’t know/I cannot remember)? 6) Why can’t you eat or drink before anesthesia (answers: So that the anesthesia can take effect. To thicken the content of the stomach. To prevent the contents of the stomach getting into the lungs [correct answer]. I don’t know/I cannot remember)? Furthermore, the questionnaire contained one question on the number of prior procedures under general anesthesia.
To compare patient satisfaction with the three techniques, the grading of the questions (from −3 to +3) was assigned one to six points in the database as follows: −3, one point; −2, two points; −3, three points; +1, four points; +2, five points; and +3, six points. To create a total point sum score to measure patient satisfaction in case of negatively formulated questions, the grading was inverted: −3, six points; −2, five points; −1, four points; +1, three points; +2, two points; and +3, one point. Thus, the sum score “patient satisfaction” could reach values between a minimum of 6 and a maximum of 30 points. In the questionnaire part “information gain,” each correct answer was assigned one point, whereas wrong answers or the response “I don’t know/I cannot remember” received no points. By adding the points of the sum score “information gain,” values between a minimum of zero and a maximum of six points could be achieved.
For data analysis, descriptive statistics were assessed with Microsoft Excel XP. For further statistical analyses, SAS Version 8.1 for Windows and WinStat for Microsoft Excel were used. The primary outcome variables of this study were patient satisfaction and information gain. For ordinal data and/or scores, nonparametric tests were applied. Possible differences in continuous variables or scores in the three groups were tested with the Kruskal-Wallis test. Pairwise data or variables were compared by using Wilcoxon’s ranked sum test. Categorical data and variables were tested with Fisher’s exact test. The effect of various independent variables (age, sex, method of preanesthetic visit, type of surgery, number of previous surgeries, and duration of preanesthetic visit) on the maximum sum score of patient satisfaction and information gain was tested with Spearman’s correlation test. P ≤ 0.05 was considered statistically significant (β-error = 0.1). Because no studies are available on the sum scores for patient satisfaction and information gain, no already-established cutoff for the relevant increase in the point scores could be used. Therefore, we assumed that a difference of two points in the sum score would reflect a relevant improvement in one preanesthetic technique compared with the others. Because 3 methods were compared, at least 51 patients per group would have been necessary to test for patient satisfaction, and at least 15 patients per group would have been necessary to test for information gain (Bonferroni).
The study population included 284 patients: 95 in the interview group, 95 in the brochure group, and 94 in the video group. Twelve patients were excluded because the brochure had not been read, and this left 272 patients. Thus, the number of patients in the brochure group was reduced to 83. There were no significant intergroup differences in demographic data.
The results for each question (Questions 1–6) of the first questionnaire part are shown in Table 1. The maximum total sum scores “satisfaction” were significantly different among the three techniques (P < 0.001; Fisher’s exact test; Table 2). In the interview group, 41.3% reached the sum score of 30 points; in the brochure group, 56.1%; and in the video group, 80.0%. The patients of the interview group reached the smallest percentage of the possible maximum sum score, whereas the patients of the video group reached the largest percentage (Table 2). The analysis of independent variables showed that only the method of preanesthetic visit exerted a significant effect on patient satisfaction (P = 0.001).
The results for each question (Questions 7–12) of the second questionnaire part are presented in Table 3. The question “number of previous surgeries under general anesthesia” did not show any statistically significant differences among the three groups (P = 0.3692; average of three previous surgeries). The maximum total sum score was significantly different among the three techniques (P < 0.001; Fisher’s exact test; Table 2). In congruence with the observations in patient satisfaction, the video group reached the largest percentage of the possible maximum sum score in information gain, and the smallest percentage was seen in the interview group. In the analysis of independent variables, age yielded a significant correlation with the maximum sum score (P ≥ 0.0001). In addition, the sum score information gain in the subgroups men and women was compared with the independent variables and showed for age a significant P value of 0.0023 (Spearman’s correlation coefficient, 0.28861) in men and a P value of <0.001 (Spearman’s correlation coefficient, 0.499) in women. The number of prior surgeries did not show a significant correlation with the maximum sum score information gain.
This study was designed to compare three different methods of conducting the preanesthetic visit. The video group showed the highest percentage of the possible maximum sum point score in patient satisfaction and in information gain, followed by the patients of the brochure group and the interview group, who reached the smallest percentages. The maximum sum scores in patient satisfaction and information gain were significantly different between the interview and the video groups and the brochure and video groups, but not between the interview and the brochure groups. Thus, the results of this study suggest that routine use of the documentary video plus interview might be implemented as the method of conducting the preanesthetic visit for elective surgical patients.
Because numerous investigations agree that the interview alone is an insufficient technique for the preanesthetic visit (5,17,18), alternative complementary methods have been focused on. Few previous investigations have examined the effect of preoperative media-based patient education on satisfaction and information gain (1,2). The analysis of patient satisfaction is continuously gaining importance in anesthesiology (6,19–21), particularly because an enhanced level of dissatisfaction might be correlated with an increased number of postoperative complications (18,22). Several authors have described the value of a written questionnaire for a standardized evaluation of patient satisfaction with the preanesthetic visit (10,14,21). A six-point scale ensures a clear measure of the level of satisfaction, because no middle category can be marked; this leads to good selectivity (14,23). The overall degree of satisfaction was high in our study, which is in agreement with an investigation by Myles et al. (18), who addressed satisfaction after anesthesia. One explanation for this high level of satisfaction could be that the patients’ responses might be modified to please the staff; the under-presentation of the true level of dissatisfaction is probably less in a written questionnaire but might still remain as a systematic error. Courtney (24) and Lee et al. (1) showed that patient satisfaction is not altered by a booklet about anesthesia, whereas Bellew et al. (23) demonstrated that the use of a brochure is superior to the interview alone. The use of a brochure depends on the patient’s active collaboration and cognitive abilities (25), and this might be a reason why the differences in the sum score of patient satisfaction were higher in the brochure group than in the interview group but did not reach significant levels. The documentary video has been shown in former studies (26) to be a useful technique in conducting the preanesthetic visit. The video is a well accepted medium that does not require the patient’s active collaboration and, thus, ensures good compliance. In our video, all perioperative sequences are shown at their original locations. On the day of surgery, patients recognize the setting, and this helps to diminish stress (23,27). Thus, our findings demonstrated a lack of satisfaction with the preanesthetic visit conducted by interview only or interview plus brochure, whereas the video plus an interview significantly enhanced patient satisfaction.
Information gain after the preanesthetic visit has been focused on in several previous studies (1,2,5,9,23,24). In our study, 30% of the patients in the interview group reached the maximum score of information gain, as did 45% in the brochure group and 73% in the video group. In agreement with our observations on Question 7 (What is an anesthesiologist?), Van Wijk and Smalhout (28) confirmed that only 81% of the patients in the interview group answered that an anesthesiologist is a medical doctor. Also, question 8 (Where is the anesthesiologist during your operation?) showed results similar to a study by Deusch et al. (9). Questions 9 and 10 (How do you breathe during anesthesia? What do you know about strong pain after surgery?) showed the worst results in all of the three information strategies. A deficit in providing information in this field is especially disadvantageous because postoperative pain therapy is one of the major concerns of patients (29). In contrast, sufficient information about pain management can positively influence pain perception. Question 11 (What is true about the duration of anesthesia?) revealed the greatest differences among study groups: whereas 98% of the video group responded to this question correctly, only 81% of the patients in the brochure group and 64% in the interview group could give the right answer. Question 12 (Why can’t you eat or drink before anesthesia?) was answered correctly most frequently in the video group. Incorrect responses in these fields imply that the purpose of informed consent has been defeated. However, our findings and those of other studies demonstrate that the use of a brochure (1,3,4,23) and, especially, the use of a video (1,2) could further improve information gain.
Additionally, a highly significant negative correlation of the age variable with the sum score was revealed, thus demonstrating that an older patient is less likely to reach a maximum sum score. Older female patients especially showed less information gain than younger patients. These results have been reported previously (30). Thus, the video and brochure techniques are promising instruments for information gain in the preanesthetic visit, especially in young patients (13). The deficit in the patient satisfaction and information gain variables retrospectively shows the necessity of conducting investigations such as this one.
Although the study confirms the benefit of a video compared with an interview alone for the preanesthetic visit, its design has several inherent limitations. The study concept ensured that all patients were reached by the assigned technique (exclusion of nonreaders of the brochure and individual video presentation). However, when the study results are transferred to clinical routine, a certain percentage of nonreaders of the brochure and of nonviewers of the video might have to be taken into consideration. Moreover, patient satisfaction and information gain were not assessed after surgery. This should be considered in future studies. Finally, to evaluate the economic benefit of the different methods, a cost-utility analysis would be helpful (31).
In summary, this study suggests that the use of a documentary video to supplement a patient interview during the preanesthetic visit may be a more effective technique than a brochure or personal interview alone for conveying information to patients undergoing elective surgery.
1. Lee A, Chui PT, Gin T. Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions. Anesth Analg 2003;96:1424–31.
2. Done ML, Lee A. The use of a video to convey preanesthetic information to patients undergoing ambulatory surgery. Anesth Analg 1998;87:531–6.
3. Thomas DM, Ray SM, Morton FJ, et al. Patient education strategies to improve pneumococcal vaccination rates: randomized trial. J Investig Med 2003;51:141–8.
4. Murphy PW, Chesson AL, Walker L, et al. Comparing the effectiveness of video and written material for improving knowledge among sleep disorders clinic patients with limited literacy skills. South Med J 2000;93:297–304.
5. Swinhoe CF, Groves ER. Patients’ knowledge of anaesthestic practice and the role of anaesthetists. Anaesthesia 1994;49:165–6.
6. Zastowny TR, Stratmann WC, Adams EH, Fox ML. Patient satisfaction and experience with health services and quality of care. Qual Manag Health Care 1995;3:50–61.
7. Shevde K, Panagopoulos G. A survey of 800 patients’ knowledge, attitudes, and concerns regarding anesthesia. Anesth Analg 1991;73:190–8.
8. Hume MA, Kennedy B, Asbury AJ. Patient knowledge of anaesthesia and peri-operative care. Anaesthesia 1994;49:715–8.
9. Deusch E, Weber T, Libal G, et al. Patient knowledge concerning anesthesia general practice and the responsibilities of the anesthesist. Anästhesiol Intensivmed Notfallmed Schmerzther 1996;31:409–13.
10. Fung D, Cohen MM. Measuring patient satisfaction with anesthesia care: a review of current methodology. Anesth Analg 1998;87:1089–98.
11. Bauer M, Böhrer H, Aichele G, et al. Measuring patient satisfaction with anaesthesia: perioperative questionnaire versus standardised face-to-face interview. Acta Anaesthesiol Scand 2001;45:65–72.
12. Zvara DA, Nelson JM, Brooker RF, et al. The importance of the postoperative anesthetic visit: do repeated visits improve patient satisfaction or physician recognition? Anesth Analg 1996;83:793–7.
13. Bauer M, Bach A. Legal framework for hospital financing: development and consequences. Anaesthesist 1999;48:417–27.
14. Dexter F, Aker J, Wright WA. Development of a measure of patient satisfaction with the monitored anesthesia care: the Iowa Satisfaction with Anesthesia Scale. Anesthesiology 1997;87:865–73.
15. Snyder-Ramos SA, Seintsch H, Böttiger BW, et al. Development of a questionnaire to assess the quality of the premedication visit. Anaesthesist 2003;52:818–29.
16. Martin E. Allgemein-Anästhesie: Narkose, Ein Wegbegleiter [company brochure]. Hamburg, Germany: GlaxoWellcome, 1998.
17. Kratz A. Preoperative education: preparing patients for a positive experience. J Post Anesth Nurs 1993;8:270–5.
18. Myles PS, Williams DL, Hendrata M, et al. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10811 patients. Br J Anaesth 2000;84:6–10.
19. Bauer M, Weber W, Bach A. Cost control in the hospital: an introduction to cost and performance management. Anaesthesist 1999;48:910–6.
20. Whitty PM, Shaw IH, Goodwin DR. Patient satisfaction with general anaesthesia: too difficult to measure? Anaesthesia 1996;51:327–32.
21. Bothner U, Schwilk B, Steffen P, et al. Perioperative monitoring of the course of anesthesia, the postanesthesia visit and inquiry of patient satisfaction: a prospective study of parameters in process and outcome quality in anesthesia. Anästhesiol Intensivmed Notfallmed Schmerzther 1996;31:608–14.
22. Tong D, Chung F, Wong D. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology 1997;87:856–64.
23. Bellew M, Atkinson KR, Dixon G, Yates A. The introduction of a paediatric information leaflet: an audit of its impact on parental anxiety and satisfaction. Paediatr Anaesth 2002;12:124–30.
24. Courtney MJ. The effect of a preanaesthetic information booklet on patient understanding and satisfaction. N Z Med J 1997;110:212–4.
25. Gillies MA, Baldwin FJ. Do patient information booklets increase perioperative anxiety? Eur J Anaesthesiol 2001;18:620–2.
26. Sykes MK. Recognition of the anaesthetist. Anaesthesia 1995;50:381–2.
27. Cassady JF Jr, Wysocki TT, Miller KM, et al. Use of a preanaesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999;88:246–50.
28. Van Wijk MG, Smalhout B. A postoperative analysis of the patient’s view of anaesthesia in a Netherlands’ teaching hospital. Anaesthesia 1990;45:679–82.
29. Lonsdale M, Hutchison GL. Patients’ desire for information about anaesthesia: Scottish and Canadian attitudes. Anaesthesia 1991;46:410–2.
30. Smits CH, Deeg DJ, Kiegsman DM, Schmand B. Cognitive functioning and health as determinants of mortality in an older population. Am J Epidemiol 1999;150:978–86.
© 2005 International Anesthesia Research Society
31. Russell LB, Gold MR, Siegel JE, et al. The role of cost-effectiveness in health and medicine: Panel on Cost-Effectiveness in Health and Medicine. JAMA 1996;276:1172–7.