Cataract surgery is the most frequently performed operation in developed health economies.1 Patient anxiety surrounding all surgery is well recognized. Previous studies have reported high levels of anxiety amongst preoperative patients, and have attempted to quantify this through the use of a questionnaire.2,3 Most of these studies relate to experiences before the administration of an anesthetic or general surgery, but anxiety in patients attending for cataract surgery has also been documented.4 A study by Morrell5 showed that information regarding the safety of cataract surgery could reduce patient anxiety. Furthermore, providing information on the procedure itself as well as risks, benefits, and alternative options are all required as part of the informed consent process.6 However, given that such large numbers of cataract operations are performed annually, delivering high-quality individual preoperative patient counseling places strain on clinicians’ time. The quality of verbal information provision is dependent on the commitment and communication skills of the physician concerned, which can be dampened by the reality of a busy clinical environment,7,8 and previous studies have shown poor information retention after clinic appointments in preoperative cataract surgery patients.9,10 Therefore, there is a need for efficient, standardized methods of delivering the necessary information to patients.
Videos are a practical method for providing preoperative information in a standardized, reproducible manner. Research has shown that a multimedia-assisted delivery of information to patients improves their retention, with videos leading to better outcomes on knowledge questionnaires than face-to-face verbal and leaflet information provisions.11,12 A study by Shukla et al.11 demonstrated that a videotape presentation, in conjunction with an information sheet at a low reading grade level, showed increased understanding of the risks and benefits of cataract surgery. In a study by Pager,13 patients were allocated to view either an “anatomy” video or an “expectations” video in cataract surgery. Patients who watched the expectations video were found to be more satisfied after the surgery than those in the anatomy group.
With cataract surgery being the most frequently performed ophthalmologic operation,14 the presence of such a simple intervention to potentially reduce anxiety levels for such a large number of patients represents an important opportunity for healthcare providers to improve the service they offer. Videos have the added advantage of being able to show patients information in a way that is not possible verbally. For example, giving a virtual-guided tour of an operating theater or including patient testimonials from previous cataract surgery patients describing their experiences.
Previous studies have evaluated the use of videos as a way of delivering information to patients undergoing surgery and outpatient procedures, assessing the effect this has on overall anxiety. A randomized trial of women attending for colposcopy15 found significantly less anxiety in the intervention group that was presented with a preoperative explanatory video. A study of preprocedure colonoscopy patients16 found significantly less anxiety in patients receiving a preprocedure information video compared with those who did not. Lee et al.17 also showed that anxiety related to anesthesia was reduced with a media-based intervention.
Despite cataract surgery being the most frequently performed surgery worldwide, and the well-recognized positive impact of preoperative information videos in various surgical settings, there is a dearth of literature exploring the effect of such videos on preoperative anxiety levels in elective cataract surgery. This research aimed to assess whether a cataract surgery patient-information video has an effect on patients’ preoperative anxiety levels.
Patients and methods
This prospective comparative study based at a hospital in West Yorkshire, United Kingdom, collected data on 200 patients undergoing their first, elective, age-related cataract surgery over a 3-month period, June to August 2015. Because of the opportunistic nature of the study, a formal ethical committee approval was not required; however, full regard was paid to the tenets of the Declaration of Helsinki.
This study focused on the evaluation of the effect of a video that was created by two of the study authors (K.A., J.B.) to reduce preoperative anxiety levels for cataract surgery. The video was created using new material and importing material under accepted terms of fair usage. It includes an explanation of the process of routine phacoemulsification cataract surgery, and it features individual patients describing their cataract surgery experience. Subsequent to the study, the video was made available online.A
The inclusion criteria were all patients scheduled for routine age-related first-eye cataract surgery with the capacity to provide informed verbal consent and the ability to see, hear, and understand the video as well as be able to complete the questionnaire. The exclusion criteria were previous cataract surgery in the fellow eye, patients who did not consent, and those who were unable to complete the questionnaire.
The control group comprised 100 consecutive patients undergoing routine cataract surgery, who had not seen the video preoperatively. The measurement of preoperative anxiety in a control group was made possible by starting the evaluation before the video was ready for routine display to those undergoing cataract surgery. As an opportunistic evaluation of a health service intervention, and because of financial and practical constraints, the patients were not randomly assigned to the study groups. However, to ensure that the general baseline characteristics were as similar as possible, the inclusion criteria were used. Also, all participants were from the same study population because they had attended the same hospital for routine surgery.
The intervention group constituted 100 consecutive patients who were shown the video preoperatively on the day of their surgery. Participants in the intervention group were shown the video on arrival to the ward before dilation. Both groups had the anxiety questionnaire scoring conducted by the researchers immediately prior to them leaving the ward to undergo elective day-case topical anesthetic cataract surgery. For comparability of the control and intervention groups, the patients’ age and sex were also recorded. Furthermore, the patients were recruited consecutively over a 3-month period, with no time gap between the control and intervention group because the completion of recruitment of 100 control patients coincided with the readiness of the video for preoperative display.
The Amsterdam Preoperative Anxiety and Information Score (APAIS) questionnaire involved three statements: “I am worried about the procedure,” “The procedure is continually on my mind,” and “I would like to know as much as possible about the procedure.” Each statement had 5-stage Likert scale responses graded from 1 (not at all) to 5 (extremely) to assess patient anxiety related to the procedure.
The visual analogue scale (VAS) score was labeled “not at all anxious” on the extreme left and “extremely anxious” on the extreme right. The patients were asked to mark how anxious they felt on the scale. The position of the mark was measured in millimeters with a range of 0.0 to 80.0 mm, where 0.0 mm meant the patient was not anxious at all and 80.0 mm meant the patient was extremely anxious.
The statistical analysis was conducted using SPSS software (version 22.0, IBM Corp.). The quantitative values are presented as means ± SD. An independent-samples t test was used to compare VAS anxiety scores between the two groups, whereas a Mann-Whitney U test was used to analyze categorical data generated from the Likert responses. A P value less than 0.05 was considered statistically significant.
Over a 3-month period, 200 patients (100 in the control group, 100 in the intervention group) were recruited. The mean age of the 88 men and 112 women was 74 years. The participants in the two groups were similar in terms of age and sex distribution (Table 1).
As an overall group, the t tests showed there was a significant difference between the mean VAS anxiety score of men (23.4 ± 20.8) and women (34.1 ± 26.9) (P < .001). On average, female patients were more anxious than male patients. The t tests also showed significant difference in the mean VAS anxiety scores between the control group and the intervention group (P < .001). Table 1 shows that patients in the control group were more anxious than those in the intervention group based on the mean VAS anxiety scores (P < .001). The Likert-scale responses to “I am worried about the procedure,” where a score of 1 meant not at all and a score of 5 meant extremely worried, also showed that patients in the control group were significantly more worried about the procedure than those in the intervention group (P < .001). The mode Likert-scale score to this statement was 3 in the control group compared with a mode score of 1 in the intervention group. Figure 1 shows the frequencies of each stage of the 5-stage Likert scale response to “I am worried about the procedure.” No patients in the video intervention group gave a rating score of 4 or 5 to this statement. The mode Likert-scale score for “The procedure is on my mind continually” was 1 (not at all) for both groups, with the majority of patients commenting that they had not thought about the surgery until the day of the procedure.
Comparisons of information needs based on responses to “I would like to know as much as possible about the procedure” showed there was no significant difference in Likert-scale scores between the two groups, with the mode score being 5 (extremely) for both groups: 34 (34%) of the 100 patients in the control group and 38 (38%) of the 100 patients in the intervention group. There was no association between VAS anxiety scores and how much information patients desired about the procedure; 86 patients (86%) and 96 patients (96%) in the control group and the intervention group, respectively, gave a Likert score of 3 or more.
This is the first study using standardized anxiety scores to investigate the potential role of a patient-information video, which includes patient testimonials, to reduce preoperative patient anxiety regarding cataract surgery. The positive result of a significant reduction in anxiety in patients who had been shown the video resonates with findings from other surgical specialties for which videos have been shown to reduce anxiety.15,16
This study involved a questionnaire based upon the APAIS and a VAS. The State Trait Anxiety Inventory (STAI) is often regarded as a gold standard questionnaire in assessing anxiety.18 However, it is a time-consuming assessment to perform, involving 40 self-report statements that are scored by the participant on a scale of 1 to 4, which makes it impractical in a high turn-over clinical environment such as most cataract surgery units. On the contrary, a VAS is a simple, quick measurement method that has been shown to correlate well with other measures of anxiety. VAS scores have been used widely with studies showing good validity, reliability, and correlation with the STAI. The APAIS has also been shown to correlate well with the gold standard STAI.19 Therefore, these were chosen as the main outcome measures for the study.18
Second-eye cataract operations were excluded to reduce the source of potential bias constituted by previous personal experience. However, we did not exclude or ascertain whether patients had a spouse or close relative who had undergone surgery; nor did we determine patients’ level of experience of previous ophthalmologic or nonophthalmologic operations. Furthermore, the educational level and occupational background of the patients was not recorded. Such factors could impact upon patients’ perceptions and their overall preoperative anxiety regarding cataract surgery; and further research into determinants of heightened anxiety would be of interest.
In terms of desire for information, both the control and intervention groups reported a high score; this suggests that despite in-clinic counseling, patients still wanted to receive more information. This resonates with findings from previous research that suggests patients (a) have low level of recollection of information given in the clinic7,14 and (b) want more information than they felt they received.20 Furthermore, studies have shown that the information provision is a substantial factor influencing overall patient satisfaction, with perceived lack of information correlating to poorer satisfaction outcomes.20–22 Subsequently, the use of a video informational tool can be crucial in improving patient understanding and recollection, reducing anxiety, and contributing to greater overall satisfaction. This is an important outcome because greater patient satisfaction has been linked to greater compliance with follow-up appointments, medical advice, and treatments, thereby enhancing health outcomes.23,24
The desire for more information was also reflected in patients’ comments, “I looked on the Internet to try to find a video to tell you what’s involved in the procedure, but the video playing in the waiting room was exactly what I wanted to know.” In a technological age, many patients source information for themselves via the Internet. This raises the issue that sometimes the vast amounts of information available online can be difficult to filter and patients might be unable to judge the quality of the information without specialist knowledge, which could increase anxiety levels. A patient-information video routinely introduced into the surgical pathway could help overcome this challenge for patients.
On the contrary, there was a small minority of patients who did not want to know as much as possible about the procedure. It is possible that although the overall effect on the population is beneficial in reducing anxiety, for a small subgroup of patients, increasing the information provision can be overwhelming and anxiety provoking. Patient preference must be respected by providing information at a level, amount, and pace that is suitable for them. This might involve excluding video information if patients feel they have adequate detail and understanding from a face-to-face clinic discussion; instead, a leaflet with written information, which includes directions to the information video if they wish to watch it at a later date, could be provided.
Although this study demonstrates that a cataract surgery informational video can help reduce patient anxiety, caution should be exercised when extrapolating these results because the content of the video has a role to play in its impact on anxiety levels.13 The inclusion of actual patient testimonies, filmed in the same location as patients found themselves at the point of watching it, was felt to be beneficial. The video demonstrated that patients who were anxious before the procedure then went on to report various, generally positive experiences of surgery. One participant commented, “It is lovely to see how happy they all are after surgery even though they were so nervous before.” Thus, the informational video in this study mainly focused on the experience of patients attending for cataract surgery rather than specific surgical detail. Furthermore, there was an attempt to make the video as generic as possible in its description of a typical experience of cataract surgery. However, it could be that a similar video but with a different focus, such as on surgical detail, might provide different results.
For this study, we did not create any differentiation in the video material in order to evaluate the specific effect of different aspects of content on anxiety levels. Further research, in particular, a randomized trial, could focus on variations of video content and timing of exposure to help create a custom-made video that can optimize the benefits of an improved patient-information provision. The outcomes could assess the effect of such a video on reducing patient anxiety, improving satisfaction, information recollection, and meeting the requirements for informed consent.
In summary, this study showed that a simple, time-efficient, and cost-effective informational and patient testimonial video could significantly reduce patients’ preoperative anxiety levels. This could help to improve overall patient experience and satisfaction by reducing anxiety and meeting information needs, which is an invaluable benefit for clinicians and patients given that cataract surgery is one of the most commonly performed procedures worldwide.
What Was Known
- Patients undergoing cataract surgery often report substantial preoperative anxiety.
- Patient-information videos are a standardized, efficient way of delivering information and can help increase the level of information retention better than that retained after a verbal briefing alone or verbal briefings with a supplementary leaflet.
- Although multimedia approaches improve information retention, there is concern and controversy about how the use of videos affects anxiety levels.
- There is a dearth of literature on the effect of patient-information videos on preoperative anxiety levels in a cataract surgery setting.
What This Paper Adds
- Most patients undergoing their first elective cataract surgery had a desire for more information.
- Anxiety levels in first-eye cataract surgery patients can be significantly reduced by use of a patient testimonial and informational video.
- Such videos would be a beneficial addition to the surgical pathway because they are a simple cost-effective and time-effective standardized way of providing information.
- Further research is required, with an emphasis on video content and timing of exposure, to identify factors that can optimize the benefits of an improved patient-information provision.
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None of the authors has a financial or proprietary interest in any material or method mentioned.
Other Cited Material:
A. Leeds Centre for Ophthalmology. Patient Information: Your Cataract Operation. Available at: http://www.leedsth.nhs.uk/a-z-of-services/ophthalmology-eye-department/patient-information