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The purpose of this study was to evaluate the efficacy of a video versus that of a paper handout for explaining operative instructions for hand and upper extremity surgeries to patients. We aimed to compare patient performance using a knowledge-based questionnaire. In addition, we aimed to compare how helpful patients found their assigned operative instructions.
Methods
This was a randomized trial of 60 patients undergoing same-day hand and upper extremity surgeries. The patients were randomized to receive educational material outlining operative instructions, either in the form of a video link or a paper handout. At the first postoperative visit, the patients’ comprehension of the content was evaluated using a questionnaire. The primary outcomes included the number of questions answered correctly and patient-reported evaluation of the provided instructions on a scale of 1–5.
Results
Patients who received video instructions scored higher in the questionnaire than those in the paper instructions group (paper: 58% correct; video: 76% correct). Moreover, patients in the video group were significantly more likely to answer questions pertaining to opioid use correctly. A higher proportion of patients in the video group than in the paper group found the information “extremely” or “very” helpful.
Conclusions
This study found that the patients demonstrated greater comprehension of the operative instructions when these were administered in a video format than when these were administered as a printed handout. In particular, the results suggest that video-based education specifically improves patients’ comprehension of proper opioid use.
Clinical relevance
There appears to be utility in implementing videos for patient education purposes, particularly in the setting of operative instructions for same-day surgical procedures.
Each surgical procedure carries its own set of risks, and counseling of patients prior to surgery is an important component of surgical care. There is no standardized method by which patients can be best counseled regarding the risks of the operation, postoperative care, and pain management. The level to which patients fully comprehend and recall this important counseling is often unclear, and few studies have evaluated patients’ understanding of instructions following an orthopedic surgery.
The use of videos has been shown to enhance postoperative outcomes in the field of orthopedics.
Videos have been demonstrated to improve patients’ operative experience and allow them to retain more knowledge when used as an adjunct to preoperative consultation.
It has been documented that compared with verbal-informed consent, video-informed consent in patients undergoing knee arthroscopy results in improved patient comprehension, improved preoperative knowledge, and enhanced postoperative recall regarding the surgery being performed.
However, there is currently a paucity of literature exploring the use of operative instructions given in a video format for patients undergoing a hand or ambulatory surgery. The purpose of this study was to evaluate the efficacy of a video compared with that of a paper handout for explaining operative instructions for hand and upper extremity surgeries to patients. We aimed to compare patient performance using a knowledge-based questionnaire. In addition, we aimed to compare how helpful patients found their assigned operative instructions. We hypothesized that patients who receive instructions in a video format would perform better in the questionnaire and that patients would find video instructions more helpful.
Materials and Methods
Institutional review board approval was obtained prior to patient enrollment. The study was organized as a balanced (1:1 allocation) randomization study, which was conducted at a single institution by a single surgeon (B.K.). Patients were approached by a research assistant (A.T.) for recruitment in our outpatient specialty clinic. The inclusion criteria for subjects were as follows: age greater than 18 years; undergoing a same-day hand and upper extremity surgical procedure; speaking English; intact decision-making capacity; and access to technology, which is required to participate in this study, such as a cell phone to receive text messages and view the instructional video. Once eligibility was confirmed, patients were randomized to 1 of the 2 operative instruction modalities, either a video or a paper handout. Allocation was done using a computer-generated block randomization sequence, with the study surgeon blinded to patient allocation. Because of the nature of the material provided, it was not possible to blind the patients to allocation. To maintain surgeon blinding to patient allocation, patients were enrolled only on days when the research assistant was available.
In the first part of this study, all the patients had operative instructions explained to them by the study surgeon and his assistants. Patients in the control group were given a physical copy of the operative instructions at the time they booked their surgery in the office and again in the postanesthesia care unit after surgery. Those in the study group received a link, which provided access to a video on YouTube outlining the same operative instructions, via a text message at the same time points, ie, when they booked their surgery in the office and again in the postanesthesia care unit after surgery. The research assistant confirmed the receipt of the video and that the link was playable via a text message sent to the patient. Patients in both the groups were aware that they would be asked questions regarding the contents of the instructions. The patients had unlimited access to the video once they were provided the link. The video was less than 10-minutes long, and it was accessible by a computer, tablet, or cell phone. The content of the video and paper handout mirrored each other and consisted of general operative instructions, such as those about incision and dressing care, symptom monitoring, and pain management (Video 1; available online on the Journal’s website at www.jhandsurg.org). The instructional materials had a Flesch-Kincaid grade level of 8.6.
At the first postoperative visit, 10–14 days after surgery, the patients were given a questionnaire to evaluate their comprehension of the concepts that were outlined in the video or the handout. The questionnaire consisted of 10 multiple-choice questions on subjects such as how to care for the incision, how to safely manage pain with and without opioids, and the side effects of opioids (Fig. 1). The questionnaire had a Flesch-Kincaid grade level of 7.7. The patients were also asked to rate how helpful they found the information in the assigned instructions using an ordinal scale ranging from not at all helpful to extremely helpful, each associated with a numeric value (1 = not at all helpful, 5 = extremely helpful), how many times they viewed the instructions, and at what time point the instructions were the most helpful to read (before the procedure, at the surgical center, or after the procedure).
Figure 1The 10 multiple-choice knowledge-based questions that the patients were asked to respond to in the postoperative survey. The correct response to each question is bolded.
The primary outcomes included the number of questions answered correctly and patient-reported helpfulness of the material. The secondary outcome was the evaluation of the percentage of correct responses to each individual question. The sample size was estimated based on the percentage of correct responses obtained from a previous study comparing video and paper instructions, anticipating a medium effect size, and assuming equally sized study groups at an α value of 0.05 and a β value of 0.80.
Accounting for a 20% dropout, 60 patients (30 in each arm) were needed to be enrolled in the study.
For data analysis, mean and standard deviation were used for continuous variables and count and percentage were used for categorical variables. Calculations of 95% confidence intervals were performed for all the outcomes. The mean number of questions answered correctly for both the groups were compared using the Student t test. Questions that were left unanswered were considered incorrect for the purpose of statistical comparison. For secondary variables and baseline characteristics, statistical testing was performed based on the type of variable: the chi-square test for categorical variables and the Student t test (parametric) or Mann-Whitney U test (nonparametric) for continuous variables. For the ordinal variable of patient-reported helpfulness, the Mann-Whitney U test was used. A P value of <.05 was considered significant for all variables.
Results
The flow of patients throughout the duration of the study is summarized in Figure 2. A total of 80 patients were screened for the study, with 17 failing the screening process: 13 patients did not meet the inclusion criteria (including 11 because of not having a cellular device or computer capable of playing the video and 1 who did not understand English), and 4 patients refused enrollment. A total of 63 patients met the inclusion criteria and were randomized between June 2020 and September 2020. Three patients discontinued the study: 1 patient opted out because of loss of interest in the study and 2 because of cancellation of surgery. This left a total of 60 patients in the final analysis.
Figure 2Flow of study patients through the stages of the study. Discontinuation of intervention referred to patients who did not present to the 10–14-day postoperative visit to fill out the questionnaire. 1One patient discontinued the intervention because of cancellation of surgery. 2One patient discontinued the intervention because of loss of interest in the study, and 1 patient discontinued the intervention because of cancellation of surgery.
The patient baseline characteristics and procedures performed on the study patients between the video (n = 30) and paper handout (n = 30) groups are listed in Table 1.
Table 1Baseline Patient Characteristics
Baseline Patient Characteristics
Paper
Video
Age, mean ± SD, y
57.3 ± 14.4
54.3 ± 14.5
Sex, n (%)
Male
16 (53.3)
15 (50.0)
Female
14 (46.7)
15 (50.0)
Procedures, n (%)
Carpal tunnel release
9 (30.0)
6 (20.0)
Mass excision
7 (23.3)
8 (26.7)
Trigger finger release
6 (20.0)
4 (13.3)
ORIF hand
1 (3.33)
1 (3.33)
ORIF distal radius
1 (3.33)
2 (6.67)
Dupuytren disease excision
2 (6.67)
1 (3.33)
Implant removal
1 (3.33)
2 (6.67)
de Quervain release
0 (0.00)
2 (6.67)
Distal biceps repair
1 (3.33)
1 (3.33)
Cubital tunnel release
1 (3.33)
1 (3.33)
TFCC debridement
1 (3.33)
1 (3.33)
Mallet finger pinning
0 (0.00)
1 (3.33)
ORIF, open reduction internal fixation; TFCC, triangular fibrocartilage complex.
Table 2 describes the results of the questionnaire that the patients received. Patients randomized to receive video instructions scored higher in the questionnaire than those in the paper instructions group: 75.7% versus 58.3%, respectively (P < .05). Patients who received video instructions found that the materials were more helpful in explaining operative instructions than those who received paper instructions (P < .05). There were no differences between the 2 groups in terms of the number of times or the preferred time point when the material was read or viewed.
Table 3 describes the performance of both the groups on each individual knowledge-based question. The table displays the count and percentage of participants in each group who answered the questions correctly. Patients in the video group more frequently answered questions 9 and 10, questions regarding opioids, correctly (P < .05). Figure 3 represents the distribution of responses for each question between the paper and video groups.
Figure 3The distribution of responses for each question between the paper and video groups: The multiple-choice letters correspond to the answer choice as represented in Appendix E1 (available online on the Journal’s website at www.jhandsurg.org). The correct answer choice for each question is bolded. Q, question number.
Patient education is a critical part of a successful surgical outcome. Patients benefit from clear instructions regarding proper preoperative procedures leading up to surgery, information for caring for their postoperative wound, and counseling on pain management following surgery. Many surgeons use a variety of methods to educate patients regarding their care, ranging from informal verbal instructions to more structured video-based platforms, but often, paper instructions are a common source of instructions.
Prior studies have shown that using videos to provide instructions improves patients’ operative experience and allows for better knowledge retention compared with traditional methods.
found that following total knee arthroplasty, patients who were educated using an educational video in addition to an instructional handout demonstrated greater knowledge, performed postoperative exercises more regularly, and had better range of motion following surgery than a control group of patients who received an instructional handout alone. In a study by Hoppe et al,
it was found that patients who received a 10-minute video in addition to standard counseling by a surgeon answered questions testing their knowledge more accurately than a group of patients who did not receive video education. However, it should be noted that in this study, the questionnaire to assess patient recall was administered immediately after viewing the educational video.
Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
demonstrated that a multimodal education program consisting of a narrated video and a handout detailing the risks of narcotic abuse decreased the number of narcotic pills taken by patients after operation. Patients were also twice as likely to discontinue their narcotic use in the interval from 6 weeks to 3 months of follow-up than patients who received standard perioperative counseling.
Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
found that in the first 3 days after a total knee arthroplasty, the visual analog scale scores of the intervention group, which viewed the educational video, were lower than the scores of those who received routine verbal care.
In this study, it was found that patients who received video instructions performed better in the questionnaire than those who received paper instructions. Furthermore, patients in the video group found the material they received more helpful in explaining the operative instructions. The video group performed considerably better in questions 9 and 10, which pertained to opioids, suggesting that video instructions improved the patients’ comprehension of proper opioid use. This is consistent with prior studies, which have demonstrated that preoperative opioid counseling can reduce opioid consumption as well as improve patient satisfaction and pain scores.
Our results add to the growing body of literature that has shown that proper preoperative and postoperative education can improve patients’ understanding of opioids. They may also suggest a role for the use of instructional videos as an additional tool to be used by hand surgeons to reduce opioid misinformation.
Our study found that overall, the patients tended to incorrectly answer questions 5 and 8, questions on wound care and proper opioid use, respectively, more frequently than others. This was potentially the result of these difficult topics not being properly explained in the education materials provided. A study on the readability of patient education materials provided by the American Academy of Orthopedic Surgeons found that the mean reading level of the material available was approximately ninth grade.
Similarly, our institution’s operative instructions had an estimated reading level of 8.6. This is well above the American Medical Association- or National Institutes of Health-recommended sixth-grade reading level for patient education materials as well as the eighth-grade mean United States adult reading level.
Because proper patient education has been shown to be associated with improved patient outcomes, it is imperative that physicians ensure that the available education materials can be well understood by their patients.
Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
Our study suggests that there is still a need to optimize the language used in patient education materials used for patients undergoing hand and upper extremity surgeries.
There were limitations associated with our study design. The patients were aware that they would be asked questions regarding the instructions that they had received, introducing the possibility of a Hawthorne effect. The patients might have reviewed the instructions just prior to taking the questionnaire-based survey, potentially inflating their score. Another limitation is that the questionnaire used in this study had not been previously validated, introducing the possibility that the results of the questionnaire might not be broadly applicable. There is a possibility that the questionnaire was biased toward participants who received video instructions. This bias was minimized by displaying the same information in both the paper handout and video instructions and by blinding patient allocation. Further, information regarding patient literacy or education level was not collected as part of the study. If these factors were different between the patients in the 2 groups, they might have served as potential confounders; however, this should have been at least partially addressed via randomization. In this study, the reading level of the educational materials provided was above the mean reading level of the general population. If both the materials had been presented at the sixth-grade reading level, it is likely that the discrepancies between the 2 groups might have been less pronounced. Another potential bias was that the video was narrated by the same surgeon who performed the procedures on all the study subjects. The patients might have been more receptive to the content of the video because they were familiar with the voice of their physician, with whom they had a previously established level of comfort. A video produced by someone other than the patient’s own physician might potentially risk subverting the patient-physician relationship.
In conclusion, this study demonstrated the value of using video-based education to improve patients’ comprehension of preoperative and postoperative instructions for hand and upper extremity surgeries. It was found that implementing instructional videos into hand and upper extremity surgery practices can be an effective way to convey information to patients regarding preoperative and postoperative instructions.
Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial.
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