Informed consent in endoscopic sinus surgery: the patient perspective

Aids to improve understanding of statistical risk in patients consenting for surgery and interventional procedures: A systematic review

BACKGROUND

Informed consent is an essential process in clinical decision-making, through which healthcare providers educate patients about benefits, risks, and alternatives of a procedure. Statistical risk information is difficult to communicate and the effectiveness of aids aimed at supporting this type of communication is uncertain. This systematic review aims to study the impact of risk communication adjuncts on patients' understanding of statistical risk in surgery and interventional procedures.

METHODS

A systematic search was performed across Medline, Embase, PsycINFO, Scopus, and Web of Science until July 2021 with a repeated search in September 2022. RCTs and observational studies examining risk communication tools (e.g., information leaflets and audio-video) in adult (age >16) patients undergoing a surgical or interventional procedure were included. Primary outcomes included the objective assessment of statistical risk recall. Secondary outcomes included patient attitudes with respect to statistical information. Due to the study heterogeneity, a narrative synthesis was performed.

RESULTS

A total of 4348 articles were identified, and following abstract and full-text screening 14 articles, including 9 RCTs, were included. The total number of adult patients was 1513. The most common risk communication tool used was written information (n = 7). Most RCTs (7/9, 77.8%) showed statistically significant improvements in patient understanding of statistical risk in the intervention group. Quality assessment found some concerns with all RCTs.

CONCLUSION

Risk communication tools appear to improve recall of statistical risk. Additional prospective trials comparing various aids simultaneously are warranted to determine the most effective method of improving understanding.

Consent for functional endoscopic sinus surgery: are we complying with the law?

OBJECTIVE

To assess the current standard of consent for functional endoscopic sinus surgery and determine whether it complies with the law following the Montgomery ruling.

METHODS

Ten complications following functional endoscopic sinus surgery were identified as common or serious from a literature search. Using questionnaires, ENT surgeons were asked which of these complications they discussed with patients, and patients were asked how seriously they regarded those risks using a five-point Likert scale.

RESULTS

Consent practice from 21 ENT surgeons and data from 103 patients were analysed. The 'reasonable patient' would expect to be consented for all risks, except for pain, and scarring or adhesions. Most ENT surgeons would routinely discuss all risks that were considered significant, except for facial paraesthesia (29 per cent) and damage to the nasolacrimal duct (24 per cent). A negative change in sense of smell was not mentioned by 29 per cent of surgeons.

CONCLUSION

This paper demonstrates that the current consent process for functional endoscopic sinus surgery is likely to be substandard medicolegally.

Validity and Usefulness of YouTube Videos Related to Endoscopic Transsphenoidal Surgery for Patient Information

Objectives  This article evaluates the completeness and accuracy of YouTube videos related to endoscopic transsphenoidal surgery (ETS) as a source for patient information. Design  YouTube was searched using relevant terms pertaining to ETS. Videos were evaluated independently by two physician reviewers experienced in ETS. Video demographics including uploader source along with validity scores based on predetermined checklists were captured. Setting  Internet. Participants  Not applicable. Main Outcome Measures  A novel ETS scoring checklist, the modified DISCERN criteria, and Journal of the American Medical Association (JAMA) benchmark score were used to measure completeness and accuracy of videos. video power index (VPI) was calculated to reflect popularity. Intraclass correlation coefficient was calculated for rater agreement. Results  Seventy-nine videos were included in final scoring and analysis. The ETS score, DISCERN, JAMA, and mean VPI across all included videos were 5.0 ± 2.7, 2.4 ± 0.83, 2.19 ± 0.62, and 8.92 ± 18.1, respectively. Based on the ETS score checklist, 31 (39%) of the videos were rated as poor, 30 (38%) were moderately useful, 17 (22%) were useful, and 1 (1%) was exceptional. There was a significant positive correlation between the ETS, DISCERN, and JAMA scores ( p  < 0.001), but no correlation with VPI and the validity scores. There were no significant differences comparing validity scores based on the uploader source. Conclusion  YouTube videos related to ETS have limited usefulness and poor overall validity for patient information. Clinicians should direct patients to other validated sources of information and aim to improve the comprehensiveness of ETS-related videos.

Educational Informed Consent Video Equivalent to Standard Verbal Consent for Rhinologic Surgery: A Randomized Controlled Trial

BACKGROUND

Informed consent is an integral part of pre-operative counseling. However, information discussed can be variable. Recent studies have explored the use of multimedia in providing informed consent for rhinologic surgery.

OBJECTIVE

To measure impact of an educational video (Video) compared to verbal informed consent (Verbal) on knowledge gained, alleviation of concerns, and efficiency.

METHODS

Patients undergoing endoscopic sinus surgery (ESS), septoplasty, or ESS+septoplasty were prospectively enrolled and randomized to receive Video or Verbal consent. The Video group watched an educational video; the Verbal group received standard verbal consent from an Otolaryngology resident per institutional protocol. Both groups had the opportunity to discuss questions or concerns with their attending surgeon. Prior to, and after, consent was signed, both groups completed surveys regarding knowledge of purpose, risks, and benefits of surgery as well as surgical concerns. Decision regret and patient satisfaction were also assessed post-operatively.

RESULTS

77 patients were enrolled (39 Video, 38 Verbal). Demographics were not significantly different between groups. Overall knowledge significantly improved (p < 0.005) and concerns significantly decreased (p < 0.001) following consent in both groups. Improvements in these metrics were equivalent between groups (p < 0.02). Furthermore, resident time to complete consent, patient satisfaction, and decision regret were not significantly different between groups.

CONCLUSION

Use of an educational video was equivalent to standard verbal informed consent for patients undergoing rhinologic surgery. Otolaryngologists can consider developing procedure-specific videos to allow allocation of time to other tasks, standardized education of patients, and streamlining of the informed consent process.

The Impact of the Informed Consent Process on the Anxiety Levels of Patients Undergoing Rhinoplasty

ABSTRACT

Septorhinoplasty is one of the most common elective surgical procedures in otolaryngology. The present study aimed to evaluate the anxiety levels of patients who underwent septorhinoplasty at different times, compare the information methods, and determine the understanding of the informed consent through recall rates of the complications explained in the informed consent process. The patients were divided into the following 2 groups: Group 1 (giving information 14 days before the surgery) and Group 2 (giving information 3 days before the surgery). For the preoperative anxiety measurement, the State anxiety scale of the State-Trait Anxiety Inventory (STAI) was used. All patients were asked to recall the complications they remembered from the consent form on the day before the surgery. Each group has consisted of 25 patients. No significant difference was found between the STAI-1 and STAI-2a anxiety scores between groups. In Group 1, the STAI-2b anxiety score was significantly lower than the STAI-1 and STAI-2a scores (P < 0.05). In Group 2, the mean score of STAI-2b was not significantly higher than the STAI-1 and STAI-2 scores (P > 0.05). When the STAI-2b scores of the two groups were compared, the scores of Group 2 were significantly higher (P < 0.05). The most commonly remembered complications were bruising and swelling in both of the groups. In conclusion, the authors believe that long-term cooperation between the surgical team and the patient will reduce the anxiety levels of the patients and increase patients' satisfaction, resulting in a significant reduction in the amount of potential legal processes.Level of Evidence: 2.

Evaluating YouTube as a Source of Patient Information for Functional Endoscopic Sinus Surgery

OBJECTIVE

To evaluate the quality of information presented on YouTube regarding functional endoscopic sinus surgery (FESS) for patients.

METHODS

YouTube was searched using FESS-specific keywords under the setting of "relevance." The first 50 videos from each keyword were reviewed and analyzed by 2 independent physician reviewers. Videos not related to FESS and duplicates were excluded. Outcome measures included the modified DISCERN score (range 0-5), the Journal of the American Medical Association (JAMA) benchmark criteria (range: 0-4), a novel scoring checklist for FESS assessing usefulness (range: 0-16), and the Video Power Index (VPI). Intraclass correlation coefficient (ICC) was calculated.

RESULTS

Of the 200 videos identified, 95 videos were analyzed after exclusions. Videos had an average VPI of 40.8 and SD 133.2. Average scores from the 3 objective checklists among all videos were low: modified DISCERN: 1.91, SD: 1.15; JAMA benchmark: 1.91, SD: 0.76; and FESS score: 3.54, SD: 1.77. The ICC between the 2 independent reviewers was excellent for all 3 checklists. We noted significant positive Pearson correlation between all 3 checklist scores (P < .001). In between-group comparisons of mean scores, there was significantly higher DISCERN and JAMA scores for videos from university/professional organizations, as compared to videos from medical advertising/for-profit companies and independent users. There were no significant differences in FESS scores noted between the 3 groups.

CONCLUSION

There were overall low scores across the modified DISCERN, JAMA benchmark criteria, and FESS scoring checklists, reflecting the poor quality of YouTube videos as a source of patient information for FESS.

Patient knowledge and expectations in endoscopic sinus surgery

BACKGROUND

The potential for patient misconceptions about endoscopic sinus surgery (ESS) has implications for the informed consent process. An understanding of patients' baseline knowledge and sources of information regarding ESS would improve surgeons' ability to counsel patients preoperatively and provide effective educational materials.

METHODS

A prospective patient survey was performed at 2 independent tertiary care medical centers. Patients who were offered ESS as part of routine rhinology care were queried about expectations, knowledge, and sources of information regarding ESS before preoperative counseling.

RESULTS

Of the 30 patients who completed the survey, 70% of patients reported doing research on ESS before the visit. The most common sources of information were friends and family (40%), YouTube (30.0%), and WebMD (26.7%). The most important factors researched included risks (95%), benefits (85%), and recovery related issues (70%). Patients in the younger group used healthcare and physician rating websites whereas none of the patients older than the median age of 44 years reported using them (33.3% vs 0%, p = 0.028). The older group more often relied upon healthcare providers than the younger group (71.5% vs 18.8%, p = 0.011). A range of responses were noted regarding early postoperative symptoms and recovery time.

CONCLUSION

This study identified a varied understanding of ESS including significant misconceptions about risks, anesthesia, and need for ongoing therapy, among others. Patients obtain their information from a variety of sources including peers, other doctors, and the Internet. Awareness of the gaps in patient knowledge and the sources of information will improve preoperative counseling.

Multimedia in the informed consent process for endoscopic sinus surgery: A randomized control trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process.

STUDY DESIGN

Prospective, randomized, controlled trial.

METHODS

Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected.

RESULTS

Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone.

CONCLUSIONS

There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process.

LEVEL OF EVIDENCE

1b Laryngoscope, 126:1273-1278, 2016.

Complication rates after functional endoscopic sinus surgery: analysis of 50,734 Japanese patients

OBJECTIVE

The complication rates associated with different types of functional endoscopic sinus surgery (FESS) remain to be fully examined.

STUDY DESIGN

Retrospective cohort study.

METHODS

We extracted data from the Japanese Diagnosis Procedure Combination database on 50,734 patients (aged ≥ 16 years) who underwent FESS for chronic rhinosinusitis between 2007 and 2013. We focused on specific types of surgery and stratified the patients into three groups: group 1 (single sinus surgery), group 2 (multiple sinus surgery), and group 3 (whole sinus surgery). Patient characteristics and early postoperative complications including cerebrospinal fluid (CSF) leakage, orbital injury, severe hemorrhage, and toxic shock syndrome (TSS) that occurred during 1 to 2 weeks of each hospitalization were compared. Multivariable logistic regression analysis was performed to assess the association between overall complication rate and background characteristics, with adjustment for within-hospital clustering.

RESULTS

The overall complication rate was 0.50%; the rates of CSF leakage, orbital injury, hemorrhage requiring surgery, blood transfusion, and TSS were 0.09%, 0.09%, 0.10%, 0.18%, and 0.02%, respectively. Ethmoidectomy combined with sphenoidotomy was associated with higher overall complication rates (1.40%). The rate of orbital injury was highest in group 2, whereas that of other complications did not differ significantly among the groups. Extent of FESS showed no significant association with overall complication rate.

CONCLUSION

More extensive FESS was not associated with increased rates of postoperative CSF leakage, hemorrhage, or TSS. Multiple sinus surgery was associated with a higher rate of orbital injury. The extent of surgery did not significantly affect the overall complication rate.

LEVEL OF EVIDENCE

2b.

Malpractice in Treatment of Sinonasal Disease by Otolaryngologists

Objective

Sinonasal disease is a common condition treated by otolaryngologists. Malpractice in this area is the most common litigation faced by otolaryngologists. This study analyzes malpractice in the treatment of sinonasal disease.

Study Design

Case series, review of legal records.

Setting

Legal databases.

Subjects and Methods

Using 2 different computerized legal databases, the phrase medical malpractice was searched with terms related to sinonasal disease involving court cases in the past 10 years (2004-2013), yielding 26 cases. The cases were analyzed for pertinent data regarding plaintiffs, presenting complaint, practice setting, type of malpractice, resulting injury, result of verdict, and amount of reward or settlement.

Results

Chronic sinusitis (42%) was the most common presenting symptom. Many cases included multiple types of alleged malpractice, with the most common being negligent technique (38%) and lack of informed consent (27%). The most common alleged injuries included cerebrospinal fluid leak, meningitis, nasal obstruction, and orbital trauma. Defendants prevailed in 13 of 18 cases in which outcomes were known, with mean award of $225,000 and mean settlement of $212,500. The cases won by plaintiffs were all in a private practice setting.

Conclusion

Otolaryngologists should be aware of the causes of malpractice litigation as it relates to treatment of sinonasal disease. Lack of informed consent continues to be a common allegation, and surgeons should ensure complete informed consent is obtained and well documented. A unified and complete database of medical malpractice cases is needed to allow for further analysis of specialty-related claims.

Preoperative concerns of patients undergoing endoscopic sinus surgery

BACKGROUND

Patient-centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient-centered care has classically been measured by posttreatment outcomes, such as patient compliance and psychosocial responses. Systematic assessment of patient concerns prior to treatment has been limited, to date. Endoscopic sinus surgery (ESS) is an elective procedure for chronic rhinosinusitis that carries a clear, defined set of risks. The objective of this prospective observational study was to determine the concerns of patients undergoing ESS for chronic rhinosinusitis.

METHODS

A total of 180 patients undergoing ESS for chronic rhinosinusitis with or without polyposis were recruited at 2 Canadian tertiary care centers. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data was analyzed using descriptive statistics and analysis of variance.

RESULTS

Patients had a low degree of concern prior to undergoing surgery (overall score 2.8/9), though individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors (mean = 1.8/9). No differences with respect to age or gender were identified. Mean scores for cerebrospinal fluid leak and orbital injury were 3 and 3.2, respectively.

CONCLUSION

Patients' level of concern prior to undergoing elective surgery is generally low. Patients' areas of greatest concern may not align with those perceived by the physician. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasizes the importance of the patient-centered approach to care.

Research methodologies in informed consent studies involving surgical and invasive procedures: time to re-examine?

OBJECTIVE

We conducted a review of informed consent studies involving surgical and invasive procedures and report the degree to which current research targets a broader scope of patient outcomes beyond comprehension.

METHODS

Using PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database, we identified 97 articles for review. Six members coded articles and generated scores of study design quality.

RESULTS

The mean quality score (10.7 out of a total score of 20) was low. Most studies were single institution-based, relying on one-time data collections. Randomly assigning subjects to study conditions, using power analysis to determine subject numbers, and reporting psychometric evidence, such as reliability and validity, were not widely reported. Most frequently targeted patient outcomes were knowledge, understanding and satisfaction. Core informed consent outcomes (e.g. capacity, voluntariness, decision making) and emotional factors (e.g. anxiety) were not extensively addressed.

CONCLUSION

Informed consent research may benefit from applying qualitative methods to more directly tap into patients' beliefs and decisions by eliciting in patients' own words their emotions and reasoning around processing informed consent content.

PRACTICE IMPLICATIONS

Research that addresses patient perspectives toward surgical interventions should tap into underexplored ethical and emotional factors that shape decision making.

Medical information prior to invasive medical procedures in otorhinolaryngology-head and neck surgery in France

Based on a review of the medical literature (PubMed database, keywords: medical information, informed consent), the authors analyse the main medicolegal aspects concerning the patient information that must be provided in France prior to any invasive diagnostic or therapeutic medical procedures in otorhinolaryngology head and neck surgery, as well as the patient's perception and recall of the information provided, the quality of the information provided and problems encountered in providing this information. In the light of this review, several solutions are recommended to improve this essential phase prior to obtaining the patient's informed consent.

Informed consent process and patient communication after complications in sinus surgery

Sinonasal surgery has always been a potential source of complications. Most legal suits involving endoscopic sinus surgery alleged lack of informed consent. In this article, the authors discuss what informed consent means, to the physician and the patient, and how it is relevant in the case of complications. They also explain that patient communication is important and helps to develop a positive physician-patient relationship.

Medicolegal issues in endoscopic sinus surgery

Endoscopic sinus surgery is one of the most litigated areas in otolaryngology. Physicians typically receive little education regarding medicolegal issues during training and may find themselves in an unfamiliar territory during litigation. This article reviews the scope of the problem and provides strategies to improve patient care and mitigate medicolegal risk in endoscopic sinus surgery.

Medical malpractice and rhinology

BACKGROUND

Physicians facing malpractice litigation are in uncharted territory. The language, concepts, rules, and strategies of the legal system are foreign to science-based physicians. Understanding the statistics of rhinology malpractice litigation may aid the physician to cope with the assault of a claim.

METHODS

Information from the 2006 Physician Insurers Association of America (PIAA) and the 2006 PIAA Risk Management Report (RMR)-Otorhinolaryngology were searched for claims data referable to the nose, nasal chamber, and paranasal sinuses. The PIAA data sharing report (DSR) is the largest single resource of malpractice claims data containing both settlement and trial judgment information.

RESULTS

The nose, nasal cavity, and paranasal sinuses represent nearly two-thirds of the total indemnity paid for improper performance from otolaryngology head and neck surgery (Oto-HNS) medical malpractice claims between 1985 and 2005 based on claims information. Improper performance accounts for 50.3% of total monies paid ($107.6 million of $213.6 million) to resolve Oto-HNS claims in this period. Of nearly 2400 operative claims closed in the period of 1985-2005, 34.1% involved procedures on the nose and sinuses. In the past 6 years, $103.5 million indemnity has been added to the otolaryngology total.

CONCLUSION

The area of endoscopic sinus surgery has substantially contributed to Oto-HNS claims in the PIAA DSR. Despite malpractice being a cost of medical practice, every claim is perceived as an assault on the surgeon's competence. Ensuring informed consent and complete documentation may assist the provider in defending their care.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Informed Consent in Sinus Surgery: Link between Demographics and Patient Desires

OBJECTIVE

To evaluate and understand differences in expectations according to patient demographics during the informed consent process for functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Multi-institutional, cross-sectional survey design.

METHODS

Anonymous surveys were administered to patients in two tertiary academic centers with a chief complaints relating to "allergy and sinus" problems. Patients completed and eight-item questionnaire that assessed demographics and the nature and level of risks that patients wished to be informed of before FESS. Univariate and multivariate analyses were performed to assess for differences in patient desires related to FESS risks according to demographics.

RESULTS

Three hundred eighty-nine completed surveys were analyzed. Younger patients (P = .049), white patients (P = .0026), and more educated patients (P = .0033) wished to know about complications at the lowest risks levels (lowest incidence), regardless of severity. With regards to specific complications, black patients and patients with less formal education were less interested in being informed about the potential risks of orbital complications, cerebrospinal fluid leak, or possible need for revision surgery. Multivariate analysis confirmed that race, education, age were independently significant factors in determining response.

CONCLUSION

Demographic-related differences exist in patient's desires and expectations in the informed consent process for a sinus procedure. Physicians should be aware of these differences when counseling patients about sinus surgery. More research is needed to elucidate the factors that underlie the observed differences.