Recall of the risks of forefoot surgery after informed consent

A Randomized Controlled Trial of Consent for Patients Undergoing Transobturator Slings

IMPORTANCE

Improving patients' recall and understanding of their planned surgery is essential for fully informed consent.

OBJECTIVE

The objective of this study was to assess if the addition of an information handout to the standard preoperative consent process for the transobturator midurethral sling procedure improved patient understanding, recall, and satisfaction.

STUDY DESIGN

This is a randomized controlled trial of adult women undergoing a transobturator midurethral sling procedure for the treatment of stress urinary incontinence. After standard counseling, participants were randomly assigned to either the control or the intervention group, with the latter receiving an extra informational handout detailing surgical information. Before surgery, all participants filled out a questionnaire assessing key points discussed during the surgical consent, which was used to calculate a knowledge score, the primary endpoint. Secondary outcomes included perception of the consent process and patient satisfaction.

RESULTS

Of 98 randomized participants (50 control, 48 intervention), knowledge scores were 43% for controls and 57% for the intervention group (P = 0.015). Despite low scores, high self-rated understanding and satisfaction were noted across both groups (78% control, 71% intervention, P = 0.4). Notably, younger individuals, those with some college education, and patients undergoing additional prolapse surgery benefited most from the handout.

CONCLUSIONS

The informational handout improved knowledge scores, though overall knowledge scores were low in both groups. High satisfaction and perceived understanding of the planned procedure persisted, but the addition of a handout was not associated with a significant difference in knowledge scores.

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.

The effects of modifying elements of written informed consent forms for elective surgical or invasive procedures: A systematic review

OBJECTIVE

To study the effect of modifying content and design elements within written informed-consent-forms (ICF) for patients undergoing elective surgical or invasive procedures.

METHODS

We included (quasi-)randomized trials in which a modified written ICF (e.g. visual aids) was compared to a standard written ICF. We searched PubMed, Web-of-Science and PsycINFO until 08/2021. Risk of Bias was assessed. The complexity of intervention was assessed using the Intervention Complexity Assessment Tool for Systematic Reviews.

RESULTS

Eleven trials with 1091 participants were eligible. Effect sizes and levels of evidence varied from trivial to moderate andthere were contradictory findings for some outcomes. Providing patients with more informationin general or specific information on risks and complications mostly increased anxiety. The use of verbal risk presentation decreased anxiety and increased satisfaction.A lower readability level decreased anxiety and improved comprehension and knowledge.

CONCLUSION

Our results suggest that providing more information and addressing certain types of risks have differential effects. While more information improved knowledge, it also increased anxiety. We did not find any or only insufficient evidence for many other possible ICF modifications.

PRACTICE IMPLICATIONS

When developing ICFs the differential impact of different elements on patient important outcomes should be carefully considered.

Influence of a Preadmission Procedure-Specific Consent Document on Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement: A Randomized Controlled Trial

OBJECTIVES

Consent is a legal and ethical requirement for undertaking surgical procedures; however, the literature suggests that there continues to be poor recall among patients of the surgical risks discussed during the consent process. The aim of this study was to evaluate whether the addition of a preadmission procedure-specific consent document would improve patient recall of surgical risks at 4 weeks after total hip replacement in patients consented with a procedure-specific consent form.

METHODS

A prospective randomized controlled trial allocated seventy adult patients who were undergoing a primary total hip replacement to either receive (intervention group) or not receive (control group) a preadmission procedure-specific consent document. All patients were also consented with a procedure-specific consent form on the morning of surgery and were contacted 4 weeks later to assess recall of surgical risks.

RESULTS

There was a very poor recall rate seen in both the intervention group (16%) and the control group (13%), with no statistically significant difference between them (P = 0.49). A large number (30%) of patients could not recall a single risk. A subgroup analysis excluding these "consent nonresponders" did show a significantly increased recall rate in the intervention group (24.5% versus 18.25%, P = 0.02).

CONCLUSIONS

Patient recall of potential complications of total hip replacement was poor despite the intervention. Although not effective overall, the use of a preadmission procedure-specific consent document did improve recall of potential complications of surgery in a subset of patients. The phenomenon of consent nonresponders is worth exploring in future research.

Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement With Standardized Versus Procedure-Specific Consent Forms

OBJECTIVES

Informed consent plays a pivotal role in the operative process, and surgeons have an ethical and legal obligation to provide patients with information to allow for shared decision-making. Unfortunately, patient recall after the consent process is frequently poor. This study aims to evaluate the effect of procedure-specific consent forms on patient's recall four weeks after total hip replacement (THR).

METHODS

This is a prospective study using a posttest-only control group design. Sixty adult patients undergoing total hip replacement were allocated to be consented using either the generic or the surgery-specific consent form. Four weeks after surgery, a phone interview was conducted to assess patient's recall of risk of surgical complications.

RESULTS

Patient demographic characteristics and educational attainment were similar in both groups. There was a statistically significant increase in the mean number of risks recalled in the study group at 1.43 compared with 0.67 in the control group (P = 0.0131).

CONCLUSIONS

Consent is a complex process, and obtaining informed consent is far from straightforward. A statistically significant improvement in patient's recall with the use of procedure-specific consent forms was identified, and based on this, we would advocate their use. However, overall patient recall in both groups was poor. We believe that improving the quality of informed consent may require the sum of small gains, and the use of procedure-specific consent forms may aid in this regard.

Brief Educational Video Improves Patient Understanding of Mohs Surgery: A Randomized Controlled Trial

BACKGROUND

Patient's retention and recall of material discussed in a medical consultation is often inadequate.

OBJECTIVE

To assess patient's knowledge, anxiety, and understanding of Mohs surgery after viewing a brief educational video.

METHOD

A prospective, investigator-blinded, randomized controlled trial of 120 consecutive patients before the first Mohs surgery procedure. Sixty subjects viewed an instructional video and 60 subjects did not. A survey was administered to both groups, measuring knowledge, anxiety, and understanding of Mohs surgery.

RESULTS

The video group scored higher than the control group on the knowledge portion of the survey (median score 78% vs 56%, p < .01), but there were no differences in anxiety or understanding scores between groups. The percentage of subjects who answered each knowledge question correctly was greater in the video group than in the control group. In the subgroup of patients who had not previously had a consultation with a Mohs surgeon, the video group had higher median knowledge scores (67% vs 44%, p < .01), higher median understanding scores (8 vs 6, p = .05), and lower median visual analogue anxiety scores (4 vs 6, p = .01) compared with the control group.

CONCLUSION

A brief educational video increases patient's knowledge of Mohs surgery. For patients who have not yet had a consultation with a Mohs surgeon, the video may also reduce anxiety.

Improving Surgical Informed Consent: Unanswered Questions

Objective

This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice.

Summary Background

Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further?

Methods

A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost.

Results

There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost.

Conclusions

No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Consent in forefoot surgery; What does it mean to the patient?

AIMS

This study aimed to assess patient risk recall and find risk thresholds for patients undergoing elective forefoot procedures.

METHODS

Patients were interviewed in the pre-assessment clinic (PAC) or on day of surgery (DOS); some in both settings. A standardised questionnaire was used for all interviews, regardless of setting. Patients were tested on which risks they recalled from their consent process, asked for thresholds for five pre-chosen risks and asked about a sham risk.

RESULTS

Across all interviews, risk recall on DOS (2.34 risks/patient interview) was significantly lower (p=.05) than in PAC (2.95 risks/patient interview) - this was repeated when comparing results from patients interviewed in both settings only with PAC mean recall of 2.93 risks/patient interview and DOS mean recall of 2.57 risks/patient interview. The mean reported risk thresholds greatly exceeded NHS Lothian's observed complication rates for forefoot procedures. The five risks tested for thresholds produced the same order in each interview setting, suggesting a patient-perceived severity ranking. Patients answering the sham risk question incorrectly tended to recall fewer risks across all interviews.

CONCLUSIONS

This study shows that patient risk recall is poor, as previous literature outlines, reinforcing that consent process improvements could be made. It also illustrates the value of PAC visits in patient education, as shown by higher levels of recall when compared to DOS.

Malpractice claims associated with foot surgery

Surgery of the foot constitutes a substantial portion of orthopedic procedures, performed by both orthopedic surgeons and doctors of podiatric medicine. Little research exists on the medicolegal implications of foot surgery amongst these specialties. This study seeks to investigate the different medical and legal factors associated with foot surgery-based malpractice litigation. Malpractice data between 2004 and 2017 was collected using the VerdictSearch legal database. Cases involving foot surgery were identified, and case information including physician specialty, procedure, medical outcome, verdict, and payment amount were obtained. A total of 72 cases were analyzed. A majority of lawsuits involved podiatrists (76.4%), with orthopedic surgeons accounting for 15.3%. Lawsuits against podiatrists primarily occurred over elective procedures (94.5%) and most frequently involved plaintiff complaints of persistent pain (41.8%) or deformation (27.3%). Podiatrist cases most often involved allegations of failure to treat (45.5%) or inappropriate surgical procedure (27.3%). Orthopedic surgeons saw higher rates of urgent cases (45.5%), with surgical complications (27.3%) occurring at higher rates than podiatrists. Despite different trends in case types, similar rates of plaintiff victories, and mean payments were seen between podiatrists (25.5%, $911,884 ± 1,145,345) and orthopedic surgeons (27.3%, $975,555 ± 448,795). This investigation is the first to analyze malpractice trends amongst podiatrists and orthopedic surgeons. Differing factors related to medical and legal outcomes can suggest quality improvement targets for both specialties. This data may assist in reducing malpractice risk and refining patient care, particularly with regards to outlining risks, benefits, and alternatives during pre-operative counselling.

Role of Patient-Reported Outcome Measures on Predicting Outcome of Bunion Surgery

BACKGROUND

Prior studies have suggested preoperative patient-reported outcome scores could predict patients who would achieve a clinically meaningful improvement with hallux valgus surgery. Our goal was to determine bunionectomy-specific thresholds using Patient-Reported Outcomes Measurement Information System (PROMIS) values to predict patients who would or would not benefit from bunion surgery.

METHODS

PROMIS physical function (PF), pain interference (PI), and depression assessments were prospectively collected. Forty-two patients were included in the study. Using preoperative and final follow-up visit scores, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) analyses were performed to determine if preoperative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve an MCID with 95% sensitivity.

RESULTS

PROMIS PF demonstrated a significant AUC and likelihood ratio. The preoperative threshold score for failing to achieve MCID for PF was 49.6 with 95% sensitivity. The likelihood ratio was 0.14 (confidence interval, 0.02-0.94). The posttest probability of failure to achieve an MCID for PF was 94.1%. PI and depression AUCs were not significant, and thus thresholds were not determined.

CONCLUSION

We identified a PF threshold of 49.6, which was nearly 1 standard deviation higher than previously published. If a patient is hoping to improve PF, a patient with a preoperative t score >49.6 may not benefit from surgery. This study also suggests the need for additional research to delineate procedure-specific thresholds.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

A decade of litigation regarding surgical informed consent in the Netherlands

OBJECTIVE

An inadequate surgical informed consent process (SIC) may result in a medical malpractice claim or medical disciplinary board (MDB) complaint. Aim of this study was to analyse characteristics of a decade of malpractice claims and MDB decisions regarding SIC in the Netherlands.

METHODS

A retrospective analysis of malpractice claims and MDB decisions concerning SIC disputes in four major surgical specialties was conducted based on company data from the largest medical malpractice insurance company and two public available online MDB databases.

RESULTS

A total of 11376 malpractice claims and 661 MDB complaints were filed between 2004-2013 and 676(6%) of these claims and 69(10%) of these complaints involved an alleged deficient SIC process. A random sample of 245(37%) claims and all MDB decisions were analysed. Reasons for filing a claim or complaint were insufficient counselling or recording of SIC elements. In 20% of lawsuits and 25% of claims the case resulted in favour of the complainant.

CONCLUSION

A substantial portion of malpractice claims and MDB decisions is related to a deficient SIC process.

PRACTICE IMPLICATIONS

Focusing on crucial SIC elements for patients may improve satisfaction and expectations and result in a lower risk for malpractice claims and MDB complaints.

Impact of Disgust on Intentions to Undergo Colorectal Surgery

BACKGROUND

Surgeons present patients with complex information at the perioperative appointment. Emotions likely play a role in surgical decision-making, and disgust is an emotion of revulsion at a stimulus that can lead to avoidance.

OBJECTIVE

The purpose of this study was to determine the impact of disgust on intention to undergo surgical resection for colorectal cancer and recall of perioperative instructions.

DESIGN

This was a cross-sectional observational study conducted online using hypothetical scenarios with nonpatient subjects.

SETTINGS

The study was conducted using Amazon's Mechanical Turk.

PATIENTS

Survey respondents were living in the United States.

MAIN OUTCOME MEASURES

Surgery intention and recall of perioperative instructions were measured.

RESULTS

A total of 319 participants met the inclusion criteria. Participants in the experimental condition, who were provided with detailed information and pictures about stoma care, had significantly lower surgery intentions (mean ± SD, 4.60 ± 1.15) compared with the control condition with no stoma prompt (mean ± SD, 5.14 ± 0.91; p = 0.05) and significantly lower recall for preoperative instructions (mean ± SD, 13.75 ± 2.38) compared with the control condition (mean ± SD, 14.36 ± 2.19; p = 0.03). Those within the experimental conditions also reported significantly higher state levels of disgust (mean ± SD, 4.08 ± 1.74) compared with a control condition (mean ± SD, 2.35 ± 1.38; p < 0.001). State-level disgust was found to fully mediate the relationship between condition and recall (b = -0.31) and to partially mediate the effect of condition on surgery intentions (b = 0.17).

LIMITATIONS

It is unknown whether these results will replicate with patients and the impact of competing emotions in clinical settings.

CONCLUSIONS

Intentions to undergo colorectal surgery and recall of preoperative instructions are diminished in patients who experience disgust when presented with stoma information. Surgeons and care teams must account for this as they perform perioperative counseling to minimize interference with recall of important perioperative information. See Video Abstract at http://links.lww.com/DCR/A776.

Improving the Consent Process in Foot and Ankle Surgery With the Use of Personalized Patient Literature

A patient-specific letter was introduced to the consent process to observe the effect, if any, on information recall and satisfaction for patients undergoing elective foot and ankle surgery. The patients attending the clinic were written a personalized letter-this was a simple personalized letter that outlined their treatment options, the proposed management plan, likely treatment course, and the benefits, risks, and likely period required for recovery. The personalized letter system was compared with the 2 existing methods of consent process: signing for consent at their outpatient encounter at which they were scheduled for surgery and a separate consent clinic without the personalized letter. A total of 111 patients (87 females, 24 males) undergoing elective foot and ankle surgery were assessed on the day of surgery for recall of the procedure, risks, postoperative course, and satisfaction with the consent process. Patients receiving a personalized letter recalled more than those who had attended a routine preoperative consent clinic visit and significantly more than those who had provided consent at their last clinic visit. Patient satisfaction with the consent process was also greater in the personalized group. Our results suggest that the consent process is improved using routine preoperative consent clinics and, most notably, with patient-specific information to improve patient recall and satisfaction.

Percutaneous coronary intervention patients' and cardiologists' experiences of the informed consent process in Northern England: a qualitative study

OBJECTIVE

Informed consent is central to ethical medical practice, but little is known about how the process takes place in clinical practice. Percutaneous coronary intervention (PCI) is a common revascularisation procedure. Studies report that patients overestimate benefits, forget the risks and are unaware of alternative treatments. The aim of this study was to describe PCI patients' and cardiologists' experiences of the informed consent process in acute care settings.

DESIGN/SETTING/PARTICIPANTS

A qualitative study with a maximum variation sample of elective and acute PCI patients and cardiologists taking their consent, recruited from a district general hospital and tertiary centre. In-depth interviews were conducted, and consent discussions were audio recorded. Data collection, coding and theorising occurred simultaneously.

FINDINGS

Forty-one (26 male) patients scheduled for elective (20) or urgent (21) PCI and 19 cardiologists (5 female) participated. Despite diversity in patients' experiences of informed consent, elective and acute patients experienced a common four-stage process of consent. Most patients made the decision to have treatment at PCI referral and took a passive role in the discussions we recorded. They recognised cardiologists as experts, trusted the medical system to 'fix' their health problem and were unaware of their role in the informed consent process. Informed consent discussions functioned as a formal 'event',enabling cardiologists to check patients' understanding and enabling patients to access treatment.

CONCLUSIONS

The configuration of services and patients' perceptions of their role in informed consent underpin a mismatch between legal and ethical principles of informed consent and current practice. The variation in patients' experiences of the current place of informed consent in service delivery represents a missed opportunity for cardiologists to work in decision-making partnerships with patients. In light of recent changes in the law, a new approach to informed consent is required.

Surgical Consent of Children and Guardians for the Treatment of Adolescent Idiopathic Scoliosis is Incompletely Informed

STUDY DESIGN

Prospective, multicenter cohort analysis.

OBJECTIVE

Assess children and guardian's comprehension of surgical consent for adolescent idiopathic scoliosis (AIS) surgery and factors associated with their comprehension.

SUMMARY OF BACKGROUND DATA

Informed consent is essential to the ethical practice of surgery. Little is known about how informed are children and guardians when consenting to operation for AIS.

METHODS

Guardians and their children (10-18 yr) undergoing spinal fusion for AIS were prospectively evaluated at 4 institutions. Each child and guardian was asked to complete a questionnaire of the risks, benefits and expected results of operative treatment and a self-assessment of overall comprehension. A site-survey questionnaire regarding teaching methods, timing between teaching and consent, and healthcare provider involved in the consent process was also used. Significance was assessed using logistic regression examining factors associated with good (≥6 scores correct) and poor (<6 scores correct) comprehension.

RESULTS

One hundred seventy six pairs of patient/guardian were enrolled. Fifty-seven patient/guardian questionnaires were discarded due to incompleteness. A greater percentage of guardians had good overall comprehension of the surgical consent (patients: 59.7%; guardian: 71.4%). Post-operative mobility (patient 31%; guardian 42%) was poorly understood. Surgical risks (i.e., neurologic injury, infection, hardware failure, future sequelae) were modestly understood (40-70% correct). Factors associated with better understanding were older patient age (>12 yr), guardian with a college degree, obtaining consent by the attending surgeon and at a separate preoperative visit than the time of teaching, the use of visual aids, and participation in a "peer-support group" preoperatively. There was a trend toward guardians' and patients' self-assessment of understanding mirroring their respective objective performances.

DISCUSSION

Patients who undergo surgical intervention for AIS and their guardians understand approximately 60% of the surgical consent. The use of preoperative multimodal teaching techniques and "peer-support groups" may improve patient and guardian comprehension.

Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period

STUDY DESIGN

Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively.

OBJECTIVE

To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status.

SUMMARY OF BACKGROUND DATA

Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk.

METHODS

Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison.

RESULTS

Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year.

CONCLUSION

Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.

LEVEL OF EVIDENCE

3.

Patients' recall of diagnostic and treatment information improves with use of the Pain Explanation and Treatment Diagram in an outpatient chronic pain clinic

Educating patients about their condition and treatment plan is an essential component of successful treatment. Patients need to understand their condition, recall treatment suggestions and comply with the treatment protocol. Unfortunately, the method of patient education most commonly used by physicians is verbal teaching and discussion, which leads to poor patient recall. The authors of this article developed the Pain Explanation and Treatment Diagram, a worksheet that the clinician completes with the patient during their first consultation to function as a record of their diagnosis, pain risk factors and an action plan for when pain occurs. In this study, patient recall, among other variables, was assessed as a function of time since first appointment.

BACKGROUND:

To maximize the benefit of therapies, patients must understand their condition, recall treatment suggestions and comply with treatments. The Pain Explanation and Treatment Diagram (PETD) is a one-page worksheet that identifies risk factors (health-related habits, sleep, exercise, ergonomics and psychosocial factors) involved in chronic pain. Clinician and patient complete the PETD together, and the clinician notes recommended treatments and lifestyle changes.

OBJECTIVES:

To examine the effect of use of the PETD on patient recall of diagnostic and treatment information on the sheet.

METHODS:

The present study was a cross-sectional analysis. Patients with chronic musculoskeletal pain seen by one physiatrist at an outpatient pain clinic in a university-affiliated hospital between 2009 and 2012 (all of whom received the PETD) were eligible. A structured telephone interview lasting approximately 1 h was used to determine recall of PETD diagnostic and treatment information.

RESULTS:

Of the 84 eligible patients, 46 were contacted and 29 completed the telephone interview. Participants recalled an average of 12.2% (95% CI 7.8% to 17.4%) of items without prompting and 48.5% (95% CI 42.0% to 53.5%) when prompted. Participants who referred to the PETD at home (n=13) recalled significantly more items than those who did not (n=15) (17.6% [95% CI 11.1% to 23.9%] versus 5.2% [95% CI 3.0% to 14.5%], P=0.004); when prompted, the rates increased to 54.3% (95% CI 48.3% to 61.2%) and 41.2% (95% CI 34.7% to 50.7%), respectively (P=0.032).

CONCLUSIONS:

The PETD is a promising, feasible and inexpensive tool that can improve patients’ recall of diagnostic- and treatment-related information.

Clinical negligence in foot and ankle surgery

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.

The use of multimedia as an adjunct to the informed consent process for Morton's neuroma resection surgery

BACKGROUND

The purpose of this study was to assess if a computer-based multimedia education module (MEM) improved patients' comprehension when used as an adjunct to the standard verbal consent process for Morton's neuroma resection surgery.

METHODS

Nineteen patients (15 females and 4 males) considered candidates for Morton's neuroma resection surgery were prospectively recruited. A standardized verbal discussion was had with each patient regarding risks and benefits of surgery, alternative treatments, and the usual postoperative course. Patient understanding was then assessed with a questionnaire. Each patient subsequently viewed the MEM and the questionnaire was repeated. Patients also rated ease of understanding and satisfaction with both methods of patient education.

RESULTS

Patients answered a significantly greater proportion of correct answers after viewing the MEM module (85%), compared to verbal discussion alone (61%) (P = .002). Patients rated both the ease of understanding of the module and amount of information provided by the module as a mean of 9.3 cm on a 10 cm Visual Analog Scale (VAS). The majority of patients (76%) rated the multimedia tool as having answered their questions about surgery as well or better than the treating surgeon.

CONCLUSION

An interactive multimedia educational tool was a useful adjunct to the informed consent process for patients considering Morton's neuroma resection surgery.

LEVELS OF EVIDENCE

Level II, prospective cohort study.

The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study

BACKGROUND

Historically, the preoperative consultation has consisted of a discussion between patient and surgeon. There is a growing literature describing efforts to integrate multimedia into surgical patient education. This study aimed to assess the efficacy of an educational video tutorial on early learning of information specific to patients undergoing shoulder arthroscopy when it was used as an adjunct to the standard preoperative consultation.

METHODS

This study was a surgeon-blinded, randomized controlled trial involving 40 consecutive patients requiring shoulder arthroscopy. After a preoperative consultation with an orthopaedic surgeon, patients were randomized in a 1:1 ratio to either a control group or a treatment group. The treatment group viewed a 10-minute video, which covered the expected preoperative, intraoperative, and postoperative experience. Immediately afterward, both groups completed a questionnaire measuring satisfaction and recall of information received. All patients completed a second questionnaire at the first postoperative visit that assessed overall satisfaction with their experience.

RESULTS

Thirty-four patients were available for follow-up. The video group (N = 15) answered 87% of the knowledge questions correctly, whereas the control group (N = 19) answered only 56% (P = .000). There was stronger agreement in the video group that the preoperative consultation contained an appropriate amount of information (P = .039). Postoperatively, there was agreement that the video was an effective preparation tool for all stages of the surgical experience. However, there was no difference between the groups in satisfaction with their overall surgical experience.

CONCLUSIONS

Video can enhance patients' operative experiences and improve their retained knowledge when it is used as an adjunct to the preoperative consultation.

LEVEL OF EVIDENCE

Basic science, education methodology study, devices to improve learning.

A Prospective Randomized Control Study on Patient's Recall of Consent after Hand Surgery: How Much They Want to Know?

Informed consent implies that the person undergoing an intervention thoroughly understands its pros and cons. We conducted a randomized control trial to evaluate patients’ recall of complications after day case hand surgery and how this can be influenced by age and/or socioeconomic factors. Patients’ wishes on the extent and type of provided information were also evaluated. A total of 124 cases were recruited. Ten cases were excluded because they presented for follow up more than 2 weeks after surgery. The other patients were randomized into 2 groups: the first one (48) received only verbal information, while the second one (66) also received written information sheets. No statistically significant difference was noted in the recall between the two groups. No difference among gender, age or socioeconomic status was noted. Most patients preferred both written and verbal information. Preference for knowledge of rates of complications increased when surgery was dangerous. Our results don’t show any significant difference in patients’ recall depending on the type of consenting method. Nevertheless, we still propose that patients should receive as much information as possible before undergoing any intervention.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Improved patient awareness and satisfaction using procedure specific consent forms in carpal tunnel decompression surgery

Carpal tunnel decompression (CTD) is a common procedure amenable to procedure specific consent forms (PSCFs). These may help better inform patients and so increase patient satisfaction with the consent process. We assessed the use of a PSCF for CTD. The PSCF mentions eight complications of carpal tunnel surgery and alternative non-operative treatments. Two groups of 40 patients each were compared prospectively. Patients in one group were issued with a PSCF prior to admission whereas those in the other group were not. After standard pre-operative consent, patients were interviewed prior to surgery and assessed for their awareness of complications and alternative treatment options. The patients who received a PSCF showed greater awareness of different complications and alternative treatments and reported greater satisfaction with the consent process. We conclude that using PSCFs is a very useful and inexpensive adjunct to improve patient awareness and satisfaction with the consent process.

Rating the preferences for potential harms of treatments for cardiovascular disease: a survey of community-dwelling adults

BACKGROUND

The Institute of Medicine has called for a new health care paradigm that integrates patient values into discussions of the risks and benefits of treatment. Although cardiovascular disease (CVD) affects one-third of Americans, little is known about how adults regard the potential harms or complications of treatment.

OBJECTIVE

We sought to determine the preferences of community-dwelling adults for 15 potential harms or complications resulting from treatment of CVD.

METHODS

In a telephone survey, adults older than 18 years residing on Long Island, New York, were asked to score the preferences for 15 potential harms or complications of treatment of CVD on a scale from 0 to 100. All statistical analyses were based on nonparametric methods. Multivariable general linear model analyses were performed to identify demographic factors associated with the score assigned for each adverse outcome.

RESULTS

The 807 individuals surveyed generated 723 unique sequences of scores for the 15 outcomes. The ranking of scores from least to most acceptable was stroke, major myocardial infarction (MI), cognitive dysfunction, renal failure, death, prolonged ventilator support, heart failure, angina, sternal wound infection, major bleeding, reoperation, prolonged recovery in a nursing home, cardiac readmission, minor MI, and percutaneous coronary intervention. Demographic factors accounted for less than 7% of the observed variation in the score attributed to each outcome.

CONCLUSIONS

Individual community-dwelling adults living on Long Island, New York, assign unique values to their preferences for potential harms encountered following treatment of CVD. Thus, risk-benefit discussions and treatment decisions regarding CVD should be harmonized to the value system of each individual.

Informed consent for sacrocolpopexy: is counseling effective in achieving patient comprehension?

OBJECTIVES

The purpose of the informed consent process is to reinforce a patient's understanding of her condition and treatment alternatives and to thoroughly review the chosen procedure with its risks and benefits. We aimed to evaluate how well women who consented to undergo sacrocolpopexy understood their planned procedure.

STUDY DESIGN

We prospectively studied women who had undergone detailed informed consent in preparation for laparoscopic or robotic sacrocolpopexy. A 15-item questionnaire was developed and administered before surgery to assess the patients' comprehension of preoperative counseling.

RESULTS

Fifty women were enrolled. The mean knowledge score was 69.7%. Sixty-four percent of the patients did not recall that they could have a prolapse repair without mesh, 44% did not understand the location of mesh attachment, and 34% believed there was no risk of recurrent prolapse. Women who completed the questionnaire within 3 weeks of signing the surgical consent had a higher mean score (78.5%) than women for whom 3 or more weeks elapsed (66.3%; P=0.02).

CONCLUSION

Despite detailed preoperative discussion, women had deficiencies in their understanding of sacrocolpopexy. New methods to improve patient education and comprehension should be considered.

The use of multimedia as an adjunct to the informed consent process for ankle ligament reconstruction surgery

BACKGROUND

Obtaining "informed consent" is an integral aspect of surgery that can be fraught with difficulty. This study assessed the efficacy of a multimedia education tool in improving patients' understanding when used as an adjunct to the traditional verbal consent process regarding ankle lateral ligament reconstruction surgery.

METHODS

A total of 56 patients (28 males and 28 females) were recruited with a mean age of 36 years. A standardized verbal discussion regarding surgical treatment was provided to each patient. Understanding was then assessed using a knowledge questionnaire. Subsequently, each patient observed a multimedia educational program following which the knowledge questionnaire was repeated. Additional supplementary questions were then given regarding the ease of understanding and satisfaction with the 2 methods of education delivery.

RESULTS

The patients answered 75% of the questions correctly before the multimedia module compared with 88% after it (P < .001). Patients rated the ease of understanding and the amount of information provided by the module highly (9.5 cm and 9.0 cm on a 10-cm Visual Analogue Scale scale, respectively), and 61% of patients considered that the multimedia tool performed as well as the treating surgeon.

CONCLUSION

Multimedia tools used in sequence after a verbal consent resulted in improved patient understanding of pertinent information regarding ankle lateral ligament reconstruction surgery.

LEVELS OF EVIDENCE

Therapeutic Level II.

A review of surgical informed consent: past, present, and future. A quest to help patients make better decisions

Background

Informed consent (IC) is a process requiring a competent doctor, adequate transfer of information, and consent of the patient. It is not just a signature on a piece of paper. Current consent processes in surgery are probably outdated and may require major changes to adjust them to modern day legislation. A literature search may provide an opportunity for enhancing the quality of the surgical IC (SIC) process.

Methods

Relevant English literature obtained from PubMed, Picarta, PsycINFO, and Google between 1993 and 2009 was reviewed.

Results

The body of literature with respect to SIC is slim and of moderate quality. The SIC process is an underestimated part of surgery and neither surgeons nor patients sufficiently realize its importance. Surgeons are not specifically trained and lack the competence to guide patients through a legally correct SIC process. Computerized programs can support the SIC process significantly but are rarely used for this purpose.

Conclusions

IC should be integrated into our surgical practice. Unfortunately, a big gap exists between the theoretical/legal best practice and the daily practice of IC. An optimally informed patient will have more realistic expectations regarding a surgical procedure and its associated risks. Well-informed patients will be more satisfied and file fewer legal claims. The use of interactive computer-based programs provides opportunities to improve the SIC process.

Converting the informed consent from a perfunctory process to an evidence-based foundation for patient decision making

BACKGROUND

Standard consent forms result in highly variable communication between patients and physicians. To enhance the consent process and facilitate shared decision making, we developed a World Wide Web-based program, PREDICT (Patient Refined Expectations for Deciding Invasive Cardiac Treatments), to systematically embed patient-specific estimates of death, bleeding, and restenosis into individualized percutaneous coronary intervention informed consent documents. We then compared patients' experiences with informed consent before and after implementation of PREDICT.

METHODS AND RESULTS

Between August 2006 and May 2007, patients undergoing nonemergent cardiac catheterization who received the original consent form (n=142) were interviewed and compared with those who received the PREDICT consent form (n=193). Hierarchical modified Poisson regression models were used to adjust for clustering of patients within physicians. Compared with the original consent group, those in the PREDICT group reported higher rates of reading the consent form (72% versus 44%, relative risk [RR] 1.64, 95% confidence interval [CI] 1.24 to 2.16), increased perception of shared decision making (67% versus 45%, RR 1.48, 95% CI 0.99 to 2.22), and decreased anxiety (35% versus 55%, RR 0.70, 95% CI 0.53 to 0.91). Although there were no differences between groups in patients' ability to name complications of percutaneous coronary intervention, among patients who identified either death or bleeding as a potential complication, more patients in the PREDICT group recalled being informed of their estimated risk of that complication (death: 85% versus 62%, RR 1.37, 95% CI 1.03 to 1.82; bleeding: 92% versus 71%, RR 1.28, 95% CI 1.06 to 1.56).

CONCLUSIONS

In this preliminary, single-center experience, individualized consent forms with patient-specific risks were associated with improved participation in the consent process, reduced anxiety, and better risk recall. PREDICT is one potential strategy for improving the current practice of obtaining informed consent for percutaneous coronary intervention.

Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review

BACKGROUND

Patient understanding in clinical informed consent is often poor. Little is known about the effectiveness of interventions to improve comprehension or the extent to which such interventions address different elements of understanding in informed consent.

PURPOSE

. To systematically review communication interventions to improve patient comprehension in informed consent for medical and surgical procedures. Data Sources. A systematic literature search of English-language articles in MEDLINE (1949-2008) and EMBASE (1974-2008) was performed. In addition, a published bibliography of empirical research on informed consent and the reference lists of all eligible studies were reviewed. Study Selection. Randomized controlled trials and controlled trials with nonrandom allocation were included if they compared comprehension in informed consent for a medical or surgical procedure. Only studies that used a quantitative, objective measure of understanding were included. All studies addressed informed consent for a needed or recommended procedure in actual patients. Data Extraction. Reviewers independently extracted data using a standardized form. All results were compared, and disagreements were resolved by consensus. Data Synthesis. Forty-four studies were eligible. Intervention categories included written information, audiovisual/multimedia, extended discussions, and test/feedback techniques. The majority of studies assessed patient understanding of procedural risks; other elements included benefits, alternatives, and general knowledge about the procedure. Only 6 of 44 studies assessed all 4 elements of understanding. Interventions were generally effective in improving patient comprehension, especially regarding risks and general knowledge. Limitations. Many studies failed to include adequate description of the study population, and outcome measures varied widely.

CONCLUSIONS

. A wide range of communication interventions improve comprehension in clinical informed consent. Decisions to enhance informed consent should consider the importance of different elements of understanding, beyond procedural risks, as well as feasibility and acceptability of the intervention to clinicians and patients. Conceptual clarity regarding the key elements of informed consent knowledge will help to focus improvements and standardize evaluations.

A systematic review of interventions to improve recall of medical advice in healthcare consultations

BACKGROUND

In order for patients to adhere to healthcare advice, it is essential that they are able to recall this following a consultation. Although psychological research exists which highlights techniques and factors postulated to influence recall, only a limited body of work has been conducted to evaluate their effectiveness in a clinical context.

AIM

To carry out a systematic review of intervention trials designed to enhance recall of medical information.

METHODS

We searched Medline (1950-April 2007); Embase (1980-April 2007); Cinahl (1982-April 2007); PsychINFO (1969-2007); and the Cochrane Library Collection. Secondary searches were made through reference to relevant journals and reference lists from relevant papers/review papers.

RESULTS

From 69 papers provisionally identified, 34 papers met the inclusion criteria. Nine recall interventions had been evaluated (audio recordings, written materials, adjunct questions, prompt sheets, visual aids, cognitive strategies, rehearsal, communication styles and personalized teaching). Despite the experimental and theoretical evidence which could have informed cognitive interventions to enhance recall of healthcare advice, most studies primarily focused on the use of written and/or audio-recorded medical instructions. Although the majority of studies supported these approaches insofar as they enhanced recall, the findings were equivocal.

CONCLUSION

While written and tape-recorded instructions appear to improve recall in most situations, a dearth of interventions incorporating psychological theory was readily apparent. Further research is required in clinical settings to determine if cognitive interventions based on a more over-arching psychological model of recall are effective.

Improvement in surgical consent with a preoperative multimedia patient education tool: a pilot study

BACKGROUND

Preoperative education and discussion is a crucial part of the surgeon-patient relationship. The purpose of this study was to assess the efficacy of a multimedia education tool to improve patients' understanding when used as an adjunct to the usual verbal consent process regarding first metatarsophalangeal joint (MTPJ) arthrodesis surgery.

MATERIALS AND METHODS

Thirty-one patients were prospectively recruited. There were 24 female and seven male patients with an average age of 56 years. Well-rehearsed, standardized and thorough information regarding the surgery, its risks, benefits, and usual post-operative course were supplied verbally to each patient. Patient understanding was then assessed with a condition specific questionnaire. Following this, each completed a multimedia educational program and repeated the questionnaire, including supplementary questions regarding ease of understanding and satisfaction with the two methods.

RESULTS

The patients answered 62% questions correctly before the multimedia presentation compared to 87% after it (p < 0.001). Patients rated the ease of understanding of the multimedia module as a median 9.3 cm along a 10-cm visual analogue scale and 9.1 cm when asked whether it contained the appropriate amount of information to make a decision about surgery. Ninety percent of patients considered that the multimedia tool answered their questions about surgery as well or better than the treating surgeon.

CONCLUSION

This study demonstrated that incorporation of a computer-based, multimedia education tool into to the surgical consent process improved patient understanding of the risks, benefits and usual postoperative course following first MTPJ arthrodesis surgery.

Quality of informed consent for invasive procedures

OBJECTIVE

To assess quality of informed consent among patients undergoing procedures and patient's preferences about decision-making.

DESIGN

Cross-sectional survey of hospitalized patients about informed consent before surgery or other procedures. Preference for decision-making was elicited in hospitalized and ambulatory patients.

SETTING

Large academic general hospital and 10 general clinics, over the years 2002-04.

INTERVENTION

Data of initial survey were presented at staff meetings, recommending asking patients to restate what was explained to them.

MAIN OUTCOME MEASURES

Rate of patient's recall for explanations on risks and alternative options; rate of patients preferring shared, autonomous and paternalistic modes of decision-making; degree of satisfaction from the decision-making.

RESULTS

Half of the patients did not recall receiving explanations about risks and two-third did not remember discussion of alternative options. The intervention failed, <10% of patients being asked to re-state what was explained to them. Expectations about decision varied: approximately 60% favored shared decision, nearly 20% preferred autonomous decision and the remainder wanted physicians to make decisions. Satisfaction was rated as good or very good by 80% of patients.

CONCLUSIONS

Most patients do not remember receiving explanations about risks or alternatives for procedures, and physicians resist attempts to improve informed consent. Tools should be developed to measure the quality of consent. Since patients significantly differ in their preferred mode of decision-making, the informed consent should be patient-specific.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented for example on the Internet, DVD, or video cassette) are one such method.

OBJECTIVES

To assess the effects of providing audio-visual information alone, or in conjunction with standard forms of information provision, to potential clinical trial participants in the informed consent process, in terms of their satisfaction, understanding and recall of information about the study, level of anxiety and their decision whether or not to participate.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (searched 20 June 2006); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 2, 2006; MEDLINE (Ovid) (1966 to June week 1 2006); EMBASE (Ovid) (1988 to 2006 week 24); and other databases. We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or oral information as usually employed in the particular service setting), with standard forms of information provision alone, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to participate in a real (not hypothetical) clinical study.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. Due to heterogeneity no meta-analysis was possible; we present the findings in a narrative review.

MAIN RESULTS

We included 4 trials involving data from 511 people. Studies were set in the USA and Canada. Three were randomised controlled trials (RCTs) and the fourth a quasi-randomised trial. Their quality was mixed and results should be interpreted with caution. Considerable uncertainty remains about the effects of audio-visual interventions, compared with standard forms of information provision (such as written or oral information normally used in the particular setting), for use in the process of obtaining informed consent for clinical trials. Audio-visual interventions did not consistently increase participants' levels of knowledge/understanding (assessed in four studies), although one study showed better retention of knowledge amongst intervention recipients. An audio-visual intervention may transiently increase people's willingness to participate in trials (one study), but this was not sustained at two to four weeks post-intervention. Perceived worth of the trial did not appear to be influenced by an audio-visual intervention (one study), but another study suggested that the quality of information disclosed may be enhanced by an audio-visual intervention. Many relevant outcomes including harms were not measured. The heterogeneity in results may reflect the differences in intervention design, content and delivery, the populations studied and the diverse methods of outcome assessment in included studies.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions for people considering participating in clinical trials remains unclear. Evidence is mixed as to whether audio-visual interventions enhance people's knowledge of the trial they are considering entering, and/or the health condition the trial is designed to address; one study showed improved retention of knowledge amongst intervention recipients. The intervention may also have small positive effects on the quality of information disclosed, and may increase willingness to participate in the short-term; however the evidence is weak. There were no data for several primary outcomes, including harms. In the absence of clear results, triallists should continue to explore innovative methods of providing information to potential trial participants. Further research should take the form of high-quality randomised controlled trials, with clear reporting of methods. Studies should conduct content assessment of audio-visual and other innovative interventions for people of differing levels of understanding and education; also for different age and cultural groups. Researchers should assess systematically the effects of different intervention components and delivery characteristics, and should involve consumers in intervention development. Studies should assess additional outcomes relevant to individuals' decisional capacity, using validated tools, including satisfaction; anxiety; and adherence to the subsequent trial protocol.

Postoperative laparoscopic bariatric surgery patients do not remember potential complications

BACKGROUND

Despite comprehensive preoperative education, patients may forget important information such as potential complications.

METHODS

Patients who had undergone laparoscopic bariatric surgery were surveyed. All patients were asked to write down as many as possible of the potential complications. Preoperatively, patients had been given an educational book, two preoperative educational appointments, a test, and an informed consent discussion and form with clear presentation of complications which may occur.

RESULTS

There were 70 patients in this investigation (75% response rate), with 49 laparoscopic gastric bypass patients (bypass), 18 laparoscopic adjustable gastric banding patients (band), and 3 patients who did not indicate their procedure. Patients listed an average of 5.1 complications. Complications were grouped in 12 categories for each procedure. Percentages reported by patients (bypass vs band) were: Death 34 (69%) vs. 13 (72%), Injury to GI tract/leak 14 (29%) vs. 5 (28%), Conversion 1 (2%) vs 0 (0%), CV/pulmonary issues 11 (22%) vs. 4 (22%), Stenosis/ulcer 6 (12%) vs NA, Band erosion/migration NA vs 9 (50%), Malnutrition 24 (49%) vs, 4 (22%), GI symptoms 19 (39%) vs. 6 (33%), Infection 15 (31%) vs. 10 (56%), Weight regain/inadequate loss 5 (10%) vs. 3 (17%), Thromboembolic event 7 (14%) vs. 3 (17%), and Hemorrhage 8 (16%) vs. 0 (0%).

CONCLUSIONS

Many patients forget some of the serious complications after laparoscopic bariatric surgery. This may have important medicolegal consequences especially during malpractice lawsuits. These data underscore the need for continual follow-up and education in this patient population.

A randomised study of three different informational AIDS prior to coronary angiography, measuring patient recall, satisfaction and anxiety

BACKGROUND

Informed consent is a basic standard of care for all patients undergoing medical procedures, but recall of information has been shown to be poor. We sought to compare verbal, written and animated audiovisual information delivery, during consent for coronary angiography, by measuring improvement in recall.

METHOD

A sample population of 99 cardiac patients at Flinders Medical Centre was randomised (1:1:1) to receive one of three information delivery methods. The information content was standardised by a risk proforma, which explained the procedure and defined 12 specific risks. Recall, satisfaction and anxiety were assessed by a questionnaire administered at three different time points: post-consent, post-procedure and at 30 days. Effect of delivery method on satisfaction and anxiety was rated on a self-reported scale from 1-5, with 5 representing very satisfied or very anxious. Groups were compared by non-parametric testing and a p-value of <0.05 was considered statistically significant.

RESULTS

Patients were a median age of 64 (i.q.r. 56, 72) years. Information delivery method had no effect on recall of risks at any time-point (p=0.2, 0.7, 0.5, respectively) and the average recall score across the population was 3-4 out of 12. There was no significant effect on median satisfaction scores: verbal; 5 (i.q.r.4, 5) versus written/audiovisual; 4 (i.q.r.4, 5) (p=ns), or on median anxiety scores: verbal; 3 (i.q.r.2, 4) versus written/audiovisual; 3 (i.q.r.2, 4) (p=ns).

CONCLUSION

Despite careful design of an innovative audiovisual delivery technique aimed at optimising comprehension and aiding memory, recall of information was poor and informational aids showed no improvement. Modes of information delivery are not the key to patient assimilation of complex medical information.

Effects of presentation method on the understanding of informed consent

BACKGROUND/AIM

Knowledge of which presentation methods impart the most information to patients can improve the informed consent discussion. The purpose of this study was to determine if the comprehension and recall of the informed consent discussion varied with presentation method.

METHODS

Randomised, prospective study at the University of Arkansas for Medical Sciences. 90 freshmen medical students were randomly assigned to one of three groups and separately went through an informed consent on cataract surgery. Group A heard an informed consent presentation. Group B was shown diagrams while hearing the same presentation. Group C heard the consent and then watched an informational video on cataract surgery. A 10 point multiple choice quiz was administered after the presentation and repeated again 1 week later.

RESULTS

Scores from each group were averaged as number correct out of 10 questions. For same day scores, group C scores (7.70 (SD 1.24)) were significantly higher than group A (6.39 (1.63)). One week testing revealed that group C (6.96 (1.62)) recalled more between the two time periods and scored significantly higher than groups A (5.15 (2.11)) and B (5.54 (1.64)).

CONCLUSIONS

This study found differences in the participants' ability to recall facts based on the manner in which the material was presented. It clearly demonstrated that the use of visual aids improved the ability to remember facts and risks associated with cataract surgery beyond a verbal presentation alone. It also showed a benefit of the repetition of information as provided by audiovisual presentations that can be used in conjunction with the physician-patient discussion.

Medicolegal aspects of foot and ankle surgery

Medicolegal aspects of orthopaedic foot and ankle surgery, including issues of standard of care, complications, and discrepancies between patient and physician expectations, generally are similar to those encountered in other orthopaedic subspecialties. However, there are some unique aspects involving foot and ankle surgery: the standard of care continues to evolve, some complications are specific to the foot and ankle, and patient expectations of particular foot and ankle procedures may exceed those of the foot and ankle surgeon, who often is confronted with challenging pathologic conditions. This review addresses issues of standard of care and complications as they pertain to current practices of orthopaedic foot and ankle surgery.

Implications of the UK NHS consent policy for nuclear medicine practice

To comply with government policy on consent, the Sheffield Teaching Hospitals (STH) National Health Service (NHS) Trust introduced a new consent policy in February 2002. Verbal or written consent (depending on the level of risk) must be obtained prior to each study. The patient must be fully informed and given time to reach a decision. Consideration needs to be given to the following: to whom, when and how to provide such information and obtain consent. Each study type and patient circumstance needs to be classified according to risk. Consideration of the risks resulted in a local policy in which written consent is required for the following: therapeutic procedures, studies on pregnant women, studies in which pregnancy needs to be avoided, research procedures, cardiac stress for myocardial perfusion scintigraphy and intrathecal administration. Patient information leaflets have been updated with new information about the study and any risks. Information is now available for both patients and hospital staff. Compliance with the consent policy in a service department provides logistic challenges, but it is possible to fully inform patients in advance about their treatment, allowing them to give informed consent.