Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Effects of medical graphic narratives (patient comic) on Patient Reported Outcome Measures (PROMs) in patients undergoing coronary angiography and PCI

Background/Introduction

Increasing evidence suggests that patients scheduled for invasive cardiac procedures such as coronary angiography / PCI feel insufficiently informed about the planned procedure.

Purpose

To improve the Patient Informed Consent (IC) before coronary angiography by using “medical graphic narratives” (patient comic) that illustrate central IC-related aspects in a simple and understandable manner.

Methods

A patient comic illustrating central steps of the procedure, risks, treatment alternatives and behavioural measures was created in collaboration with professional scientific visual communicators. In a randomised, controlled, prospective trial, we included 121 patients undergoing coronary angiography/PCI. Patients were randomised to a group that was informed about the procedure using the usual Patient IC approach (official consent form and conversation with physician; Control group) or a group that additionally obtained a patient comic for reading (graphic illustrations of central IC aspects based on the official consent form; Comic group). Patient Reported Outcome Measures (PROMs), i.e. satisfaction with and perceived quality of the patient IC, were tested in both groups comparing single items of the Client Satisfaction Questionnaire-8 (CSQ-8) and self-designed single items in both IC groups. Differences were compared using the Fisher's exact test. A p-value &lt;0.05 was considered statistically significant.

Results

PROMs showed significant benefits in favour of the Comic group: Quality of the patient IC was perceived to be “very good” in 45.0% of the Comic group compared to 24.9% of patients in the Control group (p=0.023). Only 23.0% of the patients in the Control group, compared to 40.0% in the Comic group, stated that the IC procedure completely met their expectations (p=0.012). 57.4% in the Control group and 76.7% in the Comic group stated that all of their questions were satisfactorily adressed before the procedure (p=0.015). 43.3% in the Comic group, in contrast to 18.0% in the Control group, declared to feel “very satisfied” with the obtained IC procedure (p=0.002). The acceptance of the patient comic was very high: no patient (0%) expressed feelings of not being taken seriously by reading the patient comic.

Conclusions

Our data confirm pronounced limitations of the usual Patient IC practice before coronary angiography. The use of a patient comic that narratively illustrates central steps of the procedure positively impacts on patient-centered endpoints and significantly improves the patient IC procedure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Friede Springer Herz Stiftung