Assessment of the association between preoperative anxiety and the mode of preoperative information delivery in patients undergoing thoracic surgery operations using the Amsterdam Preoperative Anxiety and Information Scale

Abstract

This study examined preoperative anxiety and its association with the mode of preoperative information delivery (verbal and/or written) in patients undergoing elective thoracic surgery using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). A prospective cross-sectional study was conducted at a university hospital in Turkey between February and June 2024, including 54 patients. The mean age was 57.1 ± 15.8 years, with 37% female. Most patients (85.2%) received verbal information, while 14.8% received both verbal and written. The mean APAIS-anxiety score was 7.61 ± 3.71, with 25.9% reporting high anxiety (⩾11). Anxiety was lower in patients with malignancy history (p = 0.049) and higher in females (p < 0.001). No statistically significant association was observed between the mode of preoperative information delivery and anxiety levels. APAIS-information requirement scores showed no demographic or clinical differences, though anxiety correlated positively with information need (p ⩽ 0.001). These findings underscore the importance of psychological preparation and adequate patient information in thoracic surgery.

Keywords

thoracic surgery preoperative anxiety patient information information requirement Amsterdam Preoperative Anxiety and Information Scale (APAIS)

Introduction

Surgical intervention is not only a physiological challenge for patients but also a source of significant psychological stress. One of the most common psychological issues experienced during this process is anxiety (Caumo et al., 2001). Preoperative anxiety refers to the intense worry a patient feels about potential surgical risks, pain, the anesthesia process, or postoperative complications, and it is highly prevalent in the pre-surgical period (Jovanovic et al., 2022; Yilmaz et al., 2012). Anxiety levels may vary depending on several factors such as age, sex, educational background, comorbidities, and previous experiences with surgery and anesthesia (Berth et al., 2007; Eberhart et al., 2020). Moreover, individuals differ not only in their levels of anxiety but also in their ability to cope with it (Bilginer et al., 2025; Celik and Edipoglu, 2018; Vergara-Romero et al., 2017). Patients with high levels of preoperative anxiety often require larger doses of anesthetics and analgesics during and after the operation (Bilginer et al., 2025; Darville-Beneby et al., 2023). Consequently, elevated anxiety is associated with multiple negative clinical outcomes, including poor pain control, prolonged recovery, reduced patient satisfaction, and increased risk of morbidity (Darville-Beneby et al., 2023; Jlala et al., 2010; Sjöling et al., 2003).

Patients undergoing thoracic procedures may be more susceptible to high preoperative anxiety due to suspicion of malignancy, the significant impact of such surgery on respiratory function, uncertainty regarding postoperative functional capacity, and concerns about long-term quality of life. Unlike many other surgical interventions, thoracic procedures are closely related to vital functions such as respiration, physical endurance, and independence in daily activities. The prolonged recovery period and the risk of postoperative morbidity can exacerbate emotional distress, making thoracic surgery patients a high-risk group in terms of preoperative psychological burden. In this context, there is a need for studies focusing on the relationship between preoperative anxiety and information needs in thoracic surgery patients using valid psychological measures.

The Amsterdam Preoperative Anxiety and Information Scale (APAIS) is a brief and psychometrically validated instrument specifically designed to assess both preoperative anxiety and patients’ information needs. Although APAIS has been widely applied across various surgical specialties, its use in thoracic surgery populations remains limited. In this prospective study, we aimed to assess preoperative anxiety levels and information needs in patients who underwent thoracic operations using APAIS. Additionally, we examined the association between verbal and/or written preoperative education and patients’ anxiety levels.

Materials and methods

This prospective study was conducted between February 2024 and June 2024 at the Department of Thoracic Surgery of a tertiary university hospital. The study included patients aged 18 years and older who were scheduled for elective thoracic surgery. To ensure the homogeneity of the study population and enhance data reliability, patients with a previous diagnosis of anxiety disorder and/or depression and individuals with cognitive impairment were excluded from the study. A total of 60 patients were targeted. One patient was excluded due to inconsistent responses, and five patients were excluded due to pre-existing anxiety and depression diagnoses, resulting in a final sample of 54 patients.

A structured questionnaire was prepared, including the native language version of the APAIS (Table 1), and collected data on demographic characteristics (age, gender, educational level), medical history (comorbidities, diagnosis, awareness about their condition, previous surgery), and the type of preoperative information provided by the physician. The “Unknown” category in the Diagnosis section of the questionnaire reflects patients who have not yet received a definitive histopathological diagnosis during APAIS procedure, as the assessments were performed preoperatively. Patients who were verbally informed by their physician but signed the surgical consent form without reading it during hospital admission were asked to mark only the “verbal” option on the relevant part of the questionnaire. Patients who were verbally informed and read the consent form thoroughly were asked to select the “verbal and written” option. All data were collected via face-to-face interviews conducted by a resident physician within 24 hours before surgery.

Table 1.

Amsterdam preoperative anxiety and information scale (APAIS).

Items	1: Not at all	2: Slightly	3: Moderately	4: Very	5: Extremely
1. I am worried about the anesthesia.
2. The anesthesia is constantly on my mind.
3. I would like to know as much as possible about the anesthesia.
4. I am worried about the procedure.
5. The procedure is constantly on my mind.
6. I would like to know as much as possible about the procedure.

Adapted from Moerman et al. (1996), and the Turkish validity and reliability study by Çetinkaya et al. (2019).

The APAIS is a six-item scale designed to quickly assess preoperative anxiety. It consists of two subscales: the anxiety subscale (items 1, 2, 4, and 5), which measures anxiety related to general anesthesia and surgery, and the information requirement subscale (items 3 and 6), which assesses the need for information regarding anesthesia and surgery. Each item is scored on a five-point Likert scale ranging from “Not at all” (1) to “Extremely” (5). The anxiety subscale (APAIS-a) score ranges from 4 to 20, and the information requirement subscale (APAIS-i) score ranges from 2 to 10. Higher scores indicate higher levels of anxiety or need for information. A score of 11 or more on the anxiety subscale is considered high anxiety, and a score of 5 or more on the information subscale is considered high information need.

APAIS-a and APAIS-i subscale scores were calculated and analyzed separately, in accordance with the original conceptual framework of the scale. In addition, the total APAIS score was calculated and reported to allow descriptive comparison with previous studies in the literature that have presented a combined score as a general indicator of preoperative psychological burden. However, given the conceptual distinction between anxiety and information need, the total APAIS score was not used as the primary basis for inferential or comparative statistical analyses. These scores were compared according to patient age group, gender, educational status, presence of comorbidities or malignancy, diagnosis, type of surgical procedure, and history of anesthesia or surgery. Additionally, the relationship between APAIS-a and APAIS-i scores was analyzed. The Ethics Committee of our hospital approved this study.

Statistical analysis

Given the exploratory nature of the study and the limited number of eligible patients during the study period, no a priori sample size or power calculation was performed. The data were analyzed using IBM SPSS version 23. The normality of data distribution was assessed using the Shapiro-Wilk and Kolmogorov-Smirnov tests. The Mann-Whitney U test was used to compare non-normally distributed variables between two groups, while the Kruskal-Wallis test was employed for comparisons among three or more groups. Given the relatively small sample size and the limited number of outcome events, multivariate regression analyses were not performed to avoid model overfitting and unstable parameter estimates. Instead, the analyses were restricted to descriptive and bivariate approaches, which were considered more appropriate for the exploratory nature of the study. Correlations between non-normally distributed variables were examined using Spearman’s rho correlation coefficient. A p-value of <0.050 was considered statistically significant.

Results

The study included 54 patients scheduled for elective thoracic surgery who agreed to participate. The mean age was 57.17 ± 15.86 years (range: 18–85), with 20 (37%) being female and 35 (64.8%) under the age of 65. Four patients (7.4%) were illiterate, while 18 (33.3%) had completed primary school, 17 (31.5%) had completed high school, 14 (25.9%) held a bachelor’s degree, and 1 (1.9%) had a master’s degree. Forty-eight patients (88.9%) had at least one comorbid condition. Surgery was planned for nine patients (16.7%) due to malignant lung diseases, for seven patients (12.9%) due to benign lung diseases, and for 38 patients (70.4%) with unknown diagnoses (without a preoperative histopathological diagnosis). The high proportion of patients categorized as having an “unknown diagnosis” reflects the preoperative timing of data collection, as many patients were undergoing surgery for diagnostic purposes and had not yet received a definitive histopathological diagnosis at the time of assessment. All patients (100%) reported being informed about their disease. Surgical procedures were planned as minimally invasive in 37 cases (68.5%) and as open surgery in 17 cases (31.5%). Thirteen patients (24.1%) had not undergone any previous surgical procedure, and 11 (20.4%) had never received general anesthesia before. While 46 patients (85.2%) received only verbal information, eight patients (14.8%) were informed both verbally and in writing (Table 2).

Table 2.

Descriptive statistics of patient variables.

Variables	Frequency (n)	Percentage (%)
Age (mean ± standard deviation (min–max))	57.17 ± 15.86 (18–85)
Age range
<65 years	35	64.8
⩾65 years	19	35.2
Gender
Female	20	37
Male	34	63
Educational status
Illiterate	4	7.4
Primary education	18	33.3
High school	17	31.5
Bachelor’s degree	14	25.9
Master’s degree	1	1.9
Comorbidity
Present	48	88.9
Absent	6	11.1
Additional malignancy
Present	17	31.5
Absent	37	68.5
Diagnoses
Malignant pulmonary diseases	9	16.7
Benign pulmonary diseases	7	12.9
Unknown^a	38	70.4
Informed about their disease
Informed	54	100
Planned surgical procedure
Open surgery	17	31.5
Minimally invasive surgery	37	68.5
Previous anesthesia experience
Present	43	79.6
Absent	11	20.4
Previous surgical experience
Present	41	75.9
Absent	13	24.1
Information provided by the physician
Verbal	46	85.2
Verbal and written	8	14.8
	(mean ± standard deviation (min–max))
Anesthesia anxiety score	3.48 ± 2.01 (2–10)
Surgical procedure anxiety score	4.13 ± 2.47 (2–10)
Information requirement subscale score	4.72 ± 2.21 (2–10)
Total anxiety subscale score	7.61 ± 3.71 (4–15)
Total APAIS score	12.33 ± 5.13 (6–25)

“Unknown diagnosis” indicates patients without a definitive histopathological diagnosis at the time of preoperative assessment.

In our study, the mean APAIS-a score was found to be 7.61 ± 3.71, and high anxiety (APAIS-a score of 11 and above) was observed in 25.9% of the patients. The mean APAIS-i score was found to be 4.72 ± 2, and a high need for information (APAIS-i score of 5 and above) was observed in 50% of the patients.

Total APAIS scores were also summarized to provide a descriptive overview of preoperative psychological burden across patient subgroups. The mean APAIS score was 12.83 in patients under 65 years and 11.42 in those aged 65 and above. The mean APAIS score was 14.7 in females and 10.94 in males. Patients with a history of additional malignancy had a mean APAIS score of 10.24, whereas those without additional malignancy had a mean score of 13.30. The mean APAIS score was 12.33 in patients who received verbal information only from their physician, while it was 12.38 who received both verbal and written information. The distribution of total APAIS scores across demographic and clinical characteristics is presented for descriptive purposes in Table 3.

Table 3.

Comparison of total APAIS scores according to variables.

Variables	Mean ± SD (min–max)	Test statistic	p
Age range
<65 years	12.83 ± 5.33 (6–25)	284,500	0.383^a
⩾65 years	11.42 ± 4.74 (6–21)
Gender
Female	14.7 ± 4.51 (9–22)	180,500	0.004^a
Male	10.94 ± 5.01 (6–25)
Educational status
Illiterate	11.75 ± 3.86 (8–16)	2562	0.464^b
Primary education	12.5 ± 5.02 (6–21)
High school	11.18 ± 5.69 (6–25)
Bachelor’s degree	13.6 ± 5.03 (6–22)
Comorbidity
Present	11.98 ± 4.8 (6–22)	108,000	0.337^a
Absent	15.17 ± 7.17 (6–25)
Additional malignancy
Present	10.24 ± 3.96 (6–21)	211,000	0.053^a
Absent	13.3 ± 5.36 (6–25)
Diagnoses
Malignant pulmonary diseases	9.78 ± 4.32 (6–16)	3331	0.189^b
Benign pulmonary diseases	13.14 ± 5.18 (6–20)
Unknown	12.79 ± 5.23 (6–20)
Planned surgical procedure
Open surgery	11.41 ± 4.85 (6–20)	261,500	0.322^a
Minimally invasive surgery	12.76 ± 5.26 (6–25)
Previous anesthesia experience
Present	12.02 ± 5.09 (6–22)	193,000	0.348^a
Absent	13.55 ± 5.35 (6–25)
Previous surgical experience
Present	11.88 ± 4.97 (6–22)	212,000	0.268^a
Absent	13.77 ± 5.57 (6–25)
Information provided by physician
Verbal	12.33 ± 4.99 (6–22)	176,000	0.858^a
Verbal and written	12.38 ± 6.26 (6–25)

Mann-Whitney U test.

Kruskall Wallis test.

Bold values indicate statistically significant results (p < 0.05).

When patients were evaluated according to the total APAIS-a scores, the mean APAIS-a score was 7.97 in patients under 65 years of age and 6.95 in patients aged 65 and over, with no statistically significant difference between the two groups (p = 0.335). When evaluated by gender, the mean APAIS-a score was 9.65 in females and 6.41 in males, and this difference was statistically significant (p = 0.001). Patients with a history of additional malignancy had a mean APAIS-a score of 6.06, whereas those without such a history had a score of 8.32, indicating higher anxiety levels in patients without additional malignancy (p = 0.049). Patients who received only verbal information from their physician had a mean APAIS-a score of 7.54, while those who received both verbal and written information scored 8.00 (Table 4). There were no statistically significant differences in APAIS-a scores among groups according to education level, age range, and presence of comorbidities, diagnoses, type of planned surgical intervention, or previous anesthesia and surgical experience. In our study, 14 cases (25.9%) were found to have a high APAIS-a score, and of these, 10 cases (71%) also exhibited a high APAIS-i score.

Table 4.

Comparison of total anxiety subscale (APAIS-a) scores according to variables.

Variables	Mean ± SD (min–max)	Test statistic	p
Age range
<65 years	7.97 ± 3.82 (4–15)	280,500	0.335^a
⩾65 years	6.95 ± 3.5 (4–15)
Gender
Female	9.65 ± 3.69 (4–15)	164,500	0.001 ^a
Male	6.41 ± 3.2 (4–15)
Educational status
Illiterate	8.5 ± 2.89 (6–11)	2501	0.475^b
Primary education	8.06 ± 4.12 (4–15)
High school	6.65 ± 3.82 (4–15)
Bachelor’s degree	7.93 ± 3.35 (4–14)
Comorbidity
Present	7.31 ± 3.5 (4–15)	99,000	0.227^a
Absent	10 ± 4.82 (4–15)
Additional malignancy
Present	6.06 ± 2.93 (4–15)	211,500	0.049 ^a
Absent	8.32 ± 3.84 (4–15)
Diagnoses
Malignant pulmonary diseases	6.11 ± 2.85 (4–11)	1903	0.386^b
Benign pulmonary diseases	7.71 ± 3.45 (4–13)
Unknown	7.95 ± 3.92 (4–15)
Planned surgical procedure
Open surgery	7.24 ± 3.35 (4–14)	298,000	0.753^a
Minimally invasive surgery	7.78 ± 3.9 (4–15)
Previous anesthesia experience
Present	7.49 ± 3.75 (4–15)	207,000	0.516^a
Absent	8.09 ± 3.67 (4–15)
Previous surgical experience
Present	7.29 ± 3.57 (4–15)	217,000	0.305^a
Absent	8.62 ± 4.11 (4–15)
Information provided by physician
Verbal	7.54 ± 3.55 (4–15)	182,000	0.971^a
Verbal and written	8 ± 4.78 (4–15)

Mann-Whitney U test.

Kruskall Wallis test.

Bold values indicate statistically significant results (p < 0.05).

When patients were evaluated according to the APAIS-i score, the mean APAIS-i score was 4.86 in patients under 65 years of age and 4.47 in patients aged 65 and over (p = 0.620). The mean APAIS-i score was 5.05 in females and 4.53 in males (p = 0.331). Among patients who received verbal information from their physician, the mean APAIS-i score was 4.78, while it was 4.38 in those who received both verbal and written information (p = 0.542). No statistically significant differences were observed between groups in APAIS-i scores based on educational level, gender, age group, presence of comorbidities, accompanying malignancy status, diagnoses, type of planned surgical procedure, or previous anesthesia and surgical experience (Table 5).

Table 5.

Comparison of information requirement subscale (APAIS-i) scores according to variables.

Variables	Mean ± SD (min–max)	Test statistic	p
Age range
<65 years	4.86 ± 2.39 (2–10)	305,500	0.620^a
⩾65 years	4.47 ± 1.87 (2–7)
Gender
Female	5.05 ± 2.16 (2–10)	286,500	0.331^a
Male	4.53 ± 2.25 (2–10)
Educational status
Illiterate	3.25 ± 1.26 (2–5)	5127	0.163^b
Primary education	4.44 ± 1.65 (2–7)
High school	4.53 ± 2.74 (2–10)
Bachelor’s degree	5.67 ± 2.13 (2–9)
Comorbidity
Present	4.67 ± 2.06 (2–10)	141,500	0.947^a
Absent	5.17 ± 3.43 (2–10)
Additional malignancy
Present	4.18 ± 1.74 (2–6)	254,000	0.253^a
Absent	4.97 ± 2.37 (2–10)
Diagnoses
Malignant pulmonary diseases	3.67 ± 1.80 (2–6)	2831	0.243^b
Benign pulmonary diseases	5.43 ± 3.05 (2–10)
Unknown	4.84 ± 2.10 (2–10)
Planned surgical procedure
Open surgery	4.18 ± 2.24 (2–10)	241,000	0.165^a
Minimally invasive surgery	4.97 ± 2.18 (2–10)
Previous anesthesia experience
Present	4.53 ± 2.15 (2–10)	179,000	0.211^a
Absent	5.45 ± 2.38 (2–10)
Previous surgical experience
Present	4.59 ± 2.19 (2–10)	224,000	0.383^a
Absent	5.15 ± 2.3 (2–10)
Information provided by the physician
Verbal	4.78 ± 2.17 (2–10)	158,000	0.542
Verbal and written	4.38 ± 2.56 (2–10)

Mann-Whitney U test.

Kruskall Wallis test.

When the relationship between the information-seeking desire score and the total anxiety score was examined, a statistically significant, positive, and moderate correlation was found (p ⩽ 0.001; Table 6).

Table 6.

Comparison of anxiety scores according to information requirement subscale scores.

	Information requirement subscale score
Anxiety subscale	r	p
Anesthesia anxiety score	0.405	0.002
Surgical procedure anxiety score	0.399	0.003
Total anxiety subscale score	0.465	<0.001

r: Spearman’s rank correlation coefficient.

Bold values indicate statistically significant results (p < 0.05).

Discussion

One of the most effective strategies for controlling anxiety is to provide the patient with accurate, sufficient, and timely information regarding the surgical process. Preoperative education aims to rationalize the patient’s perception of surgery and reduce feelings of uncertainty by offering detailed information about the surgical procedure, anesthesia, postoperative care, and the recovery process (Guo, 2015; Powell et al., 2016). For all these reasons, assessing preoperative anxiety and providing detailed patient education are of great importance.

Various scales are available to assess patients’ anxiety levels. One of the most widely used tools for this purpose is the State-Trait Anxiety Inventory (STAI). However, the STAI reflects general anxiety tendencies rather than surgery-specific preoperative anxiety and is relatively time-consuming. Moerman et al. (1996) developed the Amsterdam Preoperative Anxiety and Information Scale (APAIS) to assess patients’ preoperative anxiety and information needs. Çetinkaya et al. (2019) demonstrated that the Turkish version of the APAIS is a valid and reliable tool for measuring preoperative anxiety and information needs in Turkish patients. The APAIS is notable for its rapid applicability in clinical settings and its ability to simultaneously assess patients’ anxiety and information needs. It is widely used in various surgical disciplines, including general surgery, urology, orthopedics, and gynecology. However, studies investigating the use of APAIS in thoracic surgery patients are limited. Thoracic surgery is associated with increased stress due to concerns about cancer, limitations in respiratory function, and risks of postoperative morbidity, and therefore, preoperative psychological assessment is critical.

Eberhart et al. (2020) reported that in a series of 3087 elective surgery patients from various specialties, the mean APAIS-a score was 9.9, and 40.5% of the patients showed high anxiety. Ju et al. (2023) found that in 308 patients undergoing video-assisted thoracoscopic surgery, the mean APAIS-a score was 10.6 ± 4.2, and 48.4% showed high anxiety levels. Yaman-Çelik and Durmaz-Edeer (2024) reported that in 102 elective thoracic surgery patients, the mean APAIS-a score was 11.56 ± 3.89 and the mean APAIS-i score was 6.85 ± 2.38, and that most patients had moderate to high levels of anxiety. Perks et al. (2009) found that, in 100 elective neurosurgery patients, the mean APAIS-a score was 10.5 ± 4.0, and the mean APAIS-i score was 6.4 ± 2.4. Hernández-Palazón et al. (2018) reported a mean total APAIS score of 11.4 ± 4.3 in a cohort of cardiac surgery patients.

In our study, the mean APAIS-a score was 7.61 ± 3.71, with high anxiety observed in 25.9% of patients. The mean APAIS-i score was 4.72 ± 2.21, with a high need for information observed in 50%. The lower anxiety scores and rates in our cohort compared to the literature may be attributed to demographic differences, institutional patient management, timing, content, and the way preoperative information was presented. In addition, all patients received verbal information from their physicians, and some also reviewed written consent forms; this contextual factor should be taken into account when interpreting the relatively lower anxiety levels observed in this cohort. Relatively low information need scores may be associated with patients either being well-informed about their surgical procedures or finding the educational efforts adequate. The predominance of patients diagnosed with malignancy, who may have internalized information throughout the diagnostic and treatment processes, may also explain the observed lower anxiety.

Gender differences in anxiety have been well documented, with females consistently showing higher anxiety scores than males (Çetinkaya et al., 2019; Eberhart et al., 2020; Ju et al., 2023; Matthias and Samarasekera, 2012; Perks et al., 2009; Yu et al., 2022). Our findings align with these reports, showing significantly higher APAIS-a scores in women. This observation corresponds with epidemiological data suggesting women are approximately twice as likely as men to develop anxiety disorders (Maeng and Milad, 2015). Various biological and psychosocial hypotheses have been proposed, including fluctuating estrogen levels enhancing anxiety and stress responses in women (Maeng and Milad, 2015) and women’s higher emotional awareness and ability to express anxiety (Li et al., 2021). From a clinical perspective, these findings suggest that certain subgroups of thoracic surgery patients may benefit from closer preoperative psychological assessment and tailored communication strategies. In particular, female patients and individuals without prior malignancy experience may represent more vulnerable groups in terms of preoperative anxiety. Early identification of patients with high APAIS anxiety or information need scores could allow clinicians to individualize preoperative counseling, allocate additional time for discussion, and consider structured educational or supportive interventions when appropriate.

Sociocultural and health system–related factors may also influence preoperative anxiety and information needs. In healthcare settings where physician-centered communication is predominant, and patients tend to place high trust in verbal explanations, written materials such as consent forms may play a secondary role in alleviating anxiety.

High information need has been associated with elevated preoperative anxiety in many surgical disciplines, including thoracic surgery (Ju et al., 2023; Moerman et al., 1996). Our data confirmed a statistically significant positive correlation between information desire and anxiety scores. Conversely, factors such as age, education level, comorbidities, type of surgical procedure, and prior anesthesia or surgical experience did not significantly influence APAIS scores. This contrasts with studies from Brazil and Nigeria, where higher education, lack of surgical experience, and major surgical plans correlated with increased anxiety (Caumo et al., 2001; Ossai et al., 2023). Such discrepancies may stem from differences in sample characteristics, cultural contexts, healthcare system dynamics, or information delivery approaches. In addition to informational factors, recent evidence has highlighted the role of broader psychosocial contexts in shaping preoperative anxiety. For example, a meta-analysis by Kok et al. (2023) reported that perceived social support was significantly associated with preoperative anxiety levels in surgical patients.

Our study evaluated the relationship between verbal and written preoperative information and anxiety levels in thoracic surgery patients using APAIS. While all patients received verbal information, only a minority reviewed written consent forms. No significant difference in anxiety subscale scores was found between patients receiving verbal-only versus verbal-plus-written information. This finding suggests that patient characteristics, health literacy, and prior medical experiences may be more closely associated with anxiety levels than the mode of information delivery alone. However, since written information was limited to consent forms, comprehension might have been inadequate. In contrast to routine preoperative information practices, structured and technology-supported educational interventions have been shown to reduce preoperative anxiety. Supporting this, Shukla et al. (2025) demonstrated that multimedia-supported information significantly reduces preoperative anxiety compared to verbal information alone. Gülşen and Arslan (2026) demonstrated that an e-mobile, model-based educational intervention significantly reduced anxiety levels and improved daily living activities among surgical patients using a randomized controlled trial. Literature emphasizes that the quality of communication—personalized, clear, and reassuring information—is more crucial than its format in mitigating anxiety (Ali et al., 2024).

An interesting finding was that patients with a history of malignancy unrelated to the current surgical indication had significantly lower APAIS anxiety scores. Some studies suggest that psychological adaptation over time in cancer patients leads to greater preparedness for invasive procedures (Hanalis-Miller et al., 2022). Although this observation is limited in the literature, it may reflect increased healthcare system interaction, better access to information, and prior adjustment to diagnosis and treatment, which can reduce uncertainty and anxiety. Nevertheless, our study was not designed to establish causality for this association. Further large-scale, focused research is needed to validate this finding and elucidate underlying mechanisms.

Overall, this study adds to the limited literature on preoperative anxiety and information needs in thoracic surgery patients assessed using the APAIS. By applying a brief and surgery-specific assessment tool in a patient group exposed to unique psychological challenges, such as suspected malignancy and concerns about respiratory function, our findings provide clinically meaningful insights into anxiety and information needs in thoracic surgery practice. These results may help guide more patient-centered preoperative communication in this high-risk population.

Limitations

This study was conducted with a limited number of patients at a single center, which limits the generalizability of the findings. The relatively small sample size and limited number of outcome events prevented the use of multivariate regression analyses, as such models would carry a high risk of overfitting and unstable estimates. Standardization of the content, duration, and format of preoperative information was not feasible, as information was provided as part of routine clinical care by different physicians in a non-interventional real-world setting. Although the method of information transfer was classified as verbal or verbal and written, the content, duration, and presentation of the information were not standardized; this may have led to heterogeneity due to individual differences in patients’ understanding. Furthermore, the study relied on patients’ self-reports that they had read the written information. Additionally, the cross-sectional design of the study limits the ability to draw causal inferences regarding the relationship between preoperative information and anxiety. Future studies using experimental or quasi-experimental designs with standardized and structured educational interventions are warranted to better evaluate the causal impact of preoperative information on anxiety outcomes.

Conclusion

This study is among the few that evaluate preoperative anxiety levels and information needs in patients scheduled for elective thoracic surgery using the APAIS and relate the findings to sociodemographic variables. The results indicate that mean APAIS scores in our patient group were lower than those reported in the literature, with higher anxiety levels observed particularly in female patients. A significant positive correlation was found between information desire and anxiety levels. Additionally, patients with an additional malignancy diagnosis accompanying thoracic surgery exhibited lower preoperative anxiety. Although no significant differences were observed between verbal and written information delivery methods, the content and personalization of preoperative communication should be taken into account when interpreting anxiety-related findings. This finding should be interpreted cautiously, as the written information provided to patients was limited to standard surgical consent forms and did not constitute a structured or educational intervention. Therefore, the absence of a significant difference should not be interpreted as ineffectiveness of written information per se, but rather as a limitation related to the content and format of the information provided. These methodological limitations, particularly the non-standardized nature of preoperative information and the cross-sectional design, should be considered when interpreting the observed associations between information delivery and anxiety levels.

In this cohort, approximately one-quarter of patients met the criterion for high preoperative anxiety, while half of the patients demonstrated a high need for information, underscoring the clinical relevance of assessing both dimensions in thoracic surgery populations.

Our study highlights the importance of psychological preparation and appropriate patient education in thoracic surgery, contributing to the strengthening of patient-centered surgical approaches. The limited use of APAIS in thoracic surgery in the literature makes this study important and original in this field. Future multicenter studies with larger sample sizes will better clarify the predictive power of APAIS and help develop more effective strategies for managing preoperative anxiety.

Footnotes

Acknowledgements

The authors are grateful to Ege University Faculty of Medicine Department of Thoracic Surgery doctors, nurses and staffs for their collaboration.

ORCID iDs

Mehmet Sezer

Ahmet Kayahan Tekneci

Ufuk Cagirici

Ethical considerations

The study was approved by Ege University Faculty of Medicine Research Ethics Committees.

Consent to participate

Written informed consent was obtained from each patient. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Consent of patients and their relatives was obtained for publication.

Author contributions

U.C. equally contributed to the conception and design of the research; M.S. and A.K.T. contributed to the design of the research; U.C. and M.S contributed to the acquisition and analysis of the data; M.S., B.R.E., S.B.D., A.K.T., U.C., T.I.A., A.G.E. and A.C. contributed to the interpretation of the data; M.S., A.K.T. and U.C. drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The dataset of the research presented in this article is under record. Corresponding author can be contacted to reach the required data network.*

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