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Abstract

Background:

A good patient-surgeon relationship relies on adequate preoperative education and counseling. Several multimedia resources, such as web-based education tools, have become available to enhance aspects of perioperative care.

Purpose/Hypothesis:

The purpose of this study was to evaluate the effect of an interactive web-based education tool on perioperative patient satisfaction scores after outpatient orthopaedic surgery. It was hypothesized that web-based education prior to outpatient orthopaedic surgery enhances patient satisfaction scores.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

All patients undergoing knee arthroscopy with meniscectomy, chondroplasty, or anterior cruciate ligament reconstruction or shoulder arthroscopy with rotator cuff repair were eligible for inclusion and were randomized to the study or control group. The control group received routine education by the surgeon, whereas the study group received additional web-based education. At the first postoperative visit, all patients completed the OAS CAHPS (Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems) survey. Differences in patient satisfaction scores between the study and control groups were determined with an independent t test.

Results:

A total of 177 patients were included (104 [59%] males; mean age, 42 ± 14 years); 87 (49%) patients were randomized to receive additional web-based education. Total patient satisfaction score was significantly higher in the study group (97 ± 5) as compared with the control group (94 ± 8; P = .019), specifically for the OAS CAHPS core measure “recovery” (92 ± 13 vs 82 ± 23; P = .001). Age, sex, race, workers’ compensation status, education level, overall health, emotional health, procedure type and complexity, and addition of a video did not influence patient satisfaction scores.

Conclusion:

Supplemental web-based patient education prior to outpatient orthopaedic surgery enhances patient satisfaction scores.

Keywords

orthopaedic surgery outpatient web based education patient satisfaction OAS CAHPS

A good patient-surgeon relationship relies on adequate preoperative education and counseling. This is also an important part in the shared decision-making process.^25,26 Informed consent for a proposed procedure can be given by the patient only after he or she demonstrates adequate understanding of the information provided by the surgeon.¹⁵ McGaughey¹⁸ reported that when a patient perceives there to be a lack of information, his or her satisfaction with the surgeon and the facility decreases.

Previous studies have shown that education by the surgeon alone may not be adequate for patients to retain and recall all the provided information.^9,10,14 Several multimedia resources, such as web-based education tools, have become available to enhance aspects of the perioperative care.^{3

–6,13,21} These education platforms may aid outpatient centers in increasing patient satisfaction of the outpatient surgical experience^7,19 while improving patient safety.^16,27

Public reporting of patient satisfaction with the surgeon and the experience with a facility has become a national standard.⁷ This has led to increased transparency in the quality of health care and accountability. It has been a longtime practice for physicians and hospitals to obtain information on patient satisfaction for internal use.² However, until the arrival of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, there was no national standard for collecting or publicly reporting this information.^19,23 Having a universal national standard allows for comparisons to be made among hospitals. In addition, hospital scores are becoming increasingly important to maintain market share and to avoid the loss of reimbursement. The Centers for Medicare and Medicaid Services (CMS) plans to extend this standard to involve outpatient surgical centers in the coming years. A version of the HCAHPS survey specifically designed for outpatient surgery centers was recently released: the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS; https://oascahps.org/) (see the Appendix). This survey received final accreditation in February 2015 after field testing, reliability analysis, and finalization of the survey items.

The objective of this study was to evaluate the effect of an interactive web-based education tool on perioperative patient satisfaction scores after outpatient orthopaedic surgery. It was hypothesized that supplemental web-based education prior to outpatient orthopaedic surgery enhances patient satisfaction, as measured by the OAS CAHPS survey.

Methods

Prior to the start of this prospective study, institutional review board approval was obtained (PRO00042142). All subjects gave informed consent to participate.

Patients were eligible for inclusion in the study if they were seen in the office by either of the 2 senior authors (M.B.B., R.A.G.) and scheduled for 1 of the following procedures: knee arthroscopy with meniscectomy and/or chondroplasty, knee arthroscopy with anterior cruciate ligament (ACL) reconstruction, or shoulder arthroscopy with rotator cuff repair. These procedures were chosen because perioperative web-based patient education protocols had been previously created and successfully implemented for those surgery types. Furthermore, the perioperative instructions for these procedures vary in complexity, ranging from “simple” knee arthroscopy instructional modules to more “complex” modules for procedures, such as ACL reconstruction and rotator cuff repair. Including this diversity in procedures would allow analysis of the influence of procedure type and complexity on the effect of web-based education. The 2 senior authors who enrolled their patients are partners in a private practice setting.

Patients were required to be 18 to 65 years old and comfortable with internet use and access. Patients were excluded if their English was not proficient enough to follow the instructions or complete the survey. Eligible patients were identified from the electronic medical record and surgical scheduling system.

Once patients were enrolled, a random number generator in Excel (Microsoft Office) was used to randomize them into 1 of 2 groups. All participating surgeons were blinded to each patient’s allocation. The control group received routine education by the surgeon, office, and surgery center staff, whereas the study group received web-based education in addition to the routine education.

Routine education consisted of a preoperative visit, scheduled within 2 weeks from the date of the surgery with the attending surgeon. During this visit, the surgeon explained the procedure, outlined the potential risks and complications associated with the procedure, and detailed the recovery and rehabilitation involved. An orthopaedic sports medicine fellow who was present reiterated the information. This fellow also performed a history and physical examination and provided prescriptions. Next, the medical assistant or physician assistant working with the surgeon provided paperwork that summarized what was verbally explained by the surgeon. The night prior to the surgery, a member of the anesthesia team from the surgery center called the patient to give information and answer questions regarding the day of surgery. After the procedure, a recovery nurse provided verbal and written postoperative instructions. The day after surgery, a nurse from the surgery center called the patient to check how she or he was doing and to answer any questions. Within 2 weeks after the procedure, the patient saw the surgeon, fellow, and medical assistant for a postoperative visit to discuss the findings during surgery, recovery, and rehabilitation instructions. If indicated, physical therapy was started at this time point.

The web-based education was delivered through the cloud-based platform HealthLoop (https://app.healthloop.com/), which keeps doctors and patients connected between visits with clinical information delivered via the internet. This platform was chosen because it is provided to all physicians in the practice through the academic hospital affiliate. Custom care plans can be made by the surgeon to allow information to be sent to the patient in real time while tracking patient progress and monitoring clinical areas of concern. The web-based education contains preoperative instructions (ie, do not eat or drink after midnight, stop anti-inflammatory pain medication, what to expect in terms of pain), day-of-surgery expectations (ie, preparing for discharge home, what clothes to wear), and postoperative instructions (ie, monitoring for signs of infection, reminders to perform exercises to prevent deep venous thrombosis, tips for pain control). In addition, the web-based education dashboard can contain links to videos demonstrating an example of the surgery that the patient is to undergo. To assess the effectiveness of adding a video, only some of the patients were randomly selected to view it (see Supplemental Videos 1-3). The time frame for the instructions was from 14 days before until 14 days after the surgery. The HealthLoop website allows the surgeon to see if patients viewed the provided instructions.

At the first postoperative visit, all study and control patients were asked to complete the OAS CAHPS survey. This time point was chosen to avoid recall bias, as the web-based instructions ended 2 weeks after the procedure date. The survey consists of 24 questions divided into 5 core care measures: preoperative education, facility and staff, communication, recovery, and overall experience. In addition, it allows for certain demographic variables to be recorded, such as age, sex, overall and emotional health, education level, race and ethnicity, and English proficiency. Survey scores were normalized to a 100-point scale. In addition, whether the injury was workers’ compensation related or not was recorded.

Statistical Analysis

Descriptive statistics, including mean, range, and standard deviation, were calculated for all continuous variables. Ratios and percentages were calculated for the nominal variables.

Baseline differences between the study group and the control group were determined with an independent t test for the continuous variables and chi-square test or Fisher exact test for the nominal variables.

Differences in patient satisfaction scores between the study and control groups were calculated with an independent t test. This was done for the total score on the OAS CAHPS as well as the 5 core care measures individually: preoperative education, facility and staff, communication, recovery, and overall experience. Last, analysis of variance with a post hoc Tukey test was used to determine the effect of age, sex, race, workers’ compensation status, education level, overall health, emotional health, procedure type and complexity, and the addition of a video on patient satisfaction scores. The P level for statistical significance was set at .05.

Based on the data of a pilot study focusing solely on simple knee arthroscopy, an a priori sample size calculation was performed, and sample size was determined to be 30 patients per group, for a total of 60 patients. All analyses were performed with SPSS (v 20; IBM Corp).

Results

A total of 210 patients were reviewed for eligibility, of which 33 were excluded because they did not meet the inclusion criteria. Reasons for exclusion included insufficient comprehension of English language (n = 1), refusal to participate (n = 1), revision procedure (n = 14), ineligible procedure (n = 11), and age <18 or >65 years (n = 6). This left 177 patients for participation in this study, 104 (59%) of whom were men. The mean age was 42 ± 14 years. Twenty-four patients (14%) had surgery related to a workers’ compensation case. The procedure type was classified as simple (knee arthroscopy with meniscal or chondral surgery) for 104 patients (59%) and complex (ACL reconstruction or rotator cuff repair) for the remaining 73 patients (41%). Eighty-seven patients (49%) were randomly assigned to receive additional web-based education, and of those, 59 (68%) were invited to watch a short video (Supplemental Videos 1-3) about their procedure as well (Figure 1).

Figure 1.

Consolidated Standards Of Reporting Trials (CONSORT) flow diagram.

There were no baseline demographic differences between the study and control groups (Table 1). The total patient satisfaction score was significantly higher in the study group as compared with the control group (Table 2). When analyzing the 5 core measures individually, there were statistically higher satisfaction scores for the “recovery” core measure (Table 2). Age, sex, race, workers’ compensation status, education level, overall health, emotional health, procedure type or complexity, and addition of a video did not influence total patient satisfaction scores (Table 3).

TABLE 1

Demographic Data of Study and Control Groups

	Participants, Mean ± SD or No. (%)
	HealthLoop (n = 87)	Control (n = 90)	P Value
Age, y	43 ± 13	42 ± 15	.578
Sex: male	48 (55)	56 (62)	.341
Overall health: excellent	19 (22)	15 (17)	.588
Emotional health: excellent	22 (25)	12 (13)	.124
Education level: ≥college	46 (53)	37 (41)	.092
Race: white	37 (43)	37 (41)	.408
Procedure: simple	47 (54)	57 (63)	.225

TABLE 2

Difference in Patient Satisfaction Scores Between the Study and Control Groups^a

	OAS CAHPS Survey Score, Mean ± SD
	Total	Preoperative Education	Facility and Staff	Communication	Recovery	Overall Experience
HealthLoop (n = 87)	97 ± 5	98 ± 8	99 ± 5	98 ± 8	92 ± 13	98 ± 5
Control (n = 90)	94 ± 8	97 ± 10	98 ± 7	96 ± 10	82 ± 23	98 ± 5
P value	.019 ^b	.586	.410	.392	.001 ^b	.903

^a OAS CAHPS, Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems.

^b Significant difference between groups, P < .05.

TABLE 3

Influence of Several Demographic Factors on Total Patient Satisfaction Score

	P Value
Age	.271
Sex	.067
Race	.709
Workers’ compensation status	.628
Education level	.342
Overall health	.243
Emotional health	.137
Complexity of procedure	.270
Adding a video	.881

Discussion

The most important finding of the present study was that interactive web-based education improves patient satisfaction scores after outpatient orthopaedic surgery. This was specifically true for the OAS CAHPS core measure “recovery.” Questions in this section of the survey specifically assess the level of satisfaction attainted by the patient with regard to the postoperative instructions provided and expectations set by the surgeon, facility, and anesthesiologist (see the Appendix). Although all of these items were also addressed in the routine perioperative instructions, they were emphasized in real time in the web-based education tool. It is likely that the effects from the surgery (pain, nausea, etc) were equally common in the web-educated patients but that they felt more informed about it and therefore more satisfied. This finding is consistent with existing literature showing that better communication by physicians and nursing staff influenced patient outcomes for the better.^12,17,24 Yin et al²⁷ evaluated the effect of a web-based patient education tool on the perioperative experience of patients undergoing first-time knee arthroscopy for a meniscal tear. Patients in that study were randomized to receive standard preoperative counseling alone or in conjunction with web-based education. When all patients were tested on their knowledge of the surgery, the group that received additional web-based education was significantly more informed. Indeed, other authors have highlighted the growing interest in various types of media as a platform for information surrounding orthopaedic procedures.²⁰ In a study on patients undergoing total hip and total knee arthroplasty, patients posted experiences on the social media site Instagram within a week after surgery. The shared topics included rehabilitation, wound healing, and difficulties with activities of daily living.²⁰ In other fields, use of an educational video was linked to improved knowledge, self-efficacy in recognizing certain symptoms, and patient satisfaction.⁸ However, other types of educational material, such as handouts and brochures, may have a similar benefit and might be more easily accessible to patients who do not own a computer or have access to the internet. In the present study, adding a video to the instructions did not make a significant difference in patient satisfaction.

The improvement in overall OAS CAHPS score was statistically significant with the use of web-based education. This was largely attributable to the “recovery” items. It is difficult to discern whether these small statistical differences are clinically significant. There are currently no criteria for what constitutes a clinical meaningful difference in OAS CAHPS score. The 2 senior authors thought that implementation of this education program into their private practice was easy and did not negatively affect the flow of their practice. A small improvement in patient satisfaction may provide a competitive advantage for a practice in a saturated area.

Another finding of this study was that age, workers’ compensation status, and overall health did not influence total patient satisfaction scores. This is not consistent with the findings from Tashjian et al,²² who showed that after rotator cuff surgery, satisfaction was significantly correlated with overall health status. They also showed that married nondisabled patients who were employed at the time of surgery had greater satisfaction.²² It is possible that this was not captured in the present study, as it was conducted in an outpatient surgery center where patients with significant medical comorbidities were referred to institutions that were able to deliver the required inpatient care. A study by Abtahi et al¹ showed that older patients and those who lived farther away from the facility had higher satisfaction scores in the authors’ outpatient orthopaedic clinic. Specifically, they found that the odds ratio of satisfaction for patient age of 18 to 29 years versus >80 years was 2.78.

A strength of the present study is that it is one of the first to measure patient satisfaction after outpatient surgery with a tool designed for this goal. Although the OAS CAHPS is rather new, it is a carefully designed, nationally standardized survey that will become increasingly important in the health care world to allow for comparisons among hospitals and to comply with the CMS. This study does have limitations. Included patients were not blinded to whether they belonged to the test or control group. Although it was possible to see the compliance rate of patients viewing the instructions, it was not possible to determine if they actually followed them and how much time they spent doing so. A variety of procedures was included to determine the effect to procedure type on the effectiveness of the web-based education; however, this could also be a cause of heterogeneity. The survey was administered within 2 weeks after the procedure, and longer follow-up to evaluate the clinical outcome of the procedure was not performed. We decided to administer the survey at that time out of concern for recall bias, because the web-based education protocol that was tested provided instructions from only 2 weeks before until 2 weeks after the surgery. It is our intent to implement a web-based education program that runs longer and to evaluate the long-term effect on patient satisfaction. In addition, improved patient satisfaction does not necessarily imply improved clinical outcomes. It is a goal to see if web-based education positively affects clinical outcomes and if it can play a role in the prevention of complications. Last, this study was conducted in an outpatient surgery center that performs many of the same types of procedures. Therefore, the ancillary staff is very familiar with the perioperative care; thus, a consistent message is delivered by multiple members of the care team. As a small but statistically significant improvement was seen in this setting, this may be even more pronounced in larger-scale facilities with more diverse procedures and turnover in staff and less continuity of care.

The findings of the present study are clinically relevant, as they show that supplemental education tools may improve patient satisfaction after outpatient surgery and patient understanding of the postoperative instructions.¹¹ Patient satisfaction rates of facilities may become publicly reported, as the CMS plans to use these data for reimbursement. This is a high-yield topic in the medical field today, with the need to decrease health care costs while maintaining a high standard of care.

Conclusion

The results of this study indicate that supplemental web-based patient education prior to outpatient orthopaedic surgery can enhance patient satisfaction scores.

Footnotes

Acknowledgment

The authors acknowledge Thelma Hambrick, MA, and Adam Cady, MHS, ATC, CSCS, PA-C, without whose efforts in patient recruitment and survey administration this study would not have been possible.

One or more of the authors declared the following potential conflict of interest or source of funding: M.B.B. is a paid consultant for Stryker. R.A.G. has stock/stock options in Johnson & Johnson, is a paid consultant for Smith & Nephew, is a paid presenter/speaker for Smith & Nephew, and receives research support from Smith & Nephew.

Ethical approval for this study was obtained from Cedars-Sinai (PRO00042142).

A Video Supplement for this article is available at .

Appendix

Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey

Source: https://oascahps.org/Survey-Materials

References

Abtahi

Presson

Zhang

Saltzman

Tyser

. Association between orthopaedic outpatient satisfaction and non-modifiable patient factors. J Bone Joint Surg Am. 2015;97(13):1041–1048.

Ardern

Osterberg

Sonesson

Gauffin

Webster

Kvist

. Satisfaction with knee function after primary anterior cruciate ligament reconstruction is associated with self-efficacy, quality of life, and returning to the preinjury physical activity. Arthroscopy. 2016;32(8):1631–1638, e1633.

Beamond

Beischer

Brodsky

Leslie

. Improvement in surgical consent with a preoperative multimedia patient education tool: a pilot study. Foot Ankle Int. 2009;30(7):619–626.

Bozic

Belkora

Chan

. Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial. J Bone Joint Surg Am. 2013;95(18):1633–1639.

Cornoiu

Beischer

Donnan

Graves

de Steiger

. Multimedia patient education to assist the informed consent process for knee arthroscopy. ANZ J Surg. 2011;81(3):176–180.

Crabtree

Puri

Bell

. Outcomes and perception of lung surgery with implementation of a patient video education module: a prospective cohort study. J Am Coll Surg. 2012;214(5):816–821, e812.

Davidson

Shaffer

. Interventions to improve hospital patient satisfaction with healthcare providers and systems: a systematic review. BMJ Qual Saf. 2017;26(7):596–606.

Denny

Vahidy

Sharrief

Savitz

. Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction. PLoS One. 2017;12(3):e01719 52.

Falagas

Akrivos

Alexiou

. Patients’ perception of quality of pre-operative informed consent in athens, Greece: a pilot study. PLoS One. 2009;4(11):e8073.

10.

Falagas

Korbila

Giannopoulou

Kondilis

Peppas

. Informed consent: how much and what do patients understand? Am J Surg. 2009;198(3):420–435.

11.

Graham

Green

James

Katz

Swiontkowski

. Measuring patient satisfaction in orthopaedic surgery. J Bone Joint Surg Am. 2015;97(1):80–84.

12.

Griffiths

. Enhanced communication performance improvement and patient satisfaction in an endoscopy/ambulatory surgery unit. Gastroenterol Nurs. 2015;38(3):194–200.

13.

Hoppe

Denkers

Hoppe

Wong

. The use of video before arthroscopic shoulder surgery to enhance patient recall and satisfaction: a randomized-controlled study. J Shoulder Elbow Surg. 2014;23(6):e134–e139.

14.

Hutson

Blaha

. Patients’ recall of preoperative instruction for informed consent for an operation. J Bone Joint Surg Am. 1991;73(2):160–162.

15.

Jones

McCullough

Richman

. A comprehensive primer of surgical informed consent. Surg Clin North Am. 2007;87(4):903–918.

16.

Kemp

Santana

Southern

McCormack

Quan

. Association of inpatient hospital experience with patient safety indicators: a cross-sectional, Canadian study. BMJ Open. 2016;6(7):e011242.

17.

Mann

Siddiqui

Kurbanova

Qayyum

. Effect of HCAHPS reporting on patient satisfaction with physician communication. J Hosp Med. 2016;11(2):105–110.

18.

McGaughey

. Informed consent and knee arthroscopies: an evaluation of patient understanding and satisfaction. Knee. 2004;11(3):237–242.

19.

Piper

Tallman

. Hospital Consumer Assessment of Healthcare Providers and Systems: an ethical leadership dilemma to satisfy patients. Health Care Manag (Frederick). 2016;35(2):151–155.

20.

Ramkumar

Navarro

Haeberle

Chughtai

Flynn

Mont

. Social media and total joint arthroplasty: an analysis of patient utilization on Instagram. J Arthroplasty. 2017;32(9):2694–2700.

21.

Rossi

Guttmann

MacLennan

Lubowitz

. Video informed consent improves knee arthroscopy patient comprehension. Arthroscopy. 2005;21(6):739–743.

22.

Tashjian

Bradley

Tocci

Rey

Henn

Green

. Factors influencing patient satisfaction after rotator cuff repair. J Shoulder Elbow Surg. 2007;16(6):752–758.

23.

Thiels

Hanson

Yost

. Achieving a 5-star rating: analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores among patients undergoing elective colorectal operations. Surgery. 2016;160(4):902–914.

24.

van Osch

van Dulmen

van Vliet

Bensing

. Specifying the effects of physician’s communication on patients’ outcomes: a randomised controlled trial. Patient Educ Couns. 2017;100(8):1482–1489.

25.

Whitney

Holmes-Rovner

Brody

. Beyond shared decision making: an expanded typology of medical decisions. Med Decis Making. 2008;28(5):699–705.

26.

Whitney

McGuire

McCullough

. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med. 2004;140(1):54–59.

27.

Yin

Goldsmith

Gambardella

. Web-based education prior to knee arthroscopy enhances informed consent and patient knowledge recall: a prospective, randomized controlled study. J Bone Joint Surg Am. 2015;97(12):964–971.

Supplementary Material

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Web-Based Education Prior to Outpatient Orthopaedic Surgery Enhances Early Patient Satisfaction Scores: A Prospective Randomized Controlled Study