Perspective
Audiovisual Information in Patients Undergoing a Total Knee Replacement: Is it Important to Modify Preoperative Expectations?
Leal-Blanquet J1,2*, Hinarejos P1, Torres-Claramunt R1, Sanchez-Soler J1 and Monllau JC1
Department of Knee Surgery, Parc de Salut Mar, Barcelona, Spain
*Corresponding author: Leal-Blanquet J, Department of Knee Surgery, Parc de Salut Mar, Barcelona, Spain
Published: 01 Nov, 2018
Cite this article as: Leal-Blanquet J, Hinarejos P, Torres-
Claramunt R, Sanchez-Soler J, Monllau
JC. Audiovisual Information in Patients
Undergoing a Total Knee Replacement:
Is it Important to Modify Preoperative
Expectations?. Clin Surg. 2018; 3:
2190.
Perspective
Osteoarthritis of the knee is one of the most prevalent pathologies in our society. After many
years studying this pathology, surgical treatment is seen as most appropriate in patients with pain,
limitation of function and loss of quality of life [1-3].
The main goal for the surgeon, subsequent to any surgical treatment, is to achieve maximum
patient satisfaction with regard to the surgery performed.
Total Knee Replacement (TKR) is probably the best solution to solve the clinical symptoms
of this pathology in its advanced stages. However, the result in this type of treatment is usually
influenced by multiple factors that the surgeon does initially not control.
One of these factors is the expectation that patient has created around the outcome after
arthroplasty [4].
This expectation is formed and conditioned by the information that the patient receives before
and after the visit with the surgeon [5]. The result of the creation of the preoperative expectation
will influence postoperative patient satisfaction. The higher the coincidence between preoperative
expectation and the real final result as perceived by the patient, the greater the postoperative
satisfaction [6-8].
This leads us to see at it a triangle with three vertices made up by information, expectation and
satisfaction. The correct information must be provided in order to generate realistic expectations
that lead to maximum postoperative satisfaction.
This triangle theory is very attractive, but it will not work in all our patients. The main reason for
this ineffectiveness will be weighty external influences that the social environment can have on this
person. The role that family and friends and even Internet have on the patient may create unrealistic
expectations that will affect satisfaction and the final real result [5].
For all these reasons, the key element of the triangle is information sharing to foster realistic
expectations that lead to full satisfaction. This information can be conveyed in several ways [9]. The
most common and widespread is the classic verbal information. You can also reach the patient in
an audiovisual or a written form. They all can be carried out on an individual basis or in groups.
Most articles in the literature agree that classical verbal information sharing is the most effective
and even more so if done on an individual basis [4]. It is important to determine what kind of
information the patient needs and what expectations are generated at interview time. This is the key
moment to temper these expectations and promote better adaptation to the real final result. A more
personalized sharing of information that is tailored to the patient’s specific needs may increase the
general success of preoperative education [9].
Knowing that the best method is the personal interview information, other information systems
have been postulated as complementary tools to serve as a guide to changing expectations to give the
patient a more realistic scenario to assess the future surgical procedure [4].
One of these systems, about which little has been written in the literature, is the audiovisual
method. In 2007, our Knee Unit team at Parc de Salut Mar designed a randomized prospective study
in which we studied the effect of this system on the change in preoperative expectations in patients
undergoing a TKR [4].
Most articles in the literature studied, preoperatively, the influence
of the information on the patient's expectation in terms of how this
information generates high or low expectations. Postoperatively, the
focus of the majority of studies have been on the fulfillment of these
expectations and the assessment of final patient satisfaction [1,10-14].
Our study focuses on the assessment of how an audiovisual
system can modify the previous expectations of the patient. This
study attempts to verify whether an additional tool along with
classical verbal information sharing can affect those expectations in
some sense (increase or decrease) [4].
In addition, we attempted to identify the profile of the patient
in whom the audiovisual support would be more effective in terms
of the modification of expectations. It was considered important to
assess whether there is the need to deal with all patients or only part of
those whose profile was more suitable to changing expectations with
the audiovisual tool. This might help us better define the financial
costs of information processing.
In this sense, it is more important to know the quantitative
difference between the preoperative expectation score and the
expectation score that the patient has after information sharing. This
is more important than what most articles cover as more emphasis
is placed on the degree of expectation is high or low [10-14]. If
expectations are not compared before and after information sharing,
we cannot know the effect in each person depending on the type of
information given.
The main finding of our study was discovering that efficacy in
the modification of preoperative expectations by introducing an
additional audiovisual method was not demonstrated. We did
not find a patient profile in which this method was more effective.
After analyzing the Hospital for Special Surgery Knee Replacement
Expectations Survey, only two of the questions posed to the patient
were changed significantly. They were on range of motion and the
use of stairs [4].
In terms of change of expectations, the results of our study are
similar to those encountered by other authors [15,16]. However, they
found differences related to the race studied and how this difference
affects the level of preoperative expectations. These two studies
showed that African Americans had lower expectations relative to the
results than Caucasian patients. Weng et al. [15] also demonstrated
that these African American patients improved their expectations
more than Caucasians after information sharing. The reason for this
finding is that their initial expectations were lower and this point
makes the likelihood of an increase greater. Caucasians had higher
expectations and so did not alter (increase) those expectations with
audiovisual support [15]. Again, and in the light of these studies,
we can say that the importance of preoperative information lies in
changing the expectation and not knowing whether they are higher
or lower. It is probable that the initial level of expectation depends
on the demographics of each patient and not on the information
received. However, the information is going to have an effect on those
expectations by bringing them in line with the real final result.
Analyzing what the literature says about expectations depending
on the patient's profile, we see that the male with more intense
preoperative pain, not living alone/being married, poor general sense
of well-being and a reduced Body Mass Index (BMI) seem to be
associated with high preoperative expectations [12-14]. Other authors
demonstrate that living alone and a history of joint arthroplasty
were associated with lower expectations and that being male and
Caucasian were associated with higher preoperative expectations
[17]. In our study, in terms of modification of the expectations, no
differences were found in terms of demographics (sex, age, weight and
BMI), the functional scores (Knee Society Score, Western Ontario &
McMaster Universities Osteoarthritis Index and Short Form-36) and
radiological characteristics [4].
In the context of the items on the scale of expectations that we
used, it seems that some of them can be modified in a significant way
with the audiovisual information (range of motion and use of stairs).
In any case, the use this additional tool is probably not needed due
to the possibility of providing such information through the classical
verbal system [4]. This value does not compensate in terms of the
cost-effectiveness of this action.
In recent years, there have been some articles that refer to the
importance of preoperative information to reduce patient anxiety
with regard to the surgical procedure [18,19]. However, other
studies show that audiovisual information sharing methods improve
understanding of the process, reduce the interview time with the
patient but do not show differences in the degree of patient anxiety
[20].
In summary and in order to clarify the basic concepts related
to the triangle of information, expectation and satisfaction, it is
important to note that:
1. Patient satisfaction with the surgical process will be
essential to achieving good postoperative results [21-23].
2. It is important to note that, although it is not the reason for
this article, this patient satisfaction is highly related to compliance
with the preoperative expectations [4,6-8].
3. Adequate information about the surgical process is very
important in the doctor-patient relationship and a fantastic tool to
modify preoperative expectations and adapt better to the clinical
outcome. In turn, this information may counteract unrealistic
expectations that the patient may have before the interview with the
doctor [4,23].
4. Sometimes, the medical interview is not as long as it
should be. Then the inclusion of additional strategies in the shape
of audiovisual information tool may be appropriate in order to
complement this preoperative information [4].
5. Audiovisual information differs from the written
information (another possible complement to classical verbal
information) in that written information requires some degree
of literacy on the part of the patient and may be subject to more
subjective interpretations other than what it is intended to convey
[4,24].
6. Good information, whatever the chosen information
delivery route, will shape expectations to generate greater
postoperative satisfaction and lead to patient satisfaction with the
preoperative process, as well [4,24].
There are several studies that deal with the level of expectations
depending on the type of information received [12-14,17]. Other
studies, like ours, have evaluated the difference in expectations before
and after receiving a single type of information sharing method [4].
It is probably necessary, in future studies, to compare the change
in expectations before and after the information depending on the
different types of information sharing method. It might also be
interesting to assess how the combination of the different information
systems might influence the final results and expectations.
In conclusion, the overall preoperative expectations relative to
the postoperative results of total knee arthroplasty were not modified
by the audiovisual information. In addition, it was not possible to
identify a patient biophysical profile for which the intervention
might be most effective. Based on these results, this complementary
tool may not be systematically recommended, and, therefore, direct
contact with the patient at the clinical visit is still the most important
factor in influencing in the patient’s outlook [4].
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