Preoperative Immersive Patient Quality Experience

Age Range:18 - Any
Start Date:December 2015
End Date:April 2016

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In the current constantly changing healthcare landscape quality measurement has a central
role. As the practice of medicine is shifting from authority to accountability, the quality
of surgical interventions is under continuous scrutiny by patients, peers, payers, and
policy makers. If done appropriately quality measurement can empower all members of the
healthcare debate. There is increasing focus on patient satisfaction outcomes as quality

An important part of surgical outcomes is a patient's perception of the result of the
intervention and overall experience in the preoperative setting. When assessing surgical
outcomes, measuring patient satisfaction is necessary. A qualitative systematic review of
patient satisfaction measures noted a scarcity of well-development quality improvement
initiatives to improve patient satisfaction. Anxiety, a potent behavioral and psychological
reaction, weighs heavily on a patient's perioperative experience and is exacerbated by
preoperative concerns about underlying disease and impending anesthesia and surgery.

There are multiple stressors on the day of the surgery: unfamiliar environment, multiple
forms to be signed, and multiple short encounters with new and unfamiliar personnel. These
create confusion, increase baseline anxiety, and can negatively affect patient experience,
and by extension surgical outcomes.

Increasing familiarity with this environment can help patients feel more informed about what
matters most to them, and have more accurate expectations of possible benefits and harms of
their options. This can potentially decrease overall anxiety, improve patient satisfaction,
and decrease pain levels. With the current study investigators will have the following two
specific aims:

Aim 1. To determine whether an immersive preoperative experience (video) is associated with
decreased anxiety and improved patient experience during the perioperative phase.

Aim 2. To determine whether an immersive preoperative experience is associated with
decreased stress, improved patient satisfaction, and decreased pain during the perioperative

The study will include patients scheduled to undergo neurosurgical interventions. Patients
for whom surgical intervention is deemed necessary will be approached for participation in
the study. After signing informed consent, they will be randomized to watch a video during
their preoperative evaluation visit or have a regular standard of care evaluation during
their preoperative visit. For the patients randomized to the intervention group, the
preoperative visit will be performed, as it would be normally, with the only addition of a
5-minute video. Patients will be given a few minutes to watch the video, and will have the
chance to ask questions. The remainder of the interaction between patient and provider will
not be affected in any other way.

The video will include a simulated patient encounter (with actors not real patients)
showcasing the preoperative experience of the patient, including getting checked in, meeting
the nurses, surgeons, and the anesthesiologists. The technology used will allow the
immersion of the patient in the preoperative environment. The hypothesis is that by
introducing a way to familiarize the patients with the preoperative environment,
investigators will have an impact on their anxiety about the operation and their
satisfaction with the entire experience. Investigators hope this quality improvement
initiative will change patient experiences for the better.

Patients will fill out questionnaires immediately preoperatively on the day of the
procedure, on the day after the procedure, and 30-days after the operation (only for
patients undergoing surgery for degenerative spine disease). The outcomes of interest will
be stress level, pain level, and patient satisfaction level.

Preoperative, intraoperative, and postoperative variables will be analyzed using χ2 tests
for categorical variables and the nonparametric Wilcoxon rank-sum test for continuous
variables. Logistic regression will be performed, for each binary outcome. Linear regression
will be performed, for each continuous outcome. The variable age will be tested separately
as a continuous variable and a categorical variable (65-69 years, 70-74 years, 75-79 years,
and ≥80 years) in multivariable logistic regression models. Other variables that will be
included in the multivariable models include Charlson Comorbidity Index score, American
Society of Anesthesiologists [ASA] score, APAIS score. Mixed effects methods will be used,
with treating physician as a random effects variable, to account for clustering at the
physician level.

Investigators intend to randomize 150 patients in 1:1 allocation to the video and
conventional arms. We anticipate not being able to obtain the primary outcome on up to 10%
of patients, leaving 135, or approximately 68 completers per arm. This yields just over 80%
power at the usual 5% type 1 error rate to detect a difference between the two arms of one
half (0.5) standard deviations in the primary outcome.

Inclusion Criteria:

- all adult patients undergoing elective neurosurgical procedures (brain, spine,
peripheral nerve) under general anesthesia, for which a preoperative evaluation is

Exclusion Criteria:

- pediatric patients

- emergency procedures for which no preoperative visit has been scheduled

- patients that have undergone any prior operations, or had any exposure to the
preoperative experience

- ability to complete a self-report questionnaire preoperatively and postoperatively

- cognitive impairment
We found this trial at
1 Medical Center Dr
Lebanon, New Hampshire 03756
 (603) 650-5000
Phone: 603-650-5110
Dartmouth Hitchcock Medical Center Dartmouth-Hitchcock is a national leader in patient-centered health care and building...
Lebanon, NH
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