The effectiveness of orthopedic patient education in improving patient outcomes: a systematic review protocol

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1 The effectiveness of orthopedic patient education in improving patient outcomes: a systematic review protocol Norhaini Majid, RN, MN 1,2 Susan Lee, RN, PhD, 1,2 Virginia Plummer, RN, PhD 1,2 1 Monash University, School of Nursing and Midwifery, Victoria, Australia 2. The Centre for Chronic Disease Management: a Collaborating centre of The Joanna Briggs Institute Corresponding author: Norhaini Majid nmaj2@student.monash.edu Review objective The objective of this review is to identify the effectiveness of patient education for orthopedic surgery patients. More specifically, the objectives are to identify the effectiveness of patient education on: length of stay satisfaction pain level cost of care functional abilities knowledge anxiety quality of life in orthopedic settings. Background Patient education is an essential part of practice for all healthcare professionals. In the orthopedic setting, effective patient education contributes to positive patient outcomes. Patient education is critical to ensure that patients receive appropriate information to assist in the pre-admission, peri-operative treatment and rehabilitation process for the patient. The process of patient education is essentially one where the patient comes to understand his or her physical condition and self-care using the experience and guidance of the multidisciplinary team. 1 doi: /jbisrir Page 122

2 With an effective and well-structured patient education program, the cost benefit for health care provider and patient includes a shortened length of stay, and reduced cost of care. 2-6 According to Huang et al. 3 a simplified pre-operative education program reduced the length of stay and cost of care. Similarly, Jones et al. 4 found that length of stay of a patient who received pre-operative education was reduced. In that study, the mean length of stay was significantly reduced from seven days in patients who did not received pre-operative education to five days in patients who received pre-operative education. These results suggest that pre-operative education programs are an effective method in reducing the length of stay of orthopedic patients. Johansson et al. 7 also described pre-operative education for orthopedic patients in a systematic review published in They discussed the effect of patient education on the orthopedic patient and found that knowledge, anxiety, pain, length of hospital stay, performance of exercise and mobilization, self-efficacy, patient compliance, adherence and empowerment were all improved as a result of patient education. 7 While Johansson et al. 7 included studies up to 2003, the proposed systematic review will include studies from 2003 to Kruzik 8 also reported benefits of decreased length of stay, reduced pain medication requested post-operatively together with increased patient and family member satisfaction. Bastable reported benefits of patient education, including increased patient satisfaction, improved quality of life, enhanced continuity of care, decreased anxiety, fewer complications, promotion of adherence to the plan of care, maximized independence, and empowerment. 9 Types of education involved in this systematic review are patient education, pre-operative education, and discharge education. Only one study discussed discharge education and the outcome from this review. 10 The outcomes that have been discussed in this systematic review include length of stay, 3,4,11-15 satisfaction, 5,16-19 pain level, 5,6,11,16,17,18,19,20,21,21 cost of care, 2,23 functional abilities, 5,6,11,14,23,24 knowledge, 16,19,25,26 anxiety, 18,20,21,27,28 and quality of life. 5,6,23 Major outcomes discussed in these studies are length of stay, 3,4,11-15 pain, 5,6,11,16,17,18,19,20,21,21 functional abilities, 5,6,11,14,23,24 and anxiety. 18,20,21,27,28 Most of these studies found significant results of reduced length of stay on those patients who received patient education compared to patient who did not received any patient education or information. Studies support the positive outcomes around length of stay. 3,4,11-15 Common orthopedic conditions that have been discussed are osteoarthritis with total arthroplasty either hip or knee or joint replacement. 3,4,5,12,13,15,19,20,23,29,30 A study on spinal surgery patients and the effects of pre-operative education, 17 which stated that although there are many studies on the effectiveness on patient education, there are missing data on spinal surgery. This study found that the implementation of patient education has positive impacts upon patient satisfaction especially in managing pain. This review will look specifically at the effectiveness of orthopedic patient education for length of stay, satisfaction, pain level, cost of care, functional ability, knowledge, anxiety, and quality of life. Keywords orthopaedic; patient education; pre-operative education doi: /jbisrir Page 123

3 Inclusion criteria Types of participants This review will consider studies that include adult patients above 18 years old requiring elective orthopedic surgery in inpatient and outpatient settings. Types of interventions This review will consider studies that evaluate education programs of any type and any duration including: 1. Patient education (includes pre or post admission education interventions) 2. Perioperative education (includes pre or post-operative education interventions) 3. Discharge education. Education program offered by multidisciplinary health professionals such as nurses, physiotherapists, or physicians will be included in this review. Types of outcomes This review will consider studies that include the following outcome measures: 1. Length of stay (e.g. discharge standard) 2. Satisfaction (e.g. Cantril Life Satisfaction Ladder) 3. Pain level (e.g. Visual Analogue Scale [VAS]) 4. Cost of care (e.g. a Preoperative Costs [PC] instrument) 5. Functional abilities (e.g. the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) 6. Knowledge (e.g. Orthopedic Patient Knowledge Instrument) 7. Anxiety (e.g. State-Trait Anxiety Scale Inventory [STAI]) 8. Quality of life (e.g. Short Form [36] Health Survey [SF-36]). Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross-sectional studies for inclusion. This review will also consider descriptive study designs including case series, individual case reports and descriptive cross sectional studies for inclusion. doi: /jbisrir Page 124

4 Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Due to the limited resources available to undertake this review, only studies published in English will be considered for inclusion in this review. Studies from 2003 to 2013 will be included in this review following systematic review by Johansson et al. 7 which had covered published studies until The databases to be searched include: CINAHL EMBASE ERIC Ovid MEDLINE Scopus. The search for unpublished studies will include: ProQuest Grey literature National Medical Research Registry (Malaysia) Monash repository. Initial keywords to be used will be: patient education health education discharge education pre-operative education post-operative education orthopedic nursing length of stay satisfaction pain level doi: /jbisrir Page 125

5 cost of care functional ability knowledge anxiety quality of life. Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question, and specific objectives. Data synthesis Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest The authors have no relevant disclosures to make and there is no conflict of interest regarding this systematic review. Acknowledgements This review will partially fulfil degree requirements for successful completion of the Doctor of Philosophy at Monash University, School of Nursing and Midwifery, Australia. doi: /jbisrir Page 126

6 References 1. Redman BK. The practice of patient education: a case study approach. 10th ed. St. Louis: Mosby; Heikkinen K, Salantera S, Suomi R, Lindblom A, Leino-Kilpi H. Ambulatory orthopaedic surgery patient education and cost of care. Orthop Nurs. 2011;30(1): Huang SW, Chen PH, Chou YH. Effects of a preoperative simplified home rehabilitation education program on length of stay of total knee arthroplasty. Orthop Traumatol Surg Res. 2012;98: Jones S, Alnaib M, Kokkinakis M, Wilkinson M, Gibson AS, Kader D. Pre-operative patient education reduces length of stay after knee joint arthroplasty. Ann R Coll Surg Engl. 2010;93: McGregor AH, Rylands H, Owen A, Dore CJ, Hughes SP. Does preoperative hip rehabilitation advice improve recovery and patient satisfaction. J Arthroplasty. 2004;9(4): Siggeirsdottir K, Olafsson Ö, Jonsson H,Jr., Iwarsson S, Gudnason V, Jonsson BY. Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement. Acta Orthop. 2005;76(4): Johansson K, Nuutila L, Virtanen H, Katajisto J, Salanterä S. Preoperative education for orthopaedic patients: systematic review [Internet]. J Adv Nurs. 2005;50(2): Kruzik N. Benefits of preoperative education for adult elective surgery patients [Internet]. AORN J. 2009: 90(3): Bastable SB. Essentials of patient education. Sudbury: Jones and Barlett Publishers; Ben-Morderchai B, Herman A, Kerzman H, Irony A. Structured discharge education improves early outcome in orthopedic patients. Int J Orthop Trauma Nurs. 2010;14: Kearney M, Jenrich MK, Lyons S, Robinson R, Berger B. Effects of preoperative education on patient outcomes after joint replacement surgery. Orthop Nurs. 2011;30(6): Peterson MG, Cioppa-Mosca J, Finerty E, Graziano E, King S, Sculco TP. Effectiveness of best practice implementation in reducing hip arthroplasty length of stay. J Arthroplasty. 2008;23(1): Thomas K, Burton D, Withrow L, Adkisson B. Impact of a preoperative education program via interactive telehealth network for rural patients having total joint replacement. Orthop Nurs. 2004;23(1): Yeh ML, Chen HH, Liu PH. Effect of multimedia with printed nursing guide in education on self-efficacy and functional activity and hospitalization in patient with hip replacement. Patient Educ Couns ;57: Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W. Patient education before hip or knee arthroplasty lowers length of stay. J Arthroplasty. 2010;25(4): Nahm ES, Stevens L, Scott P, Gorman K. Effects of a web-based preoperative education program for patients undergoing ambulatory surgery: a preliminary study. J Hosp Adm. 2012;1(1): Papanastassiou I, Anderson R, Barber N, Conover C, Castellvi AE. Effects of preoperative education on spinal surgery patients. Int J Spine Surg. 2011;5: doi: /jbisrir Page 127

7 18. Sjoling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain, and satisfaction with pain management. Patient Educ Couns ;51: Thomas K, Sethares KA. An investigation of the effects of preoperative interdisciplinary patient education on understanding postoperative expectations following a total joint arthroplasty [Internet]. Orthop Nurs [cited 2014 Feb 28];27(6): Quintrec JG, Coste J, Vastel L, Pacault V, Jeanne L, Lamas J, Kerboull L, Fougeray M, Conseiller C, Kahan A, Courpied J. Positive effect of patient education for hip surgery [Internet]. Clin Orthop Relat Res. 2003;414: Wong EM, Chan SW, Chair SY. Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma. J Adv Nurs. 2010;66(5): Wong EM, Chan SW, Chair SY. The effect of educational intervention on pain beliefs and postoperative pain relief among Chinese patients with fractured limbs. J Clin Nurs. 2010;19: Beaupre LA, Lier D, Davies DM, Johnston, DB. The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty. J Rheumatol. 2004;31: Clarke HD, Timm VL, Goldberg BR, Hattrup SJ. Preoperative patient education reduces in-hospital falls after total knee arthroplasty. Clin Orthop Relat Res. 2012;470: Heikkinen K, Leino-Kilpi H, Salantera S.. Ambulatory orthopaedic surgery patients knowledge with Internet-based education. Methods Inf Med. 2012;51: Heikkinen K, Leino-Kilpi H, Taina N, Anne K. Salantera S. A comparison of two educational interventions for the cognitive empowerment of ambulatory orthopaedic surgery patients. Patient Educ Couns. 2008;73: Heikkinen K, Salantera S, Leppanen T, Vahlberg T, Leino-Kilpi H. Ambulatory orthopaedic surgery patients' emotion when using two different patient education methods. J Perioper Pract ;22(7): Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth. 2010;104(3): Gocen Z, Sen A, Unver B, Karatosun V, Gunal I. The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial. Clin Rehabil. 2004;18: Lubbeke A, Suva D, Perneger T, Hoffmeyer P. Influence of preoperative patient education on the risk of dislocation after primary total hip arthroplasty. Arthritis Rheum: Arthritis Care Res. 2009;61(4): doi: /jbisrir Page 128

8 Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message doi: /jbisrir Page 129

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11 Appendix II: Data extraction instruments MAStARI data extraction instrument doi: /jbisrir Page 132

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