A systematic review of information format and timing before scheduled adult surgery for peri-operative anxiety

Anaesthesia 2017;72:1265-1272

Presented by: Dr J. Niebla-Rodriguez


  • About 25% of patients are anxious and this is associated with pain, poor compliance and harm.
  • Advantages of preoperative information: reduce anxiety
  • Information can be conveyed in different formats: verbal, text, multimedia and in various combinations.
  • Patients retain information that is clear, concise and easy to understand.
  • Different formats of information are more effective to particular people: it depends on age, sex, education, personality and other cultural background.
  • Also when and how the information is conveyed accounts for variation in effect across trials and review.
  • Aim to assess the effects of different formats and timing of pre-operative information on perioperative  anxiety reported by adults.

Design & Setting

  • Standard, quasi and cluster RCT that reported format and timing before scheduled surgery on peri-operative outcomes in any language
  • Information formats : passive / interactive text, audio+ and video  via Person, PC, mobile phone
  • 3 months prior surgery
  • Excluded : studies comparing different information content


Jesus pic 2

  • 1º outcome = Peri-operative anxiety
  • 2º outcome = patient knowledge and satisfaction with surgery, anaesthesia or information


  • 2 reviewers: independently assessed article titles, abstract and full texts
  • Articles were included and rated by 3 reviewers by consensus

The 2 reviewers looked at:

  • Risk of bias, randomisation method, allocation concealment, blinding, completeness of outcome data, selective outcome report and other
  • Risk of bias rated as low or risk unclear in 4 domains: randomisation generation, allocation concealment, incomplete outcome data and selective reporting.
  • They also categorised trial risk of bias as high if risk was gih in any of the 4 domains.
  • No meta-analysis was performed because of disparate  interventions and outcome measure

Network plot: node proportionate to number of trials making the comparison

Jesus presentation

Green, yellow and red : comparisons of low, unclear and high risk bias.


3742 Patients undergoing a scheduled operation who were able to understand the language in which the info was presented


  • They looked at the various methods and combinations of preoperative information text, verbal, person, multimedia in comparison with the same information in a different format (as listed above) at different time durations before surgery.
  • The information content related to behavioural, procedural and sensory aspects of the patient journey.


  • A: pre-operative anxiety
  • B: postoperative anxiety
  • C: postoperative pain
  • D: length of hospital stay
  • E: participant satisfaction with surgery or anaesthesia
  • F: patient satisfaction with information; g, patient knowledge.


  • 34 trials with 3742 participants : 29 randomised controlled, 4 quasi-randomised and 1 was cluster randomised:
  • The effects of different info formats was assessed by 30 trials.
  • The effects of timing by 5 trials
  • Anxiety was measured using different scoring systems
  • Patient knowledge and satisfaction was analysed by a questionnaire individual to each study so prevented a meta-analysis.
  • The explored the bias in the papers they reviewed
  • Low risk of bias = 6, high risk of bias = 10, 17 stated blinding of participants, personnel and outcome assessors wasn’t possible

Verbal vs text in 4 studies

  • 2 trials no difference in anxiety
  • Verbal inc knowledge and satisfaction in 1 trial, dec knowledge in 2 other studies and no affect in another.

Verbal vs multimedia in 4 studies

  • Multimedia format improved anxiety in 1 study and contradicted in another studies
  • Multimedia formats were superior vs verbal in 3 studies
  • Inc knowledge and satisfaction in 2 studies
  • But inc in mod to severe pain in one study

Text vs multimedia 4 studies

  • 1 study showed no difference in anxiety
  • 2 reported multimedia significantly inc satisfaction with info
  • 1 study reported higher knowledge scores in the same group.

Addition of multimedia to verbal info 6 studies

  • 3 showed no affect on pre-op anxiety
  • 3 showed it improved knowledge
  • 2 showed no difference
  • 1 showed satisfaction with anaesthetics care was unaffected and 1 showed it increase satisfaction
  • 4 trials looked at patient satisfaction with info : 2 showed no effect of multimedia,
  • 3 studies looked the addition of multimedia to verbal and text info : 1 study showed no effect, 1 study showed inc and 1 study showed knowledge respectively. Post op pain and hospital stay was unaffected in two of the 3 studies
  • Knowledge, anxiety and length of hospital stay were unaffected by the addition of multimedia to text in 1 study but showed a dec in anxiety in another.

Addition of text to verbal info in 6 studies

  • 1 showed a dec in anxiety , 2 showed no affect,
  • 4 showed no affect on knowledge and one showed an increase
  • Satisfaction and hospital stay was unaffected

Verbal combined with text or with a multimedia format in 3 studies

  • 2 showed no difference in outcomes of : anxiety, satisfaction with info given, postoperative recall of complications and readability or usefulness of the info.
  • The 3 trial showed that multimedia format increased knowledge and satisfaction.
  • DVDs don’t increase knowledge but don’t affect length of stay.

Effect of timing in 5 studies

  • Timing doesn’t affect pre-op anxiety, post op pain, or hospital stay
  • Post op anxiety was unaffected by timing of direct teaching, or via audiotapes
  • Early text or video info reduced post-op anxiey
  • Knowledge and satisfaction after an interview and video were unaffected by the order in which they were given.


  • They were able to show effects of pre-op info on peri-op anxiety and other outcomes were affected little by format or timing.
  • Similar findings in systematic reviews that included trials of different info content
  • Other systematic reviews didn’t do meta-analyses for the same reasons
  • They want to look at tailoring formats based on personalities
  • Trials should include of poor literacy or computer unfamiliarity


  • Robust inclusion and exclusions criteria
  • Bias analysis was ok
  • Explained why they couldn’t do a meta-analysis = too much variation of study designs


  • No meta-analysis due to heterogenous studies
  • They didn’t know the methodologies of all studies so their assessment of bias was inaccurate
    One of the paper’s editors is the editor of the journal of Anaesthesia but they underwent extended external procedures.


Some health authorities spend vast resources on multimedia information formats at great cost, but keeping it simple by verbal and written formats could be just as good. Useful in a resource poor environment.

Potential for impact

  • Multimedia formats increase knowledge more than text > verbal.
  • One can incorporate this into our own pre-op assessments:
  • Provide pts with a multimedia reference after they have been to their pre-assessment appointment, or when on the ward, point them towards and app or whilst they wait for their operation if so wish so that we can empower patients in their knowledge of their procedure.