Patient Education

The Patient Education recommendation has been downgraded two levels because of inconsistent evidence.

Patient education encompasses a broad range of topics and may be delivered in multiple ways. In addition, studies in this area used a wide variety of outcome measures, from pain scores, to opioid use, to measures of patient knowledge and self-efficacy, making the identification of consistent impact of this intervention challenging. One high quality study found improved pain scores, earlier discontinuation of opioids and decreased opioid consumption up to three months after rotator cuff repair in patients who received dedicated opioid education preoperatively compared to standard counseling (Syed 2018).

One high quality study (Riddle 2019) demonstrated that among patients with high catastrophizing scores undergoing TKA, training in pain coping skills or pre-operative arthritis education resulted in no differences in WOMAC scores or level of reported pain, compared to usual care.  Given that this study focused only on those with high pain catastrophizing scores, the utility of this intervention for all patients undergoing TKA is unknown. 

One high quality study (Huang 2017) found that patients undergoing empowerment education related to their THA allowed patients to become more knowledgeable about the procedure, developed greater self-efficacy had improved Tinetti Mobility scores, and improved SF-36 quality of life scores.  No indication in this study regarding who provides this education.

One high quality study (Wong 1990) demonstrated that viewing a video, reviewing a handout and then frequent discussions with nurses after THA after anticipated changes in function led to no differences in function or psychosocial status, compared to controls, after surgery.  This video was shown to patients at 6 days (and beyond) in the hospital after surgery.  Given the current limited length of stay after THA, this study design has limited utility. 

One high quality study (von Eck 2018) demonstrated improved satisfaction with recovery after knee or shoulder arthroscopic procedures among patients who underwent web-based education prior to and after surgery.  However, the differences in satisfaction scores do not seem to be clinically significant.

One moderate quality study (van den Akker Scheek 2007) demonstrated that a 6-month home-based support program after THA and TKA had no impact on physical function or self-efficacy.  A portion of the intervention included newsletters that were mailed to participants, but there is no indication that there was confirmation that patients receive or read these. 

Benefits/Harms of Implementation

There are no known harms from this intervention.  These interventions may be of interest to patients interested in non-pharmacologic or non-invasive methods of pain control.  These interventions also address function and self-efficacy, in addition to pain and opioid use.  Providing education about opioids seems to impact amount and length of opioid use after surgery. 

Cost Effectiveness/Resource Utilization

Costs and resource utilization vary with method of delivery. Web-based education platforms may require additional expertise to design and maintain the website. Education provided by dedicated clinical personnel may require additional staffing and training. Some of the interventions described involve extensive human resources in terms of home visits, frequent follow-up phone calls, teaching in patient education modules, etc.  Additional research is needed to better determine the cost/benefit impact of this intervention.

Acceptability

Patient education is a well-accepted component of standard surgical practice. Specific to pain alleviation strategies, patients are accustomed to interventions or medications for pain control.  There would need to be assessment of acceptance of these techniques among patients undergoing surgical treatment in the US.  There would also need to be education among healthcare professionals in the US about the potential use and impact of these techniques.

Feasibility

Formalized patient education may require additional staffing, resources (websites, cellphone applications, etc.), and translating services. Patient’s own education level may affect the success of patient education efforts. Given the human resources needed for this intervention, there may be limited options for this in small or rural hospitals.  However, interactive telehealth could allow patient education classes to be taught over the internet, among different hospitals.  Use of this modality for individual teaching in patient homes or using telemedicine, rather than in-person, for follow-up is limited to those with adequate access to broadband internet.

Future Research

The optimal delivery method and timing of patient education has yet to be determined and may be specific to the topic of interest. Social and demographic variables may influence the effect of patient education efforts. Further research should seek to determine the ideal timeline and delivery platform of patient education efforts, with sub-group analyses to determine if gender- and race/ethnicity-based differences affect the acceptance and outcomes of this intervention. Future research needs to focus on relative impact of specific interventions (e.g., teaching self-efficacy vs learning more about a procedure vs learning more about post-operative limitations vs learning more about opioids and addiction).