Patient education strategies in cataract surgery: A systematic review

Methodological quality of the review: Low confidence

Author: Choi AR, Greenberg PB

Region: USA, India, Hungary, Australia, Austria, Canada, Haiti, China, Singapore and England.

Sector: Cataract surgery

Sub-sector: Patient education

Type of cataract: Age-related cataract

Equity focus: None specified

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background:

Among major surgeries, cataract extraction is virtually unparalleled in its safety and effectiveness. However, perioperative patient education can significantly affect the way that cataract patients perceive and experience the treatment process. Low-level understanding of cataract surgery is associated with increased patient dissatisfaction, anxiety, and less adherence to perioperative instructions — all of which can increase the risk for adverse outcomes. Patient education is an integral component of the informed consent (IC) process, with ethical and legal implications. In order to foster rational and autonomous decision-making, healthcare providers must provide patients with adequate knowledge (pertaining to diagnosis, prognosis, and treatment options).

Research objectives:

To systematically review the comparative effectiveness of patient education strategies in cataract surgery.

Main findings:

Authors included a total of 16 randomized controlled trials (RCTs) in the review. Three studies were conducted in the USA, three in India, two in Australia, two in Austria, and one each in Canada, Haiti, Hungary, China, Singapore and England. Authors identified 21 distinct patient outcomes, four with a multi-study evidence base: knowledge of cataract/cataract surgery, knowledge of postoperative care, proficiency in postoperative care, and anxiety. Authors found that targeted interventions significantly increased educational efficacy in 11 studies, they also note however that there were inconsistent improvements only for patient understanding of cataract/cataract surgery and postoperative care. Overall, reviewers assessed the quality of evidence as poor for all outcomes examined in the multiple studies, as well for deciding to undergo cataract surgery.

Based on the evidence included in the review, authors concluded that targeted interventions fostered patients’ understanding of cataract surgery and postoperative care. They also suggested the need to additional high-quality studies to determine appropriate educational strategies that improve other clinical, performance and humanistic outcomes.

Methodology:

Authors included RCTs of patients undergoing cataract surgery looking at perioperative patient education, baseline education intervention, and change in at least one patient-important outcome, respectively.

Authors conducted a search on PubMed, EMBASE, Web of Science, CENTRAL and CINAHL from inception to January 2017. Authors screened titles, abstracts and full-text articles to determine its eligibility for inclusion in the review. In addition, reviewers also browsed reference lists of eligible articles and considered additional articles for inclusion in the review.

Authors extracted data on the year of publication, study location, sample size, inclusion criteria, and the type of anesthesia used in surgery. To evaluate the strength of evidence authors used the GRADE guidelines, and to describe the risk of bias of included RCTs authors used the Jadad scale. Using the GRADEpro Guideline tool software, authors generated a GRADE evidence profile which delineates their findings and rationale for downgrading quality of evidence.

To synthesize the evidence authors performed a narrative synthesis.

Applicability/external validity

Authors report that one-third of the included RCTs came from rural, low-literacy communities in developing nations, therefore generalizability may be weakened by the inclusion of these studies.

Geographic focus

Authors included studies from all income settings, and note that three trials from developed nations provided an assessment of patient literacy or education level. In addition, out of the 16 included studies, 11 were conducted in industrialized countries.

Quality assessment

Low confidence was attributed to the review’s conclusions as important limitations were identified. Authors acknowledged potential publication bias within the review, only RCTs written in English were included. However, it’s not clear from the review if authors used appropriate methods to screen eligible studies for inclusion and extract data on included studies in the review, which may impact on the study’s reliability.