key: cord-0808073-ulseps4h authors: Xu, Kai Man; Mundra, Paul S.; Anabtawai, Aseel; Farrokhyar, Forough; Chan, Brian J. title: Improving the Patient Decision Making Experience for Cataract Surgery During the Covid-19 Era date: 2021-08-25 journal: Can J Ophthalmol DOI: 10.1016/j.jcjo.2021.08.010 sha: 2e64060a3dd2fa4f60b713248a281e287a71ed77 doc_id: 808073 cord_uid: ulseps4h OBJECTIVE: To explore if video-based patient decision aids (VBPDA) for cataract surgery consultation can enhance a patient's decision making process while upholding safety regulations during the COVID-19 pandemic. DESIGN: Single center consecutive case study. PARTICIPANTS: N= 147 patients, with an average age of 70 years, who came in for a cataract surgery consult were enrolled in this study. METHODS: All patients watch part 1 of the VBPDA outlining the process of cataract surgery and decisions involved. Patients then undergo cataract surgery consultation with an ophthalmologist. Afterwards, if the patient is indicated for surgery, part 2 of the VBPDA is played. At the end of the visit, all patients complete a survey assessing the effects of COVID-19 safety precautions on their appointment. In addition, patients going forward with surgery complete the Decisional Conflict Scale. RESULTS: For patients proceeding with cataract surgery, the median Decisional Conflict Scale (DCS) score was 9.38 (0-54.69, min-max) on a scale from 0-100 (low-high decisional conflict). A DCS score < 25 indicates low decisional conflict (n= 76, 68.47%) and a score > 25 indicates feeling unsure (n=35, 31.53%). The DCS can also be separated into various subscales: the informed subscale (median= 8.33, min-max= 0-66.67), values subscale (16.67, 0-58.33), support subscale (8.33, 0-50.00), uncertainty subscale (8.33, 0-83.33), and effective decision subscale (0, 0-37.50). CONCLUSION: Our study found that VBPDAs to be an effective tool to enhance the patient decision making process for cataract surgery during the COVID era. Cataract surgery is a common surgery that is one of the most cost-effective healthcare interventions, impacting quality of life and psychological wellbeing (1, 2) . Given the many treatment options available, cataract patients are uniquely faced with the task of making numerous choices that will have permanent impacts on their vision (ie. biometry, intraocular lenses, focus). COVID-19 adds another layer of challenge, as the introduction of public health measures presents obstacles to the surgical consent process, including regulations limiting family member accompaniment into healthcare facilities and masks muffling communication (especially for those who lipread) (3) . A potential solution to circumvent many of these challenges is the implementation of Patient Decision Aids (PDAs). PDAs present facts about the patient's condition, render the decision-making process more explicit, and list the features of available options (ie. benefits, harms, specific indications…etc) (4) . Spanning a multitude of medical specialties, decision aids increase patients' knowledge, clarity of values, role in decision making, and accuracy of risk perceptions, with no adverse effects on health outcomes or patient satisfaction (5) . Studies have shown that using videos in adjunct to counselling can help increase patient satisfaction and comprehension, while decreasing anxiety (6) (7) (8) (9) . These aids prepare patients to better understand their options and values in conjunction with (not instead of) health practitioner counselling (4). To date, there has not been a quality improvement study on the potential of video-based patient decision aids (VBPDA) to enhance patient experience in cataract surgery consultations. Our study aims to investigate whether a VBPDA can effectively aid the decision-making process while maintaining patient safety in the context of public health guidelines for COVID-19. Patients referred to a single center clinical practice for a cataract consult were enrolled. Exclusion criteria included patients who required a substitute decision maker (SDM) and patients with difficulty understanding English or those with significant hearing and visual impairments. Informed consent was obtained by study participants orally. The Hamilton Integrated Research Ethics Board (HiREB) determined that approval was not required for this study. Evidence shows that audiovisual PDA formats are more effective than printed materials (10, 11) . Thus, VBPDAs depicting whiteboard animations with narration and closed captions were developed with consultation from patients and healthcare professionals, via a continuous improvement (Plan-Do-Study-Act) process (see figure 1 ). The VBPDA (see Table 1 ) was developed along International Patient Decision Aid Standards (IPDAS), which include 44 evidence-based criteria for the development of PDAs (12) . Upon arrival, patients were given dilating drops in preparation for ophthalmologist examination. While waiting for full dilation, patients were shown part 1 of the VBPDA. During the encounter with the ophthalmologist, patients were put into 2 groups: those proceeding with cataract surgery (Indicated group) and those not currently proceeding (Observed group). Patients in the Indicated group then watched part 2 of the VBPDA and engaged in shared decision making with the ophthalmologist (see figure 2 ). The VBPDA videos were also uploaded onto the clinic's website for easy access. After the clinical encounter, all patients completed a survey. Decisional conflict is also associated with inadequate knowledge, unclear values, lack of support, and the perception that an ineffective decision was made (13) . The DCS is a validated 16-item scale that measures a person's perceptions of the quality of the decision made, scored from 0-100 (low to high decisional conflict). It includes subscales measuring 5 dimensions of decision making: informed, values, support, uncertainty, and effective decision (13) . Patients in the Indicated group completed the DCS to evaluate how they felt about their decisions in preparation for surgery. Scores < 25 are associated with implementing decisions and scores > 37.5 are associated with decisional delay, with scores >25 reflecting clinically significant decisional conflict (14, 15) . Both patient groups completed questionnaires about the effect of COVID-19 and its associated safety restrictions on their visits, including whether they typically have help from others who weren't able to join them for appointments, whether masks made it difficult to hear, and their fear of COVID-19 exposure. As there was no control group for safety reasons, patients were asked if they believe the decision would have been harder to make without the video, mimicking a control response. Qualitative feedback was also elicited. DCS total and subscores were calculated for each participant. The median was calculated due to high variability in individual scores; DCS scores can range from 0-100. The median was also provided for questions with 5 point Likert type scale data. Binary questions (ie. Yes/No) were evaluated as percentages. All statistical analysis was performed using the IBM SPSS 26 software. See table 2. Of the n=111 participants in the indicated group, 76 participants (68.47%) scored < 25 (low decisional conflict), 30 participants (27.03%) scored between 25-37.5 (moderate decisional conflict), and 5 participants (4.50%) scored > 37.5 (high decisional conflict). See table 3. In mimicking a control group, 79.60% agreed or strongly agreed that the decisions would have been harder to make without the VBPDA. In general, 87.08% thought the VBPDA were a good way to learn information before giving consent. Qualitative feedback was generally in support of the VBPDA with statements suggesting the video "was very organized and informative" with "excellent information". The cataract patient demographic is often more susceptible to infection, complications, and death from COVID due to underlying comorbidities (18) -our survey shows 26.06% of patients considered themselves at high risk for COVID-19. Public health measures suggest encouraging patients to come to clinics alone to limit the amount of people in the waiting area for appropriate distancing (3) . Our data shows that 53.52% of patients usually have someone assist them in appointments, challenging those who need more support in making the complex decisions involved in cataract surgery. As an age-related disease, the cataract afflicted population coincides with those hard-ofhearing (19) . Masks are essential to prevent transmission, but pose challenges to persons hard-ofhearing, as they reduce acoustic transmission and prevent lip reading (20) . In our survey, 26.06% of patients indicated that they would consider themselves hard-of-hearing and 19.86% found the ophthalmologist hard to hear. On this note, 96.45% of patients found the VBPDA clearly audible, as the VBPDA was played at a comfortable volume and the video is close-captioned. In addition, the VBPDAs showing the surgeon's face behind that mask eliminates the social disconnect that can occur with masks. Our patients have commented that being able to see the surgeon's face contributed to a positive clinical encounter. The median DCS score of 9.38 in the indicated group demonstrates that in conjunction with succinct counsel from the ophthalmologist, the VBPDA was effective in supporting decision making. Patients consistently scored < 25 in all subscales: they felt informed, believed their decision was aligned with their values, felt supported, felt sure, and felt they made an effective decision. The VBPDA optimizes workflow efficiency that has been hindered by new COVID measures: limits on the number of patients in the clinic, screening upon arrival, reduced allowance of accompanying persons...etc (21) (22) (23) . In our workflow (Figure 3) , the patient is able to watch VBPDAs while they are dilating and have a better understanding of the topic before consultation. Efficiency is improved for the physician, who can continue with their clinic while patients watch VBPDA part 1. As patients watch the VBPDA part 2, the ophthalmologist can work on tasks such as charting, ensuring that when interacting with the patient directly, the ophthalmologist is engaged and not distracted by said tasks. This approach improves workflow while providing safe and effective care. Maintaining patient safety as a priority during the pandemic excluded the possibility of a control group. Having patients watch the videos made the workflow more streamlined and reduced exposure time. However, there was no baseline group to compare the DCS results to, thus we cannot quantify exactly how effective the VBPDA was. Nonetheless, evidence from previous studies have generally shown that patient decision aids made with the IPDAS criteria decrease decisional conflict (5) . Future studies could evaluate longitudinal patient satisfaction with their decision and evaluate patient visit time with the use of a VBPDA. Dr. Brian J. Chan is a paid consultant for Allergan and has received honorariums for speaking engagements, but has no financial disclosures for this study. There are no other conflicts of interest to disclose. Our VBPDAs were shown to be an effective intervention to enhance patient decision making for cataract surgery during the COVID-19 era. Summary (2:55 min) Summarizes the decisions to be made by the patient and the options available. Prompts the patient for their choices and opens the floor for discussion/counselling with the surgeon. Cataract Surgery With Implantation of an Artificial Lens. Dtsch Ärztebl Int Rethinking Elective Cataract Surgery Diagnostics, Assessments, and Tools after the COVID-19 Pandemic Experience and Beyond: Insights from the EUROCOVCAT Group Ophthalmic Workplace Modifications for the Post-COVID Era Developing a quality criteria framework for patient decision aids: online international Delphi consensus process Decision aids for people facing health treatment or screening decisions A randomized trial of multimedia-facilitated informed consent for cataract surgery Efficiency of video-presented information about excimer laser treatment on ametropic patients' knowledge and satisfaction with the informed consent process Effect of a multimediaassisted informed consent procedure on the information gain, satisfaction, and anxiety of cataract surgery patients Video-Assisted Informed Consent for Cataract Surgery: A Randomized Controlled Trial Randomized trial of a video-based patient decision aid for bariatric surgery. Obes Silver Spring Md Impact of educational and patient decision aids on decisional conflict associated with total knee arthroplasty Decisional Conflict Scale Use over 20 Years: The Anniversary Review User Manual -Decisional Conflict Scale Decisional conflict among adolescents and parents making decisions about genomic sequencing results Clinical genetics Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 -United States Epidemiologic Survey Committee Of The Korean Ophthalmological Society OBOT. Relationships between Hearing Loss and the Prevalences of Cataract, Glaucoma, Diabetic Retinopathy, and Age-Related Macular Degeneration in Korea COVID-19 and hearing difficulties Ophthalmology in the time of COVID-19: experience from Hong Kong Eye Hospital Management of an ophthalmology department during COVID-19 pandemic in Sustainable practice of ophthalmology during COVID-19: challenges and solutions Disclosure: Dr. Brian J. Chan is a paid consultant for Allergan and has received honorariums for speaking engagements, but has no financial disclosures for this study.