A preoperative education intervention to reduce anxiety and improve recovery among Chinese cardiac patients: A randomized controlled trial

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Abstract

Background

Patients awaiting cardiac surgery typically experience significant physical and psychological stress. However, although there is evidence that preoperative education interventions can lead to positive postoperative outcomes for surgical patients in general, less is known about the effectiveness among patients undergoing cardiac surgery, especially Chinese cardiac patients.

Objectives

To determine whether a preoperative education intervention designed for Chinese cardiac patients can reduce anxiety and improve recovery.

Settings

Cardiac surgical wards of two public hospitals in Luoyang, China.

Methods

153 adult patients undergoing cardiac surgery were randomized into the trial, 77 to a usual care control group and 76 to preoperative education group comprising usual care plus an information leaflet and verbal advice. Measurement was conducted before randomization and at seven days following surgery. The primary outcome was change in anxiety measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were change in depression (HADS), change in pain as measured by subscales of the Brief Pain Inventory-short form (BPI-sf), length of Intensive Care Unit stay and postoperative hospital stay.

Results

Of 153 participants randomized, 135 (88.2%) completed the trial. Participants who received preoperative education experienced a greater decrease in anxiety score (mean difference −3.6 points, 95% confidence interval −4.62 to −2.57; P < 0.001) and a greater decrease in depression score (mean difference −2.1 points, 95% CI −3.19 to −0.92; P < 0.001) compared with those who did not. There was no difference between groups in average pain, current pain, and interference in general activity, mood and walking ability. Patients randomized to the preoperative education group reported less interference from pain in sleeping (mean difference −0.9 points, 95% CI −1.63 to −0.16; P = 0.02). There was some evidence to suggest a reduced number of hours spent in the Intensive Care Unit among preoperative education patients (P = 0.05) but no difference in length of postoperative hospital stay (P = 0.17).

Conclusions

This form of preoperative education is effective in reducing anxiety and depression among Chinese cardiac surgery patients. Based upon existing evidence and international practice, preoperative education should be incorporated into routine practice to prepare Chinese cardiac patients for surgery.

Introduction

Patients awaiting cardiac surgery typically experience significant physical and psychological stress, including high levels of anxiety and depression due to fears, worries, and uncertainties about surgery (Fitzsimons et al., 2000, Gallagher and McKinley, 2007). These can exacerbate symptoms of the existing disease, adversely affect physiological parameters before and during anesthesia, and also can result in prolonged recovery (Andrew et al., 2000, Duits et al., 1997, Pignay-Demaria et al., 2003).

Preoperative education has been used to improve patients’ experiences by providing health care relevant information, coping skills, and psychosocial support before surgery (Kruzik, 2009, Scott, 2004). Compared with usual care, preoperative education can promote positive postoperative outcomes in mixed groups of surgical patients (Shuldham, 1999a, Shuldham, 1999b). With reference to patients undergoing orthopedic surgery, the meta-analysis of Johansson et al. (2005) found that preoperative education can improve patients’ anxiety and knowledge. A randomized controlled trial (Pager, 2005) demonstrated that preoperative information for patients experiencing cataract surgery resulted in less anxiety, and greater understanding of, and satisfaction with, their treatment. Another randomized controlled trial conducted by Lin and Wang in Taiwan (2005) found that a preoperative nursing intervention had a positive effect on anxiety and pain for patients undergoing abdominal surgery.

However, although there is evidence that preoperative education interventions can lead to positive postoperative outcomes for surgical patients in general, less is known about their effectiveness for patients undergoing cardiac surgery. Previous studies have produced conflicting findings. Some studies have highlighted the effects of preoperative education on improving physical and psychosocial recovery for coronary artery bypass surgery patients (Babaee et al., 2007, McHugh et al., 2001, Shelley and Pakenham, 2007) while other studies found no evidence that cardiac patients’ anxiety is reduced (Asilioglu and Celik, 2004, Lamarche et al., 1998, Shuldham et al., 2002) or of any effect on hospital stay (Shuldham et al., 2002). Shuldham's review (2001) concluded that preoperative education did not benefit patients’ recovery from coronary artery bypass surgery. Evidence in the field of preoperative education is limited and has tended to be based on weak trial design such as non-randomized trials or randomized trials with relatively small sample sizes.

Among various forms of preoperative education interventions designed for cardiac surgery patients, few attempts have been made to evaluate the effectiveness of verbal communication assisted with the use of written information. Furthermore, most studies are conducted in western countries. The effect of preoperative education may be different among Chinese patients as there is evidence to suggest that cultural factors may influence patients’ responses to such interventions (Cheung et al., 2003). Despite a substantial increase in the availability of information about patients’ illness and treatment in many western countries, the provision of such information in Chinese hospitals is often poor, with minimal interaction between healthcare providers and patients (Henderson and Chien, 2004).

Cardiovascular diseases have become one of the leading causes of death among Chinese adults. In a country with high population growth and a rapidly expanding economy, it is estimated that over 8 million Chinese are in need of cardiac surgery with over 74,000 cardiac operations taking place in Chinese hospitals each year (Pezzella, 2006, Zhang and Chen, 2007). However, there are no current guidelines from Chinese national health organisations regarding preoperative information needs for this group of patients.

Our primary interest was to determine whether provision of a preoperative education intervention comprising an information leaflet and verbal advice could reduce anxiety among Chinese patients undergoing cardiac surgery. In this study, we also aimed to evaluate whether this form of preoperative education could reduce symptoms of depression, decrease pain, and improve recovery.

Section snippets

Methods

We carried out a randomized controlled trial to compare usual care alone with usual care plus a preoperative education intervention comprising an information leaflet and verbal advice. The trial took place in the cardiac surgical wards of two public hospitals in Luoyang, China. At each hospital approximately 300 cardiac surgical procedures are performed each year. Ethical approval for this study was granted by the First Affiliated Hospital of Henan University of Science and Technology Teaching

Results

Between 1st December 2009 and 17th March 2010, of the 245 potential participants assessed, 156 were eligible, of whom 153 (98.1%) consented to participate, completed baseline measures, and were randomized (76 to preoperative education, 77 to usual care). Of these, 18 were lost to follow-up. Reasons for attrition were having died after surgery (n = 2), being transferred to another hospital (n = 2), and being discharged without undergoing surgery (n = 14) leaving a total of 135 who completed the trial (

Discussion

Among participants randomized to the preoperative education group, there was a greater reduction in anxiety and depression and less pain interference with sleep compared with those in the usual care group. In our trial, we did not observe differences between the two groups in terms of average pain, current pain, and interference from pain in general activity, mood and walking ability. The preoperative education intervention appears to benefit these Chinese patients’ psychological health. A lack

Contributors

PG conceived the study under supervision of AA and LE. Data collection was undertaken by PG. AA and PG conducted the statistical analysis and interpreted the data. PG drafted the manuscript. AA and LE reviewed and edited the manuscript. All authors approved the final manuscript and act as guarantors for the study.

Acknowledgements

We thank the participants and their families for taking part in the trial and the staff in the cardiac wards of two study hospitals in Luoyang, China, and in particular the managers of the hospitals Xiaoshan Feng, Yawei Li, and Xingpeng Chen. We thank Chaojuan Wang, Li Li, Xin Tian, Quanxing Cao, and Jing Wang for evaluating the patient information leaflet.
Conflicts of interest

All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on

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