original article

Annals of Oncology 22: 21212128, 2011 doi:10.1093/annonc/mdq718 Published online 1 February 2011

Usefulness of a bidirectional e-learning material for explaining surgical anesthesia to cancer patients
H. Narimatsu1*, A. Kakinuma2, T. Sawa2, T. Komatsu3, T. Matsumura4, M. Kami4 & Y. Nakata2
Advanced Molecular Epidemiology Research Institute, Faculty of Medicine, Yamagata University, Yamagata; 2Department of Anesthesia, Teikyo University School of Medicine, Tokyo; 3The 3rd Department of Medicine, Teikyo University School of Medicine, Ichihara Hospital, Chiba; 4Division of Social Communication System for Advanced Clinical Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
1

Received 12 May 2010; revised 5 September 2010; accepted 15 November 2010

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Background: We developed an e-learning system, which is based on an interactive animation video that assists
anesthesiologists in preanesthetic interviews.

Materials and Methods: First, the feasibility of the system was investigated in 18 anesthesiologists and 95
volunteers from the general public. Content/quantity, operability, and satisfaction were assessed with a ve-point scale. Secondly, a randomized controlled trial was conducted on 211 cancer patients who were scheduled to undergo general anesthesia. They were divided into an e-learning group (n = 106) and a control group (n = 105). The patients in the e-learning group watched the interactive animation before a preanesthetic interview by an anesthesiologist. Results: In 10 of the 11 items for content/quantity, operability, and satisfaction, the average score for both anesthesiologists and volunteers was 3.0 in feasibility study. Then, the level of patient comprehension of preoperative rounds and postoperative complications in the e-learning group was signicantly higher than that in the control group (mean: 4.4 6 0.5 versus 4.1 6 0.7, P = 0.003, and 4.3 6 0.5 versus 4.2 6 0.5, P = 0.02); however, no signicant difference in anxiety was seen between the two groups. Patient satisfaction in the e-learning group was signicantly higher (mean: 4.3 6 0.5 versus 4.0 6 0.6, P = 0.002). Conclusion: The e-learning system is an effective supplementary tool for preanesthetic interviews in cancer patients. Key words: animation, anxiety, comprehension, interactive material, quality of life, satisfaction

introduction
Surgery is important for cancer treatment, and general anesthesia is often required. Before surgery, anesthesiologists thoroughly explain anesthesia; however, the level of patient comprehension varies from case to case, and anesthesiologists do not necessarily assess this comprehension adequately. Even when anesthesiologists think that they have sufciently explained anesthesia, patients may not clearly understand [1]. Misunderstanding and miscommunication between anesthesiologists and cancer patients represents an important medical issue because it can occasionally develop into medical lawsuits involving preanesthetic interviews. To improve the level of patient comprehension of anesthesia, educational materials such as leaets and videos have been used. The effects of these tools on patient anxiety have varied, but many studies have found that they are useful for acquiring knowledge [27]. E-learning utilizing bidirectional materials is widely used as an educational tool in various elds [8]. Major advantages are
*Correspondence to: Dr H. Narimatsu, Advanced Molecular Epidemiology Research Institute, Faculty of Medicine, Yamagata University, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan. Tel: +81-(0)23-628-5256; Fax: +81-(0)23-628-5261; E-mail: hiroto-narimatsu@umin.net

that e-learning can be designed based on the level of user comprehension and that the level of comprehension can be recorded. To improve the level of patient comprehension of preanesthetic interviews, we developed an e-learning system for explaining surgical anesthesia to cancer patients [9]. Using this tool, anesthesia is explained using an audiovisual program based on the surgery that each patient is about to undergo, and the level of comprehension is conrmed and recorded at the end. To the best of our knowledge, this was the rst attempt to utilize an e-learning system for preanesthetic interviews. In the present study, the feasibility of this system was investigated in physicians and volunteers, and its usefulness was veried in cancer patients.

materials and methods

e-learning system for explaining surgical anesthesia to cancer patients: interactive animation video
The present e-learning system for explaining surgical anesthesia to cancer patients is an interactive animation that assists anesthesiologists in preanesthetic interviews (Figures 15). Our animation is intended to help patients understand anesthesia, to help anesthesiologists determine what their patients do not understand, and to make the preanesthetic interview more effective and efcient. It is not intended to replace the preanesthetic interview

The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: journals.permissions@oup.com

original article

original article

Annals of Oncology

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Figure 1. The e-learning system, an interactive animation. This system is intended to help patients understand anesthesia, to show anesthesiologists what their patients do not understand, and to increase the effectiveness and efciency of anesthesiologists preoperative interview. This video is composed of ve brief sections.

Figure 2. One of the ve brief sections. Each section lasts from 1 to 2 min, as we thought that patients might not be able to concentrate on a long explanation. We included a series of questions at the end of each section to examine patients understanding of the explanation of anesthesia. This also serves as a legal document to prove that patients understood anesthesia and gave informed consent.

by anesthesiologists. The animation is touch-screen operated on a laptop PC with headphones. An animated character, which plays the role of a female anesthesiologist, explains anesthesia in plain Japanese language in a female voice. The animation is composed of ve brief sections, each lasting 12 min. It takes 12 min to complete all sections of the animation. In the animation, the animated character rst discusses the role of anesthesiologists during

surgery. She then explains the usual general or generalepidural anesthesia procedure and postoperative recovery. There is a questionnaire at the end of every section to assess the patients understanding of anesthesia. This is also intended to serve as a legal document to prove that patients understood the explanation of anesthesia and gave informed consent. The summary of patients answers can be reviewed. Anesthesiologists can determine

2122 | Narimatsu et al.

Volume 22 | No. 9 | September 2011

Annals of Oncology

original article

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Figure 3. Explanation page of anesthesia. The representative explanation page of anesthesia is shown. The animation character, which represents a female anesthesiologist, explains anesthesia in plain Japanese in a female voice.

Figure 4. The questionnaire page. The questionnaire page that tests patients understanding of anesthesia is shown as follows. QuestionsQ1: Do you understand that current anesthesia is carried out safely but is not 100% safe? Q2: Do you understand that the role of an anesthesiologist is not only a relief of pain but also control respiration and circulation? Q3: Do you understand that anesthetic management is carried out by a team? whether patients watched the video, and they can also know before the interview whether their patients correctly answered the questions and can obtain details of what patients did not understand well. e-learning system in ve grades in terms of content/quantity, operability, satisfaction, and applicability to other elds. The anesthesiologists were asked to more closely assess on a ve-point scale the contents and effects as well as whether they would like to use the e-learning system in clinical settings. Five points are the most positive evaluation and one point is the most negative evaluation. The items were developed by an e-learning systems company (Lightworks Corporation, Tokyo, Japan) and two anesthesiologists (AK and YN) reviewed and discussed on those items.

feasibility study in anesthesiologists and volunteers

Subjects comprised 18 consenting anesthesiologists and 95 volunteers. After e-learning, predesigned questionnaires were used to assess the e-learning system. Table 1 shows the survey contents. All participants assessed the

Volume 22 | No. 9 | 2011

doi:10.1093/annonc/mdq718 | 2123

original article

Annals of Oncology

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Figure 5. The score of patients understanding. The score of patients understanding is shown as follows. Anesthesiologists can see their patients score before seeing the patient and can explain in more details what the patient did not understand well. Answer recordAnesthesia Browsed: rst question, yes; second question, no; third question, yes (updated at 14:41:12 on 2008/02/05); Before operation Browsed: rst question, yes; second question, no; third question, yes (updated at 14:43:59 on 2008/02/05); General anesthesia Browsed: rst question, yes; second question, no; third question, yes (updated at 14:51:14 on 2008/02/05); After operation Browsed (updated at 14:53:27 on 2008/02/05). We determined that the present system would be clinically suitable if the scores for 80% of the items concerning content/quality, operability, and satisfaction were 3.0 points in both groups. Of the 14 items concerning content/quality, operability, and satisfaction, we used 11 items (Table 1). Three items were excluded because it was difcult to evaluate the answers as being positive or negative. a ve-point scale (Table 1). Six patients dropped out of the study, because the survey was not completed due to the lack of enough time. Finally, 211 patients participated in the study, which included an e-learning group (n = 106) and a control group (n = 105). The study was approved by the institutional review board of Teikyo University School of Medicine.

survey for the cancer patients in randomized controlled trial

We conducted the questionnaire study for the cancer patients who received randomized controlled trial for e-learning system. All patients scheduled for cancer surgery (including diagnostic biopsy) under general or general/ epidural anesthesia who had been admitted to Teikyo University Hospital at least overnight before surgery from September 2008 to February 2009 were considered for enrollment in the trial. Patients were excluded if, under normal circumstances, they would require a third party to complete the consent process (patients <20 years of age, those who did not adequately understand Japanese, and those with cognitive impairment). Ambulatory surgical patients were excluded. Patients were approached about enrollment in the trial before the usual preanesthetic interview on the day before surgery in the hospital ward. Of the 264 eligible patients, 217 patients gave their informed consent. Those patients were randomly divided into two groups: an e-learning group and a control group. Randomization was conducted by the doctors after informed consent was obtained using a table of random numbers. Information on the resting 45 patients who did not give their informed consent was not collected. In the control group, anesthesiologists explained the anesthetic methods and risks before surgery in person. In the e-learning group, patients watched the interactive animation before their preanesthetic interview. Anesthesiologists conducted preanesthetic interviews based on the results of e-learning. All the patients in this group completed the interactive animation. In both groups, a detailed survey was administered preoperatively on the day of surgery to assess comprehension, anxiety, and satisfaction on

statistical analysis
It was calculated that 204 patients randomly assigned in a ratio of 1 : 1 between two groups would provide 80% power at a two-tailed signicance level of 5% to detect an anticipated increase in mean of 0.5 points in e-learning group. Distributions of variables between the e-learning group and the control group were assessed using the chi-square exact test or MannWhitney U test. Results of the questionnaire were compared between the two groups by the MannWhitney U test. All probability values were two sided and had an overall signicance level of <0.05. A multiple linear regression model was used to evaluate the relationship between the results of the questionnaire and the patients age, sex, education, and whether they had completed the e-learning system. Factors associated with at least borderline signicance (P < 0.10) in univariate analyses were subjected to multivariate analysis. Values of P < 0.05 were considered statistically signicant. Statistical analyses were carried out with Stata SE 11 software (StataCorp LP, College Station, TX).

results
feasibility study in anesthesiologists and volunteers Table 2 shows the results. Cronbachs alpha of 11 items for the content/quantity, operability, and satisfaction of the e-learning system was 0.97. In 10 of the 11 items, the average score for both anesthesiologists and volunteers was 3.0 points. Hence,

2124 | Narimatsu et al.

Volume 22 | No. 9 | September 2011

Annals of Oncology

original article
Question type Animation content/quantity Questions Were the overall contents of the animation easy to understand? Were some of the expressions used in the animation difcult to understand? Is there something about the animation contents that you would like to know more about? Or do you think that the contents were too detailed?a Was the animation too long?a Were you able to quickly answer the questions posed by the animation? Was it bothersome to answer the questions?a Was the animation window easy to see? Were the animation operating procedures complicated? Were you able to quickly nd operating buttons? Were the colors and designs suitable for the contents of the animation? Were the contents of the animation interesting? Do you think that you will recommend the animation to people undergoing surgical anesthesia? Do you actively want to watch other animations for medical procedures besides surgical anesthesia? Do you think that going through the animation before surgery will ease your anxiety about undergoing surgical anesthesia? Do you think that you do not need explanations from an anesthesiologist after going through the animation? Do you think that the animation should be available at all hospitals? When compared with explanations that you normally provide to patients, were the contents of the animation sufcient? With the explanation and expression methods of the animation, do you think that patients and their families can correctly understand anesthesia? Do you think that the animation is too long for patients to use? Do you think that the animation will relieve anxiety in patients and their families? Do you think that patients understand the preanesthetic interviews that you normally conduct? When do you think is the best time for patients to go through the animation? Do you think that making patients to go through the animation beforehand will help you with conducting preanesthetic interviews? Do you think that going through the animation together with your patients during preanesthetic interviews will reduce your workload? Do you think that patients can gain better understanding by going through the animation alone after the preanesthetic interview? Do you think that the animation can shorten preanesthetic interviews with patients and families? Do you think that correctly answering the questions posed by the animation indicates a sufcient level of comprehension of surgical anesthesia? Taking into account the above points, do you think that going through the animation at some point alleviates the burden of anesthesiologists in providing explanations about anesthesia? Do you want to actively utilize the animation? Do you think that the present animation should be employed at your hospital and used by other doctors as well? Do you think that such an animation should also be used in other elds besides anesthesia? Did you understand what you should pay attention to during the preoperative visit by your anesthesiologist? Did you understand what may happen after surgery through explanations provided during the preoperative visit by your anesthesiologist? Did the preoperative visit by your anesthesiologist relieve your anxiety about surgery? On a scale of 100, 0 indicating the absence of anxiety and 100 representing the highest level of anxiety in your life, what is your current level of anxiety about surgery and anesthesia? Were you satised with the series of preoperative visits conducted by your anesthesiologist? Do you think that the animation videob made it easier for you to understand anesthesia? Do you think that actual videos are better suited for explaining anesthesia than animation? Did you want to watch the animation? Do you think that you could have better understood anesthesia by watching an animation?

Table 1. Questionnaire items Subjects Anesthesiologists and volunteers

Animation operability

Animation satisfaction

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Applicability to other uses Anesthesiologists Content

Explanation

Animation usage

Patients

All participants

E-learning group Control group

Those questions were excluded to evaluate the feasibility of e-learning system. In the patient survey, e-learning was described as an animation.

Volume 22 | No. 9 | 2011

doi:10.1093/annonc/mdq718 | 2125

original article
Table 2. Survey result summarya Questions Content/quantity Ease of understanding of overall content Ease of understanding of expressions Ease of understanding of questions Clarity of the animation screen Difculty of animation operation Arrangement of animation operation buttons Animation colors and design How interesting the contents are? Recommendation to other patients Use of the animation in areas besides surgical anesthesia Relieving anxiety about surgical anesthesia Possibility of the animation replacing the anesthesiologists explanations Necessity of the animations use at all hospitals Completeness of animation contents Animation expression methods Animation efcacy Patient comprehension by existing explanation methods Effects of animation use before interview Effects of animation use during interview Effects of animation use after interview Possibility of the animation replacing anesthesiologist explanations Efcacy as a form of record keeping Possibility of reducing workload Interest in own usage Recommendation to others Application to other elds

Annals of Oncology

Results (median, mean)a Volunteers Anesthesiologists 4.0, 5.0, 5.0, 4.0, 3.0, 3.0, 4.0, 3.0, 3.0, 4.0, 3.0, 1.0, 4.7 4.0 4.9 4.7 4.3 4.4 4.5 3.7 4.2 4.5 3.7 2.2 4.0, 2.0, 5.0, 4.5, 5.0, 5.0, 4.0, 3.5, 4.0, 4.0, 3.0, 1.0, 3.0, 2.0, 4.0, 3.0, 3.0, 5.0, 5.0, 3.0, 3.0, 1.0, 3.5, 4.0, 4.0, 4.0, 4.2 2.6 4.7 4.3 4.3 4.6 4.2 3.5 3.8 4.1 3.1 1.7 3.4 2.7 3.6 3.2 3.3 4.5 2.6 3.3 2.0 3.2 3.8 3.6 3.6 4.2

P value 0.004 0.0002 0.44 0.01 0.74 0.38 0.01 0.33 0.13 0.06 0.06 0.0002

Operability

Satisfaction

Applicability to other uses

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

Content assessment by anesthesiologists

Effect assessment by anesthesiologists

3.0, 4.1 NA NA NA NA NA NA NA NA NA NA NA NA NA

0.05

Assessment of e-learning usage by anesthesiologists

Assessed on a ve-point scale, 5 points being the most positive evaluation and 1 point being the most negative. NA, not applicable.

we determined that the system would be suitable in the clinical setting.

randomized controlled study in cancer patients Table 3 shows the patient proles and survey results. The level of patient comprehension of the preoperative visit and of postoperative complications was signicantly higher in the e-learning group (median, 4.0 versus 4.0 points, P = 0.003, and 4.0 versus 4.0 points, P = 0.02). No signicant difference existed in anxiety scores between the two groups. The satisfaction score was signicantly higher in the e-learning group (median, 4.0 versus 4.0, P = 0.002). factors inuencing the results Table 4 shows the results of analysis of the factors related to the patient survey results. Completing e-learning was signicantly related to comprehension and satisfaction but not anxiety. Moreover, age was related to comprehension; the older the patient, the lower the comprehension.

discussion
The present study showed that the e-learning system utilizing an interactive animation video was effective in increasing the

understanding of surgical anesthesia in cancer patients scheduled for anesthesia. The biggest feature of our e-learning system is that it enables bidirectional communication. This is in contrast to unidirectional supplementary tools such as leaets [2, 10] and videos [3, 4, 6] that have previously been used to explain surgical anesthesia. In the feasibility study, the content, operability, and satisfaction of the e-learning system were mostly comparable between the anesthesiologists and volunteers, except for the ease of understanding expressions, which was rated higher by patients than by anesthesiologists. Although the reason for this could not be claried, there were only three elderly people (60 years of age or older) among the volunteers (data not shown), and the low number of elderly people might have affected the results. Many cancer patients are elderly, and anesthesiologists could have assessed the system while having elderly patients in mind. Because the level of comprehension by volunteers can be considered close to that by patients, the feasibility of the e-learning system was suggested from the viewpoints of both anesthesiologists and patients. In the randomized controlled trial in cancer patients, the comprehension and satisfaction scores for the e-learning group were signicantly higher than that for the control group. This could be explained as follows: through bidirectional

2126 | Narimatsu et al.

Volume 22 | No. 9 | September 2011

Annals of Oncology
Table 3. Effects of e-learning in cancer patientsa

original article
E-learning group (n = 106) Control group (n = 105) 61 (2586) 68/37 42/63 4.1, 4.0 4.2, 4.0 3.9, 4.0 45.8, 50.0 4.0, 4.0 NA NA 3.7, 4.0 3.9, 4.0 P value 0.80 0.10 0.10 0.003 0.02 0.35 0.87 0.002 NA NA NA NA

Age [median (range)] Sex (male/female) Education (college or graduate school/other) Level of comprehension of preoperative visit (mean, median) Level of comprehension of postoperative complications (mean, median) Anxiety about surgery (median, mean) Anxiety scoreb (mean, median) Level of satisfaction with preanesthetic visit (mean, median) Contribution of e-learning to the comprehension of surgical anesthesia (mean, median) Whether or not explanation using an actual video would be better than e-learning (mean, median) Whether or not you wanted to go through e-learning (mean, median) Whether or not you think e-learning would facilitate the understanding of anesthesia (mean, median)
a

64 (2385) 57/49 31/75 4.4, 4.0 4.3, 4.0 3.9, 4.0 45.4, 50.0 4.3, 4.0 4.3, 4.0 2.7, 3.0 NA NA

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

The questionnaire was assessed on a ve-point scale, 5 being the highest and 1 being the lowest. Only this item was assessed on a scale of 100, 100 being the highest and 0 being the lowest. NA, not applicable.

Table 4. Correlation between patient attributes and survey results Univariate factors Level of comprehension of preoperative visita b 95% CI 20.01 20.02 0.27 0.05 20.01 to 20.0001 20.19 to 0.15 0.11 to 0.44 20.13 to 0.23 Anxiety about surgeryb P 0.05 0.80 0.001 0.56 b 0.13 29.05 20.43 25.51 95% CI 20.17 to 0.44 217.28 to 20.81 28.62 to 7.76 214.11 to 3.08 P 0.40 0.03 0.92 0.21 Level of satisfaction with preanesthetic visita b 95% CI 20.005 20.15 0.27 0.02 20.01 to 0.001 20.32 to 0.01 0.11 to 0.42 20.14 to 0.19

P 0.12 0.06 0.001 0.78

Higher age Sex (male = 1, female = 0) Group (e-learning group = 1, control group = 0) Education (college or graduate school = 1, other = 0) Multivariate factors Age Sex (male = 1, female = 0) Group (e-learning group = 1, control group = 0) Education (college or graduate school = 1, other = 0)
a

20.01 NA 0.27 NA

20.01 to 20.0003

0.04

NA 29.05 NA NA

217.28 to 20.81

0.03

NA 20.12 0.25 NA

20.28 to 0.04 0.10 to 0.41

0.13 0.002

0.11 to 0.44

0.001

The questionnaire was assessed on a ve-point scale, 5 being the highest and 1 being the lowest. This item only was assessed on a scale of 100, 100 being the highest and 0 being the lowest. CI, condence interval; NA, not applicable.

communication, individualized learning that considered patient status improved the patients comprehension, ultimately improving satisfaction. However, in the e-learning group, it was possible that comprehension could have improved just because they were cumulatively exposed to longer explanations of anesthesia. To verify the usefulness of bidirectional learning, it is necessary to conduct a study comparing bidirectional learning with unidirectional videos and leaets [24, 6,1013]. We plan to investigate this in a future study. It will also be necessary to ascertain the difference between bidirectional learning and prolonged careful

explanations by anesthesiologists. There may not be much difference between these two methodologies; however, making anesthesiologists give lengthy explanations increases their workload and medical costs. If comparable effects can be obtained, the use of e-learning could be benecial. This point will also need to be veried by a comparative study. Anxiety scores were comparable between the two groups, suggesting that the anxiety-relieving effects of the e-learning system are limited. This agrees with the results of past studies on adults. For example, according to a 2008 study by Cheng et al. [14], the anxiety-relieving effects of video learning were

Volume 22 | No. 9 | 2011

doi:10.1093/annonc/mdq718 | 2127

original article
limited. Past studies have suggested that anxieties experienced by patients undergoing major surgical procedures are related to the surgical procedures themselves, or in other words surgery outcomes and intraoperative diagnoses, rather than anesthesia risks or complications [14, 15]. The subjects in the present study were patients who were scheduled to undergo cancer surgery, and their situations may therefore be similar. In the present study on cancer patients, it was interesting that the older the patients, the lower the comprehension (Table 4). The anesthesiologists gave low evaluations for the ease of understanding of expressions and stated in their free responses that the system needs to be redesigned with the elderly in mind (data not shown), suggesting that expressions need to be revised when anesthesiologists who routinely treat elderly patients use this system as a supplementary explanation tool for the elderly. The present e-learning system for explaining surgical anesthesia to cancer patients is an effective supplementary tool that helps cancer patients to acquire knowledge of general anesthesia before a preanesthetic interview conducted by an anesthesiologist. It also improves the effectiveness of subsequent preanesthetic interviews. However, some issues remains to be discussed. First, more and more patients are seeking information via the Internet before a procedure or treatment. Thus, it is possible that one group had greater baseline understanding than the other. The difference in baseline measure of understanding of anesthesia might have affected the results. Secondly, given that older age was associated with poorer comprehension, this might be due to the fact that older patients may be less facile with this technology compared with younger participants. This might have affected the result. Finally, because the present study was small, there may be unexpected biases, and it will be necessary to verify the results in a larger study.

Annals of Oncology

disclosure
The authors declare no conict of interest.

references
1. Hume MA, Kennedy B, Asbury AJ. Patient knowledge of anaesthesia and peri-operative care. Anaesthesia 1994; 49: 715718. 2. Bellew M, Atkinson KR, Dixon G, Yates A. The introduction of a paediatric anaesthesia information leaet: an audit of its impact on parental anxiety and satisfaction. Paediatr Anaesth 2002; 12: 124130. 3. Cassady JF Jr, Wysocki TT, Miller KM et al. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999; 88: 246250. 4. Done ML, Lee A. The use of a video to convey preanesthetic information to patients undergoing ambulatory surgery. Anesth Analg 1998; 87: 531536. 5. Lee A, Chui PT, Gin T. Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions. Anesth Analg 2003; 96: 14241431, table of contents. 6. Salzwedel C, Petersen C, Blanc I et al. The effect of detailed, video-assisted anesthesia risk education on patient anxiety and the duration of the preanesthetic interview: a randomized controlled trial. Anesth Analg 2008; 106: 202209, table of contents. 7. Snyder-Ramos SA, Seintsch H, Bottiger BW et al. Patient satisfaction and information gain after the preanesthetic visit: a comparison of face-to-face interview, brochure, and video. Anesth Analg 2005; 100: 17531758. 8. Sajeva M. E-learning: web-based education. Curr Opin Anaesthesiol 2006; 19: 645649. 9. Kakinuma A, Sawa T, Komatsu T et al. Effects of short interactive animation video on preanesthetic anxiety, knowledge and interview time. Anesth Analg 2009; 108: S108. 10. Fitzgerald BM, Elder J. Will a 1-page informational handout decrease patients most common fears of anesthesia and surgery? J Surg Educ 2008; 65: 359363. 11. Courtney MJ. The effect of a preanaesthetic information booklet on patient understanding and satisfaction. N Z Med J 1997; 110: 212214. 12. Luck A, Pearson S, Maddern G, Hewett P. Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial. Lancet 1999; 354: 20322035. 13. Zvara DA, Mathes DD, Brooker RF, McKinley AC. Video as a patient teaching tool: does it add to the preoperative anesthetic visit? Anesth Analg 1996; 82: 10651068. 14. Cheng SS, Yeh J, Flood P. Anesthesia matters: patients anesthetized with propofol have less postoperative pain than those anesthetized with isourane. Anesth Analg 2008; 106: 264269, table of contents. 15. Kindler CH, Harms C, Amsler F et al. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients anesthetic concerns. Anesth Analg 2000; 90: 706712.

Downloaded from http://annonc.oxfordjournals.org/ at Michigan State University on April 9, 2012

acknowledgement
We are grateful to Kahori Kudo (Yamagata University) for the support of editing manuscript.

funding
Third Strategic Research Project against Cancer by the Ministry of Health, Labour and Welfare, Japan.

2128 | Narimatsu et al.

Volume 22 | No. 9 | September 2011