The Effects of Short Interactive Animation VideoInformation on Preanesthetic Anxiety, Knowledge,and Interview Time: A Randomized Controlled TrialAkihito Kakinuma, MD, Hirokazu Nagatani, MD, Hiroshi Otake, MD, MBA, Ju Mizuno, MD, PhD,and Yoshinori Nakata, MD, MBA

BACKGROUND: We designed an interactive animated video that provides a basic explanation—including the risks, benefits, and alternatives—of anesthetic procedures. We hypothesized thatthis video would improve patient understanding of anesthesia, reduce anxiety, and shorten theinterview time.METHODS: Two hundred eleven patients scheduled for cancer surgery under general anesthesia orcombined general and epidural anesthesia, who were admitted at least 1 day before the surgery,were randomly assigned to the video group (n � 106) or the no-video group (n � 105). The patientsin the video group were asked to watch a short interactive animation video in the ward. After watchingthe video, the patients were visited by an anesthesiologist who performed a preanesthetic interviewand routine risk assessment. The patients in the no-video group were also visited by an anesthesi-ologist, but were not asked to watch the video. In both groups, the patients were asked to completethe State–Trait Anxiety Inventory and a 14-point scale of knowledge test before the anesthesiologist’svisit and on the day of surgery. We also measured interview time.RESULTS: There was no demographic difference between the 2 groups. The interview time was34.4% shorter (video group, 12.2 � 5.3 minutes, vs. no-video group, 18.6 � 6.4 minutes; 95%confidence interval [CI] for the percentage reduction in time: 32.7%– 44.3%), and knowledge ofanesthesia was 11.6% better in the video group (score 12.5 � 1.4 vs. no-video group score11.2 � 1.7; 95% CI for the percentage increase in knowledge: 8.5%–13.9%). However, there wasno difference in preanesthetic anxiety between the 2 groups.CONCLUSION: Our short interactive animation video helped patients’ understanding of anesthe-sia and reduced anesthesiologists’ interview time. (Anesth Analg 2011;112:1314–8)

To give an informed consent to any medical proce-dure, patients need to have adequate knowledgeabout the nature and risks of the procedure. It is the

physicians’ duty to provide this information and to ensurethat the patients are fully informed. However, it is verychallenging to obtain informed consent.1 Generally, it isdifficult for patients to understand anesthesia because it israther intangible and metaphysical, unlike their surgeriessuch as tumor resection, which are easily imaginable.Insufficient understanding of anesthesia can potentiallyincite legal conflict over the validity of informed consent.2

Although it would be ideal to obtain a patient’s consentwith full understanding of the risks and benefits of anes-thesia, it is impractical because anesthesiologists often do

not have sufficient time to explain anesthesia until thepatient can fully comprehend it. Several studies haveshown that video-assisted patient education, in comparisonwith an interview alone or an interview plus a brochure,has mixed results on patient’s knowledge regarding theanesthesia procedures and preoperative anxiety. Reasonsfor these conflicting results may include variability inclinical venue, complexity of surgery, and specific featuresof the video.3–6 Some patients may refuse to participate invideo-assisted patient education because they do not wantto see medical interventions on video and may panic if theyare forced to do so.3

To solve these problems, we designed an interactive ani-mated video that provides a basic explanation—including therisks, benefits, and alternatives—of anesthetic procedures.a

Our animation video is intended to help patients understandanesthesia, to help anesthesiologists understand what theirpatients do not understand, and to make the preanestheticinterview effective and efficient. It is not intended as a substitutefor the preanesthetic interview by the anesthesiologist.

There are several possible advantages to our interactiveanimation video over a conventional photographic video.First, the animation video is easier to edit or modify withcomputer software. Clinical practice is ever changing, and thecontents of the explanation must always reflect this changingpractice. It is not necessary to employ actors and camera crewto modify an animation video. Second, animation video may

From the Department of Anesthesia, Teikyo University School of Medicine,Tokyo, Japan.

Accepted for publication January 3, 2011.

Funding: This study was supported by a grant from Health and LaborSciences Research Grants, the Third-Term Comprehensive Control Researchfor Cancer, to Dr. Nakata from the Japanese Government Ministry of Health,Welfare, and Labor.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citationsappear in the printed text and are provided in the HTML and PDF versionsof this article on the journal’s Web site (www.anesthesia-analgesia.org).

Reprints: Akihito Kakinuma, MD, Department of Anesthesia, Teikyo Uni-versity School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605 Japan.E-mail: icg02177@nifty.com.

Address correspondence to Akihito Kakinuma, MD, Department of Anes-thesia, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku,Tokyo 173-8605 Japan. Address e-mail to icg02177@nifty.com.

Copyright © 2011 International Anesthesia Research SocietyDOI: 10.1213/ANE.0b013e31820f8c18

aKakinuma A, Sawa T, Komatsu T, Yuji K, Kami M, Nakata Y. Effects ofshort interactive animation video on preanesthetic anxiety, knowledge andinterview time. Anesth Analg 2009;108:S108

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be more acceptable to patients who do not want to viewrealistic medical interventions.3 Third, animation video canvisually highlight the important points better than can aphotographic video, and patients can easily understand thepoint of the video image. Fourth, our interactive video canserve as proof that patients understand the explanation ofanesthesia. It is impossible to know whether patients under-stand the explanation of anesthesia with a pamphlet orconventional video. We asked patients scheduled for cancersurgery to view this animation video in the ward the daybefore surgery. We hypothesized that this video would im-prove patient understanding of anesthesia, reduce anxiety,and shorten the interview time.

METHODSParticipantsApproval of the ethics committee of Teikyo University andwritten informed consent from the patients were obtained.The study was conducted as a prospective randomized,controlled trial from August 2008 to February 2009. Allpatients scheduled for cancer surgery (including diagnosticbiopsy) under general or combined general and epiduralanesthesia, who were admitted to the ward at least 1 daybefore surgery in Teikyo University Hospital, were consid-ered for enrollment in the trial. Patients were excluded if theywould require a third party to complete the consent process(patients younger than 20 years, patients who did not ad-equately understand Japanese, and those with mental impair-ment). Ambulatory surgical patients were also excluded.Patients were approached for enrollment in the trial before thepreanesthetic interview the day before surgery.

Study DesignAll patients who agreed to participate in the study were askedto complete the State–Trait Anxiety Inventory (STAI)7 beforethe preanesthetic interview. The STAI is a general tool toassess anxiety levels, and this questionnaire is designed toassess an individual’s momentary or situational anxiety. Itconsists of 20 statements, each with 4 answers, producing ascore between 20 and 80. A higher score reflects higheranxiety. We used the STAI in a well-established and validatedJapanese translation.8 Patients were also asked to complete aknowledge questionnaire before the interview conducted bythe anesthesiologist (Appendix 1, see Supplemental DigitalContent 1, http://links.lww.com/AA/A237). The knowledgequestionnaire was intended to evaluate the patients’ knowl-edge of the purpose, procedural details, and the potentialcomplications of anesthesia. The questions asked were ad-opted from similar studies.4,5,9,10 Patients were then randomlyassigned to the video group or the no-video group. Theallocation sequence was generated by a random number table.Patients in the video group were asked to watch the shortinteractive animation video in the ward. The video wasshown to the patient using a touch-screen laptop PC withmonitor and headphones. After brief instruction, the patientwas left alone with this video for at least 30 minutes. Allpatients were allowed to repeat any part of the video as manytimes as they wanted.

After the video session, the patients were visited by aboard-certified anesthesiologist who performed a preanes-thetic interview and risk assessment. Patients in the no-video

group were visited by a board-certified anesthesiologist whoperformed a routine preanesthetic interview and risk assess-ment as usual. The standard format of the interview consistsof confirmation of the surgery, medical history, medication,physical examination, explanation of anesthesia method, andcommon and patient-specific complications, as well as aquestion-and-answer session in the no-video group. In thevideo group, anesthesia method and common complicationswere explained on the animation video. The anesthesiologistconducted the rest of the interview described above. Thisvideo was operated on a touch-screen laptop PC with head-phones. An animation character playing the role of a femaleanesthesiologist explained some of the important aspects ofanesthetic procedures in plain Japanese language with afemale voice (Appendix 2, see Supplemental Digital Content2, http://links.lww.com/AA/A238). This video comprisedseveral brief sections. Each section lasted from 1 to 2 minutes.In the video, the animation character first discussed the role ofanesthesiologists during surgery, gave nil per os (NPO) in-structions, and then explained the rationale for the NPOinstructions, usual general or combined general and epiduralanesthesia procedures, and postoperative recovery. There wasa questionnaire at the end of every section to examine thepatients’ understanding of anesthesia. This was also intendedto serve as a legal document to prove that patients under-stood the explanation of anesthesia and gave informed con-sent (Appendix 3, see Supplemental Digital Content 3,http://links.lww.com/AA/A239). The summary of patients’answers is shown in Appendix 4 (see Supplemental DigitalContent 4, http://links.lww.com/AA/A240). Before the pre-anesthetic interview, anesthesiologists knew whether patientswatched the video, and whether they correctly answered thequestions. During the interview, the anesthesiologists couldexplain in detail what patients did not understand. Wemeasured the interview time. The interview time was definedas the time from the beginning of an anesthesiologist seeingthe patients in their rooms in the ward to when the anesthe-siologist left the room. The interview time was recorded bythe primary investigator (AK). On the day of surgery thepatients were asked again to complete the STAI form and aknowledge questionnaire in the ward before leaving for theoperating room (Fig. 1). We determined our sample sizes to belarge enough to detect a difference in interview time morethan 5 minutes with �80% possibility.11

AnalysisThe data were analyzed with Microsoft Excel 2007 (Microsoft,Redmond, WA). If not otherwise stated, mean � sd (95%confidence interval [CI]) is displayed. The data on the effectsof short interactive animation video were log-transformedand were analyzed with a generalized pivotal approach.12

Ninety-five percent confidence intervals of relative effective-ness were determined by a modified signed log-likelihoodratio approach.13 Nominal data were analyzed with �2 test. Pvalue �0.05 was considered significant.

RESULTSOf the 262 eligible patients, 217 patients consented to partici-pate in this study. Of these, 6 patients withdrew after thepreanesthetic interview and had to be excluded, because of

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the time constraints to complete the 14-point-scale question-naires on the day of surgery. There was no significant differ-ence in age, gender, education, ASA classification, types ofsurgery, and previous experience of anesthesia. There was nodifference in the baseline anxiety and knowledge between thegroups (Table 1). There was also no difference in anxietybetween the 2 groups. The interview time was 34.4% shorterin the video group (video group, 12.2 � 5.3 minutes vs.no-video group, 18.6 � 6.4 minutes; 95% CI for the percentagereduction in time: 32.7% to 44.3%). Knowledge of anesthesiaon the day of surgery was 11.6% better in the video group

(score, 12.5 � 1.4 vs. no-video group score, 11.2 � 1.7; 95% CIfor the percentage increase in knowledge, 8.5% to 13.9%)(Table 2).

DISCUSSIONOur interactive animation video significantly shortened theinterview time. In a preanesthetic interview, descriptions ofanesthetic procedures may be classified as generic, orspecifically directed according to the needs of an individualpatient. A generic explanation is identical for all surgicalpatients. It appeared that time was saved because

Figure 1. Overview of the study structure and timepoints of data collection. STAI � State–Trait AnxietyInventory.

Table 1. Demographic and Baseline DataVideo group(n � 106)

No-video group(n � 105) P value

Age (years) 60.1 � 13.7 (57.5–62.7) 60.0 � 13.2 (57.5–62.5) 0.99*Gender (M/F) 57/49 68/37 0.106*Education

Primary 17 12Secondary 48 54 0.526†Tertiary 41 39

ASA classificationI 43 48II 55 51 0.699†III 8 6

Type of surgeryGeneral surgery 65 56Urological surgery 16 31 0.09†Gynecological surgery 10 7Other surgery 15 11

Previous cancer diagnosis 19 26 0.21†Number of previous general anesthetics

0 57 671 36 28 0.699†2 11 83 2 2�3 0 0

Anxiety before interview 47.8 � 8.9 45.5 � 11.1 0.10*(STAI score) (46.1–49.5) (43.4–47.6)Knowledge before interview 10.3 � 1.6 10.2 � 2.1 0.59*(Maximum score 14) (10.0–10.6) (9.8–10.6)

Values are expressed as mean � SD (95% confidence interval). STAI � State–Trait Anxiety Inventory. P � 0.05 is considered statistically significant.* P values are determined by t test.† P values are determined by chi-square test.

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the patients demonstrated their knowledge through use ofthe interactive video, and these topics covered in the videodid not need to be reiterated by the anesthesiologist. Byoffering the information in advance, the preoperative inter-view became more effective and efficient. Shortening inter-view time while maintaining the same quality can result inmedical cost reduction.14 One previous study showed thatthe preanesthetic interview time of the video group waslonger than that of the no-video group. The authors ex-plained that the patients who watched the video becameaware of more issues related to anesthesia, and that thisawareness led to more detailed questions.3 We speculatethat the interactiveness of our video prevented this fromhappening. Our patients were allowed to repeat any part ofthe video in the study. The anesthesiologist had the oppor-tunity to review the patient’s responses to the questionnairebefore the interview, and restrict his or her explanations toareas that the patient did not understand. We have dem-onstrated that this more focused approach can make thepreanesthetic interview more time efficient. Various mediatools, including pamphlets and videotapes, have been usedin conjunction with the preanesthetic interview, and haveshown results suggesting better recall of information.10

In our study, knowledge improvement after the preanes-thetic interview was greater in the video group than in theno-video group, consistent with results from previous inves-tigations.3,4,6,10,15 The effect of information provided duringthe consent process on anxiety is controversial. There has beena belief that the provision of extra information, particularlyabout risks and complications, may exaggerate patients’ anxi-ety.16 There are some reports regarding relief of anxiety byproviding detailed information.17 Previous studies haveshown that there is no significant change in anxiety levelsafter additional written information is provided to the pa-tients.18–20 Luck et al. demonstrated that preoperative videoinformation was effective for reducing anxiety in patientsundergoing colonoscopy.15 However, the cause of anxietymight have been different between our study and that of Lucket al. Colonoscopy does not require general anesthesia,whereas our patients have to have both anesthesia andsurgery for cancer. Our patients might well worry about theirsurgery and cancer prognosis rather than anesthesia, and ouranimation video explains only anesthesia. Concerns aboutanesthesia might be a relatively small part of their anxiety,particularly for patients who are going to have major sur-gery.3,21,22 Our interactive animation video was not designedto reduce surgical anxiety.

There are several limitations in this study. The firstlimitation is failure to double-blind patients and anesthesi-ologists.3 However, our study was designed to mimic theway our interactive animation video is used in a realclinical setting. Therefore, our results are valid when ourvideo is actually used. The second limitation is the possi-bility of families’ help when patients answered questions,although patients were asked to do the test by themselves.The third limitation is the difference in interview style. Thisinteractive animation video explained only general anes-thesia. Anesthesiologists could save time if they spent moretime explaining anesthesia than performing patient preop-erative assessment. Our short interactive animation videohelps patients understand anesthesia and reduces anesthe-siologists’ interview time.

DISCLOSURESName: Akihito Kakinuma, MD.Contribution: Study design, conduct study, data analysis,manuscript preparation.Name: Hirokazu Nagatani, MD.Contribution: Manuscript preparation.Name: Hiroshi Otake, MD, MBA.Contribution: Manuscript preparation.Name: Ju Mizuno, MD, PhD.Contribution: Manuscript preparation.Name: Yoshinori Nakata, MD, MBA.Contribution: Study design, manuscript preparation.

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Table 2. Effects of Short Interactive Animation VideoVideo group(n � 106)

No-video group(n � 105)

Relativeeffectiveness P value

Interview time (minutes) 12.2 � 5.3 18.6 � 6.4 �34.4% �0.0001*(�44.3%–�32.7%)

Anxiety after interview 44.5 � 8.8 44.3 � 11.2 0.4% 0.64*(STAI score) (�6.8%–3.5%)Knowledge after interview 12.5 � 1.4 11.2 � 1.7 11.6% �0.0001*(Maximum score 14) (8.5%–13.9%)

Value are expressed as mean � SD (95% confidence interval). STAI � State–Trait Anxiety Inventory. P � 0.05 is considered statistically significant.* P values were determined by generalized pivotal approach for log-transformed data.

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