Patient Education and Counseling 85 (2011) e65–e68

Patient perception, preference and participation

Utilization and impact of pre-office visit video health maintenance education

Kenneth Goodman a,*, Amy Nowacki b, Jianni Wu a, John Hickner a

a Department of Family Medicine, Cleveland Clinic, USAb Quantitative Health Sciences, Cleveland Clinic, USA

A R T I C L E I N F O

Article history:

Received 12 August 2010

Received in revised form 19 January 2011

Accepted 14 February 2011

Keywords:

Video patient education

Health maintenance

Patient activation

Patients asking questions

A B S T R A C T

Objective: To determine what percent of patients would prepare for their periodic physical examination

by viewing video education about recommended health maintenance procedures and the impact of the

video on those who viewed it.

Methods: 274 patients were invited via US mail and a reminder phone call to view the video. A patient

survey immediately followed the visit.

Results: 167 surveys were completed and 73 (44%) indicated they had viewed the video. Seventy one

percent who viewed the video reported it prompted them to ask at least one health maintenance

question and 25% were prompted to ask 4 or more questions. Those who viewed the video rated being

more prepared to discuss and keep up to date with health maintenance procedures.

Conclusions: Nearly half of patients were willing to view an educational video from home prior to their

office visits and most were prompted to ask specific health maintenance questions. Further research is

needed to confirm these preliminary findings and quantify the value of this educational video in

activating patients regarding receiving recommended health maintenance procedures.

Practice implications: Video education from home may active patients to improve their involvement in

general health maintenance during their annual examination.

� 2011 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

Patients who are activated in their health care possess theknowledge, skills and willingness for self management of theirchronic health conditions and general health [1,2]. An activatedand engaged patient is critical for better patient self-managementand improved health outcomes [1,2].

Due to patients routinely obtaining medical informationthrough the internet, many possess both preferences andknowledge concerning health care prior to seeing their doctor[3]. The advantage of a patient becoming more knowledgeablebefore their periodic health evaluation might come from anopportunity to reflect and consider preventive testing andtreatment options prior to their arrival. Instead of the physiciantaking time to both identify and explain available options, a higherlevel of baseline knowledge may free up time to reinforceappropriate decisions and negotiate possible erroneous beliefs.

Video patient education has been shown to be an effective toolfor increasing patient knowledge, decreasing anxiety, improvingcoping skills and improving self-care behaviors, especially for

* Corresponding author at: Beachwood Family Health and Surgery Center, 26900

Cedar Road, Suite 22N, Beachwood, OH 44122, USA. Tel.: +1 216 839 3918;

fax: +1 216 839 910.

E-mail address: goodmak@ccf.org (K. Goodman).

0738-3991/$ – see front matter � 2011 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.pec.2011.02.012

those with low health literacy [4]. Previous studies of video patienteducation have assessed videos which focus on a specific healthcondition, a single preventive test, discharge instructions orinformed consent [5–9]. The effectiveness of video education thatprovides an overview of multiple health maintenance topics hasnot been studied.

The purpose of this study was to evaluate if viewing videopatient education on general health maintenance procedures priorto a general physical examination would activate patients tobecome more involved in their office visit and overall preventivecare. This activation might be manifest by improved knowledge ofand comfort with discussing health maintenance screening tests,improved intention to keep up to date with screening tests andoverall visit satisfaction. Patients might be prompted to ask theirdoctor questions related to health maintenance procedures. Thequestions we sought to answer in this study were: (1) wouldpatients be willing to prepare for their periodic health evaluationby viewing a health maintenance video on the internet prior totheir visit? (2) Would viewing the video have a positive impact on apatient’s interest or activation toward health maintenance?

2. Methods

The electronic schedules of 23 consenting providers (13 FamilyPractice, 10 Internal Medicine) from five Cleveland ClinicCommunity Family Health Centers located in the surrounding

K. Goodman et al. / Patient Education and Counseling 85 (2011) e65–e68e66

suburbs of Cleveland, Ohio were searched to identify 250–300participants. Patients were 35–75 years of age who spoke Englishas their primary language and who were scheduled to have aperiodic health evaluation from July 13, 2009 to July 24, 2009.Family Health Centers had from 1 to 4 participating providers withall serving very similar patient populations (Table 1). Approxi-mately 3 weeks prior to their appointments, 274 patients wereinvited via US mail to participate in the study. The study invitationletter, signed by the principle investigator, asked patients toparticipate in the study by viewing an educational video overinternet prior to their appointment. A study coordinator placed onereminder phone call requesting they view the video prior to theirappointment. A voice mail reminder was utilized when necessary.

Video education was written and produced by the principleinvestigator, a Family Physician at Cleveland Clinic, in collabora-tion with sub specialists. The video (�9 min men, �12 minwomen) reviews basic gender specific information on healthmaintenance procedures generally considered to be part of routinehealthcare (PAP testing, colon cancer screening, adult immuniza-tions, cholesterol, glucose testing, prostate cancer screening, bonedensity testing, and mammograms). Because the timing ofrecommendations for health screening tests often change, thevideo does not discuss a specific age a test is recommended. Rather,it starts by explaining that ‘‘. . .this video will discuss healthmaintenance procedures that are recommended for you now, orsometime in the future.’’ Topics not generally indicated for patientsunder 50 (colonoscopy, bone density testing) were included forparticipants of all ages in an effort to promote general awareness.

Content of the video focuses on three primary areas for eachrecommended procedure: (1) What is the test? (2) Why is it part ofroutine testing? (3) What is the primary barrier that may prevent apatient from getting the test? A small pilot study (n = 47,unpublished data) was done one year prior to this study toevaluate the video for knowledge recall immediately after viewingit and 2 weeks later. Recall in men was statistically significant witha large effect size while women’s baseline higher knowledge mayhave created a ceiling effect.

After completion of their physical exam, patients were askedby the medical assistant or physician to complete a surveybefore leaving the office. The survey tool had been tested ona small pilot group for face validity prior to the study(unpublished data). Internal consistency of the survey will beexplored in the planned follow-up study where participantscomplete the survey and their physician confirms whether ornot and which questions were asked. The entire survey may beviewed online at www.CCFcme.org/vrs.

Table 1Comparison demographics.

Viewed the

video (n = 73)

Did not view

the video (n = 94)

Age (years)a 54 (36–75) 55 (35–75)

Male 34 (25) 36 (34)

Caucasian 93 (68) 80 (75)

College graduate

or higher

64 (47) 41 (39)

Married 82 (60) 75 (71)

Internet usageb

Very regularly/

regularly

39 (28) 35 (33)

Occasionally 46 (34) 44 (41)

Never/almost

never

15 (11) 21 (20)

Data are % (n) unless otherwise indicated.a Mean (minimum � maximum).b For viewing health related information.

In addition to basic demographics and overall visit satisfaction,the survey asked participants to rate from 1 (least) to 5 (most) theirfeelings about four aspects of the health maintenance visit: (1)How prepared did you feel to discuss health maintenanceprocedures? (2) How comfortable did you feel discussing healthmaintenance procedures? (3) How knowledgeable did you feelabout health maintenance procedures? (4) How likely you are tokeep up to date with health maintenance procedures? Participantswho indicated they viewed the video were asked to check if it hadprompted them to ask their doctor questions about specific healthmaintenance tests while those who did not view the video wereasked to check reasons why.

For this demonstration study, all presented data are descriptive.Categorical data are reported as counts and percents. Continuousdata are reported as mean and range. All statistical analyses wereperformed using JMP version 8 (SAS Institute Inc., Cary, NC).

The study was approved by the Institutional Review Board ofCleveland Clinic.

3. Results

Of the 274 patients who were sent letters of invitation, 167(61%) arrived for their appointment and agreed to take the survey.Each provider had between 4 and 25 (average 11) patients whoarrived and successfully filled out the survey. The most commonreasons a survey was not completed was the rescheduling of anappointment by the provider and the invitation letter not reachingthe patient (Table 2). Survey participants were on average age 55,65% female, 86% Caucasian and 78% married. Fifty-one percentreported they had received a college degree or higher (Table 1).

Seventy-three (44%) of those who completed a surveyresponded that they had viewed the video. The most commonreasons listed for not viewing the video were forgetting to watch it,not having the time to view it, and preferring their information inwritten format (Fig. 1). Those who viewed the video tended to bemore highly educated and married (Table 1).

Fifty-one (71%) of those who viewed the video responded that ithad prompted them to ask at least one health maintenancequestion and 18 (25%) to ask 4 or more questions. Althoughpatients asked questions in all areas of health maintenance, themajority were related to prostate cancer, general health mainte-nance and cholesterol testing (Table 3).

Table 4 shows a breakdown of responses to five surveyquestions comparing those who did and did not view the video.While none of the results reached statistical significance, therewere some trends observed in ways we might expect. Those whoviewed the video reported being more prepared to discuss healthmaintenance procedures (85% rated a 5) compared to those whodid not view the video (80% rated a 5). Those who viewed the videoreported being very knowledgeable about health maintenanceprocedures (rating of 4, 48% and rating of 5, 47%) whereas those

Table 2Why initial study invitees did not take the survey.

274 invitation letters sent

Appointment rescheduled by provider 37 (14%)

Letters returned to sender 24 (9%)

Patient no show for their appointment 14 (5%)

Patient forgot to fill out survey 13 (5%)

Survey only partially completed 11 (4%)

Appointment canceled by patient 8 (3%)

Survey declined by patient 6 (2%)

Staff forgot to pass out the survey 5 (2%)

Patient unable to complete the survey 2 (1%)

Patient not English speaking 1 (0.5%)

Fig. 1. Why study participants indicated they did NOT view the video (n = 94).

Table 3Participants were asked: ‘‘Did watching the video prompt you to ask your doctor

about any of the following: mamograms, bone density testing, adult immuniza-

tions, glucose testing, prostate cancer, cholesterol testing, colon cancer screening,

pap testing, general health maintenance.

Total

(n = 73)

Male

(n = 25)

Female

(n = 48)

Prompted to ask at least 1 question 52 (71%) 21 (84%) 31 (65%)

Prompted to ask at least 4 questions 18 (25%) 5 (20%) 13 (27%)

Specific questions asked regarding:

Mammograms 12 (25%a) – 12 (25%)

Bone density testing 16 (22%) 3 (12%) 13 (27%)

Adult immunizations (shots) 18 (25%) 5 (20%) 13 (27%)

Glucose (blood sugar) testing 17 (23%) 7 (28%) 10 (21%)

Prostate cancer testing 11 (44%a) 11 (44%) –

Cholesterol testing 20 (27%) 8 (32%) 12 (25%)

Colon cancer testing 15 (21%) 8 (32%) 7 (15%)

PAP testing 10 (21%a) – 10 (21%)

General health maintenance 35 (48%) 13 (52%) 22 (46%)

a Denominator adjusted to represent appropriate gender.

K. Goodman et al. / Patient Education and Counseling 85 (2011) e65–e68 e67

who did not view the video tended to report either low knowledge(rating of �3, 11%) or high knowledge (rating of 5, 56%). Those whoviewed the video reported being more likely to keep up-to-datewith health maintenance procedures (99% rated a 4 or 5) comparedto those who did not view the video (88% rated a 4 or 5). Contrary toour expectations, those who did not view the video reported beingmore comfortable discussing health maintenance procedures (92%rated a 5) compared to those who did view the video (82% rated a5). There was no difference in overall patient visit satisfaction.

4. Discussion and conclusions

4.1. Discussion

The benefits of patients asking questions during their office visitinclude increased involvement, improved satisfaction, and im-proved patient- provider communication [10–12]. Patients whoarrive prepared to initiate discussion about their health can greatlyfacilitate the conversation and inevitable negotiation regardingscheduling important screening tests. This study found that amajority (71%) of those who viewed this video about healthmaintenance indicated it prompted them to ask their provider

Table 4Regarding their office visit, patients rated the following: (1 = least, 5 = most or greatest

Count (column %) Prepared to discuss

HMP

Comfortable discussing

HMP

Kn

HM

V NV V NV V

�3 0 (0) 3 (3.3) 1 (1.4) 1 (1.1) 4

4 11 (15.1) 15 (16.3) 12 (16.4) 6 (6.5) 35

5 62 (84.9) 74 (80.4) 60 (82.2) 85 (92.4) 34

HMP: health maintenance procedures; V: viewed video; NV: did not view video.

questions pertaining to one or more health maintenance topics and25% were prompted to ask four or more questions. Comit et al.demonstrated similar results to ours using disease specific healthvideos. In that study, 67% (n = 67) were prompted to ask relatedhealth questions after viewing the videos [13].

While viewing the video did prompt patients to ask questions, apatient’s interest in knowledge may not necessarily translate to aninterest in shared decision making [13,14]. According to studies ofpatient–physician relationships, although patients typically ex-press a high degree of interest in learning about their illnesses andtreatment, their preference for actual participation in treatmentdecision-making is highly variable [15,16]. Therefore, furtherstudies are needed to see if a patient’s asking questions mightpositively affect their rate of healthy maintenance testing orimprove their patient activation, which can be measured reliableusing Hibbard’s method [17].

Although the video does not advise when to get each healthmaintenance procedure, many patients do have a general idea ofthe age it is commonly recommended. As a result, it is possible thatsome were not prompted to ask questions because they felt thetopic to be inappropriate for their age. This is an area we plan toexplore in a follow-up study with a larger sample size.

We were somewhat surprised that those who did not view thevideo felt more comfortable discussing health maintenance thanthose who did not (Table 4). One explanation for this might be thatthose who viewed the video obtained enough knowledge to feel onlypartially informed, and therefore less comfortable, while those whodid not view the video were less concerned about the discussion.

There are several limitations to this study. First, it was not arandomized trial, so we cannot be certain that any observeddifferences such as feeling prepared to discuss health maintenance,intent to keep up to date or feeling more knowledgeable abouthealth maintenance were related to viewing the video. An obviousnext step in evaluating the value of pre-visit videos for healthmaintenance office visits is to perform a randomized trial. Second,there was participation bias, as 45% of the 247 invitees did not fillout a survey due to ‘‘patient factors’’ (canceled appointment, forgotto fill out survey, incomplete survey, declined, no-show forappointment) (Table 2). Nonetheless, most who showed up forthe office visit completed a survey, and many who did view thevideo reported it prompted them to ask the questions.

).

owledgeable about

P

Likely to keep

up-to-date with HMP

Overall visit

satisfaction

NV V NV V NV

(5.5) 10 (11.0) 1 (1.4) 11 (12.2) 1 (1.4) 0 (0)

(47.9) 30 (33.0) 17 (23.3) 18 (20.0) 7 (9.6) 10 (11.0)

(46.6) 51 (56.0) 55 (75.3) 61 (67.8) 65 (89.0) 81 (89.0)

K. Goodman et al. / Patient Education and Counseling 85 (2011) e65–e68e68

As previously mentioned, survey questions had been testedfor face validity only. Our study lacked diversity in thatparticipants were comprised of primarily well educatedCaucasians. Finally, we measured viewing of the video andbeing prompted to ask health maintenance questions by selfreport. In our next study we will electronically measure videoviewing and we will audio tape patient encounters in a largerrandomized trial.

4.2. Conclusions

This feasibility study demonstrates that many patients arewilling to prepare for their physical examination by viewing aneducation video from home about recommended healthmaintenance procedures. Most participants who viewed thevideo were prompted to ask specific health maintenancequestions, suggesting an improved activation or engagementin their health care. There is evidence that those who viewed thevideo felt more prepared to discuss health maintenance andshowed a stronger intent to keep up to date with healthmaintenance. A randomized trial that does not rely on self reportis needed to confirm these preliminary findings and quantifypotential changes in patient activation utilizing pre and postpatient activation measurement.

4.3. Practice implications

Use of this pre-office visit health maintenance education videocould be reproduced in clinical practice using a reminder postcardand phone call. Allowing patients to review and consider optionsfor health maintenance prior to their visit might enhance theirinvolvement and responsibility in their general health mainte-nance.

I confirm all patient/personal identifiers have been removedor disguised so the patient/person(s) described are notidentifiable and cannot be identified through the details ofthe story.

Conflict of interest

None.

Acknowledgement

Robert and William Risman philanthropic fund. Kurt Stange,MD, PhD and Carl Tyler Jr, MD for guidance in study design.

References

[1] Remmers C, Judith Hibbard J, Mosen DM, Wagenfield M, Hoye RE, Jones C. Ispatient activation associated with future health outcomes and healthcare utili-zation among patients with diabetes? J Ambul Care Manage 2009;32:320–7.

[2] Hibbard J, Stockard J, Mahoney E, Tusler M. Development of the patientactivation method (PAM) conceptualizing and measuring activation inpatients and consumers HSR 2004;39:1005–26.

[3] Eiser AR, Gerber BS. The patient–physician relationship in the internet age:future prospects and the research agenda. J Med Internet Res 2001;3:E15.

[4] Krouse HJ. Efficacy of video education for patients and caregivers. ORL HeadNeck Nurs 2003;21:15–20.

[5] Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG. Involvingpatients in clinical decisions impact of an interactive video program on useof back surgery. Med Care 2000;38:959–69.

[6] Krause HJ. Video modelling to educate patients. J Adv Nurs 2001;33:748–57.[7] Steinberg TG, Diercks MJ, Millspaugh J. An evaluation of the effectiveness of a

videotape for discharge teashing of organ transplant recipients. J Transp Coord1996;6:59–63.

[8] Werner L, Klausner KD, Rietmeijer CA, Malotte K, O’Donnell L, Margolis AD,et al. Effect of a brief video intervention on incident infection among patientsattending sexually transmitted disease clinics. PLoS Med 2008;5:e135.

[9] Partin MR, Nelson D, Radosevich D, Nuget S, Flood BR, Dillon N, et al. Random-ized trial examining the effect of two prostate cancer screening educationalinterventions on patient knowledge, preferences, and behaviors. J Gen InternMed 2004;19:835–42.

[10] US Department of Health and Human Services. Be Prepared for MedicalAppointments Build Your Question List. AHRQ. Available at: http://www.ahrq.gov/qual/beprepared.htm. Accessed February 11; 2009.

[11] US Department of Health and Human Services. Ask Me. AHRQ. Available at:http://www.npsf.org/askme3/index.php. Accessed November 11; 2010.

[12] Galliher JM, Post DM, Weiss BD, Dickinson LM, Manning BK, Staton EW, et al.Patient’s question-asking behavior during primary care visits; a report fromthe AAFP National Research Network. Ann Fam Med 2010;8:151–9.

[13] Comite F, Gallagher TC, Villagra V, Koop CE. Patient eduction as a medicalintervention. HMP Pract 1998;12:17–23.

[14] Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informeddecision making in outpatient practice time to get back to basics. J Amer MedAssoc 1999;282:2313–20.

[15] Hibbard JH, Mahoney ER, Stock R. Do increases in patient activation result inimproved self-management behaviors? HealthRes EducTrust 2006;42:1443–63.

[16] Hibbard JS, Mahoney ER, Stock R, Tusler M. Self-management and health careutilization. Health Serv Res 2007;1443–63.

[17] Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patientactivation measure (PAM): conceptualizing and measuring activation inpatients and consumers. Health Serv Res 2004;39:1005–26.