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Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Randomized trial of a patient education tool about leiomyoma Prerna R. Pandya* , Rebecka B. Docken, Nicole O. Sonn, Dara P. Matthew, Juliana Sung, Allison Tsambarlis, Paula White, Linda C. Yang Department of Obstetrics and Gynecology, Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL 60153, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 September 2019 Received in revised form 7 February 2020 Accepted 21 February 2020
Objective: Uterine leiomyomata are a frequent indication for women seeking gynecologic care [1]. The objective of our study was to assess whether patient knowledge about leiomyomata, anxiety, or satisfaction with counseling differed in patients who received multimedia counseling versus standard counseling. Methods: Women with leiomyomata who presented to the gynecology clinic at a single institution were randomized to standard counseling or multimedia counseling using the drawMD OB/GYN iPadTM application. Participants completed a pre-counseling questionnaire, received the designated method of counseling, and completed a post-counseling questionnaire. Outcomes of the study included assessment of patient knowledge, satisfaction, and anxiety. Results: Seventy-two participants were randomized. There was no significant difference in postcounseling anxiety between the groups (p = 0.86). For both groups, anxiety significantly improved after counseling. Both groups were satisfied with the counseling they received, however, there was no difference between groups. Participants in both groups significantly improved their knowledge about fibroids post-counseling. Conclusion: Counseling of patients with leiomyomata improves patient satisfaction and knowledge. The addition of a multimedia tool may or may not enhance patient counseling. Practice Implications: This is the first prospective, randomized controlled trial evaluating the impact of a multimedia tool on patient education and counseling for patients with leiomyomata. © 2020 Elsevier B.V. All rights reserved.
Keywords: Fibroids Multimedia Patient education Patient counseling Symptomatic uterine fibroids Uterine leiomyomata
1. Introduction Uterine leiomyomata are the most common benign neoplasms of the smooth muscle of the uterus, and symptoms related to uterine leiomyomata are a frequent indication for women seeking gynecologic evaluation and treatment.1 Leiomyomata can cause abnormal uterine bleeding, bulk symptoms of pelvic pressure or pain, and may have an impact on reproductive outcomes. The prevalence of leiomyomata among U.S. women is estimated to be 9.6 %, with the highest prevalence among African American women (18.5 %) and women 50–54 years of age (15.9 %) [1]. Leiomyomata can be managed expectantly, medically, or surgically. In the United States, approximately 30 % of hysterectomies for women age 18–44 are done for symptomatic uterine leiomyomata [2]. Patient education and counseling about disease pathology and management options are essential components of gynecologic
* Corresponding author at: Department of Obstetrics and Gynecology, Loyola University Medical Center, 2160 S 1st Avenue, Maywood, IL 60153, USA. E-mail address:
[email protected] (P.R. Pandya).
evaluation and care. Counseling relies on effective patientprovider communication, and tools to enhance communication could improve the patient experience. Various studies have evaluated multimedia tools for patient education or informed consent, but the role of multimedia tools in patient education and counseling patients with leiomyomata has not been well studied. Furthermore, patient satisfaction is an important quality measure and a metric for patient-centered care and favorable health outcomes. Alternatively, ineffective communication between physicians and patients is associated with an increased likelihood of patients pursuing litigious actions.3 Myers, et al. performed a randomized controlled trial using a web-based tool (iPadTM application) for patient counseling for women with symptomatic vaginal prolapse comparing standard counseling to counseling with iPadTM. Both methods of counseling were associated with increased patient satisfaction with understanding of their prolapse symptoms and decreased anxiety about their symptoms, with no difference between the two methods of counseling [4]. Heller, et al. demonstrated that utilizing an interactive digital education aid for patients planning to undergo breast reconstruction had a positive impact on patient satisfaction
https://doi.org/10.1016/j.pec.2020.02.031 0738-3991/© 2020 Elsevier B.V. All rights reserved.
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and knowledge and reduced patients’ mean level of anxiety preand post-operatively [5]. The aims of this study were to assess: 1) leiomyomata knowledge scores 2) satisfaction with counseling, and 3) anxiety about symptoms before and after counseling. We hypothesized that for patients with leiomyomata, counseling using a multimedia tool would improve patient satisfaction, increase understanding of symptoms and treatment options, and reduce anxiety about symptoms, when compared to standard counseling. 2. Methods We conducted a prospective, randomized, unblinded, controlled trial to assess patient knowledge of uterine leiomyomata, satisfaction with counseling and anxiety regarding fibroid symptoms in the standard counseling (SC) group compared to the multimedia counseling (MC) group. This study was conducted between June 2015 and October 2018 at Loyola University Medical Center after approval from the Loyola University Chicago Health
Sciences Division Institutional Review Board IRB Number 207033110714. Eligibility was assessed among new patients presenting to the gynecology clinic at Loyola University Medical Center. Inclusion criteria were non-pregnant, English-speaking women, age 18–60 years, presence of fibroids confirmed on imaging, and no confirmed or suspected malignancy. Once eligibility was assessed and informed consent was obtained, patients were randomized to receive either standard counseling or multimedia counseling. The drawMD OB/GYN iPadTM application was selected as the educational tool used for the multimedia counseling group. Randomization was achieved using a computer-generated simple randomization tool and assignments were placed in opaque envelopes. After randomization, participants were given a precounseling questionnaire, which included questions about demographic information. Participants also answered a Likert scale questionnaire about degree of anxiety [6], a single question about satisfaction with their current understanding of fibroid symptoms, and twelve knowledge questions about fibroids. The research
Fig. 1. CONSORT 2010 Flow Diagram.
Table 1 Participant demographics.
Mean Age (SD) Mean BMI (SD) Race/Ethnicity (%) Non-Hispanic White Non-Hispanic Black Hispanic Asian Other Education (%) High School Vocational or Technical Some College Bachelor’s Degree Master’s Degree Doctoral Degree Professional Degree Other Missing
Multimedia Counseling (n = 40)
Standard Counseling (n = 32)
Total (N = 72)
44.68 (6.81) 31.34 (8.10)
42.50 (5.54) 32.20 (8.64)
43.71 (6.33) 31.72 (8.30)
14 (35 %) 21 (53 %) 4 (10 %) 0 1 (2.5 %)
9 (28 %) 17 (53 %) 4 (13 %) 1 (3.1 %) 1 (3.1 %)
23 (32 %) 38 (53 %) 8 (11 %) 1 (1.4 %) 2 (2.8 %)
7 (18 %) 2 (5.0 %) 12 (30 %) 11 (28 %) 6 (15 %) 1 (2.5 %) 0 1 (2.5 %) 0
5 3 8 6 7 1 1 0 1
12 (17 %) 5 (6.9 %) 20 (28 %) 17 (24 %) 13 (18 %) 2 (2.8 %) 1 (1.4 %) 1 (1.4 %) 1 (1.4 %)
(16 %) (9.4 %) (25 %) (19 %) (22 %) (3.1 %) (3.1 %) (3.1 %)
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Table 2 Change in anxiety and satisfaction from pre-counseling to post-counseling by counseling type. Valid N
Anxiety (%) Not at all anxious A little anxious Moderately anxious Very anxious Extremely anxious Understanding (%) Very dissatisfied Dissatisfied Neutral Satisfied Extremely satisfied Counseling (%) Very dissatisfied Dissatisfied Neutral Satisfied Extremely satisfied Information (%) Very dissatisfied Dissatisfied Neutral Satisfied Extremely satisfied Impact of Multimedia Tool Easier No Impact
Multimedia Counseling (n = 40)
Standard Counseling (n = 32)
p
Pre-Test
Post-Test
Pre-Test
Post-Test
9 (23 %) 11 (28 %) 10 (26 %) 4 (10 %) 5 (13 %)
13 (33 %) 17 (44 %) 3 (7.7 %) 5 (13 %) 1 (2.6 %)
2 (6.7 %) 8 (27 %) 12 (40 %) 4 (13 %) 4 (13 %)
5 (17 %) 14 (47 %) 5 (17 %) 3 (10 %) 3 (10 %)
2 (5.0 %) 7 (18 %) 12 (30 %) 15 (38 %) 4 (10 %)
5 (13 %) 0 4 (10 %) 16 (40 %) 15 (38 %)
0 3 (10 %) 16 (53 %) 9 (30 %) 2 (6.7 %)
1 (3.3 %) 0 0 16 (53 %) 13 (43 %)
– – – – –
5 (13 %) 0 0 8 (20 %) 27 (68 %)
– – – – –
0 0 0 8 (27 %) 22 (73 %)
– – – – –
6 (15 %) 0 1 (2.6 %) 5 (13 %) 27 (69 %)
– – – – –
1 (3.2 %) 0 2 (6.5 %) 7 (23 %) 21 (68 %)
– –
35 (97 %) 1 (2.8 %)
– –
– –
69
.86
70
.37
70
.43
70
.86
–
36
Note: Valid N = The number of patient responses used to compute the significance value. P-values for anxiety and understanding reflect differences in the change in anxiety and in the change in understanding between MC and SC groups.
Table 3 Change in knowledge from pre-counseling to post-counseling for specific knowledge questions. Knowledge Questions
Can fibroids cause symptoms of abnormal bleeding? Can fibroids cause symptoms of abdominal pressure? Can fibroids cause infertility or other pregnancy problems? Are fibroid symptoms different before and after menopause? Is there anything you can do to prevent fibroids? Are there medical treatments for fibroids? Does the location of fibroids have an impact on symptoms? Are fibroids cancerous? Is it necessary to have surgery for fibroids? Can fibroids be removed surgically without removing the uterus? Do ovaries have to be removed in a hysterectomy? Does the cervix have to be removed in a hysterectomy?
Valid N
70 68 67 67 65 67 63 62 63 63 63 62
Multimedia Counseling (n = 40)
Standard Counseling (n = 32)
Pre
Post
Pre
Post
36 (90 %) 31 (79 %) 23 (61%) 13 (34 %) 15 (41 %) 26 (68 %) 19 (53 %) 18 (50 %) 21 (58 %) 25 (69 %) 21 (58 %) 14 (39 %)
37 39 28 26 21 34 32 21 29 32 26 20
28 (93 %) 28 (97 %) 19 (66%) 11 (38 %) 17 (61 %) 24 (83 %) 17 (63 %) 19 (73 %) 21 (78 %) 24 (89 %) 19 (70 %) 8 (31 %)
29 (97 %) 28 (97 %) 23 (79%) 18 (62 %) 17 (61 %) 25 (86 %) 26 (96 %) 24 (92 %) 24 (89 %) 24 (89 %) 20 (74 %) 16 (61 %)
(93 %) (100 %) (74%) (68 %) (57 %) (89 %) (89 %) (58 %) (81 %) (89 %) (72 %) (56 %)
p
.53 .98 .98 .27 .17 .18 .84 .27 .44 .055 .19 .52
Note: Valid N = The number of paired patient responses used to compute the significance value. P-values reflect differences in the change in the percent correct between MC and SC groups.
study team developed a non-validated self-administered 20-item pre-counseling questionnaire and 24-item post-counseling questionnaire to assess patients’ anxiety, satisfaction with counseling, and knowledge about fibroid symptoms and treatments. Relevant patient history was obtained, pertinent imaging and laboratory studies were reviewed, and physical exam was performed per standard clinic protocol for new patient visits. Counseling was then provided by the assigned method of counseling by both an OB/GYN resident physician and a single attending gynecologist. Counseling was incorporated into the new patient visit and was modified accordingly for each patient’s case based on each patient’s given pathology and appropriate options for management. Standard counseling was defined as the counseling routinely provided using verbal counseling alone, drawings and/or diagrams. Multimedia counseling was defined as routine counseling while also using the drawMD
OB/GYN iPadTM application. This application allows providers to show visual illustrations of pelvic anatomy, insert pathology using medical art overlays (e.g. fibroid), and annotate using line drawings and text. Majority of the visit time was spent in face to face counseling with the OB/GYN resident physician and/or attending gynecologist. Patients were encouraged to ask questions throughout the encounter. Finally, participants completed a postcounseling questionnaire, which again assessed degree of anxiety, satisfaction with their current understanding of fibroid symptoms, and twelve knowledge questions. Additionally, participants were asked how satisfied they were with the way the information was provided to them and, if randomized to the MC group, what impact the application had on their counseling. The primary outcome evaluated was the difference in patient satisfaction with counseling between the two counseling groups. Secondary outcomes included an assessment of whether the
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upon the degree of overlap of the distributions (assumed to be normal) for the treatment and control groups. We proposed that the effect of the iPad in patient counseling was such that 75 % of the scores in the control group would be lower than the mean of the treatment group. Using the Cohen scheme, this corresponded to a moderate effect size of 0.68. With this effect size, calculations indicated that a sample of thirty-five per group would provide 80 % power for a two-group analysis of covariance after accounting for differences in pretest scores, using a .05 alpha level. Statistical analysis was performed using the McNemar, Wilcoxon rank-sum, Fisher’s exact, and Student’s t-tests, where appropriate. Generalized estimating equations were used to test whether any change in knowledge from pre-counseling to postcounseling was dependent on the participant’s intervention assignment. 3. Results A total of 72 participants were randomized to multimedia counseling (n = 40) or standard counseling (n = 32) (Fig. 1). In some cases, participants did not complete the questionnaires in their entirety. For each questionnaire item, missing data secondary to unanswered questions or incomplete responses were not included in the analysis. The total number of participants included for each questionnaire item is listed as indicated in the respective tables as “valid n,” the number of completed responses used to compute the significance value for a given parameter. Baseline characteristics, including age, BMI, race and education did not differ between groups (Table 1). As demonstrated in Table 2, there was no significant difference in satisfaction with the assigned counseling method between those assigned to MC and those assigned to SC. Both groups were satisfied or extremely satisfied with the counseling they received (88 % for MC and 100 %
Fig. 2. Overall percent correct at pre-counseling and post-counseling by counseling type assignment.
application impacted patient knowledge about fibroids, patient anxiety regarding fibroid symptoms, and satisfaction with assigned method of counseling. With a moderate effect size of 0.68, a sample size of 70 total participants was calculated to provide 80 % power for a two-group analysis of covariance after accounting for differences in pretest scores, using an alpha of 0.05. The sample size needed for our study could not be easily calculated using previous research studies which analyzed differences in percentages, while our current study was designed to examine differences in scores. In response to this problem, we utilized a method for computing requisite sample size described by Cohen [6]. The method calculates an effect size based
Table 4 Change in emotion response from pre-counseling to post-counseling by counseling method. Valid N
Calm (%) Not at all Somewhat Moderately Very much Tense (%) Not at all Somewhat Moderately Very much Distress/Upset (%) Not at all Somewhat Moderately Very much Relaxed (%) Not at all Somewhat Moderately Very much Content (%) Not at all Somewhat Moderately Very much Worried (%) Not at all Somewhat Moderately Very much
Multimedia Counseling (n = 40)
Standard Counseling (n = 32)
Pre-Test
Post-Test
Pre-Test
Post-Test
6 (17 %) 9 (26 %) 6 (17 %) 14 (40 %)
3 (8.6 %) 9 (26 %) 8 (23 %) 15 (43 %)
3 (13 %) 10 (42 %) 4 (17 %) 7 (29 %)
2 (8.3 %) 5 (21 %) 5 (21 %) 12 (50 %)
18 (53 %) 5 (15 %) 5 (15 %) 6 (18 %)
21 (62 %) 8 (24 %) 4 (12 %) 1 (2.9 %)
9 (38 %) 11 (46 %) 3 (13 %) 1 (4.2 %)
11 (46 %) 8 (33 %) 5 (21 %) 0
26 (74 %) 6 (17 %) 1 (2.9 %) 2 (5.7 %)
29 (83 %) 4 (11 %) 1 (2.9 %) 1 (2.9 %)
17 (71 %) 5 (21 %) 2 (8.3 %) 0
19 (79 %) 3 (13 %) 2 (8.3 %) 0
6 (17 %) 9 (26 %) 12 (34 %) 8 (23 %)
5 (14 %) 11 (31 %) 8 (23 %) 11 (31 %)
5 (21 %) 11 (46 %) 4 (17 %) 4 (17 %)
1 (4.2 %) 8 (33 %) 10 (42 %) 5 (21 %)
3 (8.6 %) 11 (31 %) 15 (43 %) 6 (17 %)
5 (14 %) 11 (31 %) 8 (23 %) 11 (31 %)
2 (8.3 %) 10 (42 %) 8 (33 %) 4 (17 %)
1 (4.2 %) 7 (29 %) 12 (50 %) 4 (17 %)
9 (26 %) 14 (40 %) 6 (17 %) 6 (17 %)
12 (34 %) 13 (37 %) 7 (20 %) 3 (8.6 %)
9 (38 %) 10 (42 %) 3 (13 %) 2 (8.3 %)
11 (46 %) 8 (33 %) 2 (8.3 %) 3 (13 %)
59
p
.04
58
.55
59
.81
59
.08
59
.51
59
.76
Note: Valid N = The number of paired patient responses used to compute the significance value.
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for SC, p = 0.43), with only five participants in the MC group being very dissatisfied. Similarly, when comparing satisfaction with how the information was relayed, there was no significant difference between the two groups (p = 0.86). Additionally, there was no significant difference in anxiety change scores between those assigned to MC and those assigned to SC (p = 0.86). Patients’ anxiety significantly declined from pre-counseling to postcounseling for both the MC cohort (p = 0.001) as well as the SC cohort (p = 0.048). Of those randomized to MC, 97 % reported that the multimedia tool had a positive impact on the counseling they received. Results were similar for patients’ understanding of their fibroid symptoms. Both groups significantly improved their understanding of fibroid symptoms from pre-counseling to post-counseling for both the MC cohort (p = 0.01) and SC cohort (p < 0.001). However, there was no significant difference of participants’ understanding of fibroids between the two groups (p = 0.37). As demonstrated in Table 3, for each knowledge item, there was no significant difference in the change in the percent correct score between the MC cohort and the SC cohort (all p-values >.05). Within the MC group, significant improvement in the following specific knowledge items were found: medical treatments available for fibroids, fibroid location and impact on symptoms, necessity of having surgery for fibroids, fibroid removal without removing the uterus, fibroid symptoms after menopause, and symptom of abdominal pressure. Within the SC group, significant improvements were observed in the knowledge items pertaining to necessity of cervix removal in a hysterectomy, fibroid symptoms after menopause, and fibroid location and impact on symptoms. As demonstrated in Fig. 2, there was no significant difference in overall change-in-knowledge from pre-counseling to postcounseling between patients assigned to the MC cohort (Mdn D = 16.67 %, IQR: 0 %–37.50 %) and those assigned to the SC cohort (Mdn D = 8.33 %, IQR: 0 %–16.67 %; p = 0.21). Both groups significantly improved in knowledge from pre-counseling to postcounseling; there was a significant improvement in number of correct knowledge questions from pre- to post-counseling for both MC (p < 0.001) and SC (p < 0.001) groups. As demonstrated in Table 4, there was a higher change from pre- to post-counseling for the calm score in the SC cohort compared to those assigned to MC (p = 0.04). However, for all other anxiety measures, there were no significant differences in scores regarding feeling tense, upset, relaxed, content, or worried between the MC and SC groups. 4. Discussion and conclusion 4.1. Discussion Developing strategies to improve patient-provider communication in order to deliver optimal patient-centered care is an important aspect of health care delivery [3]. The goal of this study was to assess whether using a visual multimedia tool would enhance patient education and counseling for patients with uterine leiomyomata. The drawMD OB/GYN iPadTM application was selected as the multimedial tool for this study because it is a free downloadable application, requires no subscription and is user-friendly with the capability of personalizing visual aides to explain medical conditions, anatomy and procedures to patients. Weaknesses of the study include the lack of generalizability given that it was conducted at a single institution. Additionally, while multiple different resident physicians conducted counseling sessions over the course of the study period, a single attending physician provider participated in the counseling sessions. Providers were instructed to provide their standard method of counseling or use the drawMD OB/GYN iPadTM application at their
5
discretion depending on the participant’s counseling group assignment. The specific method of use of the application was not standardized and was at the discretion of the provider. While this could be seen as a weakness, it more accurately reflects how counseling is conducted in a clinical setting. Another limitation of the study is that we did not document the amount of time spent counseling. Specifically, if the MC group was able to require less time counseling and achieve similar results in satisafaction, knowledge and anxiety, then the use of a multimedial tool could be presented as a way of improving office efficiency. Furthermore, validated tools for assessing patient knowledge and anxiety specific to fibroids were not available, but the use of a Likert scale to assess anxiety is currently supported in the literature [8]. As validated tools to assess patient knowledge about fibroids are not available, our research study team developed a self-administered questionnaire to assess patients’ knowledge about fibroid symptoms and treatments. 4.2. Conclusion This randomized, unblinded, controlled trial demonstrated no significant difference between counseling methods with regards to patient satisfaction with counseling, improvement of knowledge about fibroids, or anxiety regarding fibroid symptoms. Strengths of the study include the randomized study design, which minimizes selection bias and confounding. Though our study showed no differences between the two groups, our results did show that regardless of which method of counseling a patient was assigned to, counseling was overall beneficial to the patient. Patients indicated increased satisfaction with counseling, improvement in knowledge about fibroids, and decreased anxiety related to fibroid symptoms after receiving any type of counseling compared to prior to counseling. Ghant, et al. reported that most women with symptomatic fibroids experience a significant psychosocial impact, including, but not limited to anxiety [7]. Our study highlights the positive impact of counseling, regardless of type, in reducing anxiety in women with fibroids, which is an essential aspect of patient-centered care. 4.3. Practice implications There have been varied results in the literature about the impact of multimedia tools for educating patients [4,5,9]. The findings of this study highlight the importance of spending time counseling and educating patients. Regardless of the method of counseling, counseling itself is important to improve patient satisfaction and knowledge and reduce anxiety. The addition of multimedia tools may or may not enhance patient counseling. Future research should focus on developing useful tools to enhance patient-provider communication and patient education with a focus on effective exchange of information and collaborative decision-making. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Prerna R. Pandya: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing - original draft, Writing - review & editing, Visualization, Project administration. Rebecka B. Docken: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing. Nicole O. Sonn: Conceptualization, Methodology, Investigation,
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Resources, Writing - review & editing. Dara P. Matthew: Conceptualization, Methodology, Investigation, Resources, Writing - review & editing. Juliana Sung: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing. Allison Tsambarlis: Conceptualization, Methodology, Investigation, Resources, Writing - review & editing. Paula White: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing review & editing, Supervision. Linda C. Yang: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing - original draft, Writing review & editing. Declaration of Competing Interest Dara P. Matthew is a shareholder in GU Logic, Inc. Linda C. Yang has ownership interest in KLAAS, LLC. All other authors report no conflicts of interest. References [1] O. Yu, D. Scholes, R. Schulze-Rath, J. Grafton, K. Hansen, S.D. Reed, A US population-based study of uterine fibroid diagnosis incidence, trends, and prevalence: 2005 through 2014, Am. J. Obstet. Gynecol. 219 (6) (2018) 591, doi: http://dx.doi.org/10.1016/j.ajog.2018.09.039 e8.
[2] L. Wise, S. Laughlin-Tommaso, Epidemiology of uterine fibroids: from menarche to menopause, Clin. Obstet. Gynecol. 59 (1) (2016) 2–24, doi:http://dx.doi.org/ 10.1097/GRF.0000000000000164. https://www.ncbi.nlm.nih.gov/pubmed/ 26744813. [3] Wendy Levinson, Cara S. Lesser, Ronald M. Epstein, Developing physician communication skills for patient-centered care, Health Aff. 29 (7) (2010) 1310. https://search.proquest.com/docview/651809569. [4] E. Myers, B. Robinson, E. Geller, et al., Randomized trial of a web-based tool for prolapse: impact on patient understanding and provider counseling, Int. Urogynecol. J. 25 (8) (2014) 1127–1132, doi:http://dx.doi.org/10.1007/s00192014-2364-3. https://search.proquest.com/docview/1545965267. [5] L. Heller, P.A. Parker, A. Youssef, M.J. Miller, Interactive digital education aid in breast reconstruction, Plast. Reconstr. Surg. 122 (3) (2008) 717–724, doi:http:// dx.doi.org/10.1097/PRS.0b013e318180ed06. https://www.ncbi.nlm.nih.gov/ pubmed/18766034. [6] J. Cohen, Statistical Power Analysis for the Behavioral Sciences, Lawrence Erlbaum Associates, New Jersey, 1988. [7] M.S. Ghant, K.S. Sengoba, H. Recht, K.A. Cameron, K.A. Lawson, E.E. Marsh, Beyond the physical: a qualitative assessment of the burden of symptomatic uterine fibroids on women’s emotional and psychosocial health, J. Psychosom. Res. 78 (5) (2015) 499–503. [8] Heather M. Davey, Alexandra L. Barratt, Phyllis N. Butow, Jonathan J. Deeks, A one-item question with a likert or visual analog scale adequately measured current anxiety, J. Clin. Epidemiol. 60 (4) (2007) 356–360, doi:http://dx.doi.org/ 10.1016/j.jclinepi.2006.07.015. https://www.clinicalkey.es/playcontent/1-s2.0S0895435606003878. [9] E. Beranova, C. Sykes, A systematic review of computer-based softwares for educating patients with coronary heart disease, Patient Educ. Couns. 66 (1) (2007) 21–28, doi:http://dx.doi.org/10.1016/j.pec.2006.09.006. http://www. sciencedirect.com/science/article/pii/S0738399106003223.
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