This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Patients with orthopedic conditions frequently use the internet to find health information. Patient education that is distributed online may form an easily accessible, time- and cost-effective alternative to education delivered through traditional channels such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of Web-based educational interventions exists.
The objective of this systematic review was to examine the effects of Web-based patient education interventions for adult orthopedic patients and to compare its effectiveness with generic health information websites and traditional forms of patient education.
CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus, and Web of Science were searched covering the period from 1995 to 2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the internet to the adult orthopedic population and assessed its effects in a controlled or observational trial.
A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after Web-based patient education. Seven trials reported increased satisfaction and good evaluations of Web-based patient education. No compelling evidence exists for an effect of Web-based patient education on anxiety, health attitudes and behavior, or clinical outcomes.
Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopedic patient population as most trials included considerably younger, higher-educated, and internet-savvy participants only.
Patient education is a valuable part of care that enables patients to be informed, active participants in their own treatment [
Patients themselves are positive about using the internet to find health information. They perceive online health information to produce health benefits and social benefits (eg, improved self-care behavior and better social support) in a manner that is easily accessible, cost-effective, and time-effective [
This review follows the definition of Roter and colleagues [
When evaluating Web-based patient education, it is inevitable to compare its effectiveness with that of traditional patient education. Therefore, the first aim of this review was to compare the effectiveness of Web-based patient education with the more traditional methods for patient education, such as face-to-face teachings or the use of print materials. To make an accurate comparison between the two, we will provide a brief overview of the effectiveness of traditional patient education as identified in previous systematic reviews below.
In orthopedic practice, positive effects following traditional patient education include increased knowledge regarding surgical procedures and the informed consent process, improved self-management skills, and reduced length of stay [
As outlined earlier in this introduction, educational interventions are no longer the sole source of knowledge for patients, as an abundance of health information is also freely available on the internet. When patients make use of generic health information while included in the experimental arm of a Web-based patient education intervention trial, online health information forms a potential strong co-intervention [
Health information websites are often broader in scope than educational interventions, as they typically target the general population as well as patients, whereas patient education targets patients or other members of the health care system only [
Concluding, promising results of Web-based patient education interventions have been reported, but a systematic review of Web-based patient education specifically for orthopedic practice has not yet been carried out. The effects of Web-based patient education can be evaluated in itself but should also be compared with other interventions currently in place: (1) to traditional patient education interventions that are theory-based or professionally facilitated but are provided through different channels (such as verbally, written, or by using multimedia) and (2) to publicly accessible, generic health information websites that share the same channel of information provision (the internet) but are generally not theory-based or professionally facilitated. The overall aim of this systematic review was to tackle these comparisons by examining the effects of Web-based patient education interventions on patients with orthopedic conditions as reported in controlled and observational trials in comparison with traditional patient education and health information websites. The questions that guided us in examining the comparative effectiveness were as follows: (1) “what are the effects of Web-based patient education on adult patients with orthopedic conditions?” and (2) “what are the effects of Web-based patient education in comparison with the effects of traditional patient education and generic health information websites?”
This systematic review has been written according to the requirements of the Preferred Reporting Items for Systematic Review and Meta-Analyses statement [
We included peer-reviewed, controlled, and observational trials reported in English or Dutch that self-defined as studying the effects of patient education interventions delivered via an online environment, including mobile devices, websites, and online systems, to adult people with any orthopedic illness or condition and currently receiving treatment for such conditions. Following our definition of educational interventions, we excluded behavioral or affective interventions. These may include educational components but differ from educational interventions as they specifically target behavioral patterns or appeal to feelings or social relationships to change patients’ outcomes [
Studies were initially identified by searching the electronic databases CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science from September 1, 2015 to November 30, 2015. As an example, the search strategy for the PubMed database can be found in
The first author assessed the identified studies for eligibility by title and abstract. The predefined selection criteria were applied to full-text reports of potentially eligible studies primarily by the first author in discussion with two review authors (MM and HdR) until consensus was reached. A third review author (BSG) was available for arbitration, but this was not required.
A structured data extraction sheet was employed to extract data from included studies. The data extracted included (1) Study characteristics (ie, author, year of publication, design, population, and timing of outcome measures); (2) Intervention characteristics (ie, content and duration of intervention and control intervention, total sample size, and sample sizes in separate conditions); (3) Patient characteristics (ie, sociodemographic variables, health status, and experience with internet); and (4) outcomes (ie, type of outcome measure, instrument, and effect). For each study, the effect of the intervention was coded as (1) significant result (positive + or negative −), (2) nonsignificant result (=); or (3) not reported (×).
To provide a structured overview of the components in each intervention, we employed Barak and colleagues’ [
(internet OR “world wide web” OR online OR web-based OR “computer assisted” OR e-health OR network OR “web services”) AND (“patient education” OR “patient education as topic” [MeSH Terms] OR “consumer health informati*” OR “medical education” OR “health education” OR “health knowledge, attitudes, practice”[MeSH Terms]) AND (orthopedic* OR orthopaedic* OR “joint replacement” or “arthroplasty” OR “hip” OR “knee”) AND (Adult OR Aged) AND (Effect OR efficacy OR performance OR result OR outcome)
To appraise the risk of bias in included studies, data regarding reporting, external validity, internal validity, and statistical power were extracted independently by two review authors (TD and BSG) using a modified version of Downs and Black tool for assessment of methodological quality [
We examined the effectiveness of Web-based patient education interventions by describing and comparing the characteristics and results of the included studies, as summarized in the structured data extraction sheet (
The search identified 1032 eligible studies of which 10 trials, reported in 14 papers, met the inclusion criteria and were included in the review (
Seven of the 10 trials employed a randomized controlled design, two an observational design, and one a quasi-experimental design. Four trials assessed the effect of Web-based patient education in comparison with traditional patient education channels, including face-to-face education with a nurse or physician [
Most of the studies provided Web-based patient education to patients undergoing surgical treatment, including total knee arthroplasty [
Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow diagram presenting identification and selection of articles for the systematic review of effectiveness of Web-based patient education in orthopedics.
Two studies provided Web-based patient education to patients with chronic conditions, including: rheumatoid arthritis [
The intervention characteristics of all included studies are described in
Program content was specific to each intervention. Most interventions offered practical information about the orthopedic condition or treatment, such as the procedures planned for the day of surgery or instructions for postoperative monitoring [
Half of the interventions conveyed content in a moderate to highly dynamic manner, meaning that they used three or more multimedia formats such as text, pictures, videos, animations, or audio [
While half of the interventions could be considered dynamic in terms of multimedia use, only one provided highly dynamic activities (meaning, more than three interactive online activities were offered) [
Most websites offered some human support or feedback as part of the intervention [
In terms of duration and frequency of website usage, we observed considerable variation. This ranged from single 20-min visits [
The methodological quality of the studies was moderate, based on a mean Downs and Black score of 17.67±5.42 out of 28 (
Most studies assessed knowledge acquisition [
Many studies employed custom instruments that were designed by the researchers to assess the outcomes of their specific intervention. This resulted in a broad assortment of instruments that are difficult to interpret and compare (
A summary of the effects of Web-based patient education interventions is provided in
Methodological quality of included studies (ordered by quality).
Study | Downs and Black [ |
|||||
Reporting | External validity | Bias | Confounding | Power | Overall study qualityb | |
Heikkinen et al [ |
10 | 1 | 5 | 6 | 1 | High |
Fraval et al [ |
8 | 2 | 5 | 6 | 1 | High |
Drieling et al [ |
10 | 1 | 5 | 5 | 0 | High |
Nahm et al [ |
9 | 1 | 6 | 4 | 1 | High |
Heikkinen et al [ |
10 | 1 | 4 | 6 | 0 | High |
Heikkinen et al [ |
10 | 1 | 4 | 6 | 0 | High |
Heikkinen et al [ |
9 | 1 | 4 | 6 | 0 | High |
Umapathy et al [ |
10 | 1 | 5 | 3 | 1 | High |
Yin et al [ |
9 | 1 | 5 | 5 | 0 | High |
Groves et al [ |
6 | 1 | 6 | 5 | 1 | High |
Meesters et al [ |
9 | 1 | 5 | 1 | 0 | Medium |
Goldsmith and Safran [ |
7 | 0 | 5 | 2 | 0 | Medium |
Heikkinen et al [ |
5 | 1 | 3 | 3 | 0 | Medium |
Sobel and Popp [ |
3 | 0 | 1 | 0 | 0 | Low |
Median study quality | 9/11 | 1/3 | 5/7 | 5/6 | 0/1 | High |
aLowest to highest possible score for reporting (0-11), external validity (0-3), bias (0-7), confounding (0-6), power (0-1), and overall quality (0-28).
bPercentage scores were calculated by dividing the final score by the maximum score and multiplication by 100. The percentage scores were used for ordinal categorization of the studies as low quality (≤33%), medium quality (33.4%-66.7%), and high quality (≥66.8%) [
Web-based patient education significantly increased patients’ knowledge about orthopedic conditions and orthopedic treatment [
Patients who received educational interventions did not acquire more knowledge than those who independently reviewed health information websites. One trial reported that a theory-based intervention produced higher knowledge levels regarding osteoporosis than a health information website in healthy older females [
Patient satisfaction was a main outcome in 2 studies [
Seventy percent of trials investigated patient satisfaction or collected qualitative patient feedback but had not defined it as a principal outcome. Feedback on the online interventions was generally positive: patients described them as “very effective” [
In the 3 studies that assessed patients’ anxiety following Web-based patient education, no significant effects on anxiety were found. Knee arthroscopy patients reported few distressing emotions in general, and anxiety was not influenced by Web-based patient education or verbal education [
Patient outcomes and instruments used to assess the effect of Web-based patient education (alphabetical order).
Outcome measure | Instrument | Used in |
Knowledge acquisition | Deaconess Informed Comprehension Test | [ |
Hip Fractures Knowledge Test | [ |
|
Knowledge Test | [ |
|
Modified Standard Anaesthesia Learning Test | [ |
|
Osteoporosis Health Belief Survey | [ |
|
Orthopaedic Patients Knowledge Questionnaire | [ |
|
Osteoarthritis Quality Indicator | [ |
|
Sufficiency of Knowledge | [ |
|
Custom instrument (no name provided) | [ |
|
Patient satisfaction and patient feedbacka | Client Satisfaction Questionnaire | [ |
Patients’ Evaluations of Education | [ |
|
Perceived Health Website Usability Questionnaire | [ |
|
Custom instrument (no name provided) | [ |
|
Anxiety | Emotions Questionnaire | [ |
State-Trait Anxiety Index | [ |
|
Patients’ Evaluations of Education | [ |
|
Custom instrument (no name provided) | [ |
|
Empowerment, self-efficacy, and health attitudes | Calcium subscale of Osteoporosis Self-efficacy Scale | [ |
Osteoporosis Health Belief Scale | [ |
|
Outcome Expectations for Exercise Scale | [ |
|
Patients’ Evaluations of Education | [ |
|
Self-efficacy for Exercise | [ |
|
Web-based Learning Self-efficacy Measure | [ |
|
Self-management and behavior change | Behavioral Risk Factor Surveillance System | [ |
Block-National Cancer Institute Health Habits and History Questionnaire | [ |
|
Brief Physical Activity Survey | [ |
|
Health Education Impact Questionnaire | [ |
|
Yale Physical Activity Survey | [ |
|
Clinical outcomes | The Symptoms | [ |
Verbal Rating Scale of McGill Pain Questionnaire | [ |
aQualitative feedback methods [
Two studies included self-efficacy as a primary outcome measure and reported contradicting evidence [
Only one study assessed the effect of Web-based patient education on self-management [
The evidence for an effect of Web-based patient education on clinical outcomes is limited and contradictory: although access to a pain management section of an ambulatory surgery website resulted in a significant decrease in “discomforting” pain scores after ambulatory surgery [
This review set out to examine the effects of Web-based patient education in the care for adult orthopedic patients. This is an important subject, as orthopedic patients are commonly using the internet to find health information [
This review identified 14 studies that reported the effects of ten different Web-based patient education interventions targeted toward the orthopedic patient population. Although the amount of studies is limited, the overall methodological quality of the included studies is high. Still, the different studies could not be compared on a meta-analytic level given the wide variety in scope, primary outcomes, and means of outcome assessment. Furthermore, the reported findings may be limited to patients who were already able to use the internet, as 70% of the studies included in this review established criteria that excluded inexperienced, less skilled patients with limited access to the internet to the trials. Hence, it is difficult to draw definitive conclusions about the effectiveness of Web-based patient education interventions.
While keeping these limitations in mind, the currently available evidence does suggest that patients who are offered Web-based patient education find the service both usable and satisfactory [
There is still insufficient evidence to determine the effect of Web-based patient education on self-efficacy, self-management, or clinical outcomes. Only 2 studies investigated self-efficacy [
This review illustrates the typical Web-based patient educational intervention that is currently offered to people with orthopedic conditions. These are mostly websites focused on practical, informational content that is presented using multiple media formats including text, pictures, and video. Most offer some form of (human) support to patients using the programs but are still static in terms of interactivity. Still, it seems that online self-assessment is being recognized as an appropriate strategy to make educational content more engaging. At this point, there was not enough evidence to conclude that either of these intervention characteristics—content, media use, support, interactivity, or duration—has a consistent effect on the interventions’ success. However, regarding support provision, it should be noted that almost all studies that did not specify the level of support offered on the website did include some form of provider contact as part of the usual care given to both the experimental and control groups [
Most of our findings are in line with previous reviews of Web-based patient education. We found further support for the idea that changing the channel of communication in patient education can increase patient satisfaction, as was tentatively hypothesized in Nguyen and colleagues’ 2004 review [
Despite the aforementioned replications, we could not determine whether self-care behavior of orthopedic patients increased because of Web-based patient education, an effect that has been identified in cardiovascular patients who were offered online educational interventions [
This review has several limitations that relate to the representativeness of the samples included in the studies, the limited number of included studies, and the lack of a meta-analysis.
First, the quality of the reported studies was higher than what previous reviews of Web-based interventions have documented [
Second, we were able to evaluate only a limited number of studies. Although the initial search identified over a thousand potential studies, only ten trials specifically evaluated Web-based patient education interventions in a sufficiently controlled setting. As a result, we were not able to draw any reliable conclusions about the effect of Web-based patient education on patient reported outcomes, including postoperative pain and functioning, whereas reviews of traditional patient education show that these outcomes may be affected [
Third, the studies employed a wide variety of outcome measures that did not allow for a meta-analysis of the findings. Though the qualitative synthesis does indicate that Web-based patient education increases patients’ knowledge levels and satisfaction, we were not able to determine the extent of these effects. Therefore, their clinical relevance has yet to be determined.
In summary, offering patient education interventions via the internet to adult people with orthopedic conditions increases their knowledge about their condition and its treatment [
Given these findings, we tentatively conclude that Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the primary aim of the intervention is to increase patients’ knowledge and satisfaction. However, there is too little evidence to advocate for Web-based patient education to replace existing interventions that aim to improve other outcomes, including self-management skills, pain, and function. Furthermore, it should be kept in mind that Web-based interventions currently cater to younger patients who may not be comparable to the general patient population. A solution for hospital administrators or health care policy makers currently planning an educational intervention for orthopedics patients is to provide Web-based education in addition to verbal or written components, which allows patients to select the platform they are most comfortable with while ensuring satisfactory results.
Search strategies for the identification of studies assessing the effects of Web-based patient education interventions for the adult orthopedic population.
Intervention characteristics of studies evaluating the effects of Web-based patient education in orthopedics (alphabetical order).
Summary of the effects of Web-based patient education (ordered by comparison then by quality).
health care professional
This work is part of the research program Tailored healthcare through customer profiling (Project 314-99-118), which is financed by the Netherlands Organisation for Scientific Research (NWO) and Zimmer Biomet Inc.
TD, MM, and HdR conceived the study and its design. TD, MM, and HdR selected articles for inclusion and interpreted the data. TD and BSG assessed the studies’ quality. TD drafted the article. All authors provided critical input to drafts and approved the final version.
None declared.