Discussion
disorientation, postoperative pain, anxiety, pain
DISEASE, EVENTS, MOTION SICKNESS
Our randomized clinical trial focused on the effect of AR on the patient’s entire experience at our institution’s outpatient surgical center, from initial outpatient preoperative visit to completion of the scheduled surgery, and its effects on perceived anxiety and satisfaction. Our custom AR experience allowed a patient to visually walk through their day at the surgery center with narration from their surgeon, and it was designed to emulate what the patient would encounter on the day of surgery. This experience included a visual representation of the building, layout of the surgical center, progression from check-in to preoperative care, to the operating room, and finally postoperative care. Furthermore, a strength of our AR technology was that patients had the opportunity to revisit modules of the AR experience if they wanted to view them again. Users could also interact with the AR application by zooming in and out and rotating the model for a more personalized experience. The ultimate goal of our AR experience was to educate and prepare the patient for what to expect, potentially mitigating the cognitive and physiological burden of anxiety they perceived surrounding their surgery.We found that our AR experience significantly decreased patients’ preoperative anxiety even immediately from the time of screening to after intervention completion, with lasting effects until the time of surgery. This is contrasted with the control group, who had little significant change in their screening to postintervention surveys but did experience an increase in anxiety from screening to preoperative surveys. These changes subsided after surgery, with all patients showing a decrease in anxiety from their screening survey, with no significant difference between the groups. The focus of our AR application was on the day-of-surgery events and the immediate preoperative experience, which might explain the lack of observed postoperative differences. However, this study was underpowered, so this lack of statistical power increases the risk of type II error, potentially masking a significant effect.We also examined the AR experience’s effect on postoperative pain and narcotic use. There were no significant differences between groups on VAS pain scores or narcotic use. These results are limited by the fact that they were patient-reported at the time of their postoperative survey and could thus be influenced by recall bias. Our study could have been strengthened by contacting patients on postoperative day 1 to determine VAS and narcotic use at that time point. We conducted a post-hoc power analysis to assess whether this study was appropriately powered to detect a clinically meaningful difference in VAS, and we did not reach appropriate confidence for definitive conclusion for this comparison. Previous studies have suggested that pain scores might be improved with the assistance of VR.While most patients who completed the AR experience did enjoy it, some did not. Indeed, approximately 10% to 15% of patients disagreed or strongly disagreed that they enjoyed the experience, would recommend it, and would do it again. Specific factors cited for their criticism were disorientation associated with using the AR headset, as well as the quality of the animations present. Patients with glasses sometimes had difficulty with the headset and fitting their glasses inside it so that they could see it project across the room. Although visually induced motion sickness is a well-described phenomenon with VR and AR, no patients in our study experienced any.We additionally examined whether patient experience with AR had any association with their anxiety levels. Interestingly, not enjoying the AR experience was not associated with the intervention’s efficacy of decreasing preoperative anxiety, as there was no significant difference in STAI score from screening to the preoperative survey between patients who underwent the AR experience and were neutral, enjoyed, or strongly enjoyed the experience compared with those who did not enjoy or strongly did not enjoy it. This suggests that the mental exercise of experiencing the operative day walkthrough in AR has an anxiolytic effect and is not dependent on ultimate enjoyment.To our knowledge, limited randomized clinical trials have investigated the utility of an AR educational experience to prepare a patient for their day of surgery. A 2019 study by Eijlers et alOther studies have looked at VR and AR and patient education focusing on digital imaging and 3-dimensional models to educate the patient on the specifics of their involved anatomy and provide a detailed visual representation of the steps of the surgery, yet these were primarily interested in patient understanding of the disease process and not on the effect on perioperative anxiety.