Discussion
In this randomized single-blind placebo-controlled trial the effects of a standardized MRI information booklet on anxiety and satisfaction with information among adult outpatients undergoing their first MRI examination was investigated. There were no differences in anxiety between the intervention and control groups before or during scanning, but those who received the placebo booklet had a significantly higher risk of experiencing severe anxiety immediately prior to MRI. The results also showed that pre-scanning information is considered important, and that those who received MRI specific written information before their examination were more satisfied than those who received general information.
The effects of written patient information on elevating patient anxiety associated with MRI have been investigated before using the STAI questionnaire 16, 32. One study found significantly decreased anxiety during MRI among patients who received an information booklet in comparison with those who did not 16. However, the written information in that study was supplemented by other interventions such as a pre-scan counselling, which makes it uncertain to what extent the outcomes can be attributed to the written informationper se . Another study failed to demonstrate any reduction in MRI-associated anxiety from provision of an information booklet alone32. This may have been due to providing written MRI information to both study groups and only supplemental information to the experimental group 32. However, the present study demonstrates that those who received the placebo booklet had a higher risk of experiencing high pre-scan anxiety compared to those who received specific MRI information. This association was independent and beyond those of high baseline anxiety levels, pre-scan visits to the MRI and the presence of relatives during scanning. Furthermore, factors such as cause of referral, use of sedatives and gender, which all have been found associated with MRI anxiety in previous studies9, 19, 32, did not contribute to high anxiety levels once the written information was taken into account. These findings are strengthened by the randomized placebo-controlled design, which differs from previous quasi-experimental studies of the effects of written information on MRI associated anxiety 16, 32.
The comparison within the groups regarding patient perceived anxiety prior to and during the MRI showed significant differences for both groups. This may be due to a feeling of relief after the examination. That is, although STAI-SA intended to assess anxiety during the examination, it cannot be ruled out that responses may have been influenced by perceptions at the time when the inventory was answered. Furthermore, attendance and oral information by the staff (which was provided after the STAI-SB was responded to) may also have had an anxiety reducing effect 4-5, 39. For example, it has been found that support from the staff have a significant impact on patients‘ experiences of an MRI and the staff/patient interaction may facilitate self-control and coping during the examination4.
The intervention group was more satisfied with the information compared to the control group, which is contrary to previous results in MRI32. This could be explained that our study provided a booklet that was developed in interaction with people who had undergone an MRI, which probably enhances the relevance and comprehension of the information 31.
A placebo booklet was applied, which is considered a strength of the study. Nevertheless, there is also a risk to use placebo considering that the attention provided by the placebo booklet may have affected their experiences of MRI, even though it did not include any information about the examination. However, it has been argued that these effects are negligible in interventions of patient education that are applied over a short period of time 40. Indeed, the Nordic Cochrane Centre concluded that in general there is no evidence that placebo interventions have clinical effect with an exception of possible influence on experiences of pain and nausea 41.
One aspect that always should be considered in relation to any intervention is its cost-effectiveness. That is, whether the extra cost associated with printing and distributing an MRI information booklet is compensated by its effects. To the best of our knowledge, there is no such evidence available regarding written information prior to MRI. However, it appears reasonable to consider the relatively small costs to be acceptable in view of the results presented here, particularly since previous studies have suggested that this type of intervention also may reduce motion artefacts 32, 42. Nevertheless, future studies should consider cost-effectiveness in addition to motion artefacts and MRI associated anxiety and wellbeing 43.
Conclusion
This placebo-controlled single-blind randomized trial examined the effects of standardized written information to people undergoing their first MRI examination. The results showed that such information reduces the risk of experiencing high pre-scanning anxiety levels, that patients find it important to receive information before the examination, and that it increases the satisfaction with the information as compared to general information.
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