Impact of Visual Health Education on Perioperative Outcomes and Medication Adherence in Older Adults Undergoing PKP for Osteoporotic Vertebral Fractures

Abstract

Objective

This study aimed to evaluate the efficacy of visual health education (VHE) intervention in the perioperative management of older adults undergoing percutaneous kyphoplasty (PKP) for osteoporotic vertebral fractures (OVFs).

Methods

A prospective cohort of 96 patients (aged ≥65 years) scheduled for primary PKP between June 2024 and January 2025 were enrolled. Participants were allocated to a control group (n = 46) receiving conventional verbal education or an intervention group (n = 50) receiving VHE via instructional videos. The VHE program encompassed disease-specific knowledge, surgical procedures, and postoperative rehabilitation. Outcome measures included sleep quality (PSQI), anxiety (SAS), blood pressure stability, patient satisfaction, and anti-osteoporosis medication adherence.

Results

The VHE group demonstrated significant improvements across all perioperative metrics compared to controls. Preoperative sleep quality was superior (PSQI: 7.85 ± 2.16 vs 15.63 ± 3.62, P < 0.001), anxiety levels were lower (SAS: 30.62 ± 3.48 vs 55.68 ± 3.95, P < 0.001), and patient satisfaction at discharge was higher (100% vs 95.7%, P < 0.001). The intervention group also exhibited better medication adherence at 6-month follow-up (76% vs 28.3%, P < 0.001) and more stable preoperative blood pressure (systolic BP: 152.8 ± 5.9 vs 178.4 ± 7.1 mmHg, P < 0.001).

Conclusion

Disease-specific visual health education significantly enhances perioperative experiences, improves psychological well-being, stabilizes physiological parameters, and promotes long-term treatment adherence in older OVF patients undergoing PKP. This approach represents a valuable adjunct to standard perioperative care, with the potential to reduce complications and improve overall clinical outcomes.

Introduction

With the accelerating trend of global population aging, osteoporotic fractures have emerged as a major public health challenge. ¹ Among these, osteoporotic vertebral fractures (OVFs) are particularly prevalent and contribute significantly to pain, functional decline, and reduced quality of life in older adults. ² Percutaneous Vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are widely adopted as first-line surgical interventions for eligible OVF patients, offering minimal invasiveness, rapid pain relief, and early mobilization.

Despite these benefits, the perioperative period is often complicated by patient anxiety, sleep disturbances, and suboptimal management of comorbidities such as hypertension. These issues not only impair the surgical experience but also negatively impact postoperative recovery and long-term adherence to essential anti-osteoporosis therapies. Traditional health education, predominantly delivered through verbal communication, often fails to facilitate comprehensive patient understanding and retention of complex medical information.

Visual health education (VHE), leveraging instructional videos and multimedia tools, presents a promising alternative. By transforming abstract medical concepts into engaging and accessible content, VHE may enhance patient comprehension, reduce preoperative uncertainty, and promote active participation in the recovery process. This study evaluates the impact of a structured VHE program on perioperative outcomes, medication adherence, and patient satisfaction in older adults undergoing PKP for OVFs.

Subjects and Methods

Study Design and Participants

This prospective cohort study enrolled 96 older adults with OVFs scheduled for PKP at our hospital between June 2024 and January 2025. The control group (n = 46) included patients admitted to the old campus from June to October 2024, while the intervention group (n = 50) comprised patients admitted to the new campus from October 2024 to January 2025. All participants provided written informed consent, and the study was approved by the institutional ethics committee.

Inclusion criteria were: (1) age ≥65 years; (2) diagnosis of single-level OVF confirmed by MRI and bone mineral density (BMD T-score ≤ −2.5); (3) scheduled for primary PKP. Exclusion criteria included: (1) history of ischemic stroke with significant motor impairment; (2) major organ dysfunction; (3) severe cognitive impairment, psychiatric disorders, or language barriers.

Sample Size Estimation

A priori power analysis was conducted using G^*Power software. With an effect size of 0.6, alpha of 0.05, and power of 0.8, the minimum required sample size was 44 per group. The final enrollment exceeded this threshold to account for potential attrition.

Health Education Methods

Both groups received education from the same multidisciplinary team. The control group received conventional verbal education with physical demonstrations as needed. The intervention group received a supplemental VHE program consisting of 4 animated videos covering: (1) OVF pathophysiology and prevention, (2) PKP procedural animation, (3) intraoperative positioning and precautions, and (4) postoperative rehabilitation and anti-osteoporosis medication use. Videos were reinforced by nurse-led explanations.

Outcome Measures

The primary outcomes of this study included sleep quality, anxiety levels, hemodynamic stability, patient satisfaction, and medication adherence. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), ³ where a higher score (cut-off ≥7) indicates poorer sleep quality. Anxiety was evaluated with the Self-Rating Anxiety Scale (SAS), ⁴ with elevated scores reflecting greater anxiety severity. Blood pressure was measured at baseline and immediately before surgery to evaluate perioperative hemodynamic fluctuations. Patient satisfaction with the overall hospitalization experience was recorded at discharge using a simplified 4-point Likert scale (very satisfied, satisfied, neutral, dissatisfied). Adherence to anti-osteoporosis medication was prospectively monitored during scheduled outpatient follow-ups at 1, 3, and 6 months post-discharge, verified through prescription records and patient interviews.

Statistical Analysis

Data were analyzed using SPSS 21.0. Continuous variables were expressed as mean ± SD and compared using independent t-tests. Categorical variables were presented as counts (%) and analyzed using chi-square (χ²) tests. A two-tailed P-value <0.05 was considered statistically significant.

Results

Baseline Characteristics

The baseline demographic and clinical characteristics were comparable between the 2 groups (Table 1). Specifically, there were no significant differences in mean age (Control: 75.4 ± 10.2 years vs Intervention: 74.8 ± 9.9 years; P = 0.358), sex distribution (Male: 41.3% vs 42.0%; P = 0.617), or education level (P = 0.872), ensuring that the groups were well-matched at baseline.

Table 1.

Comparison of Baseline Characteristics Between Groups

Characteristic	Control group (n = 46)	Intervention group (n = 50)	P-value
Age (years), mean ± SD	75.4 ± 10.2	74.8 ± 9.9	0.358
Sex, n (%)			0.617
Male	19 (41.3)	21 (42.0)
Female	27 (58.7)	29 (58.0)
Education level, n (%)			0.872
Illiterate	14 (30.4)	17 (34.0)
Primary School	23 (50.0)	22 (44.0)
Junior high School	7 (15.2)	9 (18.0)
High School or above	2 (4.4)	2 (4.0)

Perioperative Outcomes

The intervention group demonstrated superior outcomes across all perioperative metrics. Preoperatively, the VHE group had significantly better sleep quality (PSQI: 7.85 ± 2.16 vs 15.63 ± 3.62; P < 0.001) and lower anxiety levels (SAS: 30.62 ± 3.48 vs 55.68 ± 3.95; P < 0.001), a trend that persisted postoperatively (Table 2). At discharge, patient satisfaction was markedly higher in the VHE group (100% vs 95.7%, P < 0.001), with 76.0% of patients reporting being “very satisfied” compared to 19.6% in the control group (Table 3). The VHE group also exhibited significantly better adherence to anti-osteoporosis medication at the 6-month follow-up (76% vs 28.3%, P < 0.001), as detailed in Table 4. Furthermore, preoperative systolic blood pressure elevation was substantially attenuated in the intervention group (152.8 ± 5.9 mmHg vs 178.4 ± 7.1 mmHg in controls; P < 0.001), indicating improved hemodynamic stability (Table 5).

Table 2.

Comparison of Perioperative PSQI and SAS Scores Between Groups

Parameter	Control group (n = 46)	Intervention group (n = 50)	t-value	P-value
PSQI score, mean ± SD
Preoperative day	15.63 ± 3.62	7.85 ± 2.16	7.565	<0.001
Postoperative day	9.52 ± 2.94	5.28 ± 2.42	10.213	<0.001
SAS score, mean ± SD
Preoperative day	55.68 ± 3.95	30.62 ± 3.48	8.631	<0.001
Postoperative day	32.61 ± 3.65	25.31 ± 3.23	6.545	<0.001

Table 3.

Comparison of Discharge Satisfaction Between Groups (%)

Group	Very satisfied	Satisfied	Neutral	Dissatisfied	Overall satisfaction
Control (n = 46)	9 (19.6)	14 (30.4)	21 (45.7)	2 (4.3)	95.7%
Intervention (n = 50)	38 (76.0)	11 (22.0)	1 (2.0)	0 (0.0)	100.0%
χ2					38.335
P-value					<0.001

Table 4.

Comparison of Post-Discharge Anti-Osteoporosis Medication Adherence (n)

Group	1 Month	3 Months	6 Months
Control (n = 46)	34	26	13
Intervention (n = 50)	46	43	38
χ2	5.643	10.299	21.926
P-value	0.018	0.001	<0.001

Table 5.

Blood Pressure Comparison Between Groups ( $\overline{X}$ ± SD, Mm Hg)

Group	n	SBP baseline	SBP preoperative	DBP baseline	DBP preoperative
Control	46	140.5 ± 4.2	178.4 ± 7.1	83.1 ± 4.2	94.6 ± 5.9
Intervention	50	142.1 ± 4.5	152.8 ± 5.9	81.9 ± 3.5	88.1 ± 3.6
t-value		−1.837	19.308	1.531	6.490
P-value		0.069	<0.001	0.129	<0.001

Discussion

This prospective cohort study demonstrates that a structured VHE program significantly enhances the perioperative experience for older adults undergoing PKP for OVFs. As a minimally invasive procedure, PKP has been established as a preferred treatment to achieve early pain relief and functional recovery, aligning with the current evolution in the management of osteoporotic vertebral fractures. ⁵ Building upon this surgical foundation, our findings confirm that the adjunctive use of VHE leads to comprehensive improvements, including superior sleep quality, attenuated anxiety, higher treatment satisfaction, improved long-term medication adherence, and more stable hemodynamics.

The efficacy of VHE can be understood through the lens of health behavior theories, such as the Health Belief Model. By visually demonstrating the consequences of osteoporosis (perceived susceptibility/severity) and the benefits of surgical and medical management (perceived benefits), VHE empowers patients and enhances their self-efficacy for recovery.^6,7 This approach directly addresses common sources of preoperative anxiety—such as fear of surgery, anticipation of pain, and uncertainty about outcomes—which are strongly correlated with sleep disturbances.^6,7 Our findings confirm that by demystifying the surgical process, setting realistic expectations, and clarifying postoperative rehabilitation pathways, VHE effectively reduces catastrophic thinking and builds patient confidence.

The impact on patient satisfaction underscores the critical role of effective communication in modern healthcare. ⁸ Our mobile internet-based VHE platform leverages the extensive reach and rapid dissemination capabilities of smart health technologies, ⁹ delivering standardized yet personalized education. This innovative model, which integrates video prescriptions into routine nursing workflows, successfully translates complex information into actionable knowledge, thereby substantially enhancing the patient-reported experience.

Perhaps one of the most clinically significant findings is the markedly improved adherence to anti-osteoporosis medication at 6 months (76% vs 28.3%). Given that underlying osteoporosis often remains untreated after PKP/PVP, leading to concerning fracture recurrence rates (eg, 19.2%-24% in published studies^10,11), this improvement is paramount. Postoperative bone density deterioration without adequate anti-osteoporosis treatment significantly increases the risk of new fractures.^12,13 Our VHE intervention, by emphasizing the chronic nature of osteoporosis and the importance of sustained therapy, establishes a crucial foundation for secondary fracture prevention.

Furthermore, the significant attenuation of preoperative blood pressure elevation in the VHE group reflects a blunted physiological stress response. This aligns with existing evidence that preoperative education can stabilize perioperative hemodynamics. ¹⁴ By familiarizing patients with the operating room environment and surgical workflow through immersive video content, VHE likely reduces autonomic nervous system activation, thereby potentially lowering the risk of associated cardiovascular complications.

Limitations and Strengths

This study has several limitations. Its single-center design and non-randomized allocation based on campus and time period may introduce selection bias. Although the same medical team served both campuses, unmeasured environmental or systemic differences could act as confounders. Patient satisfaction was assessed using a non-validated, simplified scale. The 6-month follow-up, while adequate for assessing initial medication adherence, is insufficient to evaluate long-term outcomes such as fracture recurrence. Finally, the cultural and linguistic specificity of the video content may limit the generalizability of the findings to other healthcare settings and diverse populations, necessitating validation in multicenter, international trials.

Notable strengths include the prospective design, the use of validated tools (PSQI, SAS) for primary psychological outcomes, and the evaluation of a practical, scalable, low-risk intervention that addresses multiple dimensions of perioperative care, from immediate psychological well-being to long-term therapeutic adherence.

Conclusion

In conclusion, disease-specific visual health education is a highly effective intervention that optimizes the perioperative journey and promotes sustained self-management in older OVF patients undergoing PKP. It improves subjective patient experiences, objective physiological parameters, and crucial long-term treatment behaviors. Future research should focus on multicenter randomized controlled trials with longer follow-up periods, the use of validated satisfaction metrics, and economic evaluations to confirm these benefits and facilitate implementation across diverse healthcare systems.