Patient prompts in surgical consultations: A systematic review

Published:September 29, 2022DOI:



      Quality communication has been found to improve patient outcomes. Despite good communication, information may still be forgotten or misunderstood by patients. A question prompt list is a document to help patients ask questions. Question prompt lists are well perceived by various stakeholders and have been found of benefit to patients. This systematic review evaluated the effectiveness of patient question prompting documents in surgical outpatient consultations.


      MEDLINE, EMBASE, and PsychINFO were searched on September 13, 2021. Study selection, data extraction, and risk of bias assessment were performed in duplicate. We included English studies that investigated the use of question prompt lists and their influence on patient outcomes. We excluded studies that did not have a comparator group. Because of heterogeneity of outcome measures, meta-analysis was precluded. This study was registered with PROSPERO (identification number: CRD42021279058).


      Searches identified 107 suitable studies; however, only 7 studies met eligibility criteria. All included studies were randomized controlled trials, but the designs of studies were heterogenous. Three out of 7 included studies were at a high risk of bias. The included studies investigated different outcomes that could be broadly categorized into 5 themes: consultation characteristics, patient engagement, patient well-being, information exchange, and patient satisfaction. None of the studies looked at patient recall of information. Aside from length of consultation, the overall results for each category were mixed.


      Current literature has suggested that question prompt lists are a low-risk intervention that could improve patient engagement and patient-doctor communication; however, there is limited evidence at present to conclusively promote their usage in perioperative surgical consultations.


      QPL (Question Prompting List), PICO (Patient Intervention Comparison Outcome), PICS (Patient Perceived Involvement in Care tool), ASK (AskShareKnow), PEPPI-5 (5-Item Perceived Efficacy in Patient-Physician Interaction), HCCQ (Health Care Climate Questionnaire), STAI (State Anxiety Index), AMSTAR (Assessing the Methodological Quality of Systematic Reviews), PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), PEMAT-P (Patient Education Materials Assessment Tool for Printable Materials), PROMIS (Patient-Reported Outcomes Measurement Information System), MYCaW (Measure Yourself Concerns and Wellbeing)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Warnecke E.
        The art of communication.
        AustFamily Physician. 2014; 43: 156-158
        • Scholl I.
        • Zill J.M.
        • Härter M.
        • Dirmaier J.
        An integrative model of patient-centeredness–a systematic review and concept analysis.
        PloS One. 2014; 9e107828
        • Zwingmann J.
        • Baile W.F.
        • Schmier J.W.
        • Bernhard J.
        • Keller M.
        Effects of patient-centered communication on anxiety, negative affect, and trust in the physician in delivering a cancer diagnosis: a randomized, experimental study.
        Cancer. 2017; 123: 3167-3175
        • Fallowfield L.
        • Jenkins V.
        Effective communication skills are the key to good cancer care.
        Eur J Canc. 1999; 35: 1592-1597
        • Street Jr., R.L.
        • Makoul G.
        • Arora N.K.
        • Epstein R.M.
        How does communication heal? Pathways linking clinician–patient communication to health outcomes.
        Pat Educ Couns. 2009; 74: 295-301
        • Kessels R.P.
        Patients’ memory for medical information.
        J R Soc Med. 2003; 96: 219-222
        • Keinki C.
        • Zowalla R.
        • Wiesner M.
        • Koester M.J.
        • Huebner J.
        Understandability of patient information booklets for patients with cancer.
        J Cancer Educ. 2018; 33: 517-527
        • Fink A.S.
        • Prochazka A.V.
        • Henderson W.G.
        • et al.
        Predictors of comprehension during surgical informed consent.
        J Am Coll Surg. 2010; 210: 919-926
        • Lavelle-Jones C.
        • Byrne D.J.
        • Rice P.
        • Cuschieri A.
        Factors affecting quality of informed consent.
        BMJ. 1993; 306: 885-890
        • Hu A.
        • Chow C.-M.
        • Dao D.
        • Errett L.
        • Keith M.
        Factors influencing patient knowledge of warfarin therapy after mechanical heart valve replacement.
        J Cardiovasc Nurs. 2006; 21: 169-175
        • Hersh L.
        • Salzman B.
        • Snyderman D.
        Health literacy in primary care practice.
        Am Fam Phys. 2015; 92: 118-124
        • Roe A.K.
        • Eppler S.L.
        • Shapiro L.M.
        • Satteson E.S.
        • Yao J.
        • Kamal R.N.
        Engaging patients to ask more questions: what’s the best way? A pragmatic randomized controlled trial.
        J Hand Surg. 2021; 46 (e1–818.e6): 818
        • Moloczij N.
        • Krishnasamy M.
        • Butow P.
        • et al.
        Barriers and facilitators to the implementation of audio-recordings and question prompt lists in cancer care consultations: a qualitative study.
        Patient Educ Couns. 2017; 100: 1083-1091
        • Lemmon M.E.
        • Donohue P.K.
        • Williams E.P.
        • Brandon D.
        • Ubel P.A.
        • Boss R.D.
        No question too small: development of a question prompt list for parents of critically ill infants.
        J Perinatol. 2018; 38: 386-391
        • Dimoska A.
        • Butow P.N.
        • Lynch J.
        • et al.
        Implementing patient question-prompt lists into routine cancer care.
        Patient Educ Couns. 2012; 86: 252-258
        • Yeh J.C.
        • Cheng M.J.
        • Chung C.H.
        • Smith T.J.
        Using a question prompt list as a communication aid in advanced cancer care.
        J Oncol Pract. 2014; 10: e137-e141
        • van der Steen J.T.
        • Heck S.
        • Juffermans C.C.
        • et al.
        Practitioners' perceptions of acceptability of a question prompt list about palliative care for advance care planning with people living with dementia and their family caregivers: a mixed-methods evaluation study.
        BMJ Open. 2021; 11e044591
        • Miller S.
        • Shipper E.
        • Hasty B.
        • et al.
        Introductory surgical skills course: technical training and preparation for the surgical environment.
        MedEdPORTAL. 2018; 1410775
        • Sansoni J.E.
        • Grootemaat P.
        • Duncan C.
        Question prompt lists in health consultations: a review.
        Patient Educ Couns. 2015; 98: 1454-1464
        • Keinki C.
        • Momberg A.
        • Clauß K.
        • et al.
        Effect of question prompt lists for cancer patients on communication and mental health outcomes—a systematic review.
        Patient Educ Couns. 2021; 104: 1335-1346
        • Brandes K.
        • Linn A.J.
        • Butow P.N.
        • van Weert J.C.
        The characteristics and effectiveness of Question Prompt List interventions in oncology: a systematic review of the literature.
        Psychooncology. 2015; 24: 245-252
        • Shea B.J.
        • Reeves B.C.
        • Wells G.
        • et al.
        AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.
        BMJ. 2017; 358: j4008
      1. Covidence Systematic Review Software [computer program]. Melbourne, Australia. Accessed November 25, 2021.

        • Sterne J.A.
        • Savović J.
        • Page M.J.
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
        • Kalbfell E.L.
        • Buffington A.
        • Kata A.
        • et al.
        Expressions of conflict following postoperative complications in older adults having major surgery.
        Am J Surg. 2021; 222: 670-676
        • Schwarze M.L.
        • Buffington A.
        • Tucholka J.L.
        • et al.
        Effectiveness of a question prompt list intervention for older patients considering major surgery: a multisite randomized clinical trial.
        JAMA Surg. 2020; 155: 6-13
        • Mariano D.J.
        • Liu A.
        • Eppler S.L.
        • et al.
        Does a question prompt list improve perceived involvement in care in orthopaedic surgery compared with the AskShareKnow questions? A pragmatic randomized controlled trial.
        Clinical Orthop Rel Res. 2021; 479: 225-232
        • Smets E.
        • Van Heijl M.
        • Van Wijngaarden A.
        • Henselmans I.
        • van Berge Henegouwen M.
        Addressing patients’ information needs: a first evaluation of a question prompt sheet in the pretreatment consultation for patients with esophageal cancer.
        Dis Esophagus. 2012; 25: 512-519
        • Fleissig A.
        • Glasser B.
        • Lloyd M.
        Encouraging out-patients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want?.
        Patient Educ Couns. 1999; 38: 69-79
        • Lim L.
        • Chow P.
        • Wong C.-Y.
        • et al.
        Doctor–patient communication, knowledge, and question prompt lists in reducing preoperative anxiety—a randomized control study.
        Asian J Surg. 2011; 34: 175-180
        • Brandes K.
        • Linn A.J.
        • Butow P.N.
        • van Weert J.C.
        The characteristics and effectiveness of Question Prompt List interventions in oncology: a systematic review of the literature.
        Psychooncology. 2015; 24: 245-252
        • Schulte-Vieting T.
        • Siegle A.
        • Jung C.
        • Villalobos M.
        • Thomas M.
        Developing a question prompt list for the oncology setting: a scoping review.
        Patient Educ Couns. 2022; 105: 1689-1702
        • Whittingham J.R.
        • Ruiter R.A.
        • Castermans D.
        • Huiberts A.
        • Kok G.
        Designing effective health education materials: experimental pre-testing of a theory-based brochure to increase knowledge.
        Health Educ Res. 2008; 23: 414-426
        • Ferguson L.A.
        Implementing a video education program to improve health literacy.
        J Nurse Pract. 2012; 8: e17-e22
        • Shepherd H.L.
        • Barratt A.
        • Jones A.
        • et al.
        Can consumers learn to ask three questions to improve shared decision making? A feasibility study of the ASK (AskShareKnow) Patient–Clinician Communication Model intervention in a primary health-care setting.
        Health Expect. 2016; 19: 1160-1168
        • Shepherd H.L.
        • Barratt A.
        • Trevena L.J.
        • et al.
        Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial.
        Patient Educ Couns. 2011; 84: 379-385
        • Corcoran N.
        • Ahmad F.
        The readability and suitability of sexual health promotion leaflets.
        Patient Educ Couns. 2016; 99: 284-286
        • Clayton J.M.
        • Butow P.N.
        • Tattersall M.H.
        • et al.
        Randomized controlled trial of a prompt list to help advanced cancer patients and their caregivers to ask questions about prognosis and end-of-life care.
        J Clin Oncol. 2007; 25: 715-723
        • Shoemaker S.J.
        • Wolf M.S.
        • Brach C.
        Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
        Patient Educ Couns. 2014; 96: 395-403
        • Tang P.C.
        • Lansky D.
        The missing link: bridging the patient-provider health information gap.
        Health Aff (Millwood). 2005; 24: 1290-1295
        • Watson P.W.
        • McKinstry B.
        A systematic review of interventions to improve recall of medical advice in healthcare consultations.
        J R Soc Med. 2009; 102: 235-243
        • Blinder D.
        • Rotenberg L.
        • Peleg M.
        • Taicher S.
        Patient compliance to instructions after oral surgical procedures.
        Int J Oral Maxillofac Surg. 2001; 30: 216-219
        • Weinman J.
        Providing written information for patients: psychological considerations.
        J R Soc Med. 1990; 83: 303-305
        • Bernier M.J.
        • Yasko J.
        Designing and evaluating printed education materials: model and instrument development.
        Patient Educ Couns. 1991; 18: 253-263