Due to continuous advancements in surgical and anesthesiologic techniques, an increasing number of surgical interventions are being performed in a day surgery setting. Consequently, patients spend less time in the hospital and are often overwhelmed by a large amount of information regarding their condition and the perioperative process provided during face-to-face interactions with medical professionals [1]. Thus, patients are required to assume greater responsibilities for self-management and self-care at home [1]. However, many patients lack the necessary knowledge and ability to effectively manage the day surgery situation, leading to an increased demand for comprehensive patient education [2]. Patients seeking online health information frequently encounter the risk of unreliable sources and incorrect information due to insufficient quality control or issues with comprehensibility [3]. Considering the low health literacy levels among some patients, this poses a substantial threat to effective health communication and patient safety [4].

Despite the low-risk profile of many ambulatory interventions, the recovery phase poses challenges, emphasizing the need for patient self-management and comprehensive education programs addressing both physical and psychological aspects [1,5] to empower patients. Patient empowerment can be defined as “a process through which people gain greater control over decisions and actions affecting their health” [6]. It can be achieved through patient education, a “process of assisting consumers of health care to learn how to incorporate health related behaviors (knowledge, skill, attitude) into everyday life with the purpose of achieving the goal of optimal health” [7]. This approach should provide patients with the health-related knowledge and skills to manage their medical conditions effectively [8]. Closely related is the concept of health education literacy (HEL), a patient’s “cognitive and social skills […] to understand and use the information as conveyed in health education programmes” [9]. HEL is based on the concept of health literacy and consists of three dimensions, that are (1) the patient’s ability to apply health-related information in an everyday life (APPLY), (2) the patient’s ability to communicate with health care professionals (COMM), and (3) the patient’s comprehension of medical information (COMPR) [9].

Open carpal tunnel release (CTR) surgery is a common day-surgery procedure for carpal tunnel syndrome (CTS) [10]. CTS affects approximately 3% of the general adult population [11] and is caused by compression of the median nerve and results in symptoms such as weakness, tingling, and pain [12]. In a recent meta-analysis, CTR as gold standard treatment results in reliable improvements in hand function and symptom severity on the long-term follow-up, while manual therapy only provides short term effects regarding pain relief [13]. To address time constraints and information overload experienced by patients during clinical visits and to enhance their comprehension of their medical condition and treatment, we aim to introduce the CTS Academy, a patient-centered web-based education program, in this study. Since the implementation of patient-centered web-based education programs focusing on the perioperative process of CTR is rare, a scoping review was conducted before this study to highlight recent gaps in existing research. Our program is tailored to the specific needs of patients undergoing day surgery for CTR and aims to provide valid and comprehensible information in a familiar environment, thereby facilitating patient self-management.

In a nonrandomized controlled study, we aimed to evaluate the CTS Academy for its effect on patients’ HEL compared with self-directed online information seeking, 3 weeks after CTR (in comparison with the baseline survey).

We hypothesize that HEL is increased by participating in a web-based, structured educational programme (CTS Academy) for patients undergoing CTR. Furthermore, we examine the comprehensibility of educational content, patients’ preferences in education, the usability of the CTS Academy platform, and clinical changes in CTS-related parameters. Our research addresses the scarcity of comparable implementations and aims to acquire further insights into the existing limited quantitative research in this domain.

Before the conduction of this study, we performed a scoping review of literature discussing the quality of online CTS information. From September to December 2022, we searched Epistemonikos, the Cochrane Library, PubMed, Connected Papers, and Google Scholar. Search prompts were for example “perioperative education,” “web-based,” “carpal tunnel release,” and “structured patient education,” and the complete search strategy can be requested from the authors. The search aimed to identify systematic reviews, original research, and related studies on web-based patient education and online information for patients undergoing open CTR surgery. No filters were applied for publication date or status, but only English and German full texts were analyzed. Publications with low evidence levels or lacking full study descriptions were excluded, while a broad search strategy ensured relevant materials not explicitly titled as web-based education were included. Reporting was performed based on the Joanna Briggs Institute Scoping Review Reporting Template [14] and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) Checklist [15].

We implemented the CTS Academy platform prototype using Microsoft Sway [16], a freely accessible web-based software for creating single-page websites.

The target group for this program consists of patients scheduled for open CTR day surgery who seek relevant information related to physical and mental preparation for CTR surgery.

The goal of CTS Academy is to assist patients preparing for surgery and managing the postoperative phase by providing textual information, multimedia content, self-check quizzes, downloadable or printable checklists for patients’ self-directed online learning.

In the CTS Academy, we primarily focus on biophysiological, functional, experiential, and social aspects, excluding financial information due to the Austrian public health insurance system. The ethical and cognitive perspectives, emphasizing patient recognition, appreciation, and knowledge form the foundation of the CTS Academy. Patient education programs that prioritize patient-centeredness and engagement rely on evidence-based strategies, including plain language and multimodal information delivery [17]. Keulers et al [18] propose practical implications for interactive patient education, advocating for varied information presentation through text, graphics, and videos, with structured text using headings and subheadings. Summaries of lengthy texts determine the relevance of content, and the inclusion of graphs, pictures, and patient role models, such as animated characters, aids comprehension [18]. Incorporating entertaining elements, such as storytelling, enhances patients’ self-efficacy, with a preference for visual materials like videos and images over plain text [19,20]. Modular approaches, including basic modules for essential knowledge and additional modules for in-depth information on living with a specific disease, are also recommended [20].

The CTS Academy is based on the information provided for informed surgery consent [21], but adds further structured and comprehensive content for various stages of day surgery. Furthermore, we included aspects of mental preparation for surgery [22-26]and instructions for the postoperative period, as well as training exercises [27]. Patients can use a printable checklist for perioperative preparation and access external links, for example, the Austrian pharmacy search to locate nearby pharmacies after hospital discharge. An animated character named Karla serves as a patient role model, guiding patients through the day-surgery process and sharing important advice. To improve accessibility, the spoken text is also displayed as written text throughout the entire video.

While the platform lacks structured patient assessments, it encourages self-assessment based on chapter summaries and offers knowledge checks. In Multimedia Appendix 1, we outline the content and media types presented on the CTS Academy platform. In Figure 1, screenshots of the CTS Academy platform are presented.

Between April 2022 and April 2023, all patients presenting with CTS symptoms at the Department of Orthopedics and Traumatology and scheduled for CTR surgery after medical assessment were assessed for eligibility for inclusion in this nonrandomized, controlled, confirmatory study.

During consultations, patients received detailed information about their condition and perioperative procedures. After obtaining written informed consent for CTR, we introduced the CTS Academy study and explained the test or control groups. Allocation to the groups was based on the patient’s preference—either participation in CTS Academy or self-directed online information seeking.

Inclusion criteria were a scheduled appointment for CTR surgery, voluntariness and age of majority (18 y of age or older), physical and cognitive aptitude to participate, sufficient language skills of written and spoken German, and access to web-connected devices.

Furthermore, patients needed sufficient skills for internet use and an active pursuit of online health information.

Patients in the test group were granted unlimited access to the CTS Academy (from informed consent to surgery until 3 w postoperatively), while the control group conducted independent online searches. Throughout the self-study period of both groups, reminders were sent via SMS text messages or email to encourage information access.

Participants completed an online questionnaire after inclusion for the study, and 3 weeks postoperatively (follow-up appointment). As the CTS Academy study was conducted with German-speaking patients, all questionnaires were used in validated German versions.

The primary outcome was assessed using the Health Education Literacy of Patients with chronic musculoskeletal diseases (HELP) questionnaire by Farin, Ullrich, and Nagl [9]. It comprises 3 subtopics, that are comprehension of medical information (COMPR), applying medical information (APPLY), and communicative competence in provider interactions (COMM). Patients rated their perceived difficulty in health-related situations on a 5-point scale, with lower values indicating fewer difficulties.

Secondary outcomes included assessing the comprehensibility of content provided in the CTS Academy using the Comprehensibility Of Health Education Programmes (COHEP) questionnaire by Farin-Glattacker et al [28] and Farin, Nagl, and Ullrich [29]. This questionnaire comprises 4 subscales: transferability scale, medical information scale, amount scale, and the trainer scale, while the latter was dismissed because we did not offer lessons by a trainer [29]. Patients had to rate the amount of information provided or the perceived usefulness of information on a 6-point ranging from 1 (strongly agree) to 6 (strongly disagree).

Knowledge checks involved answering 4 statements about CTS and its treatment [30] to check their knowledge at baseline after inclusion to the study, and 3 weeks postoperatively.

Patient preferences of information seeking in the test group were assessed using the following statements on a 5-point rating scale (1=strongly disagree, 2=disagree, 3=no preference, 4=agree, and 5=strongly agree) in the follow-up questionnaire:

Usability and utility were evaluated using selected items of meCUE 2.0 [31], rated in the follow-up questionnaire on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree).

Clinical CTS-related parameters were examined using the validated German-language version [32] of the Boston Carpal Tunnel Questionnaire (BCTQ) [33] using symptom severity scale, functional status scale, as well as the total BCTQ score at baseline and follow-up.

Before patient testing, we conducted a pre-, pilot-, and prototype testing of the CTS Academy platform in August 2021 to examine the usability as well as to detect functionality and usability issues. This testing involved 16 voluntary participants: 11 laypersons (some with previous CTS surgery experience) and 5 experts in hand surgery, psychology, sociology, e-learning, and online didactics. Laypersons were asked to imagine themselves in the role of CTS patients undergoing surgery. Experts reviewed the platform professionally. The feedback and suggestions were discussed with the other project team members and led to updates in pre- and postoperative recommendations, as well as revisions for clarity and gender-appropriate language (shortening of the sentence length, simplifying certain terms, and standardizing gender-inclusive language). Recommendations were added regarding preoperative and postoperative smoking abstinence, as well as the ergonomic use of computer mice and keyboards after surgery. A chapter about the author of the CTS Academy was added.

This study was approved and registered by the institutional review board (EK1212-2021). Written informed consent (Multimedia Appendix 2) based on the hospital’s regulative for clinical studies was obtained from every patient willing to participate in the study. To maintain data security, patients were pseudonymized by assigning each one an alphanumeric ID at the time of study enrollment. This ID was used exclusively for all surveys. A list of IDs alongside patient names was kept in the study office and was accessible to the project management team, for example, to use the reminder system (eg, reminders to complete the questionnaire). During the analysis of the results, it was not possible at any time to link the identity of the test participants to the available data. No identification of individual participants in any of the figures or additional material is possible. Patients received no compensation for study participation.

The study was reported using the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) checklist (Multimedia Appendix 3) [39].

In total, 17 reports were included for full-text analysis, finding that patients searching online for CTS information risk encounter incorrect or confusing content [3], which underlines the need for reliable education programs. An overview of the results is presented in Table 1.

Between April 2022 and April 2023, 30 patients were enrolled in each group. Figure 2 displays a flowchart of patients including the reasons for dropout.

Ultimately, both the test and the control group comprised of 18 patients each, whose characteristics are summarized in Table 2.

The average educational phase duration (CTS Academy platform or self-directed online information seeking) was 167 (range 43-267) days, from inclusion to 176 (range 43-253) days postoperatively.

Outcomes of the primary parameter and its subtypes are presented in Table 3 and Table 4.

In the test group, we found a statistically significant decrease in the group means for APPLY (P=.006) and COMM (P=.02) after using the CTS Academy, compared with baseline. However, we found no statistically significant difference regarding the COMPR subparameter. An overview of statistically significant postoperative changes on item-level is provided in Multimedia Appendix 4. In the control group analysis, we found no statistically significant difference.

In the comparison between the test and control group, significantly higher APPLY values were found in the test group during the follow-up assessment (P=.04). For COMPR, we found the test group had significantly fewer problems with comprehension of medical information at baseline (P=.03).

We found a statistically significant difference between the groups on the combined dependent variables at follow-up (P=.05). In the subsequent post hoc univariate ANOVA for each dependent variable (between-participant effects), we found a statistically significant difference between the groups for APPLY in the follow-up examination (P=.007).

As lower means indicate better results, we found the CTS Academy yielded good results on the transferability (mean 27, SD 9.74) and the medical information scale (mean 28, SD 10.12) and scored average results for the amount of medical information provided (mean 58, SD 24.61).

Both groups achieved high accuracy in describing CTS and the surgical procedure at baseline (63/72, 88% vs 62/72, 86% in test group and control group). At follow-up, the test group showed an average accuracy of 92%, with incorrect answers for only 1 statement. The control group yielded an average accuracy of 90% with incorrect answers for all 4 statements. No control group patient answered all statements correctly.

Regarding patients’ preference for using the CTS Academy, 10 out of 18 (56%) patients totally agreed and 6 out of 18 (33%) agreed that they preferred the additional use of the CTS Academy (in addition to the consultation of a medical doctor). Furthermore, 2 patients had no preferences. When asked whether they preferred the CTS Academy over independent online information-seeking, 10 out of 18 (56%) patients totally agreed and 5 out of 18 (28%) agreed, while 3 patients had no preferences.

Patients rated usability with a mean 6.22 (SD 0.82) points (4.67 to 7.00 points), and utility with a mean 6.13 (SD 0.89) points (4.00 to 7.00 points).

The CTS-related symptoms assessed via the BCTQ are displayed in Table 5.

We found no statistically relevant differences between the groups (comparison of groups at baseline: P=.34 [2-sided], follow-up: P=.47 [2-sided], and for DIFF_BCTQ: P=.86 [2-sided]).

This study introduced the CTS Academy to improve patients’ HEL compared with self-directed online information seeking. Significant improvements were observed in the HELP subscales APPLY and COMM within the test group, indicating that the CTS Academy enhances patients’ ability to apply medical information and communicate with health care professionals. Patients in the study group rated both utility (usefulness) and usability (ease of use) of the CTS Academy favorably.

CTS Academy content was evaluated favorably for transferability and medical information, with average ratings for the amount of medical information provided. Development relied on existing research in clinical patient education due to a lack of comprehensive guidelines, potentially affecting perceived content quality [17]. Future improvements could involve personalized pathways based on patient knowledge levels.

Both groups showed strong understanding of CTS etiology before and after the intervention. The test group’s understanding of CTR surgery improved notably, with all participants (N=18) having all answers correct at follow-up. Misconceptions about complete symptom removal persisted in both groups, which might be due to a focus on postoperative recovery over potential complications.

Patients preferred the CTS Academy over self-directed online searches, indicating its value as a reliable information source. We conclude that integrating the CTS Academy into patient education could effectively enhance access to information and understanding of the perioperative situation, complementing discussions with medical professionals during informed consent.

High ratings for utility and usability suggest the platform is user-friendly and effective for CTR day surgery.

No significant differences were found between groups regarding perceived symptom severity or functional status, reflecting consistent surgical intervention.

The CTS Academy is the first web-based patient education program for CTS. No direct comparisons in medical literature are available, especially because no comparable programs have health education as primary outcome. Future updates to the CTS Academy will focus on restructuring content and enhancing readability and comprehensibility. The platform has the potential to evolve into an educational program with user accounts, enabling patients to follow structured, personalized learning paths. The integration of technologies such as artificial intelligence could further personalize and enhance the learning experience. Another future goal of this project is expanding the platform to include multiple languages relevant to clinical practice at our hospital.

Patient education is crucial for day surgery, as it helps prevent adverse events and rehospitalization [57]. Pekonen et al [58] conducted a systematic review on tools for measuring patient empowerment after patient education interventions. While the Health Education Impact Questionnaire is well-established [59], the HELP questionnaire specifically addresses HEL. Because the latter not just assesses knowledge acquisition but also patients’ ability to apply and understand educational interventions, it was deemed more appropriate for the CTS Academy study.

A publication by Farin-Glattacker et al [28] assessed HEL using the HELP questionnaire as an outcome measure in patients undergoing rehabilitation for chronic back pain or osteoarthritis [60]. The study group stated a high level of self-reported HEL, with the average patient experiencing slight difficulty on the APPLY and COMM scales, and slight to moderate difficulty on the COMPR scale [9]. It aligns with the findings from the CTS Academy that difficulty in understanding medical terminology appears to be a common challenge [61-64].

Regarding computer-based education on CTS, a randomized study compared knowledge levels and satisfaction scores between patients receiving the same information either using computer-based education or using face-to-face education with a medical doctor. Ultimately, the computer-based education group scored significantly higher on the knowledge questionnaire [35].

In total, 2 previous publications focused on the topic of structured web-based patient education versus self-directed online information seeking. Finkelstein and Bedra [65] conducted this comparison on hypertension knowledge in 60 patients with hypertension. The test group used a structured web-based patient education program on hypertension, while the control group searched the internet for information. The test group showed significantly higher hypertension knowledge scores compared with the baseline and compared with the control group. Semistructured interviews indicated a better learning experience in the test group, particularly for those with limited computer and internet experience. Castro et al [66] found comparable results in a similar cohort study. Thus, both concluded that web-based patient education was effective for hypertension learning, even for participants with limited internet experience [65,66].

Although health literacy is often seen as empowering, it does not automatically lead to empowerment [67]. Health education is crucial for promoting health literacy [67], with health knowledge being a key dimension [68,69] according to the conceptual model of health literacy by Sørensen et al [70]. Low health literacy levels are associated with poorer health outcomes, increased morbidity and mortality [71], highlighting the importance of patient education. Several studies have proven that multimedia education programs can improve health knowledge, such as in patients with type 2 diabetes [72]. Despite existing literature on digital health interventions for improving health literacy, only few studies specifically measure health literacy outcomes, often focusing on knowledge-related outcomes instead [73]. This distinction underscores the importance of CTS Academy’s focus on HEL.

Various publications on web-based patient education address the quality and readability of online educational materials, but few compare structured web-based patient education and self-directed online information seeking. Many examined online resources presenting orthopedic, trauma surgery, pediatrics, or cardiology content [74-76] exceed the recommended sixth-grade reading level [77], posing comprehension challenges. The quality and accuracy of online educational resources varies, with those authored by medical professionals only being slightly better than those authored by commercial organizations or laypersons [44,48,54]. Due to a lack of structured analyses of German educational online resources, quality and accuracy of online information for German-speaking CTS patients cannot be assessed. However, studies indicate that more than one-third of German-speaking orthopedic patients used the internet before their hospital appointment, and 80% (63/79) of these patients intended to gain additional knowledge of their condition and treatment options. The majority of patients performing self-directed online information seeking would recommend it to other orthopedic patients [78]. Hertling et al [79] reports that 66% (832/1262) of orthopedic patients used the internet as a source of disease-related information, and the majority found the information trustworthy and useful. However, it is unclear whether patients can assess the reliability and correctness of online information and identify incorrect information [79]. While both studies indicated widespread use and acceptance of online sources among German orthopedic patients, the quality of the information sources remains unexamined.

Comparing the comprehensibility of CTS Academy content with other programs using the COHEP questionnaire is challenging due to differing contexts. Existing studies by Farin-Glattacker et al [28], Nagl et al [60], and Finkelstein et al [65] focused on different patient populations and did not provide detailed comparative data.

Patients provided positive feedback on CTS Academy’s usability and utility, appreciating its design and functionality, facilitating effective access and utilization of educational materials. Overall, these findings suggest that the CTS Academy is a valuable tool for educating and supporting patients undergoing day surgery for CTR.

In our study, we collected postoperative clinical parameters 3 weeks after CTR. Our clinical results align with the ones published by Mack et al [80] at 10‐14 days postoperatively and Kim et al [81] and Aloi et al [82] at 14 days postoperatively, despite slight differences in patient characteristics and surgical approaches.

This study also involves several limitations. The study was affected by COVID-19, especially by prolonged surgery waiting times leading patients to cancel their surgery appointments. This led to a smaller sample size than intended, potentially biasing our results. Furthermore, the patient-performed allocation process may have introduced selection bias. Moreover, group sizes were relatively small, potentially affecting the generalizability of the results. We did not ask patients to monitor the duration of information-seeking or the frequency of use of the CTS Academy. In addition, the quality of information accessed by the control group was not controlled, which could have influenced their outcomes and skewed comparisons with the intervention group. However, both groups completed identical baseline questions on CTS before accessing the platform content or other online resources, ensuring a basic understanding of the scope of information. These questions required basic knowledge, independent of the depth of research or exclusive platform content. This highlights a common challenge in independent online research, that is, patients struggle to identify essential information, and available content can be difficult to interpret. While the test group benefited from a patient-centered platform design, this advantage did not extend to the fundamental information itself. To preserve the natural research and learning process, patients were not required to document their sources, as this might disrupt their learning experience. For privacy reasons and to prevent artificially inflated research activities, browser histories were not collected to avoid potential identification or bias. In future research, randomization allocation to either the test or control group should be conducted to further investigate effects of the CTS Academy platform on HEL, ensuring that the results are not affected by a selection bias. In terms of usability, common usability testing guidelines report that 5 participants already detect almost all of the possible errors in a product [83]. Therefore, the usability conclusions can be seen as valid despite of the generally decreased study’s power and generalizability.

Knowledge is commonly measured as a primary outcome in patient education programs for its ease of pre and post comparisons. However, the ability to apply knowledge in daily life is crucial for effective self-management. Health literacy models emphasize both knowledge and its practical application. Hence, we recommend a comprehensive evaluation for patient education programs, beyond knowledge assessments. Our findings highlight the effectiveness of our educational intervention for patients undergoing CTR day-surgery. Despite challenges in comparing outcomes with other studies, statistical analysis favored the CTS Academy in improving overall HEL. Therefore, we rejected the null hypothesis, confirming the platform’s efficacy over self-directed online information seeking. Future research could explore the quality of German-language online educational resources by having patients document and analyze their information sources. In addition, the effectiveness of the CTS Academy following its implementation at the Department of Orthopedics and Traumatology could be assessed. Investigating patient preferences and the utility of each specific chapter could help identify the most relevant educational needs and could be analyzed on item-level of each HELP or COHEP subscale for a granulated evaluation of patients’ learning experience.