Zurich Open Repository andArchiveUniversity of ZurichMain LibraryStrickhofstrasse 39CH-8057 Zurichwww.zora.uzh.chYear: 2015Effects of art on surgical patients: a systematic review and meta-analysisVetter, Diana ; Barth, Jürgen ; Uyulmaz, Sema ; Uyulmaz, Semra ; Vonlanthen, René ; Belli, Giulio ;Montorsi, Marco ; Bismuth, Henri ; Witt, Claudia M ; Clavien, Pierre-AlainAbstract: OBJECTIVES: The aim of the study was to assess the effect of art including ambient featuressuch as music, interior design including visual art, and architectural features on health outcomes insurgical patients. BACKGROUND: Healing environments can have a positive influence on many patients,but data focusing on art in surgical patients remain scarce. METHODS: We conducted a systematic searchfollowing the PRISMA guidelines from January 2000 to October 2014 on art in surgical patients. Formusic interventions, we pooled controlled studies measuring health outcomes (eg, pain, anxiety, bloodpressure, and heart rate) in a meta-analysis. For other art forms (ambient and architectural features andinterior design), we did a narrative review, also including nonsurgical patients, and looked for examplescovering 3 countries. RESULTS: Our search identified 1101 hits with 48 studies focusing on art in surgicalpatients: 47 studies on musical intervention and 1 on sunlight. The meta-analysis of these studies disclosedsignificant effects for music on pain after surgery, anxiety, systolic blood pressure, and heart rate, whencompared with control groups without music. Effects of music were larger with self-selected music,and lower in surgical interventions performed under general anesthesia. Interior design features such asnature images and more spacious rooms, and architectural features providing more sunlight had positiveeffects on anxiety and postoperative pain. CONCLUSIONS: Self-selected music for surgical patientsis an effective and low-cost intervention to enhance well being and possibly faster recovery. Althoughpotentially very important, the impact of environmental features and spacious architecture with wideaccess to sunlight remains poorly explored in surgery. Further experimental research is needed to betterassess the magnitude of the impact and cost effectiveness.DOI: https://doi.org/10.1097/SLA.0000000000001480Posted at the Zurich Open Repository and Archive, University of ZurichZORA URL: https://doi.org/10.5167/uzh-119262Journal ArticlePublished VersionOriginally published at:Vetter, Diana; Barth, Jürgen; Uyulmaz, Sema; Uyulmaz, Semra; Vonlanthen, René; Belli, Giulio; Montorsi, Marco; Bismuth, Henri; Witt, Claudia M; Clavien, Pierre-Alain (2015). Effects of art on surgicalpatients: a systematic review and meta-analysis. Annals of Surgery, 262(5):704-713.DOI: https://doi.org/10.1097/SLA.0000000000001480
SPECIAL ESA LECTURE 2015Effects of Art on Surgical Patients: A SystematicReview and Meta-analysisDiana Vetter, MD, Jürgen Barth, PhD,y Sema Uyulmaz, MD, Semra Uyulmaz, MD, René Vonlanthen, MD, Giulio Belli, MD,z Marco Montorsi, MD,§ Henri Bismuth, MD,ô Claudia M. Witt, MD, MBA,yjjand Pierre-Alain Clavien, MD, PhD, FACS (Hon) ôObjectives: The aim of the study was to assess the effect of art includingambient features such as music, interior design including visual art, andarchitectural features on health outcomes in surgical patients.Background: Healing environments can have a positive influence on manypatients, but data focusing on art in surgical patients remain scarce.Methods: We conducted a systematic search following the PRISMA guidelines from January 2000 to October 2014 on art in surgical patients. For musicinterventions, we pooled controlled studies measuring health outcomes (eg,pain, anxiety, blood pressure, and heart rate) in a meta-analysis. For other artforms (ambient and architectural features and interior design), we did anarrative review, also including nonsurgical patients, and looked for examplescovering 3 countries.Results: Our search identified 1101 hits with 48 studies focusing onart in surgical patients: 47 studies on musical intervention and 1 onsunlight. The meta-analysis of these studies disclosed significant effectsfor music on pain after surgery, anxiety, systolic blood pressure, andheart rate, when compared with control groups without music. Effects ofmusic were larger with self-selected music, and lower in surgical interventions performed under general anesthesia. Interior design features suchas nature images and more spacious rooms, and architectural featuresproviding more sunlight had positive effects on anxiety and postoperativepain.Conclusions: Self-selected music for surgical patients is an effective andlow-cost intervention to enhance well being and possibly faster recovery.Although potentially very important, the impact of environmental featuresand spacious architecture with wide access to sunlight remains poorlyexplored in surgery. Further experimental research is needed to better assessthe magnitude of the impact and cost effectiveness.Aesthetic mattersAttractive things work betterDon Norman, Designer and AuthorUniversity of California, San DiegoFrom the Department of Surgery, University Hospital and University of Zurich,Zurich, Switzerland; yInstitute for Complementary and Integrative Medicine,University Hospital and University of Zurich, Zurich, Switzerland;zDepartment of Hepatopancreaticobiliary Surgery, Ospedale S. Maria diLoreto Nuovo, Naples, Italy; §Humanitas Research Hospital and University,Milan, Italy; ôHôpital Paul Brousse, Université Paris Sud, Paris, France; andjjInstitute for Social Medicine Epidemiology and Health Economics, CharitéUniversitätsmedizin, Berlin, Germany.First and second author contributed equally.Supplemental digital content is available for this article. Direct URL citationsappear in the printed text and are provided in the HTML and PDF versions ofthis article on the journal’s Web site (www.annalsofsurgery.com).Grant support: The study was supported by Liver and Gastrointestinal DiseaseFoundation (http://lgidfoundation.ch).Disclosures: The authors have nothing conflicts of interest.Reprints: Pierre-Alain Clavien, MD, PhD, Department of Surgery, UniversityHospital of Zurich and University of Zurich, Rämistrasse 100, 8091 Zurich,Switzerland. E-mail: [email protected] ß 2015 Wolters Kluwer Health, Inc. All rights reserved.ISSN: 0003-4932/14/26105-0821DOI: 10.1097/SLA.0000000000001480Surgery not only has an important physical impact on patients,but the loss of control, waiting periods for surgery, postoperativepain, and gradual recovery, as well as thoughts on temporary orlasting disability cause significant psychological stress. Althoughpatient tolerance to surgery varies according to the extent of theintervention, many patient-related factors play a major role depending on individual stress levels, catastrophizing mechanisms, andstress-management capabilities of patients.1Stress responses can be assessed using standardized instruments with high reliability. Stress responses compromise patients’ability to cooperate, and can, for example, lead to sleep disruptionand delay gastric emptying with a risk of broncho-aspiration.2They also increase the metabolism and oxygen consumption,as well as the probability of thromboembolic events and impairwound healing.3 The affective state of the patient (ie, anxietyand depression) alters the endocrine and metabolic function witha higher sympathetic tone, and therefore may increase heart rateand systolic blood pressure.4 Anxiety and pain-reducing therapieshave been shown to reduce perioperative morbidity5 andmortality6 in surgical patients. Thus, other modalities reducingstress responses represent a valuable approach to improveperioperative well being.Although the term ‘‘healing environment’’ is often used, it isnot uniformly defined. It suggests that the physical environment ofthe health care setting may improve the healing process and patients’feeling of well being.7,8 Art should be part of a healing environment,and is also difficult, if not impossible, to define. For the purpose ofthis study, we understand art as architectural features, ambientfeatures, as well as a variety of interior design features includingpictures, paintings, sculptures, and so on.Although possibly widely used and advocated, there is surprisingly little evidence for the benefit of art in surgical patients.9,10Ulrich’s study published in 1984 pointed out the importance of a viewon trees and landscape for an improved recovery from surgery. Hecompared patients after cholecystectomy from one ward looking outonto trees with a group of patients from another ward looking at abrick wall, and found a significant reduction of analgesic use andearlier discharge in the group looking at the landscape.11 Thus, if achange in environment can achieve such an impact, the effect ofmany art features and interventions on patients might also contributeto positive health outcomes.We therefore systematically reviewed the literature from 2000onward to compile the evidence of exposure to art divided inarchitectural features, interior design, or ambient features, such asmusic,12 during the perioperative period. We investigated whether artcan influence patients’ health, as assessed by anxiety, pain, and704 www.annalsofsurgery.comAnnals of Surgery Volume 262, Number 5, November 2015Keywords: art, intervention, meta-analysis, music, pain, surgery(Ann Surg 2015;262:704–713)Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 5, November 2015Effect of Art on Surgical Patientsphysiological parameters. Finally, we report on recent examples ofart in medicine and surgery.unclear, a consensus was found with a senior researcher. One studywas totally14 and 4 were partially15– 18 excluded for certain endpointsdue to ambiguous statistical information. One study about the effectof sunlight on patient outcome was not included in the meta-analysis.We finally included 47 studies on perioperative music interventionsin the meta-analysis (Supplemental Digital Content 1, http://links.lww.com/SLA/A861).15–61MATERIALS AND METHODSTo answer our research questions, we combined 2 approaches:(1) a systematic review and meta-analysis, mainly on music asintervention; and (2) a narrative review on other forms of art andthe effect on patients.Systematic Review and Meta-analysisLiterature SearchOur literature search aimed at controlled clinical studiesinvestigating the role of art in surgical patients. We used PubMedand combined keywords, with text words related to surgical interventions, controlled trials, and any kind of art. The performedsystematic search in PubMed from January 2000 to October 2014resulted in 1101 references, which were stored in the referencedatabase software EndNote X7 (Thomson Reuters, Philadelphia,PA). For the present meta-analysis, all references related to thesearch terms were considered for inclusion. We further handsearched promising journals such as ‘‘Journal Health&Place’’ andthe ‘‘Nordic Journal of Music Therapy,’’ both of which were negativefor articles of interest. In the journal ‘‘Journal of Music Therapy,’’ wefound 2 additional hits that were later excluded after full-text screening. One further reference on natural lighting in surgical patients13was found while screening review articles.Inclusion CriteriaWe included controlled trials comparing all kinds of art, with ano-art exposure in surgical adult patients with clinically relevantoutcomes including pain, anxiety, and physiological parameters.Studies available on music compared music versus no music before,during, or after surgery. The music intervention had to be within 24hours of surgery; otherwise, it was considered as separate therapeuticintervention. In case of more than two intervention groups (eg, nomusic, other type of music, and white noise), we selected the groupsclosest to music versus no music intervention. If one dataset waspublished in different publications, we merged the available information into one dataset. Studies on music as part of a complexintervention strategy, such as music therapy with active participationof the patient, were excluded.Study SelectionFollowing the Preferred Reporting Items of Systematicreviews and Meta-Analyses (PRISMA) guidelines (PRISMA Statment, http://www.prisma-statement.org), of 1101 references, titlesand abstracts were identified and screened for inclusion by 4independent coders (S.U., Sr.U., D.V., and J.B.) in Endnote versionX7 with a structured manual (the manual is available on request fromthe corresponding author). For training purposes and interrateragreement evaluation, a random sample of 5% of all referenceswas independently rated by all coders. The percentage of agreementfor the reasons of exclusion was larger than 75%, and all ratersidentified the same studies for a full-text screening. During thescreening, raters were able to mark references as unclear. In suchcases, a definite decision was taken by consensus with a seniorresearcher (J.B. and D.V.). Of the 1101 screened references, 87 wereof interest to us. Seventy-nine of those references were available inthe full text. Each full text was screened independently for inclusionby 2 of the 4 authors (S.U., Sr.U., D.V., and J.B.) following theinclusion criteria presented above, and data were collected in Excelversion 14.3.9 (Microsoft Corporation, Redmond, WA). Discrepancies were checked by a fifth coworker (I.M.), corrected, and, ifß2015 Wolters Kluwer Health, Inc. All rights reserved.Outcome MeasuresWe looked at 3 outcome domains in our meta-analysis: first,pain, measured by the visual analog scale (VAS) and required painmedication; second, anxiety, assessed by the State-Trait AnxietyInventory (STAI) or VAS; and third, physiological parameters(systolic blood pressure and heart rate). Every single outcome ofinterest was measured after both the surgical and the music intervention. The meta-analyses were performed for these 5outcomes, separately.Moderators of Treatment EffectsWe extracted potential moderators for treatment effects forstratified meta-analyses. The study quality was assessed with thefollowing three criteria: (1) blinding (adequate blinding of outcomeassessors vs not/unclear); (2) intention-to-treat analysis (used vs not/unclear); and (3) randomization (adequate generation of sequenceand adequate allocation of patients vs not/unclear). Clinical moderators as proxies for the extent of the surgery were as follows: (1) thetype of anesthesia (local and regional vs general anesthesia); and (2)inpatient vs outpatient surgical treatment. The moderator of selfselected vs preselected music (by study personnel) was used to lookat the importance of personalized music.AnalysisBetween-group effect sizes (ES) were calculated from thedifference of posttreatment means of the intervention group and thecontrol group, and dividing this difference by the pooled SD(Cohen’s d). In case of missing information in the publication, weestimated ES according to established procedures.62 An ES of 0.20indicates a small effect, 0.50 a medium effect, and 0.80 a large effectbetween groups.63All statistical analyses were done with STATA 12 by thecommand metan and metareg.64 The reported summary statisticswere calculated as random-effects models based on the assumptionof heterogeneity between studies. Pooling was done according to theDerSimonian and Laird method,65 using inverse variance of theprimary studies as implemented in the command metan in STATA(StataCorp LP, College Station, TX).Heterogeneity between the studies was assessed by examiningforest plots of studies and through I2 statistics. The I2 value, rangingfrom 0% to 100%, indicates the magnitude of between-study heterogeneity. I2 values of 25% indicate low, 25% to 50% moderate,and 50% to 75% high heterogeneity.66 The presence of a publicationbias was examined using funnel plots and the Egger regression test.67Narrative ReviewPubMed was screened and we found studies on room design(n ¼ 5), color (n ¼ 1), light (n ¼ 2), music (n ¼ 32), and sound (n ¼ 8),in combination with patients’ health or recovery. This search was notlimited to surgical patients and also did not have a time limit.RESULTSSystematic Review on Art and SurgeryAll 47 studies included in the meta-analysis were controlledtrials assessing the effect of music before (n ¼ 26), during (n ¼ 25), orwww.annalsofsurgery.com 705Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Vetter et alAnnals of Surgery Volume 262, Number 5, November 2015after (n ¼ 25) the surgical intervention on pain, pain medication,anxiety, blood pressure, and heart rate (Supplemental DigitalContent 2, http://links.lww.com/SLA/A861). Music was listenedto at more than one time point (before, during, and after surgery)in 21 studies. Twenty studies were conducted in an inpatientsetting, 18 in an outpatient setting, whereas 9 studies provided noreliable information about the setting. In 18 studies, patients receivedgeneral anesthesia only and in 12 studies, local or regionalanesthesia. Nine studies included patients with a combination ofgeneral and local anesthesia. One study did not apply any anesthesia,and 7 studies provided unclear information on the type of anesthesia(Supplemental Digital Content 2, http://links.lww.com/SLA/A861).Information on basic analgesia and medication like daily intakeof acetaminophen or opioids was only given in 14 (30%) of the47 studies, and only 1 of these 14 studies included patients withbasic analgesia, but matched their patients for basic analgesia intake.In 17 (36%) of 47 studies, music was preselected by the studydesigners; in the remaining 30 studies, patients selected music from aprovided collection of music (n ¼ 25) or brought their own music(n ¼ 5) (Supplemental Digital Content 2, http://links.lww.com/SLA/A861). Thirty studies assessed pain, of which 4 focused on the use ofmedication, 17 assessed pain through VAS only, and 9 studiesaddressed both pain medication and VAS score. Thirty-one studieslooked at the effect of music on anxiety. This was measured either bySTAI (n ¼ 16), VAS (n ¼ 7), or both VAS and STAI (n ¼ 3). Fivestudies did not report how anxiety was measured, and were thereforeexcluded for this analysis. Physiological parameters such as systolicblood pressure or heart rate were assessed in 30 of these studies(Supplemental Digital Content 2, http://links.lww.com/SLA/A861).Only few studies additionally looked at laboratory parameters(n ¼ 13) or hospital stay (n ¼ 7).(ES ¼ 0.34, 95% CI 0.51 to 0.17, I2 ¼ 63.9%). Systolic bloodpressure was reduced in patients receiving a music intervention(ES ¼ 0.40, 95% CI 0.59 to 0.21, I2 ¼ 76.8%), and also heartrate (ES ¼ 0.27, 95% CI 0.44 to 0.10, I2 ¼ 75.6%) (Fig. 1).In summary, all outcomes were improved with a significantclinical effect of about 0.30 by music intervention comparedwith controls without music intervention. However, theES between studies varied considerably (moderate-to-largeheterogeneity), and we therefore grouped the studies according tostudy characteristics (ie, methodological quality, clinical characteristics) to see whether differences in effects can be explained bythese characteristics.Overall Effectiveness of Perioperative Music on Pain,Anxiety, and Physiological ParametersMusic was effective to reduce pain after surgery (ES ¼ 0.31,95% confidence interval (CI) 0.46 to 0.17, I2 ¼ 62.7%), andconsequently pain medication was lower in patients who wereexposed to music (ES ¼ 0.28, 95% CI 0.45 to 0.11,I2 ¼ 38.2%) (Fig. 1). Additional data for all analyses are availablefrom the authors. The effect of music on anxiety was similarEffectiveness of Perioperative Music According toMethodological QualityThe quality of the studies according to our three qualityindicators showed some problems in study design or reporting.Thirteen of the 47 studies reported adequate blinding of outcomeassessors, but only 2 of the 47 studies mentioned the use of an intentto-treat analysis. Thirty-nine (83%) of the 47 studies did a properrandomization with an externally generated randomization sheet andwithout any possibility to foresee the allocation of the next patient. Inreality, the study might have used proper methodology, but thereporting quality of the study was low. The use of ConsolidatedStandards of Reporting Trials (CONSORT) criteria68 would behighly desirable for the reporting of studies on art in surgery, andthe problem of missing data and blinding of outcome assessorsrequires further attention.Stratified Analysis for Clinical Characteristics of theSurgical ProcedureWe meta-analyzed the studies stratified for 2 clinical characteristics as proxies for the severity of the surgical intervention: (1)studies using general anesthesia were compared to studies usingother type of anesthesia; and (2) studies using music in inpatient oroutpatient setting were compared.The positive effect of perioperative music on pain, asmeasured by VAS, persisted in studies where surgery was performedunder general anesthesia (ES ¼ 0.29, 95% CI 0.46 to 0.12).However, the effect on pain medication substantially decreasedFIGURE 1. Perioperative music has apositive effect on pain, anxiety, andphysiological parameters. This figuresummarizes the findings of the metaanalysis on perioperative music on pain,anxiety, and physiological parametersafter surgery. Music was effective toreduce pain and consequently decreasedthe demand for pain medication. Theeffect of music on anxiety was similar.Further, systolic blood pressure and heartrate were reduced in patients receiving amusic intervention.706 www.annalsofsurgery.comß2015 Wolters Kluwer Health, Inc. All rights reserved.Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 5, November 2015Effect of Art on Surgical PatientsFIGURE 2. Perioperative music forpatients with general anesthesia has alower effect on pain medication requirement and physiological parameters. Thisfigure summarizes the findings of themeta-analysis on perioperative musicon pain, anxiety, and physiologicalparameters after surgery in patientsreceiving a surgical intervention in localor regional anesthesia, compared topatients receiving general anesthesia.Perioperative music reduced pain, painmedication, anxiety, and blood pressureand heart rate in patients with local andregional anesthesia. The positive effect ofmusic was lost for pain medication, systolic blood pressure, and heart rate inpatients with general anesthesia.(ES ¼ 0.09, 95% CI 0.28 to 0.10) and was no longer statisticallysignificant (P 0.03) (Fig. 2). For anxiety, only one single studyprovided data with general anesthesia showing a positive effect.52The positive effect of perioperative music on systolic blood pressurewas present in patients with regional and local anesthesia(ES ¼ 0.48, 95% CI 0.69 to 0.28), but not in patients receivinggeneral anesthesia (ES ¼ 0.04, 95% CI 0.35 to 0.41) (Fig. 2).Similarly, we found a positive effect of perioperative music on heartrate in patients with regional and local anesthesia (ES ¼ 0.33, 95%CI 0.54 to 0.13), but not in patients receiving general anesthesia(ES ¼ 0.05, 95% CI 0.26 to 0.16) (Fig. 2). There were, however,no differences in any outcome in the effects of music interventionbetween inpatient and outpatient settings.Stratified Analysis for Self-selected Versus PreselectedMusicOverall, the effects of music interventions on different outcomes were most often larger in studies with self-selected music bythe respective patients (Fig. 3). Self-selected music was more efficacious on pain (ES ¼ 0.35, 95% CI 0.52 to 0.17) than preselectedmusic (by the study personnel) (ES ¼ 0.26, 95% CI 0.53 to 0.01).Similar differences in ES were found for pain medication(ES ¼ 0.34, 95% CI 0.65 to 0.03 vs ES ¼ 0.19, 95% CI 0.37 to 0.00). The largest difference in ES was found for anxiety.Studies with self-selected music had a significant and moderateeffect size (ES ¼ 0.47, 95% CI 0.61 to 0.33), but studies withpreselected music failed to show an effect on anxiety (ES ¼ 0.06,95% CI 0.44 to 0.32). No meaningful difference was found onblood pressure between studies with self-selected (ES ¼ 0.37, 95%CI 0.60 to 0.15) and preselected music (ES ¼ 0.45, 95% CI 0.84 to 0.05). Similarly, the magnitude of the effect of music onheart rate was comparable between self-selected (ES ¼ 0.26, 95%CI 0.43 to 0.09) and preselected music (ES ¼ 0.24, 95% CI 0.62 to 0.14).ß2015 Wolters Kluwer Health, Inc. All rights reserved.Narrative Review on the Impact of ArchitecturalFeatures, Interior Design, or Ambient Features onPatients’ HealthWe found very few studies on the effect of different art formson surgical patients beyond music. We performed a narrative reviewon art in other patient groups looking for a broader picture of thepotential effect of different art forms on medical patients. We adaptedthe art definition from the study by Harris et al,12 including architectural features, interior design features, and ambient features.Architectural features are rather permanent characteristics, such asthe spatial layout of a hospital, room size, and window placement.Interior design features are defined as less permanent elements, suchas furnishings, colors, and artwork. Ambient features compriselighting, noise levels, odors, and temperature. We assume that thepositive effects of art on anxiety and pain are caused by positivedistraction, which should affect surgical and nonsurgical patients in asimilar way.Regarding architectural features, providing a spacious, friendly,light-flooded hospital architecture may improve patient health,as measured by patient activity, pain, anxiety, and even mortality.Remodeled wards were able to improve socializing and lead to moreactive behavior.69–74 Such data were observed predominantly inpsychiatric patients by observing behavior and a standardized checklist(Norristown Behavior Checklist [NBC]).69–72 Furthermore, 4 studiesshowed beneficial effects of sunlight on perceived stress, pain, thelength of stay, and mortality.13,75–77 In a prospective study on 90patients with spinal surgery, sunlight decreased stress, pain, and theneed for postoperative analgesic medication and eventually costs.13 Aretrospective study on more than 550 myocardial infarction patientslooked at the effect of sunlight exposure on patient outcome. Patientslying on the sunny side of an intensive care unit (ICU) had a shorterhospitalization time and even lower mortality rates (13.2% vs 7.7%,P 0.005), as compared to the patients lying on the dull side of thesame ICU.77www.annalsofsurgery.com 707Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 262, Number 5, November 2015Vetter et alFIGURE 3. Personalized perioperativemusic increases the positive effect ofmusic on pain, anxiety, and physiologicalparameters. This figure summarizes thefindings of the meta-analysis on perioperative music on pain, anxiety, andphysiological parameters after surgeryin patients receiving a surgical intervention, depending on whether the musicwas self-selected or experimenterselected. Self-selected music significantlyreduced pain, pain medication, anxiety,and systolic blood pressure and heartrate. The positive effect of preselectedmusic was limited to reducing the bloodpressure.Welcoming interior design for family members was able toimprove patient support by their relatives on ICUs.78 Regardingvisual art, one study investigated patients recovering from open heartsurgery exposed to a nature image, an abstract image, or a blank pieceof paper. Patients exposed to the nature image experienced significantly less postoperative anxiety than the other 2 groups (P 0.01).They were also significantly more likely to switch from stronganalgesics to weaker pain killers during their recovery. Of note,the patients exposed to an abstract image experienced more anxietythan those with no image.79 The positive effect of nature images wassupported in a randomized controlled trial of patients undergoingflexible bronchoscopy.80 Patients looking at nature themes had lesspain than those looking at no theme.80 Furthermore, ‘‘magic windows’’ presenting scenes from nature installed on the ceilings andwalls in the waiting area and hallways increased patient satisfaction.81 The positive effect is, however, not limited to nature images.Several studies looked at the effects of different kinds of art onpatients.74,79 In a retrospective evaluation on the impact of an artcollection on patient mood, comfort level, and stress level, thosepatients who noticed the artwork had improved mood, lower stress,and reported that the art collection positively impacted their overallsatisfaction with and impression of the hospital.82 Interestingly,adding comfort as well as selected art work or ‘‘décor’’ to patientrooms83 or waiting areas84 also improved the satisfaction of patientswith their physician, and also with their overall hospital experience.83No health outcome data were, however, reported.Regarding color, there is no evidence that one single coloraffects our bodies and emotions in the long term.85 Bright (illumination), saturated (vivid) colors of low hue (wavelength), like blueand green, however, elicit high levels of pleasure and low levels ofarousal, and thereby may induce a state of calm.86 This is supportedby the observation that blue and green induce lower increase in heartrate and respiratory rate than red and yellow.87Of the ambient features, music has the strongest evidence foran effect on patients’ health. In addition to the positive effect ofperioperative music on pain, anxiety, and physiological parameters,as identified in our meta-analysis, noise reduction has also beenshown to have positive effects.88–91 In 94 consecutive patients o
following the PRISMA guidelines from January 2000 to October 2014 on art in surgical patients. For . architectural features on health outcomes in surgical patients. . One further reference on natural lighting in surgi