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Université de Montréal Objective and Structured Checklist for Assessment of Audiovisual Recordings of Surgeries/techniques (UM-OSCAARS): a validation study

Background Use of videos of surgical and medical techniques for educational purposes has grown over the last years. To our knowledge, there is no validated tool to specifically assess the quality of these types of videos. Our goal was to create an evaluation tool and study its intrarater and interrater reliability and its acceptability. We named our tool UM-OSCAARS (Université de Montréal Objective and Structured Checklist for Assessment of Audiovisual Recordings of Surgeries/techniques). Methods UM-OSCAARS is a grid containing 10 criteria, each of which is graded on an ordinal Likert-type scale of 1 to 5 points. We tested the grid with the help of 4 voluntary otolaryngology – head and neck surgery specialists who individually viewed 10 preselected videos. The evaluators graded each criterion for each video. To evaluate intrarater reliability, the evaluation took place in 2 different phases separated by 4 weeks. Interrater reliability was assessed by comparing the 4 top-ranked videos of each evaluator. Results There was almost-perfect agreement among the evaluators regarding the 4 videos that received the highest scores from the evaluators, demonstrating that the tool has excellent interrater reliability. There was excellent test–retest correlation, demonstrating the tool’s intrarater reliability. Conclusion The UM-OSCAARS has proven to be reliable and acceptable to use, but its validity needs to be more thoroughly assessed. We hope this tool will lead to an improvement in the quality of technical videos used for educational purposes.

I n this age of electronics and communication, emerging technologies are the key to education in modern medicine. Medical education must evolve at the same pace as the digitally oriented world in which we live. One of the pioneers in this field has been the Stanford University School of Medicine, which collaborated with the Khan Academy to develop a flipped classroom model, where students learn from home with a series of short videos and do their homework in the classroom. 1 It is common practice to offer educational alternatives to medical students, and the use of videos seems to meet the needs of the current digital generation of learners. 2 In a pilot study evaluating the impact of otology surgery videos in otolaryngology residency education, residents considered the videos highly useful and perceived them as a high priority for a resident's surgical preparation. 3 A recent study evaluating the impact of a flipped-classroom, video-based surgical curriculum on the surgical skills of dermatology residents showed that the use of videos in that model significantly improved the residents' surgical ability as measured by an objective structured assessment of technical skills (OSATS) instrument on simulation models. 4 Production of videos showing technical procedures or surgical techniques is gaining in popularity, as witnessed by the increase in the number of articles accompanied by videos being published in peer-reviewed journals and the number of video sessions being held at international conferences. However, surgical skills and expertise do not always carry over into skilful video production. Some articles have been published that provide guidance to clinicians on how to optimize the quality of educational videos. 5,6 However, to the best of our knowledge, there are no validated tools to assess the quality of surgical and technical videos, even though their use for educational purposes has been democratized with free online resources. Our objectives were to develop a tool to assess the quality of videos focusing on surgical procedures or medical techniques and to study its intra rater reliability, interrater reliability and acceptability.

Creation of the tool
We created an evaluation tool for videos about surgical procedures and medical techniques in the form of a checklist we named the Université de Montréal Objective and Structured Checklist for Assessment of Audiovisual Recordings of Surgeries/techniques (UM-OSCAARS). The checklist was developed by 4 expert surgeons and 1 audiovisual professional. The 4 expert surgeons were otolaryngology -head and neck surgeons who had produced videos depicting surgeries and techniques for publication or teaching purposes. The criteria were chosen through the use of a modified Delphi method with a series of 3 rounds. The checklist contains 10 criteria focusing on clinical relevance and audiovisual quality, with 5 criteria in each category (Box 1). Each of the criteria are graded on an ordinal Likert-type scale of 1 to 5 points with descriptors for scores 1, 3 and 5 ( Table 1). The descriptors were also part of the validation process, which was done using a modified Delphi method. A more thorough description of each criterion is also provided as a guide to enable users to fully understand each criterion ( Table 2).

Choice of assessors
Four otolaryngology -head and neck surgery specialists who were not involved in developing the tool volunteered to participate in the project as assessors. These 4 staff phys icians had academic practices in different subspecialties and a wide range of years of experience ( Table 3).

Choice of videos
The senior author (T.A.) chose 10 videos from various sources, including videos from YouTube and ones published in peer-reviewed journals (New England Journal of Medecine, Plastic and Reconstructive Surgery, Head & Neck). The use of videos from a video-sharing website (YouTube) and from peer-reviewed journals created an opportunity to present the assessors with videos of possibly different levels of quality. The senior author (T.A.) selected videos with a range content related to several subspecialties of otolaryngology -head and neck surgery or relevant to a general practice. The characteristics of the selected videos are provided in Table 4. The order in which the videos were shown to the assessors was randomly selected; the order was the same for each assessor. The total viewing time of the 10 videos was 59 minutes and 57 seconds.

Data collection
To assess intrarater reliability, we organized a 2-phase evaluation plan: the evaluation took place in 2 different

3-week phases separated by 4 weeks (test-retest model).
After each evaluation round, namely after the completion of all the evaluation checklists, the assessors had to choose the 3 best videos according to their personal impressions, without looking at the scores they had given to the videos. After the first evaluation round, the assessors were also asked to complete a short acceptability survey regarding the use of the UM-OSCAARS. We evaluated the acceptability of the tool with questions regarding the time required to complete the survey, the relevance of the criteria assessed, the quality of the scoring system and directions and the relevance of the tool in the context of evaluating submissions to a video contest or as a tool for peer review.
To assess interrater reliability, we compared the scores given to each video by the 4 assessors for each criterion. We calculated a correlation coefficient for each of the 10 criteria for the first phase of evaluation and then calculated an overall correlation coefficient that would represent the global interrater agreement for the 10 criteria.
Because we did not have a gold standard tool against which to compare the UM-OSCAARS, we could not thoroughly assess its external validity. We chose to compare the 4 videos that received the highest scores from the assessors with the 4 videos that assessors most frequently ranked among their top 3 videos according to their general impression.

Statistical analysis
We calculated intraclass correlation coefficients (ICCs) with 95% confidence intervals to evaluate intra-and interrater agreement. The formula used to calculate the ICC was a 1-way random effects-absolute agreement-single We calculated a global ICC for each criterion for the first phase of evaluation with the scores of the 4 assessors. We also calculated a global ICC encompassing the 10 criteria. In addition, we calculated the Cronbach α to evaluate the internal consistency of the items in the 2 phases of evaluation. Statistical analysis was performed with SPSS version 24.

Results
All of the assessors' evaluations were included in the analysis. The scores assigned by the assessors to the videos ranged from 11 to 50 (the maximum score was 50) ( Table 5). Table 6 shows the global intrarater correlation of each assessor. Every ICC was greater than or equal to 0.888, indicating almost perfect agreement. The excellent testretest correlation confirmed the intrarater reliability of the UM-OSCAARS.

Interrater reliability
The global ICC of each criterion for the first phase of evaluation varied between 0.352 (lowest value) and 0.770 (highest value). The global interrater agreement of the 10 criteria of the first phase was 0.754, indicating

Spatial orientation
The authors should make every effort to keep the audience spatially oriented, keeping in mind that the audience might not be familiar with the procedure. To do this, the authors could use illustrations, add visual landmarks during the procedure and verbally point out landmarks several times during the video, for example. substantial agreement, which confirms the good interrater reliability of the checklist ( Table 7). The results of the Cronbach α calculations are presented in Table 8. The α values were all above 0.9 except for 1 that was above 0.8, demonstrating good to excellent internal consistency between the items and the 2 phases, according to George and Mallery's rule of thumb (> 0.9 is excellent, > 0.8 is good, > 0.7 is acceptable, > 0.6 is questionable, > 0.5 is poor and < 0.5 is unacceptable). 9

E237
Validity Table 9 shows the 3 top videos ranked by each of the 4 assessors on the basis of their general impression, for each of the 2 phases of evaluation. The videos most often ranked among the top 3 were videos 1, 3, 7 and 10. These 4 videos were also the ones that received the highest mean scores (Table 10). Thus, the evaluation tool correlated well with the general impression of the assessors, which could indicate good external validity.

Acceptability
The assessors all completed the acceptability survey on the use of the UM-OSCAARS less than a week after the end of the first phase of evaluation. All 4 assessors found that they were able to complete the checklist rapidly, that the directions regarding the use of the checklist were adequate and that the criteria were well defined. One assessor would not recommend the use of the checklist for the evaluation of videos for contests or journal publication, even though he found the checklist easy to use and well conceived. This assessor did not provide any information about the reason for this opinion. All of the assessors found the tool easy to use.

discussion
The Internet has become the largest, most up-to-date source for medical information, with freely accessible audiovisual material that can be used for medical education. Videos provide the opportunity for students to have more control over their learning, enabling them to engage in ubiquitous learning; in other words, videos give learners the opportunity to learn anywhere at any time. Videobased learning offers a cost-effective, location-independent method of flexible study, allowing students to learn at their own pace and view the material as often as they wish. Studies have evaluated the quality and accuracy of openaccess video content designed for health care provider use. Even though many high-quality videos are available, the quality of video clips is inconsistent and can be poor. 10,11 In a recent pilot study evaluating the impact of otology surgery videos on otolaryngology resident education, residents reported that they found that videos were highly useful and promoted self-efficacy and that they should be a high priority for a resident's surgical preparation. 3 In light of the increased use of videos in medical and surgical teaching, more high-quality medical learning videos must be made available. However, the vast majority of videos shown to medical students or residents or as part of scientific sessions in international conferences are not peer reviewed with an objective tool. We designed the UM-OSCAARS to standardize the assessment of the quality of videos on surgical procedures or medical techniques. Our study results demonstrate that it is a reliable and acceptable tool.
Guidelines in peer-reviewed journals have been proposed to optimize video quality in the setting of medical and surgical teaching. 5,6,12 Iorio-Morin and colleagues have identified 4 workflow interventions to improve the effectiveness of video content in the context of medical education on the basis of Mayer and Moreno's cognitive theory of multimedia learning: (1) choosing appropriate content, (2) optimizing the voiceover, (3) optimizing the supporting visuals and (4) planning the shooting schedule in advance. 12,13 The authors also recommend that content creators should aim to improve their work by applying evidence-based principles.  The UM-OSCAARS could be used to facilitate video selection for events such as video sessions at conferences, for example. We aimed to create a checklist that would be easy to use and understand. If the validity of the UM-OSCAARS is confirmed in future studies, faculties, medical departments or scientific groups could use it to objectively evaluate the quality of videos submitted for a selection process and rate the videos. Having a validated objective tool could help evaluators to discriminate between videos in the case of a tie instead of engaging in a deliberation.
The UM-OSCAARS could also help video creators to improve their work. Having a checklist with objective and detailed criteria allows video creators to focus on different aspect of their videos to improve the quality of their production. This is especially relevant because most videos on surgical procedures or medical techniques are conceived by medical or surgical experts with little or no training in videography. The UM-OSCAARS could help to partially fill this gap by serving as a guide for these video creators in the making of high-quality medical and surgical technique videos.
In addition, our tool could be used for the evaluation of articles accompanied by videos submitted to peer-reviewed journals that have already adopted this format (such as the New England Journal of Medecine and Head & Neck) after more thorough assessment of if its validity. Videos submitted for online publication in scientific journals should go through the same degree of rigorous peer review and evaluation as manuscripts do. To the best of our knowledge, videos are currently being assessed for possible publication in peerreviewed journals by reviewers who have not been provided with a tool or specific training. Our results showed that the UM-OSCAARS scores given to the study videos by the assessors were consistent with their general impression of the videos. However, the fact that the tool enables evaluators to detail and break down their assessment should allow a more thorough review and give better guidance to authors on how to improve their video material.
Knowledge of the specific evaluative criteria of UM-OSCAARS might have also helped the assessors to come to a more meaningful general impression. Our assessors had different areas of expertise in the field of otolaryngology -head and neck surgery, but the good interrater reliability in our study leads us to think that video reviewers need only to be familiar with the procedures depicted to be able to judge not only the overall quality of videos but also the quality of technique and operative flow more specifically.
We chose not to provide a formal training course for the assessors on how to use the checklist; we expected the instructions provided with the UM-OSCAARS to be selfsufficient. We wanted to assess if the descriptions of the criteria were clear enough for every assessor to understand and to be able to score the videos adequately. The global interrater agreement of the 10 criteria in the first phase of evaluation was 0.754, which confirms the good interrater reliability of the UM-OSCAARS. However, the ICC of each criterion for the first phase was very heterogeneous and might be improved with better instructions.
The UM-OSCAARS needs to be validated with a wider range of asessors from different medical specialties and with videos encompassing a broader set of medical and surgical procedures. We plan to pursue the validation of this tool by forming 2 groups of assessors and using the Delphi method: 1 group of experts would discuss the quality of each video until they reached a consensus on a quality score from 0 to 10, and the other group would use the checklist. We would compare the results of the 2 approaches to thoroughly assess the validity of our instrument. Given that in the present study 1 of the 4 assessors indicated he would not recommend the use of this checklist for peer review purposes or for use in video contests, we also plan on assessing again the acceptability of the tool to improve this parameter.

Limitations
Our study has several limitations. First, a limited number of videos were included. The total viewing time of the 10 videos was 59 minutes and 57 seconds, excluding the time required to fill in the checklist. To extrapolate and conduct an analytic study, we could have increased the number of videos, but this would also have increased the evaluation time and might have weakened the rigor shown by the evaluators in this study. Another potential limitation may have been caused by asking the assessors to choose their top 3 videos after having viewed and scored the 10 videos. The evaluators could have remembered the scores they gave to the videos, which might have tainted their overall impression of the best videos. We could not have proceeded otherwise as it was essential that the evaluators fill in the checklist immediately after they viewed each video. Another possible limitation is that we tested the UM-OSCAARS with a group of surgeons from the same specialty, which could limit the generalizability of our results. However, we chose surgeons with different areas of interest in the same specialty, who graded videos encompassing a wide variety of medical and surgical techniques, sometimes not specific to their specialty (e.g., hand hygiene, intubation).

conclusion
To our knowledge, UM-OSCAARS is the first checklist developed to evaluate videos depicting medical and surgical techniques. Our evaluation tool has proven to be reliable and acceptable to use, but its validity needs to be more thoroughly assessed. Use of UM-OSCAARS does not require specific training other than reading the instructions provided with it. We hope this tool will lead to an improvement in the quality of technical videos used for educational purposes in medicine.