Evaluation of patient satisfaction and addressing areas of dissatisfaction is an important aspect of healthcare services and is a measure of quality of service provided. This process has been found to be useful in improving standards of endoscopy centers including performance of endoscopists, and possibly the reputation of endoscopy centers in the long run [9
]. Lin had echoed the importance of measuring and improving patient satisfaction, describing this aspect as of prime importance for the economic future of gastrointestinal endoscopy and for gastrointestinal endoscopy to remain competitive against rival technologies [10
]. Patient satisfaction also affects perception of the population at large towards endoscopic services as a whole and can have significant impact on patient willingness to undergo endoscopic procedures regardless of whether the patient has had endoscopy before.
Different questionnaires have been used to assess patient satisfaction towards gastrointestinal endoscopy [11
]. The American Society of Gastrointestinal Endoscopists (ASGE) recommended the use of the mGHAA-9 questionnaire to measure patient satisfaction [11
]. However, mGHAA-9 does not contain a question on patient comfort which has been found to be an important factor influencing patient satisfaction [14
]. It was also noted that patients had difficulty answering the question on technical skills of endoscopist found in mGHAA-9 [12
]. We anticipated a similar problem with our patients and have substituted this question with one on patient comfort. In addition, we included a question on bowel preparation as we felt that this is an important aspect of colonoscopy that patients may be dissatisfied with. It was reported in a study by Yacavone et al. that a significant percentage of patients found bowel preparation negatively impacting their satisfaction towards colonoscopy [14
]. Furthermore, the response obtained by Yacavone et al. was through open-ended questioning and not part of their 15-item questionnaire meaning that the true significance of negative impact of bowel preparation towards patient satisfaction could have been underestimated. To our best knowledge, this is the first time a question on bowel preparation is included in the mGHAA-9 questionnaire. Interestingly, we found discomfort during bowel preparation to be the leading cause of unfavorable responses among patients attending our outpatient colonoscopy service and propose that this item be included in future studies evaluating patient satisfaction towards colonoscopy.
Although the bowel preparation regime that we used (reduced volume PEG-ELS) has been shown to be better tolerated compared to 4-liter PEG-ELS [15
], nearly half of our patients gave unfavorable response towards their bowel preparation experience. Discomfort promotes nonadherence to bowel preparation and leads to inadequate colon cleansing which could in turn adversely affect diagnostic yield and technical performance [16
]. A separate study in our center [17
] showed that 23.6% of patients failed to comply with bowel preparation instructions and poor quality bowel preparation was seen in 30.1%. Colonoscopic examinations of these patients were associated with increased technical difficulty and patient discomfort. Discomfort during bowel preparation has also been shown to be a major deterrent for patients to undergo colonoscopy regardless of whether they have or have never undergone colonoscopy before [5
]. Improving patient comfort during bowel preparation is therefore imperative not only to ensure compliance but also to enhance patient receptiveness towards colonoscopy. Split-dose PEG-ELS has been reported to be better tolerated with significantly lower discontinuation due to adverse effects compared to conventional single-dose PEG-ELS [18
] and may be helpful in addressing the issue of patient discomfort with bowel preparation faced by our centre. Moreover, split-dose PEG-ELS has been shown to provide superior colon cleansing [18
Large number of patients scheduled for colonoscopy and limited resources have resulted in long appointment waiting times in our center while prolonged waiting on the day of colonoscopy may be the result of combination of factors including overscheduling of cases for each session. More than half of our patients were dissatisfied with waiting time for colonoscopy appointment while close to one-third were unhappy with their waiting on colonoscopy day. As dissatisfaction towards appointment waiting time could have resulted in a proportion of patients transferring to another outpatient colonoscopy service, our figure could be an underestimation of the true proportion of patients who were dissatisfied in this aspect. Waiting times for endoscopy appointment and on endoscopy day are problems not restricted to our center but appear to be major causes of unfavorable responses in other centers as well [6
]. Prolonged colonoscopy appointment waiting time may reduce patient motivation to keep to their appointment and to adhere to bowel preparation instructions. In fact, prolonged colonoscopy appointment waiting time has been recognized as an independent risk factor for poor quality bowel preparation in our center [17
]. In this aspect, it is vital that increasing patient load is matched by increasing allocation of resources to maintain a service that meets the expectations of not only patients but also of healthcare providers.
Besides bowel preparation experience and waiting times, other factors have yielded unfavorable responses from our patients. However, utilizing the principle of “vital few and trivial many” [22
], we identified that discomfort during bowel preparation and waiting times constituted to nearly 80% of the problems faced by our patients. By focusing on improvement in these aspects, there is great likelihood of substantially reducing the problem rate among patients attending our outpatient colonoscopy service. Based on our analysis, aiming for colonoscopy appointment waiting time of within 1 month and waiting time on colonoscopy day of within 1 hour will result in an improved rate of favorable response of over 80% in these two aspects. However, as this is a single-center study, this result may not be generalizable to other populations. Nevertheless, by using a similar approach, other centers may be able to gauge the waiting times that are acceptable for their patient population.
Despite our efforts, this study has several limitations. First, the modified questionnaire that we used has not been formally validated, except for obvious face validity. Secondly, it is possible that other factors which may adversely impact patient satisfaction were unaccounted for in our study. For example, we did not include physical environment as an item in the questionnaire although this has been found to be associated with patient satisfaction [8
]. However, we were satisfied that the modified mGHAA-9 questionnaire that we used in this study has covered the most important factors since no additional factors were brought up by patients when additionally asked in an open-ended manner on other aspects of dissatisfaction at the beginning of the study. Third, we concentrated on procedure-related factors and did not look into patient-related factors in our study as we felt that the former were at least partially under our control and therefore could provide more opportunities for improvements than the latter.
Although this is a single-center study, it complements well with the existing literature as there are currently limited published studies on this matter from this part of the world. Our center practices an open-access outpatient colonoscopy service and approximately 40% of patients scheduled for colonoscopy are from the primary care clinics attached to this institution [23
]. Hence data from this study is generalizable to local populations scheduled for colonoscopy in general. Consecutive, instead of random, sampling was used to maximize the number of subjects recruited within the study period. It is acceptable to use consecutive sampling, which happens to be the best choice of nonprobability sampling. A good representation of the overall population was possible by studying all subjects.
It has been found that different methods of evaluation of patient satisfaction at different times may yield significantly different responses. For example, responses tend to be better when interviews were conducted on-site immediately after endoscopy or even on phone-back after a short period of time following endoscopy as opposed to when they were conducted through mail-back after a prolonged interval [8
]. Interesting terms such as “social desirability response” bias and “ingratiating response” bias have been used for this phenomenon where satisfaction scores were better when obtained through more personal and earlier communications with patients [10
]. This factor should be considered when comparing the results of satisfaction survey between centers or between two time points in the same center but may not be a strong reason to reject on-site interviews given the higher response rate of such method and its ease of administration.
In conclusion, we found bowel preparation to be the leading cause of patient dissatisfaction of the outpatient colonoscopy service in an Asian tertiary care hospital, followed by waiting times for colonoscopy appointment and on colonoscopy day. Waiting times for colonoscopy appointment and on colonoscopy day should not exceed 1 month and 1 hour, respectively, as favorable responses diminished to undesirable levels beyond these waiting times.