The incidence of colorectal cancer is rapidly increasing in the Asia-Pacific region [
However, there are various barriers toward patient acceptance of colonoscopy whether in the context of colorectal cancer screening and surveillance or even as an investigational tool in symptomatic patients. One such barrier pertains to patient dissatisfaction towards the procedure. Patients who are dissatisfied are less likely to comply with management plan or more reluctant to continue utilizing a particular healthcare service [
For example, discomfort during bowel preparation and discomfort during colonoscopy, factors which may be related to dissatisfaction towards the procedure, have been recognized as two of the most important deterrents for screening colonoscopy regardless of among screened or never-screened patients [
Factors contributing to patient dissatisfaction may vary with different populations. For example, in a Canadian study, Ko et al. [
University of Malaya Medical Centre is a 1200-bedded university hospital which functions as a general-type hospital serving a mainly residential suburban area of Kuala Lumpur which is the capital city of Malaysia. Our center provides inpatient and outpatient diagnostic (including screening and surveillance) and therapeutic colonoscopy services. Our center practices an open-access outpatient colonoscopy service receiving patients from primary care clinics, other specialist clinics, and those discharged from inpatient wards in addition to patients from the gastroenterology clinic. Colonoscopy appointments are given on a first-come-first-serve basis. When a patient is deemed to require an earlier colonoscopy appointment, the doctor in charge would negotiate the patient’s appointment to an earlier date on a case-to-case basis.
Patients receive instructions on bowel preparation on the day the appointment is given. A standardized bowel preparation regime consisting of polyethylene glycol electrolyte lavage solution (PEG-ELS) (Fortrans) and bisacodyl is used for all patients. Bowel preparation starts three days prior to scheduled colonoscopy appointment. Patients will take two tablets of bisacodyl at 2000H on D1. Patient should be on low-residue diet from D2 onwards and will take another 2 tablets of bisacodyl at 2000H on D2. Patients will take 2 liters of Fortrans within an hour from 1800H till 1900H on D3. Patients are allowed plain water only till colonoscopy once they start taking Fortrans. For patients whose colonoscopy is scheduled in the afternoon, Fortrans is taken within an hour from 0800H till 0900H on colonoscopy day.
Appointment time on colonoscopy day is staggered half hour per patient to reduce waiting time. A support staff will register patients and a staff nurse will help patients change their dress for the procedure. All patients receive a combination of Midazolam 2.5 mg to 5 mg and Pethidine 25 mg to 50 mg or Fentanyl 50
This is a single-center patient satisfaction survey using an on-site investigator-administered questionnaire of consecutive patients attending the outpatient diagnostic (including screening and surveillance) colonoscopy service in University of Malaya Medical Center between 1st February and 31thJuly 2010.The questionnaire used was based on the modified Group Health Association of America-9 (mGHAA-9) questionnaire but with the question on technical skill of endoscopist being replaced by a question on patient comfort level during endoscopy and the addition of a question on comfort level during bowel preparation. The items in the questionnaire used are as follows: Q1—length of time spent waiting for the appointment—Q2—length of time spent waiting at the Endoscopy Suite for the procedure—Q3—comfort level during bowel preparation—Q4—personal manner of the physician who performed the procedure—Q5—personal manner of the nurses and other support staff—Q6—adequacy of explanation of what was done for you—Q7—comfort level during the procedure—Q8—overall rating of the visit—Q9—would you have the procedure done again by this physician? Q10—would you have the procedure done again at this facility? The original ordinal five-value Likert scale (excellent, very good, good, fair, and poor) was used.
Additional information on patient characteristics (age, gender, ethnicity), whether colonoscopy was surveillance or nonsurveillance, duration of waiting time for colonoscopy appointment, and duration of waiting time on colonoscopy day were obtained. Colonoscopy was categorized as surveillance if a patient already had a colonoscopy previously and the repeat colonoscopy was for surveillance where a predetermined interval from the last colonoscopy was intended. These patients would be aware of the intended interval from their last colonoscopy and would unlikely give unfavorable response to waiting time for colonoscopy appointment and were therefore excluded in the analysis of data on waiting time for colonoscopy appointment. On the other hand, colonoscopy was categorized as non-surveillance if it was the patient’s first colonoscopy, whether it was a screening colonoscopy in an asymptomatic patient or a diagnostic colonoscopy in a symptomatic patient. Waiting time for colonoscopy appointment refers to the duration from the day the procedure was planned to the day that it was performed while waiting time on colonoscopy day refers to the duration from the time of registration on the day of the procedure to the time the procedure was performed. The first twenty patients interviewed were also asked an open-ended question regarding any aspects that they were dissatisfied with that were not covered in the questionnaire.
Face-to-face interview based on the questionnaire was conducted after patients have recovered from sedation and given explanation about their colonoscopy findings just before they left the Endoscopy Suite. The investigators who interviewed the patients were not involved in any aspects of the care of the patient on colonoscopy day. The investigators introduced themselves as research personnel who are conducting a patient satisfaction survey. Patients were encouraged to give an honest response to each of the questions in the questionnaire with the reassurance that their identity and responses will remain confidential. Informed consent was obtained from all subjects before entering the study. The study conforms to the provisions of the Declaration of Helsinki 1995 and was approved by the hospital Ethics Committee.
Data were analyzed using a statistical software program, Statistical Packages for the Social Sciences (SPSS) version 11.5. (Chicago, Illinois, USA). Continuous variables were expressed as mean ± SD. Waiting time for colonoscopy appointment was categorized as within 1 week, between 1 week to 1 month, between 1 month to 3 months, between 3 months to 6 months, and over 6 months. Waiting time on colonoscopy day was categorized as within half hour, between half hour to 1 hour, between 1 hour to 2 hours, and over 2 hours. Patient response for each of the questions 1 to 8 was dichotomized to favorable (excellent, very good, good) and unfavorable (fair, poor). The percentages of favorable and unfavorable responses for each of the questions were calculated. A problem rate was also estimated by dividing the sum of unfavorable responses with the sum of questions asked and multiplying by 100. A Pareto chart was used to illustrate the contribution of each of the questions to the overall unfavorable responses. Finally, the percentages of favorable and unfavorable responses were estimated across the categories of waiting time for colonoscopy appointment and waiting time on colonoscopy day and analyzed using Chi-square test.
A total of 426 patients were interviewed consisting of 222 (52.1%) men and 204 (47.9%) women. Mean age ± standard deviation of the study population was
Ninety-five patients (22.3%) came for scheduled surveillance colonoscopies and were excluded from the analysis for waiting time for colonoscopy appointment. The mean waiting time for colonoscopy appointment in the group of 331 patients who came for non-surveillance colonoscopies was
The percentages of favorable and unfavorable responses for each of the questions are shown in Figure
Patient responses for Q1 to Q8.
The problem rate was 22.2% (641 unfavorable responses out of 2887 questions asked). The main factors that contributed to unfavorable responses were comfort level during bowel preparation followed by waiting time for colonoscopy appointment and waiting time on colonoscopy day (Figure
Pareto chart showing the contribution of each of the questions to unfavorable responses. The bars represent the number of unfavorable responses for each of the questions Q1 to Q7 (total number of unfavorable responses = 641). The black line represents the accumulated percentage.
Favorable response significantly decreased as waiting time for colonoscopy appointment became longer across categories of waiting time (Figure
Patient response towards waiting time for colonoscopy appointment across the different duration of waiting time for colonoscopy appointment (
Favorable response also significantly decreased as waiting time on colonoscopy day became longer across categories of waiting time (Figure
Patient response towards waiting time on colonoscopy day across the different duration of waiting time on colonoscopy day (
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 [
Different questionnaires have been used to assess patient satisfaction towards gastrointestinal endoscopy [
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 [
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 [
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” [
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 [
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 [
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 [
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.
The authors declare that they have no potential conflict of interests.