A prospective audit of patient experiences in colonoscopy using the Global Rating Scale : A cohort of 1187 patients *

*Co-first authors. 1Department of Gastroenterology and Hepatology; 2Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; 3Divisions of Gastroenterology and Hepatology, University of Alberta Hospital; 4Royal Alexandra Hospital; 5Misericordia Community Hospital; 6Grey Nuns Community Hospital, Edmonton, Alberta Correspondence: Dr Vincent de Jonge, s Gravendijkwal 230, 3000 CA Rotterdam, The Netherlands, PO Box 2040. Telephone 31-10-703-3040, fax 31-10-703-4682, e-mail v.dejonge@erasmusmc.nl Received for publication December 1, 2009. Accepted February 8, 2010 Colonoscopy is the most commonly used and most accurate procedure to image the large bowel (1). The demand for colonoscopy has increased over the past decade, largely for the purpose of colorectal cancer screening and the surveillance of adenomas (2,3). Simultaneously, interest in quality assurance (QA) has increased (1,4). Several studies have addressed factors that influence the technical quality of colonoscopy including female sex, poor bowel preparation, lower endoscopist skills, and a history of abdominal or pelvic surgery (5,6). oRiGinAl ARticle

Patient experiences are also important to the overall quality assessment of the procedure and have been suggested as quality indicators for colonoscopy (7).Several studies have identified variables that are associated with increased levels of discomfort during a colonoscopy such as higher socioeconomic status, the presence of psychological distress and previous hysterectomy (8,9).High tolerance and satisfaction are required for patients to be compliant with medical care (10).Dissatisfied patients are more likely to change physicians and to engage in litigation (11)(12)(13)(14).
In 2004, the results of an audit conducted in the United Kingdom (UK) (15) demonstrated an urgent need to improve the quality of endoscopy.For that purpose, a comprehensive program was developed to evaluate and improve all aspects of endoscopy and has become known as the Global Rating Scale (GRS) (16).The GRS is a patient-centred QA program that provides objective measures for the overall quality of the endoscopic service.Acceptance of the GRS by endoscopy units in the UK has been high, and improvements in quality have been achieved (17).
The GRS has four main domains: 'Clinical quality', 'Quality of patient experience', 'Training' and 'Workforce' (16).Each domain consists of different items, which are presented in Table 1.Items were discussed and created at several national meetings in which input was provided by health care providers, patient groups and others.Recently, efforts have been made to adopt the GRS outside of the UK, including Canada (18).
The aim of the current study was to evaluate several items within the 'Quality of patient experience' domain of the GRS outside the UK, in a North American setting.

MEthodS
The present prospective cohort study was performed in the endoscopy departments of the following four hospitals in Edmonton, Alberta: The University of Alberta Hospital (UAH), Royal Alexandra Hospital (RAH), Misericordia Community Hospital (MH) and Grey Nuns Community Hospital (GNH).The study protocol was submitted to the Health Research Ethics Board of the UAH and RAH, and the Ethics Board of the Caritas Health Group of the MH and GNH.Both boards deemed that the study fell under the umbrella of QA projects and, subsequently, research ethics approval was granted.

Patients
Consecutive patients undergoing colonoscopy in one of the four hospitals included in the present study were asked to participate.Patients were enrolled between May and August 2008.Verbal consent was obtained from all patients participating in the present study.The main inclusion criterion was that patients were scheduled to undergo an outpatient colonoscopy.Exclusion criteria consisted of the following: patients who did not consent to participate, were not able to speak or read English, or had a medical condition that made it difficult to complete the questionnaire.
Colonoscopies were performed by gastroenterologists and fellows.No information regarding the specifics of sedation (neither drugs nor dosage) used during the procedures was collected.

Questionnaire
A questionnaire that was used in the UK, which contained the relevant items of the GRS, was adopted for the present study (Figure e1) (16).The items in the GRS were developed based on focus group discussions with all stakeholders of endoscopy, including patients.Some questions derived from the previously validated modified Group Health Association of America nine-item survey (14) were incorporated to address all of the established domains that may influence patient experiences.Because the modified Group Health Association of America nine-item survey does not incorporate questions regarding pain tolerance, acceptance and embarrassment, questions based on the 'Health Belief Model' (19) were also included.The following aspects were assessed: accessibility and timeliness, informed consent and information, interpersonal skills of staff, privacy and dignity, comfort and discharge.
First, the questionnaire was pretested at the UAH endoscopy outpatient department.During the pretesting phase, 30 patients were asked to complete the pre-and postprocedure questionnaire.These patients were subsequently interviewed by the investigators to evaluate the clarity of the tool.Input from health care professionals was also obtained during this period.After feedback, the final questionnaire was designed.Patients completed the first part of the questionnaire before their colonoscopy while waiting in the preprocedure area.Patients received a postage-paid, pre-addressed envelope and were asked to complete the postprocedure questionnaire at home within three days and return it by mail.

Statistical analysis
Analyses were performed using SPSS version 15.0.1 (SPSS Inc, USA).Categorical data differences between hospitals were analyzed using c 2 tests.Numerical data were analyzed using one-way ANOVA.To determine differences in nominal data between hospitals, the Kruskal-Wallis test and Mann-Whitney U test were used.A two-sided P<0.05 was considered to be statistically significant.
Multivariate logistic regression analysis was used to identify associations among the willingness to return for colonoscopy, overall comfort, acceptance and the following factors: sex, age, body mass index, specialist consultation before colonoscopy, receipt of an information sheet before colonoscopy, comfort in the waiting area, excessive delay before or after the colonoscopy, adequate time in the endoscopy room, a colonoscopy that was more uncomfortable than expected, discussion of preliminary results and embarrassment during the colonoscopy.For this purpose, the outcome variables were transformed into binary variables (patients who were either [very] satisfied or willing to return, or somewhat or not [very] satisfied or willing to return), as was previously performed by others (20).

RESuLtS
Preprocedure questionnaire Patient characteristics: A total of 1187 patients (43.1% men, mean age 56 years) completed the preprocedure questionnaire during the study period.Tables 2 and 3 summarize the patient characteristics and results.Overall, 656 patients (59.6%) had undergone a previous colonoscopy.Patient characteristics were similar among the hospitals.
Booking procedure: Before undergoing colonoscopy, 634 patients (54.0%) had seen the specialist in an outpatient setting and 541 (46.0%) were directly referred for the procedure without previous consultation of the specialist.Among 442 patients who underwent first-time colonoscopy, 218 (49.3%) had not consulted with the physician before the procedure in the outpatient clinic.The rate of patients who had a preprocedure visit with their physician differed significantly among hospitals, with rates ranging from 40.3% to 80.5% (P<0.01).
A choice of date and time for the procedure was offered to 427 patients (37%).information provision: Before colonoscopy, 1048 patients (89.3%) received an information sheet (range among hospitals 79.5% to 95%; P<0.01).In addition, before the actual procedure, the endoscopist or nurse explained the details of the procedure to 906 patients (77.8%).
While waiting for colonoscopy, the indication for the procedure was not known or could not be recalled by 177 patients (15.3%).When the analysis was stratified according to preprocedural outpatient visits, 61 patients (9.8%) who had previously visited the outpatient clinic did not know the indication for their colonoscopy compared with 116 patients (21.8%) who had not consulted with their specialist before the procedure (P<0.01).Overall, any of the complications (Table 3) were mentioned to 729 patients (65.1%; range among hospitals 49.7% to 75.2%; P<0.01), and 433 patients (41%) recalled that they were informed about all four complications assessed in this questionnaire (range among hospitals 29.6% to 52.1%; P<0.01).Patients who consulted with their specialist before colonoscopy recalled more often that any of the risks of complications were mentioned to them compared with patients who were directly referred (167 [27.7%] versus 223 [43.4%]) (P<0.01).Among 999 patients who received an information sheet, 326 patients (32.6%) were not aware of the potential complications of colonoscopy, compared with 63 (53.8%) of the 117 patients who did not receive an information sheet (P<0.01).
If patients received both an information sheet and a precolonoscopy consultation, they retained more information about complications than when information provision was limited to one of these methods or when they received no information whatsoever (394 [73.4%] versus 330 [57.3%];P<0.01).

Postprocedure questionnaire
A total of 851 patients completed the postprocedure questionnaire (response rate 71.7%).The results of the postprocedure questionnaire are summarized in Tables 4 and 5.
Admission and waiting before procedure: Almost all patients (824 [97.3%]) were comfortable waiting for their procedure in the preprocedure area.However, 165 of the patients (19.7%) believed there was an excessive delay before entering the endoscopy room.Virtually all patients (842 [99.5%]) signed an informed consent form before undergoing the procedure.Procedure: According to patient reports, sedation was used in 756 procedures (94%).A choice to receive sedation was recalled to be offered by 195 patients (24%).Among the patients who were not offered a choice, 128 (22.3%) would have preferred to have a choice.
Acceptability of the procedure is shown in Table 5. Colonoscopy was rated as (very) comfortable by 591 patients (72.2%), and 748 found the burden (very) acceptable (91.0%).However, 189 patients (22.7%) rated the experience of the colonoscopy as more uncomfortable than expected (Table 4).Patients who were seen in a precolonoscopy consultation by the specialist rated the experience of the colonoscopy as more uncomfortable than anticipated more frequently (n=114 [26.1%]) than patients who were directly booked for colonoscopy (n=74 [18.9%]) (P<0.05).There was no difference between patients who underwent their first colonoscopy and those who underwent a previous colonoscopy.
If necessary, the majority of patients (693 [83.9%]) were (absolutely) willing to return for a repeat procedure.
discharge and aftercare: The preliminary results of the colonoscopy were discussed by the endoscopist before discharge with 707 patients (86.9%).A total of 608 patients (74.6%) stated that a written result would be (very) important.Additionally, 470 patients (58.5%) would (very much) prefer to consult with the endoscopist before discharge.
Among 93 patients who did not receive an information sheet, 26 (28%) were not aware of what to do if problems arose, as opposed to 35 of 692 patients (5.1%) who did receive an information sheet (P<0.01).
At discharge, 171 patients (21.1%) did not know how they would receive their final results.When patients received an aftercare information sheet, they knew more often how they would receive the final results (556 [80.5%] versus 67 [68.4%];P<0.01).

Factors influencing patient satisfaction
The results of the multivariate logistic regression models are summarized in Table 6.
No embarrassment (OR 5.06; 95% CI 2.82 to 9.08) and a less uncomfortable procedure than expected (OR 2.80; 95% CI 1.85 to 4.24) were positively associated with being comfortable during the procedure, while younger age was negatively associated with comfort during the procedure (OR 0.99; 95% CI 0.97 to 1.00).
The following variables were positively associated with patients' willingness to return for a colonoscopy: comfort while waiting for the procedure (OR 9.93; 95% CI 2.99 to 32.99), no embarrassment (OR 6.65; 95% CI 3.51 to 12.61), less uncomfortable procedure than anticipated (OR 2.99; 95% CI 1.80 to 4.97), an acceptable waiting time until discharge (OR 2.66; 95% CI 1.00 to 7.05), and discussion of preliminary results after the colonoscopy (OR 2.31; 95% CI 1.24 to 4.31).

diSCuSSioN
Patient experience has become an important indicator in colonoscopy QA because it is a measure of patients' acceptance of the procedure and is likely a factor in compliance with follow-up recommendations (14).Our study evaluated the experiences of patients undergoing colonoscopy in four Canadian hospitals using a questionnaire based on the GRS -a comprehensive QA program developed in the UK (16).The GRS is now the accepted standard for endoscopy units in the UK that participate in the National Health Service colon cancer screening program.Acceptance of the GRS in the UK has been high; however, to date, full-length peer-reviewed publications pertaining to the GRS are lacking (17,18,21).
Overall, patient satisfaction was high for most aspects of colonoscopy; however, the present study identified areas in which improvements can be made.Patients prefer to be offered a choice for booking their procedure on a convenient date and time.In our study, only 37% of patients were offered a choice for their procedure date.Nevertheless, 77.6% of patients believed that their procedure was booked in a timely fashion.The results are similar to those reported in a French study (22) in which only 13.7% of patients responding in a telephone interview were poorly or fairly satisfied with the time they were required to wait to obtain their colonoscopy appointment.
It is important for patients to understand the indication for their procedure and the risk of rare but serious complications, especially because dissatisfied patients may be more likely to engage in litigation (1,13,23,24).Several studies (25)(26)(27) have addressed ways to improve information provision such as the distribution of information leaflets, video instruction and precolonoscopy consultations.As our data show, patients appeared to be better informed about several aspects of the procedure when they had a separate outpatient visit or received an information sheet before the procedure was scheduled.This highlights the importance of ensuring that patients receive and read information pamphlets detailing the procedure, and that sufficient time is given to explain the details of the procedure.
In our study, 34.9% of patients stated that they were not aware of any of the complications when this was asked just before the procedure at the time they were waiting for their colonoscopy.This number is surprisingly high given that the information sheets of all four hospitals explicitly mention perforation and bleeding as risks, and almost all study participants (99.5%) signed an informed consent form.It is unclear whether these patients did not recall, did not read the information sheet carefully or, were indeed, not informed about the complications.Among the patients who were seen by their specialist, 27.7% stated that the complications were not mentioned, while more than 40% of those who did not have an outpatient visit were not aware of them.This is consistent with the results of a small study of 31 patients (28) that showed the benefit of a precolonoscopy outpatient consultation resulting in more information about the procedure being retained.Furthermore, our data support the rationale for a physician visit before the actual procedure combined with distributing information sheets because it results in the highest retention of information.
Our results demonstrate that colonoscopy was well tolerated by patients.This is consistent with the results of a study by Eckardt et al (29) in which 88% to 92% of patients were An OR of greater than 1 indicates a positive association, while an OR of less than 1 indicates a negative association willing to return for a repeat procedure.Nevertheless, in our study, 22.7% of patients found the colonoscopy to be more uncomfortable than they expected and, surprisingly, this was higher for patients who were seen by the physician in the outpatient clinic before their procedure.This was reported despite the use of conscious sedation in 94% of the procedures.Perhaps patients should be better informed about the extent of discomfort they may experience or, alternatively, physicians should be more aware of discomfort and ensure that measures are taken to mitigate excessive discomfort during the procedure.Additionally, the importance of a representative presentation of discomfort associated with the procedure that can be expected during the colonoscopy is emphasized by the results that patients were more willing to return for a procedure (OR 2.99), reported less discomfort (OR 2.80) and found the colonoscopy to be more acceptable (OR 2.48) when they experienced the colonoscopy as less uncomfortable than anticipated.Privacy and dignity are important issues addressed by the GRS, and their importance is reflected by the results of our study demonstrating that the absence of embarrassment is positively associated with a comfortable (OR 3.22) and acceptable (OR 3.91) procedure, and the willingness to undergo a repeat procedure (OR 6.65).Ko et al (20) found that the personal manner, both from nurses and endoscopists, was of importance in patients' overall satisfaction.In our study, no direct association was found among courteous and considerate physicians or nurses and any of the outcome measures because almost none of the patients had a negative experience with the attitude of the endoscopy staff.
The GRS endorses that patients should be informed about the preliminary results and, if final results depend on further testing, such as pathology results, how these will be reported to them (16).An important finding in our study was that 21.1% of patients left the hospital without knowing how to obtain their final results.A previous study (30) showed that apart from informing the patient of the results after the procedure, it is beneficial to also provide a written result.In our study, patients who received a written and verbal report were more likely to recall the recommendations for follow-up and therapy, compared with those who only received a verbal report (72% versus 42%, respectively).Our study confirms these results because patients who received an aftercare information sheet were more aware of what to do when problems arose and were more aware of how they would receive their final results.Furthermore, patients who received the preliminary results of their procedure before they left the endoscopy unit were more often willing to return for colonoscopy (OR 2.31).This aspect of care can be easily incorporated into everyday practice.
We reported the data for the four participating hospitals separately because it highlighted the differences that may exist among hospitals that are in the same geographical region.The baseline measurements obtained in the present study provided data that can be used to improve the patient experience during colonoscopy.Our data also demonstrate that the GRS can be easily applied in a North American setting to help identify service gaps.
The present study has some limitations.First, no formal validation of the questionnaire was performed, although previously validated questions were used and the questionnaire was pretested by patients (14).Second, some findings indicate that the parameters that were deemed to be important to doctors were not necessarily considered to be important to patients.Third, although patient groups contributed to the development of the GRS, some of the investigated items may, therefore, be less important to patient satisfaction than others.Fourth, language barriers could be an issue in patient experiences; however, we did not evaluate this in our study.The outcome of patients whose first language was not English (and were excluded from the study) may be worse.Considering the patient population, however, we suspect that the number of patients not enrolled because of language barriers was low, although we do not have formal supportive data.Fifth, the GRS accounts for the equality of access, and future studies should address the current status of information provision among these patients.Finally, we relied entirely on the information the patient provided and did not verify the data with the endoscopist or the colonoscopy report.

CoNCLuSioN
The results of our study show that overall patient satisfaction with colonoscopy was high; however, differences existed among the four centres, leaving room for improvement in pre-and postprocedure protocols.The GRS appeared to be an excellent tool for identifying service gaps in patient experiences during colonoscopy, which can serve as a guide for future improvement initiatives.


want to reach you to clarify or ask something about the questionnaire would you please give the best phone number (-s) where we can reach you?During the day: ………………… (or alternative) in the evening: …………………… Please put this part of the questionnaire in an envelope at the black box on the registration desk, or return it to one of the nurses.You have had a colonoscopy and completed a questionnaire before the procedure, this one is about the procedure itself and the aftercare  Please complete this part within 2 days after the procedure at home  You can send it back to the investigators in the stamped addressed envelope  In case you have any questions, please do not hesitate to contact the investigators at 780-248-1039

Yes No Any comments on how we could improve the service would be gratefully received. Please feel free to make any comment(s):
Did you have the ability to ask questions?Yes No 16.Do you have a preference for the gender (male or female) of the doctor doing the procedure?
Yes No13.Did the doctor/nurse discuss alternative tests or treatments (which might include doing nothing, trying some treatment without doing the procedure just to see if it helped, barium X rays or other scans) if applicable?Yes No14.Did the doctor/nurse mention that there are risks of: 1. Was your journey through the unit well coordinated?Yes No 2. Were you comfortable when waiting for the colonoscopy?Yes No 3. Was there an excessive delay in waiting for your colonoscopy?Yes No 4a.Did you feel that you had an opportunity to ask the nurses or doctors any further questions you may have had -Before going into the endoscopy room?-In the endoscopy room?4b.Do you prefer asking your questions in the endoscopy room or before you go in the endoscopy room?Did you feel that you understood that sedation medication was given for pain and to make you sleepy?Did you feel in any way discouraged from having the sedative injection?Yes No 8a.Did you have sedative medication?8b.Were you given a choice to have a sedative injection?8c.If no, would you want to have a choice in having a sedative injection?Do you feel that you had adequate time in the endoscopy room and that you and the doctor/nurse doing the colonoscopy were not rushed?