Dissections OBSERVATIONAL

9 September 2009
Evidence-based Medicine for Surgeons

Factors influencing patient satisfaction when undergoing endoscopic procedures

Authors: Ko HH, Zhang H, Telford JJ, et al
Journal: Gastrointestinal Endoscopy 2009; 69:883-91
Centre: St. Paul’s Hospital, Vancouver, British Columbia, Canada
The identification of reliable predictors of adverse endoscopic experiences might allow us to
BACKGROUND pinpoint areas upon which we can focus to improve a future patient’s experience. Theoretically,
this should lead to better patient care and compliance.

IN SUMMARY
RESEARCH QUESTION Satisfaction with gastrointestinal endoscopy

Population 'p'
A series of patients undergoing Number of patients studied - 261
gastrointesinal endoscopy at a
Statistically significant factors
single centre in Canada.
Endoscopists’ personal manner 0.001
Indicator variable
Nurses’ personal manner 0.001
Elective, ambulatory, esophago-
gastro-duodenoscopy (EGD) or Patient perception of endoscopist’s technical skills 0.003
colonoscopy. Physical environment 0.007
Outcome variable Time physician spent explaining the procedure * 0.04
Primary: patient satisfaction with Of 261 patients, 141 (54.0%) completed the follow-up questionnaire. Patients
the procedure. were less satisfied and recalled experiencing more pain during procedures
when questioned at a later date (more than 14 days after the procedure).
Comparison
* Most physicians (71.7%) spent less than 10 minutes
- Patients who underwent colonoscopy tended to report less satisfaction

Authors' claim(s): “...identified several factors that impacted patient satisfaction. ... However, patient
satisfaction tended to decrease over time, possibly because of recall bias. ”

THE TISSUE REPORT

Nothing more than common wisdom here: be nice, explain the process to the patient, look like you know what you are
doing, do it in a clean and pleasant environment ... and be prepared to have them think it was a little worse than it really
was. This piece of advice applies to all interventions that are invasive: from injections to complex surgery. Specifically, three-
quarter of the cohort were colonoscopies - a procedure done under sedation and thereby likely to be viewed more
favourably than UGI endoscopy.

EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective  Ethical l | Resource saving l

The devil is in the details (more on the paper) ... 

© Dr Arjun Rajagopalan
 SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random 18 years and older ERCP, capsule endoscopy, Survey
scheduled to or endoscopic ultrasound ?
Stratified random Target ?
undergo esophago- Cognitive impairment 
Cluster gastroduodenoscopy Inability to read or write Accessible 330
(EGD), colonoscopy, English ?
Consecutive or both  Unwillingness to complete Intended 261
Convenience the questionnaires  Drop outs ?
Judgmental Study 261

 = Reasonable | ? = Arguable |  = Questionable

Duration of the study: June 19, 2006, and July 20, 2006

Sampling bias: About half of the patients, 54.8% (143/261), had a prior endoscopic experience, and 21.7%
(31/143) of them found these experiences uncomfortable, painful, or difficult to endure. During the study period,
72.6% of the procedures were colonoscopies. Of 261 patients, 141 (54.0%) completed the follow-up questionnaire.

COMPARISON
Randomized Case-control Non-random Historical None

Controls - details
Allocation details Research assistants administered 2 questionnaires (preprocedure and postprocedure) to all
patients on the day of the procedure after reassuring patients at the beginning of each
questionnaire that their responses would be confidential and anonymous. A third
questionnaire, identical to the postprocedure questionnaire, was administered to the patients
by mail or by telephone at least 1 week after the procedure. The patients were randomized
into 2 groups: half of them were contacted by telephone and the other half by mail. All
endoscopic procedures were performed in the standard fashion by any 1 of 7 endoscopists.
Comparability -
Disparity -

Comparison bias: -

MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.

Device suited to task

Training

Scoring

Blinding
Repetition

Protocols

Y ? N

1.9-item instrument (mGHAA-9) ? N ? N N N N

The questionnaire involved rating the patient's satisfaction with 6 aspects of the endoscopic experience: (1) waiting
time for an appointment, (2) waiting time before the procedure, (3) personal manner (courtesy, respect, sensitivity, and
friendliness) of the physician performing the procedure, (4) personal manner of the nurses and support staff, (5)
technical skills (thoroughness, carefulness, and competence) of the physician performing the procedure, and (6)
adequacy of explanation of the procedure. The remaining 3 questions included the overall rating of the visit and
inquiries into whether the patient would have the procedure done again by the same physician or at the same facility.
The patient satisfaction outcome was regrouped to construct a binary variable, either ‘‘not very satisfied’’ or ‘‘very
satisfied.’’ The ‘‘not very satisfied’’ group consisted of patients who rated ‘‘somewhat satisfied’’ (32), ‘‘fair’’ (1), and
‘‘somewhat dissatisfied’’ (2), whereas the ‘‘very satisfied’’ group consisted of patients who rated ‘‘very satisfied’’.
Measurement bias: The patient's perception of the items was obtained on a Likert-type scale with the experiences
being rated along a continuum. The decision to analyze the responses after clubbing them into a binary state appears
arbitrary and post hoc.

© Dr Arjun Rajagopalan