Patient satisfaction with on-demand sedation for outpatient colonoscopy

Background and study aim: To reduce the costs of colonoscopy the feasibility of unsedated procedures has been explored. The aims of our study were to assess patient satisfaction with on-demand sedation and identify factors related to painful colonoscopy.

Patients and methods: The Norwegian Gastronet quality assurance documentation tools consist of endoscopy reports (completed on site) and a patient satisfaction questionnaire (completed by the patient on the day after colonoscopy). Data were collected from January 1 2004 to December 31 2006. Colonoscopies reported to be moderately or severely painful were defined as ”painful colonoscopy.”

Results: Nine endoscopy centers representing 86 endoscopists reported 14 915 examinations and 12 354 patient reports were returned (83 % response rate). Patient satisfaction with service and information given was greater than 95 % for all centers. Mean rate of painful colonoscopy was 34 % and mean sedation rate 34 %. Odds ratio (OR) for painful colonoscopy was 2.2 (P < 0.001) when sedation was given. The ORs for painful colonoscopy were similar for all but one center (no. 4) with OR 1.6 (P = 0.04), while the OR for giving sedation was higher for all but one center (no. 1) compared with the reference center (ORs 2.2 to 7.5, all P-values < 0.001).

Conclusion: A surprisingly high rate of painful colonoscopy was found. High sedation rates were not associated with low rates of painful colonoscopy. Recommending increased sedation rates as the only intervention to improve suboptimal performance might not lead to lower rates of painful colonoscopy.

References

• 1 Parkin D M, Bray F, Ferlay J. et al . Global cancer statistics, 2002.  CA Cancer J Clin. 2005;  55 74-108
• 2 Harewood G C, Wiersema M J, Melton III L J. A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy.  Am J Gastroenterol. 2002;  97 3186-3194
• 3 Naylor G, Gatta L, Butler A. et al . Setting up a quality assurance program in endoscopy.  Endoscopy. 2003;  35 701-707
• 4 Bell G D. Preparation, premedication, and surveillance.  Endoscopy. 2004;  36 23-31
• 5 Aisenberg J, Brill J V, Ladabaum U. et al . Sedation for gastrointestinal endoscopy: new practices, new economics.  Am J Gastroenterol. 2005;  100 996-1000
• 6 Yoruk G, Aksoz K, Unsal B. et al . Colonoscopy without sedation.  Turk J Gastroenterol. 2003;  14 59-63
• 7 Leung J W, Mann S, Leung F W. Options for screening colonoscopy without sedation: a pilot study in United States veterans.  Aliment Pharmacol Ther. 2007;  26 627-631
• 8 Takahashi Y, Tanaka H, Kinjo M. et al . Sedation-free colonoscopy.  Dis Colon Rectum. 2005;  48 855-859
• 9 Petrini J L, Egan J V, Hahn W V. Unsedated colonoscopy: patient characteristics and satisfaction in a community-based endoscopy unit.  Gastrointest Endosc. 2009;  69 567-572
• 10 Cancer Registry of Norway. Gastronet. www.kreftregisteret.no/en/Research/Projects/Gastronet/ . 
• 11 Hoff G, Bretthauer M, Huppertz-Hauss G. et al . The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres.  Scand J Gastroenterol. 2006;  41 481-487
• 12 Park D I, Kim H J, Park J H. et al . Factors affecting abdominal pain during colonoscopy.  Eur J Gastroenterol Hepatol. 2007;  19 695-699
• 13 Skovlund E, Bretthauer M, Grotmol T. et al . Sensitivity of pain rating scales in an endoscopy trial.  Clin J Pain. 2005;  21 292-296
• 14 Ristikankare M K, Julkunen R J. Premedication for gastrointestinal endoscopy is a rare practice in Finland: a nationwide survey.  Gastrointest Endosc. 1998;  47 204-207
• 15 Froehlich F, Gonvers J J, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 1994;  26 231-234
• 16 Campo R, Brullet E, Junquera F. et al . Sedation in digestive endoscopy. Results of a hospital survey in Catalonia (Spain).  Gastroenterol Hepatol. 2004;  27 503-507
• 17 Ladas S D. Factors predicting the possibility of conducting colonoscopy without sedation.  Endoscopy. 2000;  32 688-692
• 18 Seow-Choen F, Leong A F, Tsang C. Selective sedation for colonoscopy.  Gastrointest Endosc. 1994;  40 661-664
• 19 Eckardt A J, Swales C, Bhattacharya K. et al . Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?.  Endoscopy. 2008;  40 98-105
• 20 Rex D K, Imperiale T F, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.  Gastrointest Endosc. 1999;  49 554-559
• 21 Early D S, Saifuddin T, Johnson J C. et al . Patient attitudes toward undergoing colonoscopy without sedation.  Am J Gastroenterol. 1999;  94 1862-1865
• 22 Ma W T, Mahadeva S, Quek K F. et al . Tolerance and safety to colonoscopy with conscious sedation in Malaysian adults.  Med J Malaysia. 2007;  62 313-318
• 23 Speroni K G, Hannah J, Atherton M. et al . Evaluation of demographic, behavioral, and procedural factors on pain perception by patients undergoing colonoscopy and moderate sedation.  Gastroenterol Nurs. 2005;  28 502-508
• 24 Ehrle U B, Horschler B, Singer M V. Acceptability of high colonoscopy using different premedication – a comparison of the effect of midazolam versus midazolam and pethidine from the viewpoint of the patient and the physician.  Z Gastroenterol. 1995;  33 704-708
• 25 Radaelli F, Meucci G, Terruzzi V. et al . Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial.  Gastrointest Endosc. 2003;  57 329-335
• 26 Froehlich F, Thorens J, Schwizer W. et al . Sedation and analgesia for colonoscopy: patient tolerance, pain, and cardiorespiratory parameters.  Gastrointest Endosc. 1997;  45 1-9
• 27 Dafnis G, Granath F, Pahlman L. et al . The impact of endoscopists’ experience and learning curves and interendoscopist variation on colonoscopy completion rates.  Endoscopy. 2001;  33 511-517
• 28 Harewood G C. Relationship of colonoscopy completion rates and endoscopist features.  Dig Dis Sci. 2005;  50 47-51
• 29 Larsen I K, Grotmol T, Bretthauer M. et al . Continuous evaluation of patient satisfaction in endoscopy centres.  Scand J Gastroenterol. 2002;  37 850-855
• 30 Zandbelt L C, Smets E MA, Oort F J. et al . Satisfaction with the outpatient encounter: A comparison of patients’ and physicians’ views.  J Gen Intern Med. 2004;  19 1088-1095
• 31 Rex D K, Khalfan H K. Sedation and the technical performance of colonoscopy.  Gastrointest Endosc Clin N Am. 2005;  15 661-672
• 32 Hoff G. Colonoscopy without sedation.  Scand J Gastroenterol. 2000;  35 225-226
• 33 Hoff G, Bretthauer M, Dahler S. et al . Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy.  Scand J Gastroenterol. 2007;  42 885-889
• 34 Shah S G, Brooker J C, Williams C B. et al . Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial.  Lancet. 2000;  356 1718-1722