Patient satisfaction: current and future effects on daily clinical (colonoscopy) practice

Historically, technical and objective medical outcomes have served as the only benchmark upon which endoscopists, as well as surgeons, measured patient satisfaction. While endoscopy has been primarily used to diagnose or treat a specific condition, the main priority of patients has been the optimal resolution of their health issue without stringent demands being placed on them by other aspects of the whole process. Overall, physicians felt at ease with this position of strength and allowed themselves to neglect some qualitative and subjective aspects of the health service; however, this scenario is no longer valid.

Modern medicine is patient-centered and needs to be efficient. These two factors have a direct impact on patient satisfaction, which affects clinical outcomes, patient retention, and medical malpractice claims. Furthermore, it also has an economic impact, as higher levels of patient satisfaction are proven to result in benefits for the health industry. As a consequence, patient satisfaction has become a very effective indicator to assess doctor and hospital performance. The validity of these precepts – in private practice – is clear when we look at the USA: since 2012, Medicare physician bonuses have been linked to patient satisfaction and surveys completed by patients [1]. In Europe, where public health systems predominate, delivery of care increasingly needs to be more timely and efficient in order to provide universal coverage without collapsing the system. In this scenario, patient satisfaction becomes of the utmost relevance.

In addition to these general precepts about modern medicine, the implementation of screening programs has been another element that has placed patient satisfaction as a proxy for quality in the field of endoscopy. With the introduction of gastric cancer screening programs in Asia and colorectal screening programs all around the world, endoscopy rooms are now busy with screening examinations that have come to replace the once more prevalent “life-saving” procedures. Currently, more than 80 % of all endoscopy procedures are associated with screening or surveillance. These examinations are performed in asymptomatic individuals who were happily unaware they needed a test before we told them so. They give their consent to have an endoscopy because we advise them to do so as a means to a potentially longer, better life.

Behavioral economics has shown people’s tendency to strongly prefer avoiding losses to acquiring gains; more than anything else they are averse to losing. In other words, the fear of monetary loss can produce a greater behavioral response than the opportunity to acquire its equivalent gain. This kind of reaction can be transposed perfectly to health: individuals prefer a lack of improvement if the alternative to it poses the risk of a potential loss [2]. Screening programs are intended to increase patient health, even though they entail a risk as well. Over the past decade, technical improvements have reached an increasing complexity, leading to an upsurge in therapeutic procedures and, therefore, to higher chances of complications. Obviously, the occurrence of a complication would translate into a loss rather than a gain and would potentially prevent the patient from having a further endoscopy. However, this relatively rare situation is the accepted downside to any medical intervention, and has been palliated by an effort to increase procedure standardization [3].

Nonetheless, screening encompasses subtler possibilities of loss. False positive results induce medicalization of an otherwise healthy population. Waiting times for results, incidental findings, or subsequent additional tests can make patients lose their “feeling of health.” In this regard, some critical voices have arisen in the medical community claiming that the secondary effects of breast cancer screening programs are greater than the gains in mortality reduction [4]. Consequently, an optimal balance between beneficial effects and adverse events is crucial to attain the final goal of screening programs. The patient experience during the whole process will be a key feature in reaching this balance.

Furthermore, patients place great value on the physician – patient interaction, and consequently satisfaction with colonoscopy may be associated with patient compliance. In healthcare, patient satisfaction is often a good predictor of patient adherence to physician-recommended treatments or tests. Therefore, an unsatisfactory colonoscopy screening experience may discourage participation in a screening program, which would represent another important drawback.

How are things from the patients’ point of view? What is their perception on this? It is true that we usually obtain patients’ subjective feedback during outpatient visits or after a procedure; we can also make a more objective analysis based on complications and claims registries. Obviously, these are only partial approximations to what patients really care about: How long will I have to wait for my test? How long will the results take? What does “intermediate risk adenoma” mean? These are the questions that also impact on patients’ perception of quality. Unfortunately, patient satisfaction has a multifaceted nature and is a very challenging parameter to define. Patients’ expectations and attitudes towards healthcare greatly contribute to their level of satisfaction; other psychosocial factors, including pain and depression, are also known to contribute to patient satisfaction scores.

At some point in our life, we have all answered or performed a satisfaction questionnaire and know how troublesome it can be to make your point in just a few questions. On the one hand, as doctors, we encounter difficulties when selecting the questions that will be representative of the process we want to evaluate, and we need to choose those that will provide us with the answers we are looking for. On the other hand, we face the complexity of writing them down in a language understandable to patients. Obviously, we want them to give us an answer on exactly what we intend to evaluate and we need them to be consistent and coherent. Finally, we face a further challenge because we are asking about a past event that modified the patients’ states of health.

Non-validated questionnaires are not to be trusted. If not reliable and validated, questionnaires are useless because it is hard to extract any conclusion from them. As a result, despite strong recommendations in guidelines to use these as a standard of quality, physicians – and particularly endoscopists – have always been reluctant to spend much time on them.

The development of a validated tool to objectively assess patient satisfaction has therefore been a fundamental challenge in modern endoscopy. The article by Hutchings et al. [5] provides a standardized survey instrument for measuring patients’ perspectives on endoscopic procedures. The Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ) presented by the authors has been validated with psychometric tests in a large multi-institution nurse endoscopy trial based in secondary care in the UK. It has shown high internal consistency and covers four clinically relevant components: “skills and hospital,” “pain and discomfort during and after endoscopy,” “information before endoscopy,” and “information after endoscopy.”

To date, there have been few studies that have used satisfaction questionnaires in endoscopy [6]. None of these have covered such a wide spectrum of items concerning cognitive and emotional responses to patients’ experience of endoscopy, and none of them has been validated with such a thorough methodology. The authors acknowledge that this first step still needs further work to establish the construct and criterion validity of the questionnaire. It will also need to be tested and validated in other countries. However, the present article provides us with an initial tool for implementing the requisites of modern high quality endoscopy. Patient satisfaction is nowadays central to quality. It is time for us to widen our minds and incorporate patients’ feelings and points of view as a mirror to upscale quality in our practice.

• References

• 1 Fenton JJ, Jerant AF, Bertakis KD et al. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012; 172: 405-411
• 2 Sunstein CR. Nudging smokers. NEJM 2015; 372: 2150-2151
• 3 Von Karsa L, Patnick J, Segnan N et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013; 45: 51-59
• 4 Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet 2012; 380: 1778-1786
• 5 Hutchings HA, Cheung W-Y, Alrubaily L et al. Development and validation of the Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ). Endoscopy 2015; 47: 1137-1143
• 6 Chartier L, Arthurs E, Sewitch MJ. Patient satisfaction with colonoscopy: a literature review and pilot study. Can J Gastroenterol 2009; 23: 203-209