Evaluation of patient satisfaction of an outpatient gastroscopy service in an Asian tertiary care hospital

Patient satisfaction is considered a measure of a high-quality endoscopy [1], and many endoscopy units administer patient satisfaction surveys for quality-control purposes [2]. Deficiencies in an endoscopy unit can be identified through such studies and these can then be analyzed and solutions can be made to improve the overall quality of endoscopy. Patient satisfaction also affects health care outcomes. Patients who are dissatisfied are likely to be non-compliant [3], transfer care to other centres [4] and engage in litigation issues [5]. From the business point of view, satisfaction scores can be used for marketing purposes if they are sufficiently impressive [6].

The Endoscopy Suite in University of Malaya Medical Centre caters to 3000 – 3200 gastroscopies per year. In the year 2010, over 2000 outpatient gastroscopies were performed and the number is increasing. Despite this figure, no studies have been done to assess patient satisfaction. Therefore we decided to perform a survey to assess patient satisfaction of our outpatient gastroscopy service and to identify areas of dissatisfaction for improvement. Moreover, there are limited published studies on patient satisfaction towards endoscopy from Asian countries.

Many studies on patient satisfaction were carried out immediately after the procedure [7–9]. Sedation given during the procedure may affect patient satisfaction score and this raises the question on whether answering a questionnaire immediately after the procedure may yield different satisfaction scores compared to administering the questionnaire at a later date. In a study by Lin et al [10], on-site survey resulted in higher satisfaction scores compared to mail back survey. Besides the possible influence of sedation, it was hypothesized that patients may feel disinclined to give low satisfaction scores in the presence of endoscopy unit staff. Another study by Harewood et al [11] reported that survey methods that involved more personal interaction such as on-site surveys and phone interviews tend to generate higher response rates than less personal methods such as mail back surveys and electronic mail surveys. To the best of our knowledge, there is till date no study comparing on-site interview and phone interview in terms of success rate and patient satisfaction score of endoscopy services. Thus, the secondary aim of our study is to compare the results of immediate on-site interview and delayed phone interview in these aspects.

This is a cross sectional study of consecutive patients attending the outpatient gastroscopy service in University of Malaya Medical Centre between July 2010 and January 2011. Written informed consent was obtained from all patients and the study was approved by the ethical committee of this institution.

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 [2]. Patient satisfaction also affects perception of the population at large towards endoscopic services and can have significant impact on patient willingness to undergo endoscopic procedures regardless of whether the patient has had endoscopy before.

Different questionnaires have been used to assess patient satisfaction towards gastrointestinal endoscopy [10, 14, 15]. The American Society of Gastrointestinal Endoscopists (ASGE) recommended the use of the mGHAA-9 questionnaire to measure patient satisfaction [15]. However, mGHAA-9 does not contain a question on patient comfort which has been found to be an important factor influencing patient satisfaction [16]. It was also noted that patients had difficulty answering the question on technical skills of endoscopist found in mGHAA-9 [14]. We anticipated a similar problem with our patients and have substituted this question with one on patient comfort.

As different health care system may vary in term of aspects that patients consider being important [17], areas of dissatisfaction unique to local patient population should be identified and analyzed and corrective measures instituted for improvement accordingly. Five independent factors affecting overall rating were identified in our population: waiting time for appointment, waiting time on gastroscopy day, personal manner of physician, adequacy of explanation and discomfort during procedure. Of these, waiting times and discomfort during procedure ranked the highest in terms of unfavorable responses.

Increasing number of patients scheduled for gastroscopy and limited resources have resulted in long appointment waiting times in our center while prolonged waiting on the day of gastroscopy may be the result of combination of factors including over-scheduling of cases for each session. Nearly half of our patients were dissatisfied with waiting time for gastroscopy appointment while close to one quarter were unhappy with their waiting on gastroscopy day. As dissatisfaction towards appointment waiting time could have resulted in a proportion of patients transferring to another outpatient gastroscopy service, our figure could be an under-estimation 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 [18–21]. In this aspect, it is vital that increasing patient load is matched by increasing allocation of resources to maintain a service that meets the expectations of not only patients but also of healthcare providers.

Discomfort during procedure was recognized as the main cause of patient dissatisfaction in some studies [22, 23]. Despite using proven measures to minimize discomfort during gastroscopy, including pharyngeal anesthesia and conscious sedation [7–9, 24], nearly a quarter of our patients were not satisfied. We found that patients who were only minimally sedated were more likely to give unfavorable response for comfort during procedure (data not shown). In this aspect, routine use of OAASS as an objective measure of adequate (moderate) sedation prior to commencing the procedure may be of benefit. Besides sedation, other factors such as the diameter of the endoscope [25] and level of experience of the endoscopist [23] may affect the level of comfort during the procedure. However, our study was not designed to look into these factors.

Besides waiting times and discomfort during procedure, other factors have yielded unfavorable responses from our patients. However, utilizing the principle of “vital few and trivial many” [26], we identified that waiting times and discomfort during procedure constituted to nearly 90% of the problems faced by our patients. By focusing on improvement in these aspects, there is great likelihood of substantially reducing the problem rate among patients attending our outpatient gastroscopy service. Based on our analysis, aiming for gastroscopy appointment waiting time of within 1 month and waiting time on gastroscopy day of within 1 hour will result in an improved rate of favorable response to nearly 80% and over 90%, respectively. However, as this is a single-center study, this result may not be generalizable to other populations. Nevertheless, by using a similar approach, other centers may be able to gauge the waiting times that are acceptable for their patient population.

Previous studies have shown that survey collection method may impact on subject responses. Phone-back methods are generally associated with more favorable responses compared to mail-back methods [27–30] although some studies did not find any difference between the two methods [11, 31, 32]. Among patients who underwent endoscopy, satisfaction scores were better when surveys were completed on-site compared with when they were mailed back [10, 22]. Interesting terms such as “social desirability response” bias (patients giving better responses than they feel because they feel it is more acceptable) and “ingratiating response” bias (patients giving better responses than they feel because they wish to ingratiate themselves with their providers) have been used for the phenomenon where satisfaction scores were better when obtained through more personal and earlier communications with patients [6]. Success rates are also generally better with on-site and phone-back methods compared with mail-back methods [11, 27, 28, 32]. To our best knowledge, no studies have been conducted to compare on-site interview versus phone-back interview in evaluation of patient satisfaction of endoscopy services.

We found that satisfaction scores were better for waiting time for appointment but lower for personal manner of nurses/staff and for adequacy of explanation during phone-back interview compared with on-site interview. We hypothesize that dissatisfaction towards waiting time for appointment naturally diminished over time after the procedure helped in reassuring patients when there was nothing wrong or facilitated effective treatment following accurate diagnosis of the underlying condition. On the other hand, patients may have been more reluctant to give a low score for personal manner of nurses/staff and for adequacy of explanation during the on-site interview while still within the vicinity of the Endoscopy Suite. There was no significant difference in satisfaction scores for other questions, including overall rating between the two methods although there was a trend towards better scores during phone-back interview. This factor should be considered when comparing individual items of the questionnaire between centers or between two time-points in the same center if different methods (i.e. on-site vs. phone-back) were used. However, overall rating and some of the items may still be comparable. Caution should also be exercised when interviewing patients through phone-back when they have missed their on-site interview in patient satisfaction studies as some of the results may not be comparable when obtained using the two different methods. We would prefer on-site interview when conducting satisfaction survey due to its better success rate and because it is arguably easier and less costly to administer compared with phone-back interview.

Our center practices an open-access outpatient gastroscopy service receiving patients from primary care clinics, other specialist clinics and those discharged from in-patient wards in addition to patients from the gastroenterology clinic. Hence data from this study is generalizable to populations scheduled for gastroscopy at large. Despite our efforts, this study has several limitations. Firstly, we conducted the interview on the same group of patients and the response to the second interview may be biased by that of the first interview. Our findings should be confirmed with randomized study of two distinct groups of patients i.e. one for on site interview while the other for phone interview. Secondly, while the questionnaire used has obvious face validity, it has not been formally validated for our local population. There is currently no formally validated satisfaction survey questionnaire for endoscopy for our local population.

We found waiting times and discomfort during procedure to be the main causes for patient dissatisfaction towards the outpatient gastroscopy service of an Asian tertiary hospital. Measures to reduce waiting times for gastroscopy appointment and on gastroscopy day to less than 1 month and 1 hour, respectively may improve patient satisfaction substantially. Phone-back interview may result in different patient satisfaction scores compared with on-site interview. This should be taken into account when comparing results obtained using these two different methods. On site interview may be preferred as it gives a better success rate and is arguably easier and less costly to administer.