Published ahead of print on July 19, 2002, doi:10.1164/rccm.200203-231OC
© 2002 American Thoracic Society
Patient Satisfaction with BronchoscopyDivisions of General Internal Medicine and Pulmonary and Critical Care Medicine, School of Medicine, Departments of Epidemiology and Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland; and University of Arkansas for Medical Sciences, Little Rock, Arkansas Correspondence and requests for reprints should be addressed to Noah Lechtzin, M.D., M.H.S., Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Jefferson B1-170 Baltimore, MD 21287. E-mail: nlechtz{at}mail.jhmi.edu
We conducted a cohort study to characterize patient satisfaction with flexible bronchoscopy (FB) and to determine patient characteristics, care factors, and patient evaluations of bronchoscopy that are associated with a patient's willingness to return for repeat FB. Physicians and patients completed surveys between February 1997 and June 1998. Data from 481 patients were analyzed. Over 80% of the patients rated physicians as very good or excellent, but they were least satisfied with the information that they were provided about FB, waiting time before and after FB, and the FB environment. Seventy-one percent of the patients would definitely return, and 22% would probably return for a repeat FB. Better health status (odds ratio [OR] 1.4; 95% confidence interval [CI], 1.1–1.7), not being bothered by scope insertion (OR 2.0; 95% CI, 1.2–3.3), better rating of information quality (OR 1.2; 95% CI, 1.0–1.3), and better rating of physician quality (OR 1.1; 95% CI, 1.0–1.2) were associated with patients reporting that they would definitely return for a repeat FB. Although patient satisfaction with providers is high, there are specific patient and process of care factors that should be improved. Sicker patients may be at a risk of dissatisfaction with FB. Process of care measures that could improve satisfaction with FB include providing better information to patients and optimizing the experience of bronchoscope insertion.
Key Words: bronchoscopy • patient satisfaction • procedures • quality of care
Flexible bronchoscopy (FB) is a safe and frequently performed procedure (1) for the diagnosis and treatment of pulmonary disorders (2). Since its introduction in 1968 (3), the number of applications for FB has grown tremendously. Advanced diagnostic techniques such as transbronchial needle aspiration (4) are now possible, as are therapeutic interventions, including laser ablation of tumors and placement of endobronchial stents (5, 6). Current bronchoscopy literature reflects an emphasis on the technologic aspects of the procedure rather than patient-centered outcomes (7–9). Although FB is associated with few serious adverse events (10), it has been shown to cause dysphagia, nose pain, throat pain, and fear (11–14). We have previously shown that in FB patients who received intravenous sedation and analgesics, 10% reported pain control to be only fair or poor (13). Beyond evaluations of patient symptoms, there has been little published on patient satisfaction with bronchoscopy. In the increasingly competitive health care business, consumers and health care administrators have realized that patient satisfaction is an important component of health care (15). Patient satisfaction is closely associated with willingness to return for continued care (16) and is also associated with improved physician satisfaction (17), decreased numbers of malpractice suits (18), and improved adherence with discharge instructions (19). Studies of emergency department care and other ambulatory settings have found patient factors and process of care factors that influence patient satisfaction, including age, race, gender, wait times, and patient–provider communication (20–22). There are divergent opinions among bronchoscopists about many basic aspects of the procedure, including whether sedation is beneficial (23) and what route of scope insertion is preferred (24, 25). Better understanding of patient opinion regarding FB and the factors that affect it can lead to enhanced care and improved patient experience. The purpose of this study was to assess patient satisfaction with FB and to identify the determinants of a patient's willingness to return if FB were needed again.
We conducted a prospective cohort study of adults undergoing FB at two academic hospitals. Our study is part of the Bronchoscopy Quality Improvement project (12, 13). Eligibility for the study included all adults (18 years old or more) undergoing FB from February 1997 to June 1998. Exclusion criteria included endotracheal intubation and mechanical ventilation, inability to speak English, other communication deficits that precluded answering questions, and death within 48 hours after FB. Physicians and patients completed standardized report forms. Physicians reported patient characteristics, indications for the procedure, details of how the procedure was performed, and outcomes of the procedure. Patients completed two questionnaires. The first questionnaire completed just prior to FB assessed baseline symptoms before bronchoscopy. A second questionnaire completed 48 hours after the procedure assessed symptoms experienced during and after the procedure and assessed satisfaction with several aspects of their care. Questionnaires were completed 48 hours after the procedure to allow sufficient time for medications to wear off while not allowing too much time to pass. There is evidence that recall of pain from surgical procedures is accurate for at least 5 days after the procedure (26).
Outcomes Patient outcomes assessed included symptoms associated with specific aspects of the procedure. Patients were asked how much they were bothered by numbing of their nose, taste of the throat spray, and insertion of the bronchoscope (on a three-point scale: not at all, a little, and a lot). They also reported how much they remembered about the FB on a five-point scale (remember nothing at all, no details, some details, most details, or every detail).
Analyses
Multivariable analyses were performed using multiple logistic regression. Likelihood of returning for repeat FB was the dependent variable (definitely would return versus all other categories). We began with a model that included all of the variables from bivariate analysis that were significant, and we then removed all variables that were not significant at p  0.05. This process was repeated until only significant factors remained in the model. All analyses were performed with SAS statistical software (SAS Institute, Cary, NC). Please see online data supplement for additional details.
Study Population and Characteristics During the study period of February 1, 1997, to June 30, 1998, 840 eligible patients were identified; 584 patients (69.5%) completed the pre-FB survey, and 519 patients (61.8%) completed the post-FB survey. We confined our analysis to the 481 patients (57.3%) who completed both questionnaires. Patients who completed both questionnaires were similar to those who did not with respect to age and gender. Nonwhites were less likely than whites (63.3% versus 74.5%, p < 0.02) to complete both forms. The study population included 49.8% men, 62.6% whites, and 37.4% nonwhites, nearly all of whom were African American (Table 1) . Over half of the group reported their health status as poor or fair, and nearly one third were ill enough to require supplemental oxygen before the procedure. Seventy-one percent of patients reported that they would definitely return if they needed a repeat FB, whereas 22.2% probably would return, 4.3% were unsure, and only 2.4% would not return (probably or definitely not) (Figure 2) . There were 16 full-time pulmonary/critical care faculty members who performed more than five bronchoscopies during the study period. Seventeen percent of the cases were performed without pulmonary fellow involvement, and there was no significant difference in patient likelihood of returning for repeat bronchoscopy between cases with and without fellow involvement (71.3% versus 70.5%, p = 0.6).
Sampling methods used to obtain clinical specimens and medication usage are reported in Table 2 . Bronchoalveolar lavage was the most commonly performed sampling method (73.8% of cases), and transbronchial biopsy was performed in 34.8%. There were wide variations in the amounts of medications used. In cases in which fentanyl was used (95%), the mean dose given was 104.6 mcg (range 12.5–250.0 mcg). The mean dose of midazolam, in cases where midazolam was used (93%), was 3.7 mg (range 0.5–10.0 mg). Patient willingness to return for repeat FB was not associated with the indication for the procedure, the sampling method used, or complications, including pneumothorax and bleeding.
Patient Evaluations of Bronchoscopy Patient evaluations of various aspects of the bronchoscopy experience are shown in Table 3 . Patients were least satisfied with information given about how to obtain test results and with waiting times before and after the procedure. Fewer than 70% of the patients gave very good or excellent marks to information they received, waiting times, and the bronchoscopy environment. The latter included ratings of the receptionist, patient privacy, and the family waiting area; 16.9% of patients rated information about obtaining results as fair or poor. In contrast, over 80% of the patients rated physicians very good or excellent in all categories, and no patients rated physicians as poor in courtesy or skill.
Patient Characteristics Associated with Willingness to Return for Repeat Bronchoscopy Patient age, gender, and race were not significantly associated with willingness to return for a repeat FB. However, patients with better health status (indicated by self-report and lack of oxygen use) and those who had bronchoscopy performed as outpatients were significantly more likely to be willing to return for a repeat FB (Table 1). Current smokers and nonsmokers reported a similar willingness to return for repeat FB (67% would definitely return in each group, p = 0.6). There were 159 (34.2%) bronchoscopies performed for a cancer indication. For cases with a primary indication of "rule-out" cancer, 78% of the patients stated that they would definitely return for repeat bronchoscopy.
Process of Care Factors Associated with Willingness to Return for Repeat Bronchoscopy
Other Outcomes Associated with Willingness to Return for Repeat Bronchoscopy
Positive, statistically significant relationships were seen between higher ratings of physician quality, information about the procedure, pain control, and willingness to return for repeat FB (Figure 4) . Patients were also significantly more likely to state that they would definitely return for a bronchoscopy if they had more favorable ratings of the bronchoscopy environment and waiting times. Of patients who rated the bronchoscopy environment highest (using a combined scale grading multiple aspects of the environment), 82% were definitely willing to return compared with only 29% of patients who rated it lowest. Eighty-two percent of the patients who gave the most favorable rating of waiting times on a combined scale of waiting before, during, and after the procedure would definitely return, whereas only 34% would definitely return when they rated waiting in the lowest quartile.
Multivariable Analyses to Predict Likelihood of Returning for Repeat FB In the model that examined patient and process of care factors, there were two factors that were significantly associated with a likelihood of returning for a repeat FB: site of scope insertion (nose versus mouth or tracheostomy) and health status (Table 5) . There were higher odds of definitely being willing to return in patients who considered themselves to have better health compared with patients with worse health (odds ratio 1.4; 95% confidence interval, 1.1–1.7). The odds of definitely returning were higher when the bronchoscope was inserted through the nares than when it was inserted via the mouth or tracheostomy. These results show that health status and route of instrument insertion are significant independent predictors of patient satisfaction after adjusting for other factors, including medication use, age, sex, and race.
In the model that examined the association of other patient-reported outcomes with willingness to return (Table 6) , willingness to return was related to comfort with anesthesia of the nose, better rating of information, and better rating of physician quality.
This is the first study to evaluate multiple aspects of patient satisfaction with FB and the factors that influence a patient's decision to return for a repeat FB. Patients gave lower ratings to the information that they received about FB, the waiting times before and after FB, and the bronchoscopy environment and higher ratings of the physicians. Most (71% definitely and 22% probably) of the patients would return for repeat FB if needed, confirming the general clinical impression that this procedure is quite tolerable. There are specific patient factors, process of care factors, and other patient-reported factors that appear to influence a patient's willingness to return for a repeat procedure. Better health status is an independent predictor of patient satisfaction. If patients were not bothered by nose numbing, rated their physician higher, and reported better quality of information, they were also more willing to return for a repeat procedure. We have identified factors that are common across many types of patient care as well as some that are specific to bronchoscopy. The association that we found between information provided to patients and patient satisfaction has been found in other settings, including emergency room care (20), oncologic clinics (27), asthma care (22), and gastrointestinal procedures (28). In this study, patients clearly identified information about the procedure as an important determinant of whether they would return for a repeat procedure. Such information included information about what to expect during the procedure, what to expect after the procedure, and how to obtain results from the procedure. Although it appears obvious that bronchoscopists should explain all aspects of FB to their patients, it is likely that this may not always be done and varies from person to person and between institutions. As a result of these findings, we have begun using standard written information at our institution and plan to study whether patient satisfaction improves as a result. Although patients were critical of waiting times and aspects of the FB environment, these factors were not important determinants of the decision to return for a repeat FB. It is apparent that this decision is influenced by certain patient characteristics and other care factors. Worse health status has also been previously shown to be negatively associated with patient satisfaction (29). Knowledge that patients with worse health status are less likely to return for a repeat procedure should prompt physicians to pay special attention to these patients. Bronchoscopists may improve the patient experience by spending extra time preparing them and carefully informing them about all aspects of the procedure. Special attention should be given to local anesthesia of the upper airway, bronchoscope insertion, and information about what to expect during the procedure and after the procedure and how to obtain results. Preparation of the nose with topical anesthesia is one area in particular that is specific to bronchoscopy that needs further attention. Whether FB is best performed via the transnasal or transoral approach has been debated by experienced bronchoscopists (24, 25). These findings provide support for the former but should be viewed in the correct context. At our center, FB is preferentially performed transnasally, with the bronchoscopist behind the supine patient's head. In most instances, the transoral approach is used when a narrowed nasopharynx limits insertion of the instrument, often after multiple attempts have been unsuccessful. Therefore, insertion through the mouth is probably indicative of a difficult case in which there may have been significant nasal pain. Thus, the association of less patient willingness to return with transoral FB is consistent with a technically more difficult procedure for both the bronchoscopist and the patient, providing another indicator that pain and trauma to the nose result in lower patient satisfaction. Consistent with our previous observation that patients who are bothered by numbing of the nose and scope insertion report significantly worse pain control during FB (13), being bothered by numbing of the nose is an independent predictor of willingness to return. Local anesthesia is frequently administered before parenteral sedation and analgesia. It remains to be determined whether an approach in which parenteral sedation preceding local anesthesia improves patient tolerance of FB. We recommend further investigation into this question. There are several limitations to this study. First, we have characterized patient satisfaction by inquiring about the likelihood of returning for a repeat FB. This decision is influenced by factors in addition to satisfaction such as costs of care, insurance coverage, and geography. For example, a patient may be dissatisfied with the most conveniently located hospital but may still opt to return there for repeat procedures rather than travel a greater distance. However, it has been shown that willingness to return for further care is closely associated with overall patient satisfaction (16, 30). Second, of those patients who were eligible for this study, 57% completed all of the questionnaires. The patients who completed all of the questionnaires were similar to those who did not with respect to age and gender but were less likely to be white. The overall similarity of responders and nonresponders suggests that internal validity was not significantly compromised, especially as race was a factor, which was not associated with satisfaction domains or willingness to return for a repeat procedure. It is not clear when is the ideal time to assess patient satisfaction. In this case, patients completed questionnaires 48 hours after the procedure. This slight delay carries the risk that patient recall of the procedure had diminished. Completing the questionnaires closer to the procedure could have been problematic, however, because of the effects of sedatives and analgesics. We recognize that asking questions on the second day after the procedure represents a compromise and that, if we had assessed patients at a different time, could have affected the results. However, there is evidence that recall is accurate 5 days after surgical procedures (26). Finally, the generalizability of the findings is potentially limited by study patients concentrated in one United States location at two academic medical centers. As indicated in Table 1, our study population was quite heterogeneous, with a wide range of ages, balanced gender representation, and good minority representation. Although individual bronchoscopists may use different techniques than those studied, the findings reported here should be generalizable to other academic medical centers. Nevertheless, other bronchoscopists are encouraged to conduct similar studies to learn whether there are additional factors that affect the satisfaction of their own patients as well. As health care becomes an increasingly competitive industry, with insurers and consumers asserting greater influence on where and how services are rendered, patient satisfaction has become an important concern. We have identified four factors—better health status, less discomfort from scope insertion, better patient ratings of information quality, and better patient ratings of physician quality—that independently predict the decision to return should a repeat FB become necessary. Special attention should be directed to patients in worse health to improve their experience. Improving communication with patients is feasible, and further studies of patient information protocols should be performed. We feel that bronchoscopists should direct efforts to improving the techniques for upper airway anesthesia and bronchoscope insertion to improve the bronchoscopy experience. Efforts toward improving communication and minimizing discomfort should improve patient satisfaction and increase the likelihood that patients will return if a repeat procedure is necessary.
The authors thank Drs. Ed Haponik and Albert Wu for their critical review of earlier versions of this manuscript. They also thank Dr. Charles Wiener for his leadership role in their understanding of satisfaction.
Supported by Johns Hopkins Medicine, the National Heart, Lung, and Blood Institute (training grant 2 T32 HL07534, N.L.), and The Johns Hopkins Clinician Scientist Award (N.L.) This article has an online data supplement, which is accessible from this issue's table of contents online at www.atsjournals.org Received in original form March 19, 2001; accepted in final form July 18, 2002
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ABSTRACT
INTRODUCTION
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