Introduction
Per-procedural patient comfort is one of the key performance measures for colonoscopy [1]. In daily practice, patient comfort is generally reported by clinicians using rating scales such as the Gloucester Comfort Scale (GCS) [2]. However, despite the widespread use of the GCS, insights regarding the extent to which clinician-reported GCS scores really represent the patient's experience are lacking. Therefore, we aimed to assess the level of agreement between clinician-reported GCS scores and the level of patient-reported discomfort and pain.
Aims & Methods
Consecutive patients undergoing colonoscopy for any indication at two Dutch endoscopy clinics were invited to complete the Newcastle ENDOPREM™, a validated measure of patient experience of gastrointestinal endoscopy [3], within 48 hours after colonoscopy. Colonoscopies were performed by gastroenterologists or supervised gastroenterologists in training. Per-procedural comfort from the clinician’s perspective is routinely reported by either the endoscopy nurse or endoscopist using the GCS (1 to 5 scale). Per-procedural experience from the patient’s perspective was reported in terms of both the level of discomfort and pain on a 1 (no discomfort/pain) to 5 (worst discomfort/pain imaginable) scale. Moderate to high discomfort scores were defined as scores >3. Levels of agreement between clinician- and patient-reported scores were assessed using Cohen's kappa statistic. Regression analyses were used to identify factors associated with moderate to high discomfort and pain scores.
Results
Of 579 invited patients, 243 (42%) returned a completed questionnaire and fulfilled the inclusion criteria (signed informed consent, no deep sedation [4]). Percentual agreement between GCS and patient-reported scores is displayed in Table 1. A GCS score >3 was reported for 18 (7%) patients. Discomfort and pain scores >3 were reported by 53 (22%) and 60 (25%) patients respectively. For these patients, GCS underestimated discomfort and pain levels as reported by patients in almost all cases (discomfort: 49/53 [92%], pain: 54/60 [90%]). The level of agreement between GCS and discomfort scores was minimal (Cohen’s κ: 0.34), agreement between GCS and pain scores was weak (Cohen’s κ: 0.47). Levels of agreement were better for sedated patients (asleep but with response to verbal or tactile stimulation, n = 125) compared to patients who were awake or slightly drowsy (n = 116) for both discomfort (Cohen’s κ: 0.45 vs. 0.20) and pain (Cohen’s κ: 0.45 vs. 0.38). Based on multivariable regression analyses, female gender, age <55 years and high procedural difficulty (as defined by the endoscopist) were associated with moderate to high patient-reported discomfort and pain scores. Moreover, where patients reported that they were anxious about discomfort and pain, anxious about procedure results, had a negative bowel preparation experience, felt unsafe, felt embarrassed or where procedures were longer than expected, moderate to high discomfort and pain scores were more common (all p<0.05).
| Matching GCS score and patient-reported score, n (%)
| GCS score lower than patient-reported score, n (%)
| GCS score higher than patient-reported score |
Discomfort
| 119 (49%) | 72 (30%) | 52 (21%) |
| Pain | 133 (55%) | 71 (29%) | 39 (16%) |
Conclusion
Clinician-reported GCS scores, used to indicate per-procedural patient comfort, underreport discomfort and pain as reported by patients. A validated experience tool also allows the definition of patient factors that may be associated with greater patient reported discomfort and pain at colonoscopy. These findings support the use of patient-reported comfort scores for accurate monitoring of patients’ experience.
References
[1] Kaminski MF, Thomas-Gibson S, Bugajski M et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397. DOI: 10.1055/s-0043-103411
[2] Ekkelenkamp VE, Dowler K, Valori RM et al. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19: 2355-2361. DOI: 10.3748/wjg.v19.i15.2355
[3] Neilson LJ, Sharp L, Patterson JM et al. The Newcastle ENDOPREM: a validated patient reported experience measure for gastrointestinal endoscopy. BMJ Open Gastroenterol 2021; 8. DOI: 10.1136/bmjgast-2021-000653
[4] Lee JK, Lee YJ, Cho JH et al. Updates on the Sedation for Gastrointestinal Endoscopy. Clin Endosc 2019; 52: 451-457. DOI: 10.5946/ce.2019.172
Disclosure
PF received research support from Boston Scientific and a consulting feefrom Olympus and Cook Endoscopy. CR has received grant funding from ARC medical, Norgine, 3-D Matrix, Medtronic and Olympus medical. He was an expert witness for ARC medical and for Olympus medical. ED received a research grant from Fujifilm, a consulting fee for medical advice from Olympus, Fujifilm, GI Supply, PAION, Ambu and CPP-FAP and a speakers fee from Olympus, Roche, GI Supply, Norgine, Fujifilm and IPSEN.
