Patients' time investment in colonoscopy procedures

AORN Journal,  Jan, 2008  by George Allen

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American Journal of Gastroenterology

November 2007

There are several screening tests available for colorectal cancer (CRC), the leading cause of cancer death in the United States. Despite the availability of these tests, however, screening test utilization remains low. In recent years, colonoscopy has become the most popular screening tool; consequently, it is important to identify and reduce patient and system barriers to its use.

One important barrier from the patient perspective is time. Colonoscopy is likely the most time-intensive of all the screening tests for CRC. The time required includes time for the procedure itself, preparation time, travel time, waiting time, and recovery time. Understanding and measuring patient time for screening colonoscopy is important for numerous reasons: namely, excessive time requirements may be a barrier to a patient's undergoing recommended screening; measuring time requirements can guide quality improvement efforts focused on improving efficiency; time requirements may play an important role in medical decision making; and time requirements are needed to accurately assess the true cost and cost-effectiveness of different options for screening in economic analyses. Although some studies have attempted to measure the amount of patient time related to a variety of health care activities, no studies had attempted to measure the amount of time related to the colonoscopy screening process. The purpose of this prospective study was to measure the time patients invested in the colonoscopy procedure using patient time diaries.

Between October 2005 and June 2006, patients from an off-campus, university hospital-owned, open access endoscopy center in Chapel Hill, North Carolina, were recruited for the study. Eligible patients were between 50 and 85 years of age, English speaking, and able to complete the diary and questionnaire; had a history of colon cancer; and were having a colonoscopy for screening or surveillance of polyps. Patients were excluded if they were having colonoscopies for other reasons, such as evaluation of anemia, bloody stools, or other symptoms.

Patients enrolled in the study were asked to fill in the time and date they began each step in the colonoscopy process in a formatted time diary. Items recorded before colonoscopy included when they changed their diet, started taking the preparation medication, departed home for the colonoscopy, and arrived at the endoscopy center. All the participants gave their diaries to the research assistant who recorded the times when sedation was initiated, the colonoscopy started, the colonoscopy ended, and the patient departed from the endoscopy center. The diaries were returned to the patients on departure and they were encouraged to fill out the postcolonoscopy portions that included the times and dates for arrival home after the colonoscopy, returning to routine activities, and feeling completely back to normal. The patients also completed a questionnaire at home within one week after the colonoscopy. It included questions about the overall test experience, preparation, travel, complications, missed work, missed activities, and recovery. Additionally, questions were asked about the following themes: travel cost, side effects, demographic data, health history, and assistance needed to perform activities of daily living. Patients who completed the diary and questionnaire received a $25 gift card for their participation. Common statistical techniques including means, medians, and ranges; the Wilcoxon rank sum test; and the Kruskal-Wallis test were used to analyze the data.

FINDINGS. One hundred ten patients completed the study. The mean age was 61.9 years (range 50 to 81 years), 57% were female, 85% were white, and 90% were insured. Ninety percent rated their general health as good or excellent. A total of 17% of the patients reported side effects from the colonoscopy; these included abdominal pain, abdominal cramps, vomiting, lightheadedness, sharp right hip pain, and feeling very tired. At the completion of the study, there were no major complications, hospitalizations, or deaths. Patients spent a median of 21 hours in the screening colonoscopy process for preparation (ie, 16.5 hours); travel (ie, 0.8 hours); waiting (ie, 1.4 hours); sedation (ie, 12 minutes); and colonoscopy (ie, 20 minutes). Patients spent a median of 2.8 hours at the endoscopy center with a median on-site recovery time of 47 minutes. The patient time requirement was sensitive to their having a history of depression, the type of person accompanying the patient, income, and employment status.

CLINICAL IMPLICATIONS. The results of this study revealed that a screening colonoscopy requires a substantial commitment of a patient's time, with the majority of time spent in the preparation and recovery phases. Perioperative nurses and managers should realize that time is a potential barrier to screening and that advances in preparation and sedation practices could reduce the time required of patients.