Influence of additional post-bronchoscopy visit on patient satisfaction after flexible bronchoscopy.

Abstract

Many patients undergoing a flexible bronchoscopy (FB) experience anxiety and discomfort during the procedure. We assessed whether an additional patient visit after a FB would improve patient satisfaction.
The study patients were randomly assigned to a control and post-visit groups. The physicians who were scheduled to perform the FB visited the study patients. The control group had one visit before the FB and the post-visit group had a before and after FB visit. The post-visit group received additional information and support during the second visit. Twenty-four hours after the FB, the participants completed questionnaires about discomfort and satisfaction with the procedure.
The control and post-visit groups included 151 and 153 patients, respectively. The post-visit group reported having more information after the FB than the control group. The additional post-bronchoscopy visit improved the general patient tolerability of the procedure. The willingness to return for another FB was not affected by the post-bronchoscopy patient visit.
The post-bronchoscopy visit improved patient satisfaction and general tolerability to the procedure. Subjective patient tolerability with the FB may be improved through a post-bronchoscopy visit by providing more information and emotional support to patients.

Full text

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Influence of Additional Post-Bronchoscopy Visit on Patient
Satisfaction after Flexible Bronchoscopy
Jong Sun Park1, Jeong-Seon Ryu2, Sang-Min Lee1, Jae-Joon Yim1, Chul-Gyu Yoo1, Young Whan Kim1,
Sung Koo Han1, Young-Soo Shim1, and Seok-Chul Yang1
1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research
Center, Seoul National University College of Medicine, Seoul; 2Division of Pulmonary and Critical Care Medicine, Department
of Internal Medicine, Inha University School of Medicine, Incheon, Korea
DOI: 10.3904/kjim.2010.25.4.392
Background/Aims: Many patients undergoing a flexible bronchoscopy (FB) experience anxiety and discomfort
during the procedure. We assessed whether an additional patient visit after a FB would improve patient
satisfaction.
Methods: The study patients were randomly assigned to a control and post-visit groups. The physicians who were
scheduled to perform the FB visited the study patients. The control group had one visit before the FB and the post-
visit group had a before and after FB visit. The post-visit group received additional information and support during
the second visit. Twenty-four hours after the FB, the participants completed questionnaires about discomfort and
satisfaction with the procedure.
Results: The control and post-visit groups included 151 and 153 patients, respectively. The post-visit group
reported having more information after the FB than the control group. The additional post-bronchoscopy visit
improved the general patient tolerability of the procedure. The willingness to return for another FB was not
affected by the post-bronchoscopy patient visit.
Conclusions: The post-bronchoscopy visit improved patient satisfaction and general tolerability to the
procedure. Subjective patient tolerability with the FB may be improved through a post-bronchoscopy visit by
providing more information and emotional support to patients. (Korean J Intern Med 2010;25:392-398)
Keywords: Bronchoscopy; Patients; Personal satisfaction
Received: April 7, 2010
Revised : May 3, 2010
Accepted: May 4, 2010
Correspondence to Seok-Chul Yang, M.D.
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul
National University College of Medicine, Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea
Tel: 82-2-2072-0354, Fax: 82-2-762-9662, E-mail: scyang@snu.ac.kr
INTRODUCTION
Flexible bronchoscopy (FB) is a commonly performed
invasive procedure that is useful for the diagnosis and
treatment of respiratory disease [1,2]. Many patients who
undergo bronchoscopy are fearful of the procedure and
experience anxiety and discomfort during FB [3,4].
Sedative premedication has been used frequently in an
attempt to relieve such anxiety and discomfort, but use of
these drugs may result in undesired complications such as
hypoxia or hypotension [5] and poor patient cooperation
because of the sedative effects.
Some studies suggest that a patient's discomfort can be
relieved by providing better or more complete information
about the examination [6-10]. Moreover, the quality of the
information provided to patients is a major determinant of
the satisfaction with their care [11]. However, many
patients are provided limited information about their
hospital care [12-14], and feel that more attention should
be paid to nontechnical aspects of their care [15]. In one
study [13], 20% of the patients who underwent diagnostic
tests reported problems with communication of the test
results. If physicians provided patients with more
information and an opportunity to ask questions after
ORIGINAL ARTICLE

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Park JS, et al. Post-bronchoscopy visit and satisfaction 393
procedures, patients may be more satisfied with them.
Therefore, the goal of this study was to determine whether
providing more information and emotional support after a
FB would increase patient satisfaction. We assessed
whether an additional patient visit after a FB would
improve patient satisfaction.
METHODS
Study design and subjects
A prospective randomized study was conducted at Seoul
National University Hospital, a tertiary care hospital. The
study was approved by the Seoul National University
Hospital ethics review committee and conducted in
compliance with the Declaration of Helsinki. Adult
patients (aged 18 years or older) admitted to the respiratory
department were enrolled. Exclusion criteria were as
follows: involvement in outpatient procedures;
therapeutic FBs (e.g., cases of photodynamic therapy,
electrocautery, or laser therapy), an expected operation or
discharge within 24 hours after a FB, sedative premedica-
tion, endotracheal intubation with mechanical ventilation,
and inability to speak Korean.
The enrolled patients were randomized to either the
control or post-visit groups after the procedure was
completed, according to a random sample chart of numbers.
One day prior to the FB, all study patients had a visit from
the physician who was scheduled to perform the opera-
tion. During the pre-bronchoscopy visit, the patient was
examined and received information about the FB,
including a general description and possible complica-
tions related to it (Appendix). Patients in the control
group had only the pre-bronchoscopy visit. Patients in the
post-visit group had an additional post-bronchoscopy
(second) visit, as well as the pre-bronchoscopy visit within
24 hours after the FB. After the operation, all patients
received the results from the attending doctor.
Additionally, the post-visit group had the FB results report
repeated with emotional support provided by the
examiners. During the post-bronchoscopy visit, the
patients were examined again and evaluated for FB-
related complications using a standardized protocol
(Appendix).
The patients completed self-administered questio-
nnaires 24 hours after the FB. Patients were asked to
grade their discomfort (anesthesia, cough, dyspnea, and
throat pain) and satisfaction (adequacy of information
before and after the FB, general tolerability, and
willingness to return). Each item was scored as one of four
grades: 1, never; 2, minimal; 3, moderate; 4, severe.
Questionnaires were analyzed by comparing the number
of patients who checked grades 1 and 2 vs. grades 3 and 4
between the control and post-visit groups. Other variables
were analyzed including the details on how the FB was
performed, the outcomes of the procedure, and the
amount of time spent visiting patients. The medical
records were reviewed to examine smoking history, level
of education, and patient insight into the relevant disease.
Bronchoscopy
The FB was performed by faculty or fellows in the
pulmonology division under the supervision of faculty
staff. An intramuscular injection of 25 mg pethidine
(meperidine) was used as baseline premedication. For
local anesthesia, aerosolized lidocaine (2%, 20 mL) was
sprayed into the oropharynx with the patient in a seated
position. The bronchoscope was then inserted through the
mouth. After insertion of the scope, a 1% lidocaine
solution was sprayed into the tracheobronchial tree
through the scope for additional local anesthesia.
Statistical methods
Analyses were performed using SPSS version 12.0 (SPSS
Inc., Chicago, IL, USA). χ2tests for categorical data and
independent sample t tests for continuous data were
performed to evaluate the differences between the two
groups; pvalues < 0.05 were considered significant.
RESULTS
Study population and baseline characteristics
During the study period, 389 of 488 eligible patients
were enrolled; 196 and 193 patients were randomly
assigned in a 1 : 1 ratio to the control and post-visit groups,
respectively (Fig. 1). A total of 304 patients (78%) completed
the questionnaire, and we confined our analysis to those
patients. Finally, 151 controls and 153 post-visit patients
were evaluated. The baseline characteristics of the
patients are shown in Table 1. No differences were
observed between the groups for age, gender, smoking
history, supplemental oxygen use, previous experience
with FB, education level, or insight into their diseases.
Procedure-related factors, such as the duration of FB,

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394The Korean Journal of Internal Medicine Vol. 25, No. 4, December 2010
Table 1. Baseline characteristics
Variables Control
(n = 151)
Post-visit
(n = 153)
p value
Age, yr
Male
Smoking
Supplemental oxygen use
Yes
No
Experience with FB
First time
One or more previously
Education (completed)
Elementary school
Middle school
High school
College or above
Insight
Yes
No
58.6 ± 12.4
72 (58.5)
83 (55.0)
59.9 ± 11.4
69 (58.5)
75 (49.0)
0.33
0.99
0.29
14 (9.3)
137 (90.7)
14 (9.2)
139 (90.8)0.56
136 (90.1)
15 (9.9)
136 (88.9)
17 (11.1) 0.73
45 (29.8)
25 (16.6)
34 (22.5)
47 (31.1)
46 (30.1)
29 (19.0)
31 (20.3)
47 (30.7)0.93
143 (94.7)
8 (5.3)
144 (94.1)
9 (5.9)0.82
Values are presented as mean ± SD or number (%).
FB, flexible bronchoscopy.
Figure 1. Participant flow through the trial.

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Park JS, et al. Post-bronchoscopy visit and satisfaction 395
amounts of lidocaine and saline used, and operator skill did
not differ between the two groups (Table 2). The mean time
spent on the pre-procedure visit was 4.7 ± 2.4 and 4.1 ±
1.8 minutes in the control and post-visit groups, respect-
ively. In the post-visit group, the mean time spent on the
post-bronchoscopy visit was 4.0 ± 2.5 minutes.
Measures of patient satisfaction
The post-visit group reported having more information
after the FB than the control group (Table 3). Furthermore,
the general tolerability of the procedure was greater in the
post-visit group than in the control group (58.8% vs.
37.7%;p< 0.001). However, no differences were observed
between the two groups regarding willingness to return
for another FB or discomfort due to anesthesia, cough,
dyspnea, or throat pain (Table 3).
DISCUSSION
Several studies have investigated methods for reducing
fear and discomfort during a FB, but most have focused
on the use of medication [16,17]. Relatively few studies
have investigated the change in patient satisfaction with a
FB through non-pharmacological interventions [18,19].
This is the first study to evaluate whether an additional
post-bronchoscopy patient visit affected patient satis-
faction with a FB. This study was unique in that we did not
depend on medications, such as sedatives or anxiolytics,
to comfort patients, but rather investigated the impact of a
post-bronchoscopy visit on patient satisfaction.
Information provided before a procedure increases
patient satisfaction [1,7], but the effects of providing
information and emotional support after the procedure
had not been determined. The post-bronchoscopy visit
significantly improved patient tolerance of the FB without
changing the procedure technique or providing premedi-
cation, suggesting that patient tolerance of an invasive
procedure can be changed by an intervention after its
completion. Psychological and/or physical stress from the
invasive procedure likely can be influenced by counseling
and support provided after the event, such as with post-
traumatic stress syndrome [20].
Several studies have shown that patients and physicians
have different opinions about patient care [15,21,22]. In
one study [21], patients and physicians agreed that the
most crucial element of outpatient care is clinical skill, but
they disagreed about the importance of other aspects of
care, particularly on the effective communication of
health-related information. Therefore, understanding
these differences in physician perceptions compared to
patient perceptions may be important in improving
patient care and satisfaction. In this respect, the post-
bronchoscopy visit improved patient tolerance of the FB
Table 2. Procedure-related outcomes
VariablesControl
(n = 151)
Post-visit
(n = 153)
p value
Duration, min
Amount of lidocaine, mL
Amount of saline, mL
Intrabronchial bleeding
Bronchoscopic procedures
None
Washing
Biopsy
BAL
TBLB
Brushing
TBNA
Examiner
Faculty staff
Fellow
15.1 ± 5.4
45.0 ± 8.6
51.8 ± 55.2
33 (21.9)
15.2 ± 5.1
46.0 ± 14.0
51.9 ± 49.6
28 (18.3)
0.87
0.46
0.98
0.43
33 (21.9)
95 (62.9)
41 (27.3)
16 (10.6)
6 (4.0)
1 (0.7)
5 (3.3)
30 (19.6)
105 (68.6)
44 (28.9)
14 (9.2)
7 (4.6)
4 (2.6)
8 (5.2)
0.62
0.29
0.75
0.67
0.79
0.18
0.40
57 (37.7)
94 (62.3)
55 (35.9)
98 (64.1)0.74
Values are presented as mean ± SD or number (%).
BAL, bronchoalveolar lavage; TBLB, transbronchial lung biopsy; TBNA, transbronchial needle aspiration.

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396 The Korean Journal of Internal Medicine Vol. 25, No. 4, December 2010
by enhancing the communication between patient and
physician. Furthermore, Bernasconi et al. [23] reported
that among patients who had pre-bronchoscopy anxiety,
50% rated their anxiety as unjustified after the procedure.
A post-bronchoscopy visit might play an important role in
alleviating post-procedure anxiety in patients.
Although the post-bronchoscopy patient visit increased
patient tolerance of the FB, the acceptance of a repeat FB
was not changed by this intervention. The acceptance of a
repeat FB procedure may be influenced by various factors
other than a post-bronchoscopy visit such as personal
values, insight into their diseases, health status, as well as
cost [9]. Otherwise, willingness to return for a repeat FB
might not be a significant factor associated with patient
satisfaction in Korean subjects, as suggested by Choi et al.
[24].
In our study, the overall willingness to return for a FB
was 13%, which is very low compared to previous studies
(27 to 98%) [9,23-25]. Several explanations are possible
for this finding. First, a sedative drug was not used. As
sedative premedication for FB is not used routinely in our
institution, we performed FB without sedative drugs in
this study. However, sedatives for FB should be considered
because a post-bronchoscopy visit alone did not improve
the overall willingness to return. Second, our question
about willingness to return did not include the clause, ‘if
necessary’ which might have reflected patient responses
that were more emotional than rational.
The limitations of this prospective study include the
following. First, factors other than the post-visit that can
influence patient satisfaction were not completely
considered [7,9,17]. Individual anxiety levels or coping
Table 3. Patient satisfaction and discomfort with flexible bronchoscopy
VariablesControl
(n = 151)
Post-visit
(n = 153)
p value
Satisfaction
Information before FB
Very poor, poor
Good, fair
Information after FB
Very poor, poor
Good, fair
General tolerability
Tolerable
Not tolerable
Willingness to return
Yes
No
Discomfort
Anesthesia
Discomfort
No discomfort
Cough
Present
Absent
Dyspnea
Present
Absent
Throat pain
Present
Absent
79 (52.3)
72 (47.7)
83 (54.2)
70 (45.8) 0.73
105 (69.5)
46 (30.5)
60 (39.2)
93 (60.8)< 0.001
57 (37.7)
94 (62.3)
90 (58.8)
63 (41.2) < 0.001
14 (9.3)
137 (90.7)
21 (13.7)
132 (86.3)0.22
32 (21.2)
119 (78.8)
28 (18.3)
125 (81.7)0.52
43 (28.5)
108 (71.5)
36 (23.5)
117 (76.5)0.32
36 (23.8)
115 (76.2)
30 (19.6)
123 (80.4)0.37
13 (8.6)
138 (91.4)
9 (5.9)
144 (94.1)0.35
Values are presented as number (%) and analyzed with χ2tests.
FB, flexible bronchoscopy.