Open Journal of Gastroenterology, 2013, 3, 5-11 OJGas Published Online February 2013 (
Patient preferences and factors related to the
pre-procedure process at a large, urban county hospital
Lukejohn W. Day1,2,3*, Michelle Nazareth3, Justin L. Sewell1,2,3
1Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, USA
2GI Health Outcomes, Policy and Economics (HOPE) Research Program and Center for Innovation in Access and Quality, Depart-
ment of Medicine, University of California, San Francisco, USA
3Gastroenterology Division, Department of Medicine, University of California, San Francisco, USA
Email: *
Received 8 November 2012; revised 8 December 2012; accepted 15 December 2012
Background: Evaluation of the pre-procedural proc-
ess prior to endoscopic procedures has never been
conducted. Methods: Prospective cross-sectional, m ul ti-
language survey was administered to outpatients un-
dergoing endoscopy at a large, diverse county hospi-
tal that examined patients’ pre-procedural prefer-
ences. Multivariate logistic regression was used to
assess the relationship between patient preferences
and several patient-related variables. Results: 128/156
outpatients completed the survey. The majority of
respondents were female (53.1%), did not speak Eng-
lish (61.7%), were of Asian (39.1%) or Hispanic
(29.7%) racial background, and had a mean age of
56.1 ± 15.7 years. Most patients underwent colono-
scopy (48.4%) with 90.6% of patients knowing the
indication for their procedure. While waiting for their
endoscopic procedure, 42.2% of patients preferred
waiting in a gurney while 28.1% preferred to wait in
a chair. In terms of being comfortable wearing a hos-
pital gown and sitting in a chair or gurney in the
pre-procedure area, mean patient anxiety scores were
5.2 ± 3.3 and 6.1 ± 3.2, respectively (scale of 1 - 10).
Race was associated with several pre-procedural pa-
tient preferences; Hispanics were less comfortable
than Asians wearing a hospit al gown while sitting in a
chair with other patients prior to their procedure (OR
= 0.3, CI 0.1 - 1.0) while Whites and African-Ameri-
cans were less likely than Asians to prefer sitting in a
chair as co mpared to a gurn ey befo re their procedure
(OR = 0.09, CI 0.008 - 0.9 and OR = 0.07, CI 0.007 -
0.8, respectively). Patients who had undergone a prior
endoscopic procedure were less comfortable wearing
a hospital gown and sitting in a chair (OR = 0.3, CI
0.1 - 0.7) or gurney (OR = 0.4, CI 0.2 - 1.0) in the
pre-procedure area. Conclusion: A patient’s race and
having had a prior endoscopic procedure were the
most powerful predictors on pre-procedure patient
preferences while sex, type of endoscopic procedure
and patient knowledge of the indication for their
procedure were not. Our study highlights the impor-
tance of patient preferences and factors involved in
the pre procedure process at a large, diverse county
Keywords: Pre-Procedure Process; Quality; Endoscopy;
Patient Preferences
Nearly twenty million endoscopic procedures were per-
formed in 2011 and this number has been dramatically
increasing over the years. Personal preferences play a
central role in patients’ experiences at endoscopy centers
and affect patients’ willingness to return for subsequent
endoscopic procedures. A number of patient preferences
have been examined, but these preferences have solely
focused on the procedure itself. Sex and training of the
endoscopist [1-3], sedation received for their procedure
[4], and the communication of post-endoscopy results [5]
have been shown to influence patients’ anxiety during
the procedure and influence overall patient satisfaction.
However, there is little literature examining the process
and patient related factors that occur before an endo-
scopic procedure.
A number of factors are involved in endoscopy that
occurs both before and after the procedure that may in-
fluence quality, efficiency and patient satisfaction. The
pre-procedure process (i.e. the steps that occur while the
patient is waiting for their procedure to begin) is an im-
portant part of a patient’s experience at an endoscopy
center. To date, scant information is available describing
patient preferences with regards to the pre-procedural
process. Available data is based on expert opinion or
*Corresponding a uthor.
L. W. Day et al. / Open Journal of Gastroenterology 3 (2013) 5-11
consensus (rather than quantitative data provided by pa-
tients), and focuses only on the architectural layout [6-8]
and staffing [9,10] of the pre-procedure space. This gap
in the literature is critical to understand in order to be
able to deliver the highest possible quality of care to pa-
To address this knowledge gap, we administered a
survey to patients presenting for elective, ambulatory
endoscopic procedures that investigated patient prefer-
ences related to the pre-procedure pr oces s, and examine d
factors related to these preferences.
2.1. Study Population and Setting
San Francisco General Hospital and Trauma Center
(SFGH) provides subspecialty care for the safety net
healthcare system of the City and County of San Fran-
cisco, which includes multiple primary care clinics man-
aged by the San Francisco Department of Public Health,
and affiliated independent Federally Qualified Health
Centers and Federally-Funded 300 (h) Grantee Centers.
The SFGH GI Division receives 5300 referrals annually
and performs over 3100 procedures per year on an eth-
nically diverse, underserved patient population.
The pre-procedure process at the SFGH endoscopy
center is outlined as follows: After the patient h as Regis-
tered for their procedure they are escorted from the
waiting room to a separate pre-procedure area. This pre-
procedure area is a dedicated open room that consists of
three gurneys which are separated by a series of parti-
tions and curtains for patient privacy. After arriving at
the pre-procedure area the patient is then escorted to a
private bathroom and asked to change into a hospital
gown and place their belongings into a separate bag. Af-
ter changing into a hospital gown the patient is taken
back to a gurney, asked to lie down, and then both a
nursing and provider pre-assessment is performed, in-
formed consent obtained, and an intravenous catheter is
placed if moderate sedation is planned for their proce-
dure. The patient will wait laying in a gurney until a
procedure room and provider is available to perform
their procedure. Once ready, the patient is then escorted
on the gurney from the pre-procedure area to an available
procedure room down the hall. Of note, directly adjacent
to the pre-procedure area is the recovery area where at
any given time up to three patients are recovering from
their procedure(s). There is an open doorway connecting
the pre-procedure and recovery areas.
2.2. Study Design
We conducted a prospective, cross-sectional survey fo-
cused on the pre-procedural process among patients who
were scheduled for an elective outpatient endoscopic
procedure at the SFGH endoscopy center. We used pub-
lished expert opinions/consensus on the pre-procedure
process to develop the survey [7,8,10]. Since 95% of our
patients speak English, Spanish, or Cantonese, the survey
was offered in these three languages. The initial survey
was pilot tested on 45 consecutive patients (15 English,
Spanish, and Cantonese speaking patients each) during
May 2011 to assess for completeness and understand-
ability by patients. The survey was then subsequently
revised to its final version.
Patients undergoing an elective endoscopic procedure
were invited to participate. LWD approached all outpa-
tients in the pre-procedure room from June 1, 2011 to
June 30, 2011 and invited p atients to participate. In cases
where a patient did not speak English an interpreter was
used to invite patients to participate. As this was a qual-
ity improvement project only verbal consent was obtained.
2.3. Data Collection
The survey was divided into three parts. The first part of
the survey asked questions relating to patient demo-
graphics (8 questions). The second part asked questions
relating to patient preferences and the pre-procedure
process (8 questions). Patient preferences solicited were:
1) privacy (private vs. non-private pre-procedure room);
2) method of waiting in the pre-procedure area (gurney
vs. chair); 3) materials/media available (television, read-
ing); 4) interaction with other patients; 5) proximity of
the pre-procedure area to the recovery area and 6) how
patients preferred to be escorted to the procedure room
(gurney vs. walking). Lastly, patients were asked to rate
their anxiety and how comfortable they felt sitting in
either a chair or gurney wearing a hospital gown while
waiting in the pre-procedure area with other patients.
Patients were asked to respond to these three questions
using a visual scale of 1 - 10 ( 1 = very uncomfortable/very
anxious, 10 = very comfortable/not anxious).
2.4. Statistical Analysis
The mean and standard deviation were calculated for
continuous data and proportions calculated for nominal
data as it pertained to demographic information and pa-
tient preferences. Multivariate logistic regression models
were built to assess the association between several pa-
tient-related independent variables of interest (sex, age,
racial backg round, prev ious procedur e, knowledge of the
indication for the procedure, type of endoscopic proce-
dure, and English as their primary language) and indi-
vidual patient preferences. A statistically significant re-
sult was noted with 95% confiden ce interval (CI) and a p
value < 0.05. All calculations were performed on Stata
11.0 (Stata Corp®, College Station, Texas).
Copyright © 2013 SciRes. OPEN ACCESS
L. W. Day et al. / Open Journal of Gastroenterology 3 (2013) 5-11 7
2.5. Ethical Considerations
This study was part of an ongoing quality improvement
project aimed at evaluating our performance in the
SFGH endoscopy center with respect to a patient’s ex-
perience. Our goal was to design a pre-procedure area
aimed at improving clinical care, patient safety and
health care operations. Given our study was related to
quality improvement, did not include testing the safety
and efficacy of a drug or device in a human subject, and
no personal health information was collected at any time
formal institutional review was not required per the pol-
icy of the University of California San Francisco Com-
mittee on Human Research.
A total of 156 patients were approached for particip ation
in the survey and 128 patients completed the survey
(participation rate of 82.1%). The mean age of patients
was 56.1 ± 15.7 years with the majority being female
(53.1%). Racial and language diversity were represented
in our study population; Asian (39.1%) and Hispanic
(29.7%) were the most frequently reported racial back-
ground with 61.7% of patients not speaking English as
their primary language. Colonoscopy (48.4%) and upper
endoscopy (21.1%) were the most commonly performed
procedures with 18.0% of patients undergoing dual en-
doscopy. More than half of the patients reported that this
was their first endoscopic procedure. The vast majority
of patients understood the indication for their procedure
(90.6%). See Table 1 for demographic a n d p a ti e nt data.
3.1. Patient Preferences and the Pre-Procedural
A variety of patient preferences were considered with
regards to the pre-procedure process and focused on pa-
tient location before a procedure, privacy, transpo rt w i th in
the endoscopy center, media options and clothing attire
before the procedure. While waiting for th eir endoscopic
procedure 42.2% of patients preferred waiting in a gur-
ney as opposed to 28.1% wanting to wait in a chair. Al-
most half (44.5%) of patients preferred to wait in a pri-
vate pre-procedure room with no other patients, and
nearly as many (39.1%) had no preference as to the pri-
vacy of the pre-procedure area. At the same time, ob-
serving other patients recovering from a procedure did
not result in increased anxiety for most patients (64.1%).
The mean patient anxiety score while waiting for their
procedure was 6.6 ± 2.9 (scale of 1 - 10). Slightly more
patients would have preferred being transported to the
procedure room in a gurney (45.3%) rather than walking
to the procedure room (30.5%). However, most patients
(48.4%) preferred to begin the pre-procedure process in a
Table 1. Demographics of outpatients undergoing an endo-
scopic procedure who participated in the survey.
Patient demographics Number of patients (%)
Mean age, years (SD) 56.1 ± 15.7
Female 68 (53.1)
Male 55 (43.0)
No answer 5 (3.9)
Asian 50 (39.1)
Hispanic 38 (29.7)
White 20 (15.6)
African-American 14 (10.9)
Other 6 (4.7)
Endoscopic procedure
Colonoscopy 62 (48.4)
Upper endoscopy 27 (21.1)
Colonoscopy/upper endoscopy 23 (18.0)
Flexible sigmoidoscopy 4 (3.1)
Other 1 (0.8)
No answer 11 (8.6)
English as primary language
Yes 49 (38.3)
No 79 (61.7)
Knowledge of procedure indication
Yes 116 (90.6)
No 7 (5.5)
No answer 5 (3.9)
Previous endoscopic procedure
Yes 50 (39.1)
No 76 (59.4)
No answer 2 (1.6)
designated pre-procedure area, rather than being taken
directly to the procedure room. With regards to media
being available within the pre-procedure area most pa-
tients preferred being able to watch television while
waiting for their procedure (47.7%) while slightly less
patients wanted reading material present (43.0%). With
respect to clothing attire, mean patient comfort scores
were 5.2 ± 3.3 an d 6.1 ± 3.2 fo r wearing a ho spital gown
and sitting on a chair or laying in a gurney, respectively
(scale of 1 - 10). See Table 2 for summary of patient
3.2. Predictors of Pre-Procedural Patient
Several predictors were analyzed with respect to patient
preferences and the pre-procedural process (Table 3). A
patient’s racial background and having had a prior endo-
scopic procedure were the most powerful predictors of
Copyright © 2013 SciRes. OPEN ACCESS
L. W. Day et al. / Open Journal of Gastroenterology 3 (2013) 5-11
Tab l e 2 . Patient preferences related to the pre-procedure proc-
Patient preferences regarding
the pre-procedure process Number of
patients (%)
Do you prefer to wait in a chair or gurney?a
Gurney 54 (42.2)
Chair 36 (28.1)
No preference 37 (28.9)
No answer 1 (0.8)
Do you prefer to wait in a private or shared room?a
Private room 57 (44.5)
Shared room 13 (10.2)
No preference 50 (39.1)
No answer 8 (6.3)
Would you have liked reading material?a
Yes 55 (43.0)
No 60 (46.9)
No answer 13 (10.2)
Would you have liked to watch television?a
Yes 61 (47.7)
No 55 (43.0)
No preference 1 (0.8)
No answer 11 (8.6)
Would you have preferred to have been taken
directly to the procedure room?
Yes 48 (37.5)
No 62 (48.4)
No preference 3 (2.3)
No answer 15 (11.7)
Do you prefer to walk or be escorted on a gurney
to the procedure roo m ?
Gurney 58 (45.3)
Walk 39 (30.5)
No preference 23 (18.0)
No answer 8 (6.3)
Do you feel more anxious observing other patients
who have just completed their procedure?a
Yes 24 (18.8)
No 82 (64.1)
No answer 22 (17.2)
Would you have preferred your procedure
outside of the hospital?
Yes 8 (6.3)
No 112 (87.5)
No answer 8 (6.3)
aPertains to p atient waiti n g in the pre-procedure area.
pre-procedure patient preferences. Hispanics were less
comfortable than Asians wearing a hospital gown while
sitting in a chair in the pr e-procedure area (OR = 0.3, CI
0.1 - 1.0, p = 0.04). Whites and African-Americans were
less likely than Asians to want to sit in a chair as com-
Table 3. Independent predictors of pre-procedure patient pref-
Patient preferences Odds ratio
(95% CI) p-value
Patients prefer a private pre-procedure
English as prim a ry language
Yes 0.1 (0.01 - 0. 7)0.02
Patients prefer to wait in a chair versus a
Asian 1.0
White 0.09 (0.008 - 0.9)0.04
African-Amer ican 0.07 (0.007 - 0. 8 )0.03
Patients prefer sitting in a chair wearing a
hospital gown prior to their procedure.
Asian 1.0
Hispanic 0.3 (0.1 - 1.0)0.04
Prior Procedu re
Yes 0.3 (0.1 - 0.7)0.01
Patients prefer laying in a gurney wearing
a hospital gown prior to their procedure.
Prior procedure
Yes 0.4 (0.2 - 1.0)0.05
Patients prefer to walk versus being taken
on a gurney to the procedure room.
Asian 1.0
Hispanic 0.2 (0.07 - 0.9)0.03
Patients prefer to be taken directly to the
procedure room versus waiting in a
pre-procedure area.
20 - 30 1.0
61 - 70 9.5 (1.0 - 90.2)0.05
Asian 1.0
White 0.2 (0.06 - 0. 9)0.04
Note: An adjusted analysis was performed on each patient preference con-
trolling for the following predictors: age group, sex, race, history of previ-
ous procedure, knowledge of the indication for the procedure, type of endo-
scopic procedure, and English as their primary language. Only statistically
significant independent predictors are reported. CI (Confidence interval).
aGiven that Asians were the most prevalent raci al group they w ere selected
as the reference group.
pared to a gurney in the pre-procedure area (OR = 0.09,
CI 0.008 - 0.9, p = 0.04 and OR = 0.07, CI 0.007 - 0.8, p
= 0.03 respectively). Also, Whites were less likely than
Asians to want to be taken directly to the procedure room
rather than wait in a pre-procedure area (OR = 0.2, CI
0.06 - 0.9, p = 0.04). Patients who had undergone a prior
endoscopic procedure were less comfortable wearing a
hospital gown and sitting in a chair (OR = 0.3, CI 0.1 -
0.7, p = 0.01) or gurney (OR = 0. 4, CI 0.2 - 1.0, p = 0.05)
Copyright © 2013 SciRes. OPEN ACCESS
L. W. Day et al. / Open Journal of Gastroenterology 3 (2013) 5-11 9
in a pre-procedure area with other patients. Finally, Eng-
lish speakers were less likely to prefer a private pre-
procedure room (OR = 0.1, CI 0.01 - 0.7, p = 0.02). Sex,
type of endoscopic procedure and patient knowledge as
to the indication for their procedure were not associated
with any pre-procedural patient preferences.
To our knowledge, this study is the first to critically ex-
amine the pre-procedural process in an outpatient endo-
scopy center at a large, diverse county hospital. A num-
ber of strong patient preferences with respect to privacy,
transport within the endoscopy center, media options,
location of the pre-procedure area and clothing attire
before the procedure were evident in our patient popula-
tion. Additionally, patient’s race and having had a prior
endoscopic procedure were the most powerful predictors
of pre-procedure patient preferences while sex, primary
language and patient knowledge of the indication for
their procedure were less important. Knowledge of pa-
tient’s preferences regarding the pre-procedure process
helps inform clinical decision making with respect to
efficiency and optimizing patient flow, and helps to bal-
ance these consideration s with patient satisfaction.
The pre-procedure process is integral to a patient’s
overall satisfaction with their experience at an endoscopy
center and can affect their decision to return, as well as
shape their perception of the endoscopic procedure itself .
It is for this reason that understanding patient’s percep-
tions and factors that affect it are critical; however there
is a dearth of research on this important aspect of endo-
scopy. Existing studies of the pre-procedure process have
centered solely on enhancing efficiency by maximizing
the number of patients that can be accommodated, im-
proving work flow, and increasing productivity and
utilization [7,8,11 ,12]. Implementation of these data may
help maximize endoscopic efficiency, but this may not
necessarily improve patient experience, and actually has
the potential to harm it. Accordingly, scant reco mmenda-
tions on the pre-procedure process have been put forth,
with none being evidence based, and all relying on pro-
vider perception and experience.
A critical element at enhancing a patient’s experience
at the endoscopy center is to reduce their anxiety. Patient
anxiety plays an important role in the safety and success
of endoscopic procedures. Higher levels of anxiety can
lead to physiologic changes such as increased blood
pressure and heart rate which may lead to more sedating
medications used for patients, increased procedure times,
and increased patient discomfort making it more difficult
to perform a thorough examination [13-15]. Such anxiety
not only can affect specific aspects of the procedure but
also a patient’s willingness to return in the future and
how they communicate such an experience to others.
Addressing such anxiety before endoscopy is essential.
Pre-procedure teaching [16], relaxation techniques [16]
and music [16-18] have been shown to dramatically re-
duce patient anxiety during a procedure as well as some
physiologic parameters, yet none of these interventions
have been studied in the pre-procedure setting. We ex-
amined factors that are an essential part of the pre-pro-
cedure process that could potentially be used to reduce
anxiety for patients waiting for their endoscopy. We dis-
covered that specific forms of media, similar to music
from previous studies, are important to patients during
their endoscopy experience and exposure to it may help
to minimize feelings of anxiety. While our patients were
not more anxious seeing other patients recovering from
an endoscopy, they preferred to have their own individ-
ual pre-procedure room indicating that privacy is also
important. Many have argued that creating a hospital-like
environment before endoscopy where patients change
directly into a hospital gown, lay in gurneys, and are
escorted to their procedure in a gurney may elevate feel-
ings of anxiety and that such settings be modified [8] or
even discouraged. However, our study demonstrates that
many patients prefer a more hospital-based experience
from the moment they arrive at the endoscopy center. All
of these preferences need to be taken into consideration
when creating the process flow and pre-procedure envi-
ronment as it can have an effect on patient anxiety and
ultimately the procedure. Our information is crucial in
that it not only can be incorporated into one’s practice to
improve patient satisfaction but can also be used to help
reinforce and support proposed efficiency models at en-
doscopy centers. Additionally, as patient satisfaction be-
comes tied to reimbursements in the future our data can
help to potentially aid in achieving such outcomes.
Interestingly, we found a number of predictors related
to patient pre-procedure preferences; specifically patient
race was by far the most dominant predictor. Racial and
cultural differences have been observed in colorectal
cancer screening choices and prog rams [19], and it is not
surprising that such differences would also be noted in
patient preferences while waiting for an endoscopy. Dif-
ferences observed between English and non-English s p e a k -
ers in our study are likewise probably due to cultural
beliefs from our diverse patient population. All of these
differences need to be considered when designing and
organizing the pre-procedure area and flow as it may
affect each group differently and thus the overall experi-
ence and future willingness for some patients to return
for a procedure. Moreover, we also noted that patients
who had undergone a previous endoscopic procedure
were less willing to sit in a chair or lay in a gurney while
wearing a hospital gown while waiting for their proce-
dure. Perhaps this group of patients had a less than fa-
Copyright © 2013 SciRes. OPEN ACCESS
L. W. Day et al. / Open Journal of Gastroenterology 3 (2013) 5-11
vorable experience during their previous endoscopy or
not knowing what to expect prior to a procedure makes
patients more willing to accept a specific situation; both
of which could shape this particular group of patient’s
There were several limitations to our study. First, our
study population consisted mostly of immigrant, non-
English speaking individuals, and may not be generaliz-
able to all endoscopy center populations across the US.
Second, our survey has not been validated by previous
research, however this area of research is sparse and no
validated surv ey is currently available. Third, we subject-
tively assessed patient’s anxiety prior to their procedure
and did not correlate it with objective findings such as
vital signs or amount of sedation used during the proce-
dure. Fourth, previous studies on patient satisfaction dur-
ing surgery [20] have found that predictors of patient
satisfaction include a number of factors such as per-
ceived length of stay which we did not account for in our
study. Lastly, we did not obtain data on patient’s comor-
bidities, including anxiety disorders or patient’s taking
ant-anxiety medications, which could potentially influ-
ence patient’s preferences prior to endoscopy.
In summary, we conducted a comprehensive evalua-
tion of the pre -pr ocedure p rocess a t a l arg e, d ivers e county
hospital. The pre-procedure process is crucial at reducing
anxiety for patients, shaping the patient’s overall experi-
ence at the endoscopy center and possibly affecting fu-
ture decisions about returning or having an endoscopy.
We discovered a number of patient preferences relating
to the method of waiting before a procedure, privacy,
transport within the endo scopy center, media options and
clothing attire before the procedure. Patient race and
having had a prior procedure strongly affected these
preferences. This information will not only help endo-
scopy centers in improving efficiency and patient flow,
but when taken into consideration can lead to the crea-
tion of a more patient-centered environment.
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