Who is willing to undergo endoscopy without sedation: patients, nurses, or the physicians?

Objectives: Some studies suggest that the majority of the United States population is now willing to undergo unsedated endoscopy. We studied the willingness of patients, nurses, and physicians to undergo endoscopy without sedation.

Methods: Adult patients presenting to us for outpatient endoscopy at two large tertiary care level 1 trauma hospitals were asked to fill out a survey questionnaire recording their demographic information, prior experience with endoscopy and sedation, and whether they were willing to undergo unsedated endoscopy. Their anxiety level was assessed using the Beck Anxiety Inventory. After the endoscopic procedure, patients were asked whether they had any change in their decision regarding unsedated endoscopy. A random convenience sample of physicians and nurses were also given a questionnaire asking about their experience with endoscopy and whether they were willing to undergo such procedures without sedation.

Results: A total of 127 patients, 117 nurses, and 51 physicians participated in the study. Only 19.5% of patients were willing to undergo upper endoscopy without sedation. Among patients, the willingness dropped to 6.75% postprocedurally. Results were similar for colonoscopy. Physicians were least likely to agree to an unsedated procedure (2.2%). Gastroenterology (GI) nurses were more likely to undergo unsedated esophagogastroduodenoscopy (39.3%) as opposed to non-GI nurses (7.1%, P < 0.001). 19.6% of GI nurses agreed to unsedated colonoscopy versus 0% in the non-GI group (P = 0.001). Preprocedure anxiety level was not found to be a predictor for willingness to undergo unsedated endoscopy. Female patients were more likely to forego sedation preprocedurally (OR = 5.75; 95% CI = 2.05-16.2). However, postprocedurally, gender was no longer a significant predictor. Similarly, among the nurses and physicians, neither age nor gender was a significant predictor of willingness to undergo unsedated endoscopy. Patients with a high school (OR = 0.01; 95% CI = 0.01-0.06) or associates degree (OR = 0.02; 95% CI = 0.01-0.35) were less likely to forego sedation.

Conclusion: In contrast to reports from some major medical centers, the current study found that most patients as well as medical professionals were unwilling to undergo endoscopy without sedation.

Key Words: endoscopy, sedation, unsedated endoscopy

**********

It is a standard practice in the United States to use conscious sedation for various endoscopic procedures. (1) In contrast, in most countries outside the United States, similar procedures are carried out without the use of any sedation. (2,3)

Recently there have been several studies from major medical centers throughout the United States suggesting a change in attitude among the adult US population toward these procedures. They have reported that most patients may be willing to opt for endoscopic procedures, especially colonoscopy, without being sedated. (4,5) This, if true, will lead to a significant decrease in the risk of complications from endoscopy and reduced health-care costs. (6)

Our anecdotal experience suggests that findings from these studies are not relevant for the population at large. Our experience indicates that patients not only ask for sedation during endoscopy, but a few demand even general anesthesia for procedures like flexible sigmoidoscopy. Even the thought of unsedated endoscopy sends waves of chills down patients' spines.

There are no studies examining the attitudes of the public toward undergoing unsedated endoscopy as seen at large community-based tertiary care centers. There are no studies examining the effect of preoperative anxiety on the decision to forego sedation for endoscopy. In addition, no other study has looked at the willingness of healthcare professionals themselves to undergo unsedated endoscopy.

We conducted a study to assess the willingness of patients in our tertiary care hospital setting to undergo endoscopy without sedation. We sought to identify any patient characteristics like age, gender, race, educational level, preprocedure anxiety level etc, which determine such willingness. We also surveyed physicians, nursing staff related to gastroenterology and nongastroenterology fields and interviewed them to determine their perception about unsedated endoscopy and whether they themselves will be willing to undergo endoscopy without sedation.

The study was approved by our Institution Review Board. All subjects in the study provided informed consent before participation.

Materials and Methods

Patients

Between July 2001 and January 2002, all patients above 18 years of age who presented to the outpatient gastroenterology clinic and were to undergo an endoscopic procedure for any reason were asked to participate in the study. Patients who were admitted to the hospitals, were unable to provide informed consent for any reason, were mentally challenged, or were incarcerated, were excluded from the study. In addition, patients undergoing emergent endoscopy were excluded.

If patients agreed to participate in the study, they had explained to them the whole concept of conscious sedation, including its risks and benefits. Patients were then asked to fill out a questionnaire, which solicited information about their age, gender, race, educational level, and occupation. We also asked patients if they had undergone any endoscopic procedure previously, and whether conscious sedation was used at that time. Subjects also filled out the Beck Anxiety Inventory questionnaire to assess their preprocedure anxiety level.

Finally, patients were asked if they would be willing to undergo the endoscopic procedure without any sedation. The question was framed as follows: "In a few hospitals, endoscopy is done without any painkillers or sedation because it may decrease the risk of complications and allow the patient to return to their normal activities sooner. Will you be willing to undergo endoscopy without any painkillers or sedation?" This question was similar to the one used in a prior study. (7)

Endoscopy

The endoscopy was performed at one of the two tertiary care level 1 trauma hospitals in central Illinois. The combined capacity of the hospitals exceeds 1,000 beds. More than 600 physicians are on staff at these two hospitals. In addition, there are about 700 nurses employed at each hospital. The endoscopic procedures were carried out in a standard fashion, using conscious sedation, regardless of patients' responses on the preprocedural questionnaire. Sedation was withheld only if a patient specifically requested no sedation for the endoscopic procedures. No attempts were made to convince patients to undergo endoscopy without sedation. All the endoscopic procedures were carried out by either a board certified gastroenterology attending physician alone or by gastroenterology fellows under direct supervision by an attending gastroenterologist.

One to four weeks after the procedure, patients were contacted again over the phone and were asked about their experience with endoscopy and whether they still would be willing to undergo endoscopy without sedation. The question asked was the same as on the preprocedure questionnaire.

Healthcare professionals

We also contacted physicians and nursing staff working in gastroenterology and nongastroenterology fields in six different large hospitals in central Illinois. The gastroenterologists and GI nurses were contacted via the endoscopy suites at these hospitals. The nongastroenterologists were recruited at a medical staff meeting at one of our hospitals. The non-GI nurses were recruited from staff working the day-shift at the same hospital. These healthcare professionals were given a questionnaire which collected information about age, gender, race, prior experience with endoscopy and their current willingness to undergo endoscopy without sedation. The question which was asked was, "Based on your knowledge and experience, will you be willing to undergo endoscopy without sedation?"

Statistics

Results are reported as percentages and mean [+ or -] one standard deviation, as appropriate. McNemar test was used to assess the relationship between preprocedure and postprocedure willingness of patients to undergo unsedated endoscopy. Pearson [chi square] test, Fisher Exact test, and Pearson correlation and likelihood ratios were used as appropriate. Logistic regression analysis was used to learn if age, sex, educational level, and/or anxiety levels were significant in predicting willingness to undergo unsedated endoscopy. Educational level was not coded for the nurses or physician groups, as they were assumed to have a relatively high level of health-related medical knowledge. A P value of <0.05 was considered statistically significant.

Results

A total of 127 patients who were scheduled for outpatient endoscopic procedures (esophagogastroduodenoscopy [EGD] and/or colonoscopy) between July 2001 and January 2002, participated in the study. All the patients filled out the preprocedure questionnaire and Beck Anxiety Inventory. Two patients either cancelled or did not show up for their endoscopic procedures, but their responses on the preprocedure questionnaire were used in analysis. They were, however, excluded from postprocedure questionnaire analysis. One hundred and twenty five patients completed both preprocedure and postprocedure questionnaires. Patients who were unsure of their answers were included in the category of unwilling subjects for the purpose of the statistical analysis. None of the patients specifically requested unsedated endoscopy (including those willing to forego sedation) and as such, per protocol, every patient who underwent endoscopy received sedation.

Sixty physicians were also invited to participate in the study and 51 of them completed the survey. We also invited 125 nurses to take part in the study and 117 nurses agreed to participate. Again, physicians and nurses who were unsure of their answers were included in the category of unwilling subjects.

Table 1 outlines the demographic characteristics of patients who participated in the study. Table 2 outlines the baseline characteristics of physicians and nurses who took part in the study. A majority of the participating nurses were females as is true in any hospital in the United States. Thirty-five percent of participating physicians and 55.9% of patients were females. All but four of the physicians were nongastroenterologists. Table 3 shows a summary of the results of the willingness of different study groups to undergo endoscopy without sedation.

Physicians

Responses from 51 physicians who completed the survey were used for final analysis. Prior experience with endoscopic procedures (EGD and/or colonoscopy) was limited to only 19.1% of non-GI physicians as compared with 75% of GI physicians (P = 0.036). All the physicians who had undergone endoscopy before this study had received sedation for their procedure. Overall, only 2.2% of physicians were willing to undergo future endoscopy without being sedated. None of the non-GI physicians were willing to forego sedation as compared with one out of four GI physicians (P = 0.089). The results were similar for both EGD and colonoscopy. Neither age nor gender was found to be a significant predictor of willingness to undergo endoscopy without sedation.

Nurses

A total of 117 nurses responded to our survey. These included 61 GI nurses and 56 nurses related to specialties other than gastroenterology (non-GI). Twenty-one (34.4%) nurses among the GI group and eleven (19.6%) non-GI nurses had a prior exposure to endoscopic procedures (P = 0.204).

Among the 32 nurses who had had a prior procedure, all of the non-GI nurses had been sedated as compared with 71.4% of the GI nurses (P = 0.07). For a future EGD, only 7.1% of the non-GI nurses were willing to forego sedation. In contrast, 39.3% of the GI nurses were willing to undergo EGD without sedation (P < 0.001). Similarly, only 19.6% of the GI nurses agreed to unsedated colonoscopy, while none of the non-GI nurses wanted colonoscopy without sedation (P = 0.001). Neither age nor gender was significant when predicting willingness to forego sedation for endoscopic procedures. The above analysis was repeated including departmental affiliation (GI versus non-GI).

Patients

A total of 127 patients responded to our survey. Only 19.5% of the patients were willing to undergo EGD without sedation on their preprocedure questionnaire. Two patients did not show up for their scheduled endoscopic procedures. Among the patients who underwent endoscopy, the willingness to undergo EGD without sedation dropped to 6.75% on postprocedure questionnaire. An overwhelming 93.25% of patients refused to undergo unsedated EGD postprocedurally. The results were similar for willingness to undergo unsedated colonoscopy. There was a positive relationship between patients' opinion before and after the procedure (P = 0.007). In other words, the procedure did not change the opinions of a statistically significant number of patients.

Table 1 shows the data on preprocedure anxiety based on the Beck Anxiety Inventory. On the preprocedure questionnaire, the willingness to undergo EGD without sedation was 20.3% among patients with minimal anxiety, 16.7% among those with mild anxiety, and 23.5% among those with moderate to severe anxiety. There was no significant correlation between preprocedure anxiety levels and willingness to undergo endoscopy without sedation.

After the EGD was performed, only 10.1% of patients with minimal anxiety, 4.2% of those with mild anxiety, and 5.9% of patients with moderate to severe anxiety would be willing to undergo an unsedated EGD in the future. For colonoscopy, the willingness to undergo an unsedated procedure pre- and postprocedure was 19% versus 10.1% for minimal anxiety, 16.7% versus 4.2% for mild anxiety, and 23.5% versus 5.9% for moderate to severe anxiety levels. After one endoscopy (EGD or colonoscopy), there was a statistically insignificant but perhaps clinically significant decline in the number of patients willing to undergo an unsedated endoscopy in the future.

Effect of prior endoscopy

Among the patient group, 44.1% had experience with a prior endoscopic procedure. Of these, 85.7% of subjects had received sedation on their prior procedures. There was a slight tendency for those subjects who had had a prior procedure to report that they had a moderate or severe level of preprocedure anxiety, and the results showed a trend toward statistical significance (P = 0.136). Only 16.7% of patients who had prior endoscopic experience were willing to undergo EGD and/or colonoscopy without sedation as compared with 21.7% of those without a history of prior endoscopy. However, there was no statistically significant correlation between willingness to undergo unsedated endoscopy and prior exposure to endoscopic procedures.

Logistical regression

There were no differences between men and women in age or in anxiety levels. We also did not find any positive correlation between patients' age and their preprocedure anxiety levels (P = 0.835). Neither the patient's age nor preprocedure anxiety levels were a predictor of a patient's willingness to undergo endoscopy without sedation. Patients with either a high school (OR = 0.01; 95% CI = 0.01-0.06) or an associate's degree (OR = 0.02; 95% CI = 0.01-0.35) were less likely to forego sedation as compared with those with bachelor's or postgraduate degrees. Female patients were more likely to forego sedation before EGD (OR = 5.75; 95% CI = 2.05-16.2) or colonoscopy (OR = 5.04; 95% CI = 1.8-14.09). However, the sex was no longer a significant factor for their future preferences after the patient had undergone the procedure. In other words, after the endoscopy, women were just as unlikely to accept unsedated endoscopy as men.

Discussion

In the United States, it is considered the standard of care to conduct routine endoscopic procedures under conscious sedation. Recently, a number of studies have been published which have shown that up to 90% of patients are willing to undergo unsedated endoscopy. (8) This has sparked a major debate, because if patients are so willing, this could lead to a marked reduction in the hospital stay of patients, and procedural costs. This will also lead to decreases in costs related to conscious sedation, and patients will be able to return to their daily lifestyles sooner, thus causing a tremendous gain in work hours and increased productivity.

Hoffman et al (5) reported that they were able to complete colonoscopy without any sedation in 75 of 80 (94%) patients. When questioned after the procedure, 73% (58 of 80) of their patients were willing to undergo subsequent colonoscopy without sedation. They also concluded that severity of pain during the procedure was a strong predictor of willingness to undergo unsedated endoscopy in the future. However, this study was not a randomized study, therefore raising the possibility of selection bias.

Cataldo (9) conducted a prospective evaluation of 258 unsedated colonoscopies and found that 84% of patients were willing to repeat the procedure without sedation. Sixty-one percent of these patients reported procedural pain as none or mild. Out of 112 patients who had previously undergone unsedated colonoscopy, 92% of patients preferred unsedated to sedated colonoscopy. However, selection bias is always a possibility in this study, as only unsedated colonoscopies were evaluated. According to Ladas' (10) experience, 91.9% patients did not require any sedation for colonoscopy. He concluded that male gender and segmental colonic resection were the major factors that predicted the possibility of conducting unsedated colonoscopy. This-Evensen et al (8) found that unsedated colonoscopy is only moderately or not at all uncomfortable. However, colonoscopy without sedation may reduce the rate of cecal intubation, and increase the risk of missing adenomas and cancers. Rex et al (4) reported that male gender, increasing age, and absence of abdominal pain were major factors associated with willingness to accept no sedation or as-required sedation. However, in the Rex study, 163 of 250 patients refused to undergo colonoscopy without sedation.

In contrast to the above studies, Early et al (7) found that only 16.9% of their patients were willing to undergo unsedated colonoscopy preprocedurally, and this willingness increased marginally to 22.6% after the procedure. They also concluded that male sex and a college degree may predict such willingness to undergo endoscopy without sedation. Our results are consistent with their finding of a correlation with education level. However, we found that females rather than males are initially more likely to forego sedation for endoscopy, although the sex was no longer a predictive factor after the initial endoscopy.

The correlation between the preprocedure anxiety level of patients and experience of a previous endoscopy has not been well studied. Endoscopy is associated with an increase in anxiety, but endoscopists' ability to estimate anxiety is poor. (11) Music therapy has been successfully used to reduce the physiologic anxiety and need for sedation during the procedure. (12) Early et al found that low preprocedure anxiety is one of the factors predicting willingness to undergo a future unsedated colonoscopy, although only about a fifth of their study population was willing. (7) Mulcahy et al (13) demonstrated that preference for future sedation correlates with high levels of apprehension. Similarly Campo et al (14) found that poor tolerance of an endoscopy is related to apprehension and a high level of anxiety. Anxiety level is associated with patient dissatisfaction with endosopy. (15) In contrast to findings by Early et al, we found that patients desire sedation irrespective of their anxiety levels.

In contrast to some of the optimistic literature from some medical centers, our experience indicates that not only do most patients in a community setting ask for sedation during endoscopy, but a few even ask to be "knocked out" during procedures like flexible sigmoidoscopy. Our results demonstrate that only a minority of patients is agreeable to unsedated EGD and/or colonoscopy. Such an attitude is preserved across the board, since we did not find any positive correlation between the preprocedure anxiety levels, gender, or age and the willingness of patients to undergo endoscopy without sedation.

Our study also provides a unique perspective on the attitude of healthcare providers toward unsedated endoscopy. Our study of physicians and nurses indicates that only a small minority of the healthcare professionals was willing to undergo unsedated endoscopy. We were surprised to learn that physicians were the least likely to agree to an unsedated procedure. Now with the increasing availability of ultrathin nasal endoscopes, it remains to be seen how many patients will be willing to undergo upper endoscopy without sedation.

Although unsedated endoscopy with its associated decreased costs, decreased hospital stay, and early return to normal life seems to be an attractive idea, we conclude that the adult US population, including most physicians and nurses, are not ready at this time to undergo unsedated endoscopy. Further studies are needed to examine whether increasing the out-of-pocket expenses for endoscopy would alter such decisions.

Not everything that can be counted counts, and not everything that
counts can be counted.
--Albert Einstein

Table 1. Patient baseline characteristics (n = 127)

Age (yr)                              52.5 [+ or -] 15.2
Gender (M/F)                          56/71
Educational level
  High school                         86
  Associate's degree                  14
  Bachelor degree                     17
  Post graduate                       10
Occupation
  Administrator                       11
  Clerical                            14
  Healthcare                           5
  Home maker                          40
  Laborer                             30
  Professional                        27
Prior endoscopy
  No                                  71
  Yes                                 56
Prior sedation
  No                                   8
  Yes                                 48
Preprocedure anxiety
  Mild                                26
  Minimal                             83
  Moderate (10) or severe (8)         18

Table 2. Baseline characteristics of physicians and nurses (a)

                        Physicians               Nurses
                          n = 51                 n = 117

Age (yr)                37.1 [+ or -] 8.6        41.4 [+ or -] 8.2
Gender (M/F)            33/18                    13/104
Specialty
  GI                     4                       61
  Non-GI                47                       56
Prior endoscopy
  No                    39                       87
  Yes                   12                       30
Prior sedation
  No                     0                        4
  Yes                   12                       26

(a) GI, gastroenterology.

Table 3. Willingness to undergo endoscopy without sedation in the study
groups (a)

                         Colonoscopy         EGD

Physicians (n = 51)           1               1
  GI (n = 4)                  1               1
  Non-GI (n = 47)             0               0
Nurses (n = 117)             12              28
  GI (n = 61)                12              24
  Non-GI (n = 56)             0               4
Patients (n = 127)
  Preprocedure               23              24
  Postprocedure              10              10

(a) GI, gastroenterology; EGD, esophagogastroduodenoscopy.

Acknowledgment 

We are thankful to Beth Dawson, PhD, Division of Biostatistics, Southern Illinois University School of Medicine, for her help with statistical analysis.

Accepted March 11, 2004.

Please see Ronald A. Leo's editorial on page 797 of this issue.

References

1. Keefe EB, O'Connor KW. 1989 ASGE survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990;36:S13-S18.

2. Ristikankare M, Julkunen R. Premedication for gastrointestinal endoscopy is a rare practice in Finland: a nationwide survey. Gastrointest Endosc 1998;47:204-207.

3. Froehlich F, Gonvers JJ, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland. Endoscopy 1994;26:231-234.

4. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: Associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999;49:554-559.

5. Hoffman MS, Butler TW, Shaver T. Colonoscopy without sedation. J Clin Gastroenterol 1998;26(4):279-282.

6. Ristikankare M, Julkunen R, Mattila M et al. Conscious sedation and cardiorespiratory safety during colonoscopy. Gastrointest Endosc 2000;52:48-54.

7. Early DS, Saifuddin T, Johnson JC et al. Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol 1999;94:1862-1865.

8. Thiis-Evensen E, Hoff GS, Sauar J et al. Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps. Gastrointest Endosc 2000;52:606-610.

9. Cataldo PA. Colonoscopy without sedation. Dis Colon Rectum 1996;39:257-261.

10. Ladas SD. Factors predicting the possibility of conducting colonoscopy without sedation. Endoscopy 2000;32(9):688-692.

11. Jones MP, Ebert CC, Sloan T, et al. Patient anxiety and elective gastrointestinal endoscopy. J Clin Gastroenterol 2004;38:35-40.

12. Smolen D, Topp R, Singer L. The effect of self-selected music during colonoscopy on anxiety, heart rate, and blood pressure. Appl Nurs Res 2002;15:126-136.

13. Mulcahy HE, Kelly P, Banks MR, et al. Factors associated with tolerance to, and discomfort with, unsedated diagnostic gastroscopy. Scand J Gastroenterol 2001;36:1352-1357.

14. Campo R, Brullet E, Montserrat A, et al. Identification of factors that influence tolerance of upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol 1999;11:201-204.

15. Schutz SM, Lee JG, Schmitt CM, et al. Clues to patient dissatisfaction with conscious sedation for colonoscopy. Am J Gastroenterol. 1994;89:1476-1479.

RELATED ARTICLE: Key Points

* Most patients are unwilling to undergo unsedated endoscopy.

* Health care professionals are less willing than patients to forego sedation for endoscopy.

* Willingness to undergo unsedated endoscopy is unrelated to anxiety levels.

Anand Madan, MD, and Anil Minocha, MD, FACG 

From the Division of Gastroenterology, Southern Illinois University School of Medicine, Springfield, IL, and the Division of Digestive Diseases, University of Mississippi Medical Center, Jackson, MS.

Reprint requests to Anil Minocha, MD, Director, Division of Digestive Diseases, 2500 North State Street, Jackson, MS 39216. E-mail: [e-mail]