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PAPERS: Christian Kremer, Sean Duffy, and Michelle Moroney Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial BMJ 2000; 320: 279-282 [Abstract] [Full text]

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What is patient satisfaction?

Richard Baker   (1 February 2000)

Difficulties in comparing groups

J C R Hardwick   (4 February 2000)

Patient satisfaction with outpatient hysteroscopy : type of GA may have influenced the results

Sadik K Kodakat   (4 February 2000)

What is patient satisfaction? 1 February 2000
Richard Baker, Professor Clinical Governance R&D Unit, Dept General Practice & Primary Health Care, University of Leicester Send response to journal: Re: What is patient satisfaction?	Increasingly, trials of new interventions include patient satisfaction as an outcome measure. As the editorial (Naftalin and Habiba) points out, this is to be welcomed. Yet the methods used to measure satisfaction are often questionable. The problem is illustrated by the study of patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy. First, what is meant by satisfaction?1 In this study, it is defined as the choice of the respondent to choose the procedure if it should be required again. Is there justification for assuming that this indicates satisfaction - in other words, is this a valid measure? It is concievable that a patient may be dissatisfied with aspects of their experience, yet still opt for choosing the same procedure, perhaps because of convenience or other factors. Also, those who have not experienced the alternative cannot make a fully informed choice. In such studies, it is common to find that patients express preferences for what they have experienced. Preliminary investigation of the factors determining satisfaction might have overcome these problems. In a qualitative study, the issues of importance to patients could have been identified, the findings being used to guide the selection of appropriate questions to ask.2 Second, is a single question the best measurement method? Single questions tend to have lower reliability than groups of questions. Does a yes/no response format adequately account for the range of patient views? Can a single question adequately account for the various factors that consitute "satisfaction"? Kremer et al should be applauded for measuring patient satisfaction, and since their methods are typical of those usually employed in trials, it would be unreasonable to single them out for criticism. However, researchers planning to measure satisfaction in future trials should give careful thought to what they mean by patient satisfaction and how it should be measured. 1. Baker R. Pragmatic model of patient satisfaction in general practice: progress towards a theory. Quality in Health Care 1997;6:201-204 2. Preston C, Cheater F, Baker R, Hearnshaw H. Left in lombo: patients' views on care across the primary/secondary interface. Quality in Health Care 1999;8:16-21.
Difficulties in comparing groups 4 February 2000
J C R Hardwick Send response to journal: Re: Difficulties in comparing groups	Editor, Studies that may reduce the number of unnecessary investigations or treatments are always welcomed by clinici ans. Kremer et al (1) perceive a reluctance to abandon general anaesthetic procedures for the investigation of menstrual problems and this is echoed elsewhere (2). This study found no significant difference between the two groups with respect to post-operative pain but it is difficult to compare these groups accurately for a number of reasons. Outpatient hysteroscopy was performed without analgesia but general anaesthetic procedures presumably included a short-acting opiate with the anaesthetic. The analgesics used for general anaesthesia are unfortunately not described. Was the method of anaesthesia standardised? Only 62% of the outpatient hysteroscopy patients had endometrial sampling performed, whereas 100% of the women undergoing general anaesthetic hysteroscopy had curettage. This makes comparison of the groups difficult as curettage may be an additionally painful procedure in itself. It may be possible to reduce the pain associated with outpatient hysteroscopy further by using mefanamic acid prior to the procedure (3) or using smaller diameter scopes than the 3.6 mm hysteroscope used in this study. There is no evidence that smaller hysteroscopes are less sensitive for endometrial pathology. Postmenopausal women were less satisfied with outpatient hysteroscopy, the question is as to whether these women needed hysteroscopy as a primary investigation. Transvaginal ultrasonography combined with endometrial sampling is as sensitive as hysteroscopy for the detection of endometrial adenocarcinoma and is more sensitive than vaginal examination for the detection of ovarian pathology (4,5). However it must be accepted that a significant number of these women will eventually need hysteroscopy due to common benign abnormalities causing false positive results on ultrasonography(6,7). If reluctance to initiate services for the outpatient investigation of menstrual symptoms is to be overcome, it must be backed by larger and more robust studies. Dr JCR Hardwick MRCOG Specialist registrar, Glasgow 1. Kremer C, Duffy S, Morony M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. BMJ 2000;320:279-282 2. Penney G, Vale L, Souter V, Templeton A. Endometrial assessment procedures: and audit of current practice in Scotland. Human Reprod 1997; 12:2041-2045 3. Nagale F, Lockwood G, Magos AL. Randomised placebo controlled trial of mefenamic acid for premedicationat outpatient hysteroscopy: a pilot study.Br J Obstet Gynecol 1997;104:842-844 4. Garuti G, Sambruni I, Cellani F, Garzia D, Alleva P, Luerti M. Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding. Int J Gynecol Obstet 1999;65:25-33 5. Gupta JK, Wilson S. Desai P, Hau C. How should we investigate women with postmenopausal bleeding? Acta Obstet Gynecol Scand 1996;65:475- 479 6. Nagele F, O’Conner H, Davies A, Badawy A, Mohamed H, Magos A. 2500 Outpatient diagnostic hysteroscopies. Obstet Gynecol 1996;88:87-92 7. Akkad AA, Habiba MA, Ismail N, Abrams K, al-Azzawi F. Abnormal uterine bleeding on hormone replacement: the importance of intrauterine structural abnormalities. Obstet Gynecol 1995; 86:330-334
Patient satisfaction with outpatient hysteroscopy : type of GA may have influenced the results 4 February 2000
Sadik K Kodakat, Specialist Registrar King's College Hospital, London Send response to journal: Re: Patient satisfaction with outpatient hysteroscopy : type of GA may have influenced the results	Sir, Kremer et al in their article (1) concluded that patient's satisfaction rates with outpatient hysteroscopy using semiflexible hysteroscope with out any anaesthesia and day case hysteroscopy using rigid hysteroscope under anaesthesia were similar. While appreciating their efforts to popularise a technique which may have potential advantages to both patients and health care providers, I wish to point out a flaw in thier methodology or its reporting in this article, which raises doubts about the validity of their conclusion. There is no mention in the article whether the general anaesthetic employed was standardised or not. It is not a secret that each anaesthetic agent has its own unique properties. For example, a technique using target controlled infusion of propofol can on its own reduce the incidence of postoperative nausea and vomiting (PONV)by 27% when compared to a technique using sevoflurane for induction and maintenance. This in itself could have had significant impact on the results of the study as the main clinical outcomes addressed were recovery characteristics including PONV and requirements of analgesia. PONV is still one of the leading causes of dissatisfaction among patients who have had an operation under general anaesthetic (3). Also, many anaesthetists nowadays administer antiemetics, opioid and non opioid analgesics routinely during a general anaesthetic. Hence, a sensible comment on the patients' satisfaction rating would not be possible with out taking these factors into account. However, I agree that it is unlikely that the above mentioned factors would have significantly influenced the differences in other observed outcomes like days away from work or even minutes away from home. I believe this is an example of lack of interdisciplinary consultation and participation, marring the value of a research which could have been otherwise useful. References : 1. Kremer C, Duffy S, Moroney M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy : randomised controlled trial. British Medical Journal.2000;320:279 - 82 2. Smith I, Thwaites AJ. Target-controlled propofol vs. sevoflurane : a double blind randomised comparison in day-case anaesthesia. Anaesthesia.1999;54:745 - 752 3. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10811 patients. British Journal of Anaesthesia. 2000;84(1):6 - 10