Most Patients Are Willing to Undergo Elective Endoscopic Procedures During the Reopening Period of the Coronavirus 2019 Pandemic.

As endoscopy units prepare to reopen for elective procedures, patient perceptions of the risk of coronavirus disease 2019 (COVID-19) exposure from undergoing elective endoscopy are largely unknown. Therefore, we organized a survey of patients whose elective procedures scheduled in late March and April 2020 were canceled or rescheduled. To our knowledge, this is the first survey of this type.

Methods

The Indiana University institutional review board approved the survey instrument (Supplementary Table 1) on April 10, 2020. Eligible patients were scheduled for elective outpatient procedures in March or April 2020, which were cancelled or rescheduled because of the pandemic. We excluded patients scheduled for endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Elective status was established by consensus among our endoscopists. The survey solicited perceptions in 2 main domains: (1) undergoing endoscopy during the pandemic with no effective treatment or vaccine available and (2) the impact of adopting new safety measures and staff COVID-19 testing on willingness to proceed. Stay-at-home orders were active in Indiana (only essential travel) during the survey period. Indiana announced that elective procedures, including endoscopies, could resume on April 27, 2020.

Six research assistants administered all surveys by telephone. The first and final surveys were conducted on April 14 and 25, 2020, respectively.

Statistical Analysis

To calculate the mean value score for protective measures, we assigned score 0 to no value, 1 to little value, 2 to important, should be done, and 3 to critical. When up to 3 protective measures were ranked as most important for each patient, a score of 3 was assigned for the top measure, 2 for the second, and 1 if a third was ranked.

Chi-squared and Fisher’s exact tests were used to compare patient responses regarding willingness to proceed and concern about acquiring COVID-19 infection. McNemar’s test was used to compare the proportions of patients willing to proceed with and without critical protective measures that patients deemed important. Significance was set at .05. All analyses were performed using SAS, version 9.4 (SAS Institute, Cary, NC).

Sample Size

Assuming 70% were willing to undergo procedures without information on additional protective measures, a sample size of 230 had 80% power to show a 15% increase in willingness to proceed after being informed about additional protective measures with 30% discordant responses at .05 significance.

Results

We telephoned 578 patients and connected with 303. Of these 303, 72 (23.8%) declined participation (no time, 14; not familiar with COVID-19, 2; did not want to answer a survey, 40; no reason provided, 16). Among the 72 who declined, the mean age was 59.2 ± 14.4 years, and 47.2% were female. There were 231 who agreed to participate (mean age, 58.9 ± 14.3 y; 59% female; P = .094 for sex difference from refusers). Among respondents, 153 (66%) were married, 84 (36%) had children at home, 17 (7%) had parents at home or were the caretakers of parents, and 194 (84%) were sheltering in place. Four patients reported current or previous symptoms consistent with COVID-19, but none had been tested. The remaining 227 (98%) reported no symptoms and no testing.

The level of concern for acquiring COVID-19 by attending endoscopy was ranked very concerned or somewhat concerned by 102 patients (44%) (Supplementary Table 2). Patients without children at home were more often very or somewhat concerned compared to those with children at home (50% vs 35%; P =0.026). Age, sex, and parents at home were not associated with level of concern.

Supplementary Table 2

Level of Concern About Acquiring COVID-19 From Undergoing Endoscopy in May 2020

Level of concern before presentation of safety measures	n (%)
Very concerned	36 (15.6)
Somewhat concerned	66 (28.6)
Neutral	25 (10.8)
Only a little concerned	62 (26.8)
Not at all concerned	42 (18.2)

When asked if willing to undergo their procedure in May 2020, 172 (75%) replied yes, 10 (4%) replied no, and 49 (21%) were unsure. Age, sex, and having parents or children at home were not associated with willingness to proceed. Of participants, 109 (47%) preferred a free-standing endoscopy unit, 45 (20%) preferred a hospital, and 77 (33%) had no preference. A total of 124 (54%) responded that staff should be tested for COVID-19 weekly, 45 (20%) responded that staff should be tested daily, and 61 (27%) responded that it doesn’t matter.

Table 1 shows perceptions regarding specific protective measures. One measure was ranked important or critical by ≥90% of respondents: that all endoscopy staff should wear a mask at all times. Three others were ranked critical or important by ≥80% of patients, including that all staff who touch the patient wear gloves (86%), the patient is provided a mask while in the unit (84%), and staff are tested weekly for COVID-19 (82%). When respondents were asked to rank up to 3 most important measures, the highest scores were for (1) all staff wear surgical masks, score of 280; (2) patients are provided a mask, score of 222; and (3) the staff are tested weekly for COVID-19, score of 206. If all measures they considered critical were in place, 192 (83%; 95% confidence interval, 77.7-87.7) responded they would proceed with their procedure, which was higher than the 172 (75%; 95% confidence interval, 68.3-79.9) who would proceed before protective measures were presented (P = .002).

Table 1

Proposed Protective Measures and Patient Perceptions of Their Value

Measure	No value, n (%)Score = 0	Little value, n (%) Score = 1	Important, n (%) Score = 2	Critical, n (%) Score =3	Mean scorea	Not sure/ don’t know, n (%)
Your driver is asked to drop you off and not enter the building	42 (18.3)	63 (27.4)	59 (25.7)	39 (17)	1.5	27 (11.6)
Your driver is allowed to enter the building and is asked to stay in a single person cubicle in the waiting room that is protected and cleaned with disinfectant after each use	21 (9.1)	51 (22.1)	99 (42.9)	48 (20.8)	1.8	12 (5.2)
You are provided with a surgical mask as soon as you reach registration and wear it for your entire stay	13 (5.7)	16 (7)	92 (40)	102 (44.3)	2.3	7 (3)
All staff wear surgical masks at all times during your stay	6 (2.6)	8 (3.5)	84 (36.4)	130 (56.3)	2.5	3 (1.3)
All staff who touch you are wearing gloves	8 (3.5)	16 (6.9)	87 (37.7)	112 (48.5)	2.4	8 (3.5)
All staff while wearing gloves and masks stay at least 6 feet from you except when required	21 (9.1)	52 (22.5)	87 (37.5)	63 (27.3)	1.9	8 (3.5)
You receive a COVID-19 rapid test (15 min) on entry into the endoscopy unit	18 (7.8)	41 (17.7)	86 (37.2)	66 (28.6)	1.9	20 (8.6)
All staff are tested daily for COVID-19 infection	28 (12.1)	60 (25.9)	61 (26.3)	53 (22.8)	1.7	27 (11.8)
All staff are tested weekly for COVID-19 infection	10 (4.4)	20 (8.8)	93 (40.1)	95 (40.9)	2.3	10 (4.4)

Mean scores do not include responses of not sure and don’t know.

When asked how effective a treatment for COVID-19 should be to eliminate the need for protective measures considered critical, the most common response was that it didn’t matter (ie, the measures should be in place regardless) (35%), followed by 100% effective (27%), 75% effective (24%), 50% effective (8%), and 25% effective (4 %). Absent a 100% effective treatment or vaccine, 62% anticipated the need for long-term use of protective measures.

Discussion

Only 4.3% of surveyed patients indicated they were unwilling to undergo elective endoscopy in May 2020, although another 22% were unsure. Thus, most patients were willing to undergo endoscopy, despite 44% being very or somewhat concerned about acquiring COVID-19 by attending.

Patients expressed strong preferences about safety measures and placed high value on staff wearing masks and gloves, on being provided a mask while in the endoscopy unit, and on weekly COVID-19 testing of staff. Having safety measures considered most important in place increased the fraction willing to present to elective endoscopy by 8%.

Study strengths include the sample size and high response rate (76.2%). Limitations include the fact that most participants resided in Indiana, which could limit generalizability. The study surveyed patient perceptions and may not reflect which actual behaviors patients will follow.

Factor	No value	A little value	Important—should be done	Critical for your confidence	Not sure or don’t know	Ranking
Your driver is asked to drop you off and not enter the building
Your driver is allowed to enter the building and is asked to stay in a single-person cubicle in the waiting room that is protected and cleaned with disinfectant after each use
You are provided with a surgical mask as soon as you reach registration and wear it for your entire stay
All staff wear surgical masks at all times during your stay
All staff who touch you are wearing gloves
All staff while wearing gloves and masks stay at least 6 feet from you except when required
You receive a COVID-19 rapid test (15 min) on entry into the endoscopy unit
All staff are tested daily for COVID-19 infection
All staff are tested weekly for COVID-19 infection