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Endoscopy
Impact of digital health interventions on patient satisfaction in outpatient gastrointestinal endoscopy: a systematic review
  1. Seán Fennessy1,2,
  2. Caoimhe McGarvey3,
  3. Edel McDermott1,
  4. Richéal Burns4,5,
  5. Patrick Redmond6
  1. 1Gastroenterology, St Vincent’s University Hospital, Dublin, Ireland
  2. 2School of Medicine, University College Dublin, Dublin, Ireland
  3. 3Trinity College Dublin, Dublin, Ireland
  4. 4Department of Health and Nutritional Science, Atlantic Technological University Faculty of Science, Sligo, Ireland
  5. 5Health and Biomedical Research Centre (HEAL), Atlantic Technological University Faculty of Science, Sligo, Ireland
  6. 6Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
  1. Correspondence to Dr Seán Fennessy; sean.fennessy{at}ucd.ie

Abstract

Objectives The integration of digital health technologies in gastrointestinal (GI) endoscopy presents opportunities to enhance patient experience, an important dimension of care quality. This systematic review aims to evaluate the impact of digital health interventions on patient satisfaction and experience in outpatient endoscopy settings.

Design A systematic review and narrative synthesis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and the Grading of Recommendations Assessment, Development and Evaluation approach.

Data sources PubMed/Medline, EMBASE, PsycInfo, and Cochrane databases were searched through 9 March 2023.

Eligibility criteria Studies were eligible if they involved adult patients (≥18 years) undergoing outpatient colonoscopy or gastroscopy and in English. Interventions included any form of educational digital health technology aimed at enhancing healthcare delivery. Telehealth studies were not included.

Data extraction and synthesis Two independent reviewers extracted data and assessed risk of bias, using the Mixed Methods Appraisal Tool. A mixed-method approach was employed for the narrative synthesis, focusing on the primary outcome of patient experience and satisfaction.

Results Nine studies met the inclusion criteria, all assessing patient satisfaction rather than experience. Five studies reported improved satisfaction associated with digital interventions, three showed no significant change, and one lacked statistical analysis. Interventions ranged from smartphone applications to online educational resources, and satisfaction measurement tools varied significantly. Overall, the evidence was characterised by heterogeneity and very low methodological quality.

Conclusion Digital health interventions may have a positive impact on patient satisfaction in GI endoscopy, although evidence quality is very low and outcome measurement is inconsistent. Future research should focus on standardising measures of patient experience and satisfaction, ensuring robust study designs to inform the integration of digital health tools into endoscopy practice.

PROSPERO registration number CRD42023428609.

  • ENDOSCOPY
  • HEALTH SERVICE RESEARCH
  • COLONOSCOPY
  • GASTROSCOPY

Data availability statement

Data extraction forms, analysis data can be sought directly from the corresponding author Dr Seán Fennessy.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgast-2025-001744

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Patient experience is increasingly recognised as a crucial dimension of healthcare quality. While endoscopy-specific patient-reported experience measures have recently been developed, to the best of our knowledge, no prior reviews have evaluated the impact of digital interventions on patient experience in gastrointestinal endoscopy.

    WHAT THIS STUDY ADDS

    • This review identifies significant gaps in measuring patient experience in endoscopy, highlighting the lack of standardised approaches and the need for patient-centred interventions. The findings underline the necessity to incorporate direct patient input to enhance research focused on addressing patient needs.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This review highlights the limitations in understanding as a result of poorly designed studies and deficiencies in the current measurement methods of patient experience in endoscopy. It strengthens calls for targeted interventions that prioritise patient experience measurement, which, in turn, may inform hospital systems, healthcare professionals and researchers, to advance person-centred care. The increasing recognition of public and patient involvement in research underlines the need for its integration in the design of both interventions and trials to ensure relevance and effectiveness in improving patient outcomes.

    Introduction

    Gastrointestinal (GI) endoscopy is a frequently performed diagnostic and therapeutic procedure, with over 1.5 million procedures carried out in the UK in 2021. Approximately one in three adults will undergo an endoscopy during their lifetime.1 Despite its routine nature, GI endoscopy can provoke significant anxiety, embarrassment, and concerns about discomfort in patients.2

    Patient experience has gained increasing recognition as a key dimension of healthcare quality, alongside clinical effectiveness and patient safety.3 Evidence suggests that positive patient experiences are associated with improved health outcomes, better adherence to treatment, and reduced healthcare utilisation.4–6 In response to this, patient-reported experience measures (PREMs), such as the Newcastle ENDOPREM and Comprehensive Endoscopy Satisfaction Tool (CEST), have been developed to assess care quality in endoscopy.7 8 However, these tools remain underutilised in research assessing the impact of digital health interventions on patient-centred outcomes.

    Digital interventions and healthcare delivery

    Emerging digital health interventions, from smartphone applications to online educational resources, have the potential to improve patient experience by enhancing education, engagement, and preparedness for medical procedures.9 Studies suggest that such interventions can alleviate anxiety, improve adherence to preprocedural instructions, and enhance overall satisfaction.10–12 The adoption of digital health tools is increasing globally, with Ireland demonstrating strong readiness for digital integration in healthcare.13

    Despite this, evidence on the impact of digital interventions specifically in outpatient GI endoscopy remains limited. Additionally, much of the existing literature does not distinguish between one-way digital education and interactive telemedicine interventions. In this review, telemedicine interventions (eg, virtual consultations or real-time patient–provider communication) are excluded, as they introduce variability in patient experience based on provider interaction and clinical setting. Instead, this review focuses on one-directional digital interventions that deliver educational content without requiring active healthcare provider engagement.

    Aim and objectives

    This systematic review aims to evaluate the impact of digital health interventions designed for patient education and engagement on patient experience in outpatient GI endoscopy. Given the limited availability of studies directly measuring patient experience, patient satisfaction will be used as a surrogate outcome, as it reflects aspects of patient-centred care relevant to digital health interventions.14

    The objectives of this review are to:

    1. Assess whether digital health interventions improve patient satisfaction in GI endoscopy.

    2. Examine their impact on healthcare system outcomes, including late cancellations and non-attendance rates.

    Methods

    A systematic review and narrative synthesis were conducted to evaluate the impact of digital health interventions on patient experience and satisfaction in GI endoscopy, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines15 (online supplemental file). This was prospectively registered on PROSPERO (registration number CRD42023428609).

    Eligibility criteria

    Studies were eligible if they involved adult patients (≥18 years) undergoing outpatient colonoscopy or gastroscopy. The interventions assessed included educational digital health technologies designed to enhance healthcare delivery, such as smartphone applications, email, and short message service (SMS) based educational resources. Studies focusing solely on appointment reminders without an educational component were excluded. Telemedicine interventions involving direct two-way communication with healthcare providers were also excluded, as were studies involving inpatient or emergency endoscopy settings.

    Information sources and search strategy

    A comprehensive literature search was performed across PubMed/Medline, EMBASE, PsycInfo, Cochrane, and Campbell databases up to 9 March 2023. The search strategy encompassed terms related to GI endoscopy, digital interventions, and patient experience/satisfaction (see online supplemental appendix A for full search strategy details). We involved a healthcare librarian to ensure that we had a comprehensive and reproducible search throughout each database.

    Study selection process

    References were imported into Covidence for deduplication and initial screening, based on titles and abstracts.16 Full-text articles were then reviewed for eligibility by two independent reviewers (SF and CM, both non-consultant hospital doctors). Any discrepancies in selection were resolved by consensus with a third reviewer, a consultant gastroenterologist (EM). This was required on two occasions in the screening process.

    Outcome definitions and data items

    The primary outcomes of this review were patient satisfaction and patient experience. Patient experience and satisfaction are closely related but distinct concepts. While experience refers to a patient’s interaction with healthcare services, satisfaction reflects their perception of care based on expectations. Due to the limited availability of studies directly measuring patient experience, satisfaction will be used as a practical proxy measure, as it is routinely incorporated into patient-reported experience assessments. Although satisfaction may be influenced by subjective factors, it remains a valuable indicator of patient engagement and perceived quality of care.17

    The secondary outcome assessed healthcare utilisation metrics, such as rates of late cancellations (<7 days), non-attendance, and postendoscopy healthcare visits (eg, general practitioner (GP), emergency department).

    Data extraction

    Data were extracted using a standardised template, capturing details on study objectives, design, population demographics, intervention characteristics, outcome measures, and healthcare utilisation (see online supplemental appendix A for the data extraction template).

    Risk of bias assessment

    The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the risk of bias across diverse study types, including randomised controlled trials (RCTs) and observational studies.18 MMAT categorises study designs into five groups: qualitative studies, RCTs, non-randomised trials, quantitative descriptive studies, and mixed-methods studies. For each category, the tool rates the risk of bias as low, high or unclear. To align with Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment, studies were given an overall bias risk rating of low, moderate, high or unclear. Two reviewers independently assessed bias, with a third reviewer consulted to resolve discrepancies (EM).

    Data synthesis

    A mixed-method approach was employed for the narrative synthesis, focusing on the primary outcome of patient experience and satisfaction. The synthesis considered:

    1. Variability in participant demographics.

    2. Diversity and nature of digital interventions.

    3. Study methodologies.

    4. Outcome measures used.

    5. Contextual factors such as healthcare setting and geographic location.

    A sensitivity analysis was not carried out due to the heterogeneity of methodology and outcome measures between the studies.

    The secondary outcome examined the impact of digital interventions on healthcare utilisation, specifically looking at non-attendance rates and last-minute cancellations.

    Assessment of evidence strength

    The GRADE framework was applied using GRADEpro software to assess evidence quality, considering factors like risk of bias, indirectness, imprecision, and publication bias.19 Given the diversity of study designs, each study was individually evaluated for evidence strength. Inconsistency was not assessed across studies due to the heterogeneity of interventions and outcome measures.20

    Patient and public involvement

    Richeal Burns, a coauthor, is a patient researcher and is the patient and public involvement (PPI) representative on this paper. Dr Burns is also the health economics advisor for the inflammatory bowel disease (IBD) research group, INITIative.

    Results

    Study selection and characteristics

    A total of 1686 records were identified from database searches, and after screening titles, abstracts, and full texts, nine studies were eligible for inclusion. These studies comprised seven RCTs, one randomised controlled quality improvement (QI) study, and one prospective service improvement study. The study selection process is depicted in the PRISMA diagram (figure 1). Studies excluded were primarily those utilising SMS reminders without an interactive component or requiring specialised equipment like virtual reality for pre-endoscopy visits.

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.

    Study populations

    The nine studies included a total of 3086 adult participants, with a mean age of 54.2 years (range 18–84) and a nearly equal gender distribution (50.6% female).21–29 All participants were scheduled for outpatient GI endoscopy, either colonoscopy or gastroscopy. There was variability in demographic characteristics and clinical backgrounds across studies. Some studies included patients with IBD,24 while others excluded this population.22 26 29 Access to a digital device was required for most studies, with two exceptions,25 26 reflecting diverse clinical settings and patient needs.

    Interventions

    The digital interventions were aimed at enhancing patient education and engagement to improve outcomes. Interventions included smartphone applications, email/text links to educational content, social media platforms, quick-response (QR) codes, and brochures with online access:

    • Smartphone applications: two studies utilised smartphone apps, one providing bowel preparation instructions and reminders, and the other offering personalised educational content.21 25

    • Email/text links to online educational materials: four studies used email or text messages to distribute educational materials, such as videos and interactive content.24 26 28 29

    • Social media platform: a Chinese social media platform was used in one study to deliver educational content.27

    • QR code for interactive educational content: one study offered access to interactive online resources via QR codes.23

    • Brochures with online information access: A study provided printed brochures with instructions to access supplementary online content.22

    Details of interventions, including their delivery methods and educational content, are summarised in table 1.

    View this table:
    Table 1

    Study characteristics

    Comparison

    In each study, the control group received the standard of care, which included written instructions (n=9). Some studies received written instructions only (n=5), other received written and verbal instructions, either via phone or in a clinic visit (n=3) and one study received written instructions and a link to an online video.

    Outcomes

    The primary and secondary outcomes of the studies addressed bowel preparation quality, patient satisfaction, healthcare utilisation, and other person-centred outcomes:

    • Bowel preparation quality: the primary outcome for seven of the RCTs was to evaluate the effectiveness of digital interventions in improving bowel preparation.

    • Patient satisfaction: assessed as a secondary outcome in eight of the nine studies, with one study focusing on satisfaction as the primary outcome.28 Various home-designed questionnaires and scales were used to measure satisfaction, leading to notable heterogeneity in assessment tools and definitions. Three studies modified validated patient satisfaction questionnaires and used as their patient satisfaction scales, which may potentially reduce the questionnaires' ability to accurately measure patient satisfaction.25 28 29 None of the studies pretested or did factor analysis on their questionnaires.

    • Healthcare utilisation: two studies reported on metrics such as no-show rates, same-day cancellations, and cancellations within 7 days.24 28

    • Other person-centred outcomes: some studies assessed additional metrics, such as anxiety reduction and understanding of preparation instructions.

    Due to the heterogeneity of the study populations, interventions, and outcome measures, a meta-analysis was not feasible. Consequently, a narrative synthesis was conducted. The mean response rate for satisfaction questionnaires was 86.5%, although as satisfaction was a secondary outcome for most studies, sample sizes may not have been adequately powered to detect differences.

    Risk of bias

    Risk of bias was assessed using the MMAT. Four studies were categorised as having ‘moderate’ risk, and five as having ‘high’ risk. Principal sources of bias included lack of blinding, unclear randomisation procedures, and incomplete reporting of satisfaction outcomes. Detailed bias assessments are provided in table 2 and online supplemental appendix B.

    View this table:
    Table 2

    Risk of bias (RoB) assessment

    Effect of digital interventions on patient satisfaction

    Five out of nine studies reported increased patient satisfaction with the digital interventions compared with standard care, though with varying levels of significance,21 24 26 27 30 please see table 3. These interventions primarily aimed to enhance the patient experience through education, engagement, and procedural preparation. One study did not provide statistical comparisons.22 Three studies found no statistically significant difference in satisfaction outcomes between the intervention and control groups.25 28 29 The sole study that evaluated satisfaction as a primary outcome (Broder et al) noted improvement in preprocedural satisfaction (p=0.038), but this did not result in a significant difference in overall satisfaction (p=0.397).28

    View this table:
    Table 3

    Study outcomes

    Comparison of intervention types

    The variability in intervention types makes direct comparison challenging. However, some patterns were observed:

    • Smartphone applications: one study reported improved satisfaction,21 while the other showed no significant change.25 This suggests that the design and content of the application may play a crucial role in patient satisfaction.

    • Email/text-based educational links: among four studies utilising email or text-based links, results were mixed: two demonstrated improved satisfaction,24 26 while two found no significant change.28 29 This highlights a need for standardisation in the content and delivery of educational materials.

    • Alternative digital interventions: a social media-based intervention27 and a QR code-based intervention23 showed improved satisfaction, suggesting that platforms with interactive and widely accessible features may be more effective. Conversely, brochures with online access did not result in a satisfaction improvement.22

    Healthcare utilisation outcomes

    Two studies specifically assessed healthcare utilisation as a secondary outcome, measuring rates of no-shows and cancellations.24 28 Both found that digital interventions led to reduced no-shows and cancellations, suggesting potential improvements in operational efficiency. For instance, Broder et al reported a reduction in no-shows and cancellations (4% in intervention arm and 20% in the control arm; p=0.023), while Solonowicz et al observed decreased no-show (10% vs 16%; p=0.0003) and cancellation rates within 7 days (18% vs 26%; p=0.0008).

    Variability and gaps in measuring patient satisfaction

    The measurement of patient satisfaction across studies was characterised by variability in assessment tools, lack of validated PREMs, and suboptimal statistical power. The use of non-standardised, home-designed questionnaires limited the comparability of results. Furthermore, the reliance on satisfaction as a proxy for ‘patient experience’ may not fully capture the multifaceted nature of person-centred outcomes. There was also a discrepancy in the timing of these questionnaires, with five studies administering the questionnaires on the day of the procedure and before the procedure, one study administering the questionnaire in the department after the procedure and before being discharged. Another study sent an email with a link to the questionnaire 2 days postprocedure, and two studies did not detail when they collected the data.

    Consideration of specific patient populations

    The characteristics of study populations further limited the generalisability of the findings. Only two studies excluded patients with prior endoscopy experience, aiming to reduce bias; however, the majority did not report or account for patients’ previous exposure to endoscopy, which could act as a significant confounder. The inclusion criteria of several studies also excluded vulnerable populations, such as individuals with IBD, mental health conditions, cognitive impairments or limited digital literacy. The exclusion of these groups not only restricts the applicability of the results but also raises concerns about the accessibility and inclusiveness of digital health interventions in practice.

    Strength and quality of evidence

    The overall strength and quality of evidence for the impact of digital health interventions on patient satisfaction and healthcare utilisation were suboptimal. Using the GRADE criteria, the quality of the studies reviewed ranged from low to very low (please see online supplemental appendix C). The primary factors contributing to this assessment included variability in study design, non-standardised outcome measures, and inadequate statistical power to detect differences.

    Discussion

    Principal findings

    The results of this review indicate that there are potential benefits of digital health initiatives to improve patient satisfaction in GI endoscopy, with six studies reporting favourable results and three studies reporting no difference. However, the quality of the study design, data and the strength of the studies are weak, suggesting further studies in this area are required.

    The differences in results observed between similar digital health initiatives (eg, application-based) may point to the effectiveness being dependent on the patient population, or the modality in which the digital health initiatives are implemented and targeted at the population. We found no significant difference between application-based, email/SMS links, social media or QR code-accessed initiative studied in this review on patient satisfaction. On balance, the results of this narrative review show there may be a positive impact of digital health initiatives, but further research is required to confirm this.

    Patient experience within research

    No studies specifically looking at patient experience were identified as part of this comprehensive search process. There may be a number of reasons for this, including that the definition of patient experience varies within the research community, which complicates its use in research studies. Wolf et al have addressed this challenge by synthesising the different definitions and publishing two studies, 7 years apart, trying to establish a consensus definition.31 32 Clear definitions of patient experience and satisfaction, along with appropriate and objective measurement tools, are important for consistent future research in this field.

    The Newcastle ENDOPREM and the CEST are two examples of PREMs that could have been used in each of the nine studies in our review. The above PREMs take patient factors into account, such as their experience, preferences and attitudes, relating to GI endoscopy. PREMs are designed to capture the ‘what happened’ and ‘how it happened’ during a person’s care and can be used as an indicator of care quality, but not as a direct measure of patient care.33 One of the criticisms of PREMs is that they can be seen as too long or cumbersome to perform.34 Another point to note is the timing of administration for these questionnaires. It is important to standardise a correct timing for measurement of this experience/satisfaction, be it preendoscopy or postendoscopy.

    Patient satisfaction was not the primary aim in the majority of studies included in our review (89.9%). Instead, the primary outcome was bowel preparation rates. As a secondary outcome, patient satisfaction was prioritised below polyp and adenoma detection rates. Prior research has overlooked the potential impact of patient attitudes towards digital health initiatives or their digital/health literacy on the success of their interventions.35 None of the studies quantified these factors. Furthermore, only one study, Broder et al, used PPI design in the development of their digital intervention, by convening a focus group made up of endoscopists, nursing staff and patient representatives.

    Context of existing literature

    We were unable to find any studies specifically addressing patient experience in relation to one-way digital communication initiatives and GI endoscopy. Patient experience in research and endoscopy-specific PREMs is relatively new. Digital and health literacy are major considerations for the implementation of digital interventions in healthcare settings going forward, and we must be mindful of not increasing discrepancies between cohorts.36–38

    Strengths and limitations

    The main strength of this review is that it focuses specifically on patient-orientated feedback for improving care in the search strategy for our review.

    There are two major limitations to this study. First, the quality of evidence is weak and the definition and measurement tools used are heterogeneous, making it difficult to directly compare. Second, given the limited direct research on patient experience in this area, patient satisfaction was used as a proxy measure. We understand that there are limitations to this as it does not capture the broader range of aspects related to the patient’s interaction with the healthcare system.39 As well as this, patient experience/satisfaction was not the primary outcome in the vast majority of included studies, and even as a secondary outcome, it was not the first or second secondary outcome.

    Other limitations include that only English language studies were included, which means other relevant studies published in other languages may have been missed. Some studies that we included have incomplete data due to lack of response from authors.

    Implications for research, policy, and practice

    There is an area for improvement within the endoscopy research field and patient involvement, not just participation through feedback forms, should be a key part to planning person-centred interventions.40–42 Many funding bodies have tied their contributions to the condition of PPI in research and so we suggest that PPI is utilised throughout intervention and trial design, to ensure maximum impact.43

    Conclusion

    The findings of this review highlight a paucity of quality evidence for understanding the impact of digital interventions, which include educational supports, to improve patient experience and engagement in GI endoscopy. Further high-quality studies are required to confirm whether or not education-based digital health interventions can improve patient experience/satisfaction and impact healthcare utilisation. The incorporation of patient satisfaction or patient experience into research on person-centred care in GI endoscopy and digital initiatives has not been adopted. The acknowledgement of PPI importance in the development and implementation of health services research necessitates prioritisation of a standardised approach to measuring patient experience. Overall, digital health interventions may have a positive impact on patient satisfaction in GI endoscopy, although evidence quality is very low and outcome measurement is inconsistent. This review provides encouragement for further studies incorporating robust design features, outcome measurement strategies, PPI and informs patient-centred research and experience.

    Data availability statement

    Data extraction forms, analysis data can be sought directly from the corresponding author Dr Seán Fennessy.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • Contributors SF: acquisition, analysis and interpretation of data; manuscript drafting. CMcG: acquisition, analysis and interpretation of data. EMcD: conception; manuscript drafting. RB: manuscript drafting; reviewing of analysis. PR: manuscript drafting; reviewing of analysis. SF is the guarantor for this study and accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding While the compilation and funding for this article have not received any external funding, the literature search was performed for another project in St Vincent’s University Hospital that has received funding by way of a competitive grant through the Pfizer Global Medical Grants programme (grant number 89233305).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer-reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.