key: cord-0841603-axiyl734
authors: Rex, Douglas K.; Vemulapalli, Krishna C.; Kane, Meghan J.; McHenry, Lee; Sherman, Stuart; Al-Haddad, Mohammad
title: Most Patients Are Willing to Undergo Elective Endoscopic Procedures During the Reopening Period of the COVID-19 Pandemic
date: 2020-05-16
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.039
sha: ed62e34df7f753a76ff2e2b2f02b3b81ffb861b2
doc_id: 841603
cord_uid: axiyl734

nan

As endoscopy units prepare to reopen for elective procedures, patient perceptions toward the risk of 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. Table 1 ) on April 10, 2020. Eligible patients were scheduled for elective outpatient procedures in March or April 2020 and were cancelled or rescheduled because of the pandemic. We excluded EUS and ERCP patients. "Elective" status was established by consensus among our endoscopists. The survey solicited perceptions in two 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-athome orders were active in Indiana (only essential travel) during the survey period. Indiana announced elective procedures, including endoscopies, could resume on April 27, 2020 1 .

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

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 to the top measure, 2 for the second, and 1 if a third was ranked.

Chi-square and Fisher's exact test were used to compare patient responses regarding willingness to proceed and concern about acquiring COVID-19 infection. McNemar's test was used to compare proportions of patients willing to proceed with and without critical protective measures that patients deemed important. Significance was set at 0.05. All analyses were performed using SAS version 9.4 (SAS Institute, Charlotte, NC, USA).

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 0.05 significance.

We telephoned 578 patients and connected with 303. Of 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, mean age was 59.2 years ± 14.4 and 47.2% were female. There were 231 who agreed to participate (mean age, 58.9 years ± 14.3; 59% female; p = 0.094 for gender 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" or "somewhat" 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, gender, and parents at home were not associated with level of concern.

When asked if willing to undergo their procedure in May 2020, 172 (75%) replied yes, 10 (4%) no, and 49 (21%) were unsure. Age, gender, or having parents or children at home were not associated with willingness to proceed. One hundred nine (47%) preferred a free-standing endoscopy unit, 45 (20%) preferred the hospital, and 77 (33%) had no preference. One hundred twenty-four (54%) responded staff should be tested for COVID-19 weekly, 45 (20%) daily, and 61 (27%) responded it doesn't matter. Table 1 shows perceptions regarding specific protective measures. One measure was ranked important or critical by ≥ 90% of respondents: all endoscopy staff should wear a mask at all times. Three others were ranked critical or important by ≥ 80% of patients, including 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 280;

2) patients are provided a mask, score 222; and 3) the staff are tested weekly for COVID-19, score 206. If all measures they considered critical were in place, 192 (83%, 95% CI: 77.7 to 87.7) responded they would proceed with their procedure, which was higher than the 172 (75%, 95% CI: 68.3 to 79.9) who would proceed before protective measures were presented (p = 0.002).

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 it didn't matter, i.e. 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.

Only 4.3% of surveyed patients indicated they were unwilling to undergo elective endoscopy in May 2020, though 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 most subjects resided in Indiana, which could limit generalizability. The study surveyed patient perceptions, and may not reflect which actual behaviors patients will follow. 

Executive Order 20-24: Resumption of elective and non-urgent medical procedures 2020

 Supplementary Table 1 .

Hi, this is ________. I'm a research assistant with Dr. Rex in the Division of Gastroenterology at Indiana University. I'm calling to see if you would be able to answer a short survey on your willingness to undergo your previously scheduled endoscopic procedure after the current corona virus shutdown period is over. This survey is a research study being conducted by Dr Rex. It was not commissioned by IU or the endoscopy center. The information learned from the survey is for research only, and should not be expected to influence or determine patient care or your experience when you travel to the endoscopy center.

This survey is about measures that could be taken at the endoscopy units to increase your confidence about the safety of undergoing your procedure from the perspective of being exposed to the corona virus. How effective any particular measure will be and whether it will be available in the next few months is currently unknown. The actual measures that will be taken at the time that you undergo the procedure are under ongoing review.You are under no obligation to participate in this survey, and refusing to participate will not affect your care at Indiana University in any way. If you participate, your identity will be confidential and will not be made known to the doctors reviewing the results of the survey. We expect that approximately 500 patients who have had their procedures delayed will be called to participate in this survey. The survey is expected to take 5-10 minutes to complete. Are you willing to help us by participating in this survey? For this section you should assume that we are past the peak of the infection but it is still around and there is some risk of acquiring it from going out into public. In addition you should assume that no effective treatment for active infection has become widely available. Also assume that no vaccine is available. After I read each measure, I'll ask you to rate it according to how valuable or important you perceive the measure to be in making you confident about the safety of having your procedure and not being exposed to coronavirus. The lowest rating is that this measure has "no value" from your perspective -meaning it doesn't increase your confidence at all, the next rating is "a little value", then the next rating is "important-this measure should be in place at the endoscopy unit", and the highest rating is "critical for my confidence in undergoing the procedure." Finally, if you aren't sure or don't know what the measure is you can rate it you are "not sure or don't know".12. How would you rate the value of each of the following measures in reducing your concern about having your procedure in May 2020?