Patient priorities and decision-making process when choosing between colonic investigation alternatives: a qualitative interview study

Abstract

Objective

To establish patients’ perceptions of decision-making and prioritisation of test attributes when considering a colonic investigation.

Methods

National Health Service Highland patients on the waiting list for a colon capsule endoscopy (CCE) and colonoscopy were invited to undergo a semistructured qualitative telephone interview. A diverse sample was sought using a purposive sampling strategy, aiming for differences in age, gender and test awaited between participants. An interview guide was developed using an iterative approach and published data on patients’ experience of colonic investigations. Data were analysed using phenomenological approach and thematic analysis.

Results

Between 12 June 2022 and 02 August 2022, 12 patients underwent telephone interviews. Nine of those patients were on the waiting list for colonoscopy and three were waiting for a CCE. Patients described a mixed level of involvement in the decision-making process for a colonic investigation; some were not involved in the process at all, while others were guided by their clinician. The most important test aspect reported by patients was diagnostic quality, focused on getting a diagnosis, ruling out cancer or the diagnostic accuracy of the test. The importance of the waiting time for the test, the amount of pain or discomfort experienced during the test and the invasiveness of the test were also discussed by patients.

Conclusion

Through qualitative interviews, we have identified patients’ priorities for colonic investigations, which should be further explored to quantify the value patients place on these aspects of the test. Areas of improvement in the decision-making process have been reported, which could be addressed to improve patient care.

Trial registration number

NCT05391529.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Patients’ preferences for colonoscopy and colon capsule endoscopy are equal, but there are varied reasons for patients’ reported preferences for the two tests.

WHAT THIS STUDY ADDS

• Interviewed patients described a mixed level of involvement in the decision-making process for a colonic investigation, as some had the test chosen for them while others felt involved in the process.

• Patients in this study described diagnostic quality as the most important test aspect to them when considering a colonic investigation.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Areas of improvement in the decision-making process have been identified in this study, which clinicians should be aware of when discussing colonic investigations with patients.

• Further research is needed to quantify the value patients place on different test aspects and their relative priorities for some aspects over others.

Introduction

Colon capsule endoscopy (CCE) is now an established test in National Health Service (NHS) Scotland and England. CCE has comparable diagnostic accuracy for the detection of colorectal pathology to colonoscopy, the gold standard. However, the experience for patients undergoing each test is very different. CCE is a non-invasive and painless test which can be carried out closer to or in patients’ homes.¹ However, some patients require a further test (often colonoscopy or flexible sigmoidoscopy) after CCE because pathology is found, or the test is incomplete.² In comparison, colonoscopy is more likely to visualise the whole colon and rectum and has the ability to biopsy or treat mucosal lesions (such as polyps). However, colonoscopy is often found to be uncomfortable or painful for a significant proportion of patients.3,5 Waiting times for colonoscopy have also substantially increased following the COVID-19 pandemic, and the effects this may have on patients’ experience must also be considered.^{6 7}

Patients’ preference for colonoscopy and CCE has been reported in a recently published systematic review and meta-analysis.⁸ Pooled preferences for CCE and colonoscopy from 14 studies were 52% and 45%, respectively, with no significant difference between them. Patients reported preferring CCE due to its non-invasive nature and it was associated with less discomfort and embarrassment, while colonoscopy was preferred as it has the capability to perform biopsies and requires comparatively less bowel preparation. Both tests were found to be equally well tolerated with low rates of adverse events. Patient experience of CCE in Scotland has been reported in the ScotCap evaluation.⁹ Questionnaires (n=209) and telephone interviews (n=18) were conducted after patients had undergone CCE. Findings suggest that patients valued the potential to avoid unnecessary colonoscopy by undergoing CCE and valued the less invasive and less painful nature of CCE compared with colonoscopy. However, negatives such as the bowel preparation taste and volume of liquid that needed to be consumed and potential need for further tests were reported.

Patients’ preferences for CCE, compared with colonoscopy, have been examined, mostly after undergoing the test. Previous research has failed to establish patients’ priorities when choosing between colonic investigations without the bias of recent test experience. There is currently a paucity of published evidence regarding patients’ experience of the decision-making process when choosing between colonic investigations, and a better understanding of the decision-making process could help to improve it. Therefore, we conducted a study aiming to: (1) establish patients’ priorities for different aspects of tests when considering colonic investigations and (2) understand patients’ perceptions of the decision-making process when choosing between colonic investigations, through qualitative interviews.

Methods

Participants and recruitment

This was a qualitative interview study using a phenomenological approach, involving patients on the waiting list for colonoscopy or CCE in NHS Highland. NHS Highland is the largest territorial health board in NHS Scotland with four hospitals (one district general hospital and three rural general hospitals), which provide healthcare for around 320 000 patients. NHS Highland patients were reviewed by a clinical researcher to ensure they met the eligibility criteria (table 1) for the study. Patients meeting the eligibility criteria were invited to take part in an individual telephone interview by letter in a stepwise fashion until data saturation was achieved. Potential participants wishing to take part were asked to complete a consent to contact form online (Microsoft Forms) or in paper form. The consent to contact form was also used to collect demographic information from patients including: (1) date of birth, (2) gender, (3) ethnicity, (4) previous colonic investigation, (5) their postcode and (6) their contact phone number to arrange an interview. A purposive sampling strategy was used, aiming to recruit participants with differences in age, gender and test awaited (CCE vs colonoscopy), providing a sample representative of the range of patients on the waiting list for both tests.¹⁰ This study was registered at ClinicalTrials.gov (NCT05391529) and the study protocol is available online (https://osf.io/mhxc4/files/osfstorage/6462a57f753371354993ffa2).

Table 1. Eligibility criteria.

Inclusion criteria	Exclusion criteria
Patients aged ≥18 years Patients awaiting investigation for new symptoms suggestive of colorectal pathology Patients on the waiting list at time of invitation for colonoscopy or CCE Patients able to participate in an interview in the English language	Patients unable to give informed consent Patients on the waiting list for colonic surveillance, a repeat procedure, planned therapy or biopsy for any pathology Patients who were awaiting investigation for a positive Scottish Bowel Screening Programme test (ie, asymptomatic)

CCE, colon capsule endoscopy.

Data collection

The primary objective of the interviews was to establish patients’ priorities for different aspects of tests when considering colonic investigations. The secondary objective was to understand patients’ perceptions of the decision-making process when choosing between colonic investigations (ie, colonoscopy and CCE). Individual telephone interviews were carried out based on the University of Aberdeen COVID-19 guidance (available at the time of applying for approval to carry out the research).¹¹ The telephone interviews were carried out at a time convenient to the patient. Patients were verbally consented to participate in this study immediately prior to commencing the interview. Semistructured interviews were carried out by CM, a surgical research fellow who had undergone formal training in qualitative research. The telephone interviews were recorded using a dictaphone and transcribed verbatim into Microsoft Word documents. Interviews were carried out until data saturation. Data saturation was determined as the point when no new data were generated that could be used to form new themes or subthemes, based on notes taken during the interviews.¹²

A summary of the interview guide is included in box 1, and the full interview guide is detailed in online supplemental appendix A. The questions in the first part of the interview focused on determining how the patient made the decision to have the test they were waiting for. These questions were written with input from clinicians in the study advisory group (PW and AJMW). The second part of the interview was designed to establish patients’ priorities for different test aspects. Open questions were used to determine the most and least important test factors according to the patients, while closed questioning was used to ask about specific test factors that were not raised by the participant on open questioning.¹³ The test factors used were identified from published research involving CCE and colonoscopy.^{4 8 9} Probes were also employed to encourage interviewees to expand on initial answers given.¹⁴ The interview guide questions were devised through an iterative process primarily between CM and SR, and the finalised interview guide was agreed on by all authors. No changes were made to the interview guide once the study was commenced.

Box 1. Summary of interview questions.

Part 1. Colonic investigation decision-making process

1. Can you tell me about your involvement, if any, in the decision-making process to choose between different bowel tests?

2. What information, if any, were you given to help make the decision to have the test you are waiting for?

3. What information do you think should be given to help you choose between different bowel tests?

4. Could you discuss whether a bowel test was suggested for you and what your thoughts about that were?

5. Can you tell me whether the advantages and disadvantages of different tests were discussed with you, and if possible, could you describe that discussion?

6. In relation to your experiences during this process, is there anything that you think could be done differently for future patients?

Part 2. Priorities when considering colonic investigations

1. When choosing a bowel test, what aspects of the test, if any, did you take into consideration?

2. When choosing a bowel test, what aspects of the test, if any, are the most important to you?

3. If any, what aspects of tests do you think are not important when considering a bowel investigation?

4. Can you discuss whether or not the bowel preparation (ie, the medicine you take to clean your bowels before your test) is important to you when choosing a bowel test to have?

5. When choosing a bowel test to have, can you discuss whether or not the amount of pain or discomfort you might experience is important to you?

6. When choosing a bowel test to have, can you discuss whether or not the distance you would have to travel to where you would undergo a bowel investigation is important to you.

7. Can you discuss whether or not the length of time you will have to wait for a test is important to you when choosing a bowel investigation?

8. When choosing a bowel test to have, can you discuss whether or not the amount of time spent on the day of the test is important to you?

9. Can you discuss whether or not the chance that you might need to undergo a second test after the first bowel test is important to you when choosing a bowel test?

10. We have a specific example of two tests we would like to ask you about. If you imagine there are two tests, test A and test B. Test A has a short waiting time and can rule out bowel cancer effectively, but if it does find a bowel cancer, then you would have a short wait to have a second test to confirm this. Test B has a longer waiting time, but if it did find a suspected bowel cancer, it would be able to confirm that, and you would not need a second test. Can you discuss which of these tests you would be more likely to have and whether you think the potential delay caused by needing a second test after test A is important to you?

11. When choosing a bowel test to have, can you discuss whether or not the risk of complications from a bowel test is important to you?

12. Can you discuss whether or not the need to return equipment the day after your test is important to you when choosing a bowel test?

13. When choosing a bowel test to have, can you discuss whether the impact the test may have on the environment is important to you?

14. How important to you is the amount of time you might have to wait for results from a bowel investigation when considering different bowel investigations?

15. Do you have any additional feedback or comments about the topic or questions that you would like to include? Is there anything I have missed which you would like to talk about in relation to colonic investigation decision-making process and/or priorities when considering colonic investigations?

Data analysis

A phenomenological approach (an approach concerned with participants’ perspectives or perceptions) was used as it would match the requirements of the study to understand patients’ perceptions of the test aspects and experience of the decision-making process.¹⁵ Thematic analysis, following a six-phase approach, was chosen to report patients’ perceptions and priorities in this research.¹⁶ Data coding was conducted by CM and a sample was reviewed by SR to ensure that coding was accurate. Theme and subtheme development were carried out through an iterative process involving CM and SR to improve the quality of the data analysis and trustworthiness.

An inductive–deductive approach was also used depending on the interview question.^{17 18} To gain insights into any areas where new responses could emerge, open questions were used, for example, when asking patients about which test aspect is most important to them. This approach also allowed patients’ experience of the decision-making process to be captured through the interviews as an area previously unexplored in the published literature. A deductive approach was used for more specific questions about established test aspects, which were already known from published studies. Member checking was also carried out to establish credibility by sending a sample of interviewees (n=4) their interview transcripts for voluntary feedback via telephone.

Descriptive statistics were used to analyse the patient’s demographic data. The patient’s postcode was used to obtain a participant’s Scottish Index of Multiple Deprivation (SIMD) decile and Scottish Government Urban Rural Classification 8-fold classification (UR-8) to ensure the participants were from varied backgrounds and different degrees of rurality.^{19 20} Qualitative data were analysed using NVivo V.12.6 (QSR International) and demographic data were analysed using Microsoft Excel. The Standards for Reporting Qualitative Research checklist was used to report the findings of this study (online supplemental appendix B).²¹

Results

199 patients on the waiting list for colonoscopy (n=166) and CCE (n=33) were screened for inclusion. Of those screened, 52 and 28 patients on the waiting list for colonoscopy and CCE, respectively, met the inclusion criteria and were invited to take part. 12 patients consented to take part in the study and were interviewed between 12 June 2022 and 2 August 2022. Patient characteristics and demographic data are described in table 2. The median age of participants was 64 years (range 45–81 years) and 50% were women. Nine patients were on the waiting list for colonoscopy and three were waiting for a CCE. All participants self-reported their ethnicity (table 2) and 75% reported that they had previously undergone a bowel investigation. Patients resided in a range of 3–9 for SIMD classification and 2–8 for UR-8 classification. The median duration of the interview was 32 min (range 16–57 min). Data saturation was reached by 12 interviews, as no new themes were identified in the 11th and 12th interviews. Quotations and subthemes for all themes are described in online supplemental appendix C. No patients responded to the voluntary member checking process.

Table 2. Patient characteristics.

Participant	Self-report ethnicity	Test awaited
A	White British	CCE
B	White British	Colonoscopy
D	White	Colonoscopy
E	White Scottish	CCE
F	Caucasian	Colonoscopy
G	White	Colonoscopy
H	White	Colonoscopy
I	White British	CCE
J	Scottish	Colonoscopy
K	Welsh	Colonoscopy
L	White	Colonoscopy
M	White British	Colonoscopy

CCE, colon capsule endoscopy.

Colonic investigation decision-making process

Four themes were identified from interviewees relating to the decision-making process; initial stages in the decision-making process, test information provided to the patient, perceived test information that should be provided and improvements suggested by patients for the decision-making process (online supplemental appendix C table 1). Patients described a mixed level of involvement in the colonic investigation decision-making process. Many patients described being guided by medical professionals to reach a decision regarding their colonic investigation:

Yes I was involved [in the decision-making process]. I was. I discussed the symptoms with my GP, Dr [name redacted]. We sort of chatted them over and she was very good. Because I’ve had previous bowel tests, she went away and came back to me after she’d looked at my records really. – Participant K

Other patients suggested they were not involved in this decision-making process at all. Patients did not appear to have a negative view of their lack of involvement, and in later interview sections, patients described the perceived importance of trusting the doctor when making decisions or being guided by them. Patients also said they decided to opt for colonic investigations by wanting to determine the cause of concerning symptoms. Positive experiences were also discussed in relation to consultations with the patients’ general practitioner (GP).

A lack of, and variable quality in the test information from primary and secondary care was voiced by most patients. In primary care, patients described not being given enough detail about tests and the short consultation times experienced:

I think the GP was very much, in terms of the capsule, he certainly didn’t give me a great deal of information about it… I’m not too sure about that question because you have quite a short period of time with the GP – Participant A

Patients discussed a lack of contact from secondary care clinicians in relation to being provided with information about tests also. A minority of patients had different test options discussed, which was consistent with the mixed levels of involvement in the decision-making process as very few patients reported being offered different tests to choose between. As a result, when asked about test information that should be provided, patients were keen to receive more information about different options and the advantages and disadvantages of these tests.

Priorities when considering colonic investigations

Patients’ perceptions of test attributes were divided into four overarching groups: pretest, test experience, post-test and broader implications of colonic investigations. Broadly, themes were placed in the group which best represented the part of the test process which they were most related to.

Pretest attributes

When asked which aspect of the test was most important, many patients reported diagnostic quality. Significant importance was placed on this, particularly with a view to getting a diagnosis, ruling out cancer or the diagnostic accuracy of the test:

To be sure that anything, if there was anything there that it was going to get picked up on. – Participant H

Patients discussed wanting to get an answer to explain their symptoms and address their concerns about cancer, with some wanting their test primarily to exclude cancer. Similarly, the waiting time for the test was perceived as important for many patients. One patient discussed seeking private healthcare to reduce their waiting time for the test. The benefits of early diagnosis and subsequent treatment because of reduced waiting time were reported by patients:

I think if it’s been identified that you should have it then you feel it should be done fairly quickly because if there is an issue I would imagine some action may need be to taken. – Participant G

The bowel preparation was discussed by patients as a necessary part of the test and acknowledged the unpleasant experience associated with it. The potential effect of the bowel preparation on continence, symptoms and day-to-day life was highlighted by patients. Mixed responses were obtained when patients were asked about the potential delay involved when comparing two hypothetical tests A and B (box 1, part 2, question 10). When specifically asked about this scenario, patients discussed the benefits of getting an earlier or faster diagnosis, some preferred a single test to confirm a diagnosis and others said they would choose depending on the level of concern they had regarding their underlying diagnosis.

Test experience attributes

The importance of pain or discomfort experienced during the test was frequently discussed by patients. In general, participants wanted to avoid pain or discomfort associated with the test, with some identifying these as the most important test aspects:

Comfort, and lack of knowing that I was undergoing it. – Participant B

However, there was an acceptance among other interviewees that there would be some pain or discomfort associated with the test and that they would be guided by their doctor towards the best test for them, regardless of the potential for there to be pain involved. The invasiveness of tests was important to many participants, as some talked about a preference for the test to be less invasive. In line with other aspects of the test, the unpleasant experience associated with the invasiveness of the test was acceptable to some participants as something that they would tolerate and a minority considered the invasiveness of the test unimportant.

Few patients reported that the duration of the test was important; most were accepting that the test would take as long as it needed to and prioritised the quality of the test over the test duration. One participant did note that there was anxiety associated with the time waiting for the test to happen and found being seen early, or having a short waiting time on the day, helped reduce their anxiety. The travel required to get to their test was not important to many of the participants, as there was a general acceptance that some travel would be required to get to their test:

As long as it’s the same quality of care, I don’t mind travelling a bit. – Participant F

The quality of the test and waiting time were prioritised over the travel time for the test, as some patients described a willingness to travel further to reduce their waiting time for the test. Most participants discussed the risk of complications, but few placed significant importance on this. Patients did note that it was important to be aware of the level of risk involved:

I know that things can go wrong. Nowadays, it is less of a percentage…, you know it is important that you know, that you are aware that there is a risk. – Participant D

Post-test attributes

The chance of needing a second test was not important for most patients. Patients discussed prioritising getting a diagnosis over the chance of needing a second test and a general acceptance of the possibility of further testing as part of the investigation process.

That actually happened to me at the [hospital] one because the bowel hadn’t cleared enough and they couldn’t get a good visual image so I had to go home and go through the whole thing again which you know nobody wants to do. But if it’s got to be done it’s got to be done. – Participant G

Most patients reported that getting their test results in good time was important, with some indicating that around less than 2 weeks would be preferable. Patients described having no concern with returning equipment after their test, but it was identified that other less able patients may have issues with this aspect.

Broader implications of colonic investigations

The financial cost of the test was discussed by a patient as something that everyone had a shared responsibility for in terms of individual patient resource use. When sharing their views on the importance of the environmental impact of the test, participants described wanting less plastics to be involved in the test and that the ability to use public transport to get to the test would be a positive. Several patients wanted to prioritise the quality of their test over the environment, and some felt that the environmental impact of the test should be addressed by others, not the individual patient.

I can’t get down to that micro level of worrying… whether my test has affected the environment. I’ve got solar panels up, I do what I can. – Participant B

Discussion

In this qualitative study, patients identified diagnostic quality and pain or discomfort as the most important test factors to them when choosing between colonic investigations. The theme of diagnostic quality had not been identified on review of the literature as a potential aspect of importance to patients. An inductive–deductive approach was needed to identify this priority (using open questioning), which will be an important addition to other established test attributes prioritised by patients. CCE and colonoscopy have well-established diagnostic accuracies that can be relayed to patients.²² In addition, both tests are sensitive for the detection of cancer, which should meet patients’ requirements that their test can effectively rule out CRC.^{23 24}

The General Medical Council, a public body that maintains the official register of doctors in the UK and sets professional standards, has published guidelines for UK doctors on shared decision-making and consent to help facilitate good decision-making.²⁵ Unfortunately, patients in this study described a lack of involvement in the decision-making process and the test information provided. Many had a test suggested for them without discussion of alternative test choices. The patients in this study may not have been suitable for alternative tests, or clinicians may not have been aware of alternatives. In addition, patients may have been referred to ‘straight to test’ pathways which focus on the efficiency of test delivery. These pathways allow patients referred from primary care to undergo a colonic investigation in secondary care without a clinic or telephone appointment. Clinicians will therefore need to balance patients’ wishes for contact and discussion against waiting times and resource management.

The extent to which pain or discomfort influences decision-making for a colonic investigation is unclear in the current literature. Pain or discomfort is commonly identified as a negative test aspect of colonoscopy, as a significant proportion of patients’ experience pain during or after the procedure.⁴ Some participants in this study discussed a desire to avoid pain or discomfort while undergoing their test. CCE may be best suited to these patients and should be discussed given the less painful nature of the test compared with colonoscopy. However, some patients discussed an acceptance of pain or discomfort as well as other test aspects which are associated with a negative experience such as invasiveness of the test. There was a willingness from patients to tolerate these aspects because either the doctor had recommended the test or to achieve their aim of getting a diagnosis. The extent to which test attributes, such as pain, influence decision-making could be further explored using a discrete choice experiment, which has been used in healthcare research to better quantify patients’ relative preferences for different test attributes.²⁶ A better understanding of patients’ decision-making when choosing between colonic investigations may also ensure that the diagnostic pathway remains patient-centred and supportive throughout.

The waiting time for the test was discussed by most participants in this study and was identified as important. As all the participating patients were still awaiting their test, many without confirmed test dates, waiting times were likely to have been at the forefront of their minds. Patients described increased anxiety associated with prolonged waiting, which correlated with concerns about their symptoms. This is in keeping with published research, which has identified anxiety experienced by patients on the waiting list for tests.²⁷ Furthermore, the Health Foundation-commissioned Ipsos survey of the UK public (n=1858) found that reducing waiting times was the priority of respondents for the NHS over the next 10 years.²⁸ Patients described being willing to travel further for the test to reduce the waiting time for their test, indicating the importance of this test attribute. Furthermore, private healthcare had been explored by a patient to get their test sooner. The increased use of private healthcare has been the focus of recent media articles and the extent of private healthcare use to reduce patients’ waiting times should be further researched.^{29 30} Given the ongoing substantial waiting times for colonoscopy in Scotland, this is likely to remain an important issue for patients and should be considered when discussing tests with patients or evaluating patients’ test experience in future research.⁷ The expediency of obtaining a diagnosis with a colonoscopy versus a potential delay in a CCE diagnostic pathway was explored in this study using two hypothetical tests (Box 1, part 2, question 10). A preference for both options was identified from different patients, as some preferred getting diagnostic confirmation in one test, and others desired an earlier diagnosis. It is likely patients have a preference for CCE and colonoscopy when considering this test aspect in isolation, but the degree to which may be influenced by the relevant time frames for each test and could be explored further in future research.

The need to undergo a second test has been a notable disadvantage of CCE reported in previously published research.³¹ However, in this study, it was not identified as important as patients accepted the potential need for a second test, when weighed against a potentially faster route to diagnosis. Furthermore, we did not ask patients’ views on the reason for the further test (incomplete test or therapy for pathology). This context could be important and careful framing of this question may be useful in future research. Ismail et al.’s study examining patients’ experience undergoing CCE in Ireland found that patients had a strong preference (77.4%) for CCE despite the potential need for a further test.³² These findings, combined with ours, suggest that the need for further tests may not be a significant concern for patients. The bowel preparation required for patients’ tests was not identified as significantly important by participants in this study. Many described it as a negative experience, but one which they accepted as part of having their test. The bowel preparation was the aspect most commented on in surveys from the patients’ perspective, a clinical evaluation of CCE in Scotland (ScotCap evaluation).⁹ Many patients found it a negative experience, particularly due to the volume of liquid required compared with colonoscopy. These results have also been reported by other studies evaluating patients’ experience of CCE.^{8 33} A distinction should be made between patients’ negative experience of test aspects and their priorities for colonic investigations, which may explain the differences in results. Results from this study suggest that the bowel preparation will not have a significant influence over decision-making, but further research could involve examining patients’ priorities before and after undergoing a colonic investigation.

The NHS has committed to reaching a net-zero carbon footprint by 2040.³⁴ Recently published research has reported the significant contribution gastrointestinal diagnostics has on greenhouse gas emissions and waste production within the NHS.³⁵ At present, there is no published research comparing the environmental impact of CCE and colonoscopy. The importance of plastic waste and reducing environmental impact by using public transport was discussed by patients in this study. However, other patients discussed prioritising the quality of their test over the potential impact it will have on the environment. In relation to colonic investigations, this is the first study to examine patients’ views on the environmental impact of their test. Similar findings were reported by the more general Ipsos MORI UK, Health Foundation survey, which found that many of those surveyed (82%) were concerned about climate change, but only a small proportion (19%) thought that reducing environmental impact should be a top priority for the NHS. These results suggest there is potential conflict between the patients’ priorities and the health service’s aims. Future debate will be needed as work continues to reduce the environmental impact of healthcare services, as any reduction in test quality may not be acceptable to patients.

Strengths and limitations

A notable strength of this study is that a range of measures were used to maintain trustworthiness in this study including member checking and supervised data analysis. Furthermore, this study exclusively involved patients on the waiting list for a colonic investigation who had recently experienced the decision-making process for a CCE or colonoscopy in a diagnostic pathway. At the time of this study, CCE was well established in NHS Highland as it was embedded into routine care as part of the standard lower gastrointestinal diagnostic pathway in 2019.² In addition, patients had not undergone their test yet, so their responses could not be influenced by experience of the test, which has been an identified weakness of other studies. Finally, the interviews were transcribed by a single research fellow (CM) to increase familiarity with and increase immersion in the data.

This study is not without limitations. First, the sample size obtained was smaller than planned in the study protocol; however, data saturation had been met and varied participant characteristics within the sample were obtained through a purposive sampling. Within our sample, a significant proportion (75%) of patients had undergone a previous colonic investigation, which had influenced responses. Further, patients included in this study were all symptomatic and so results may not be applicable to other groups, such as surveillance or bowel cancer screening patients, who may have different priorities. In addition, this study was conducted in a single health board and no patients were interviewed who resided in large urban areas (UR-1); however, the views of participants were from varied rural and urban areas (UR-2 to UR-8). Therefore, the geography of the health board may have reduced the generalisability of the findings to patients residing in more urban areas. The interviewer (CM) and other authors of this study have been involved in previous research related to CCE, which may have introduced bias. However, this previous experience will have improved the quality of the interview discussions, and the supervising author (SR) has not been involved in any previous CCE research. At last, we chose not to include patients waiting for CT colonography in this study since it is often reserved for those who are not suitable for colonoscopy due to frailty or age, so the choices for these patients may be limited and their views different from the patients included in this study.

Conclusion

Diagnostic quality, pain or discomfort associated with the test, and waiting time for the test are priorities for patients when considering colonic investigations. Patients described valuing some test aspects over others, such as a willingness to travel further to reduce their waiting time. Future research to quantify the relative value patients place on different test aspects could be examined using a discrete choice experiment. Few patients were offered alternative tests during the decision-making process and there was a desire from patients to be better informed about test alternatives.

Data availability statement

Data are available upon reasonable request.