Measurement of patient satisfaction with screening colonoscopies in the Hungarian population-based screening program: A nationwide, cross-sectional survey study

Abstract

BACKGROUND

Patient satisfaction plays a pivotal role in ensuring sustained adherence to colonoscopy-based colorectal cancer screening programs.

AIM

To evaluate patient satisfaction following endoscopic procedures in the Hungarian population-based colorectal cancer screening program.

METHODS

Data were obtained from an anonymous, standardized self-administered questionnaire completed between January 2021 and November 2023. Most items were closed-ended, and satisfaction was measured on a 5-point scale.

RESULTS

A total of 4010 questionnaires were analyzed, with a patient-level response rate of 40.6%. Overall satisfaction with the procedure was 4.89 ± 0.42 on a 5-point scale, with 95% of respondents rating each individual assessed aspect as good (score of 4) or very good (score of 5). However, 9.96% of participants reported severe pain (scores of 1 or 2), and 24.80% reported moderate pain (a score of 3) during the examination. The sedation rate was 61.42%. Procedure-related discomfort was significantly negatively associated with male gender, age > 61 years, the use of sedation, the quality of preprocedural information provided by the endoscopist, and the perceived experience of the endoscopist and staff. Procedure-related pain, the quality of the recovery area, post-procedural information, communication skills, and the perceived competence of the endoscopy unit staff were significant determinants of overall patient satisfaction.

CONCLUSION

Positive patient feedback indicates high-quality care. Further improvements in overall satisfaction may be achieved by optimizing pain management, sedation practices, post-procedural recovery conditions, and communication between healthcare professionals and patients.

Key Words: Colorectal cancer; Screening; Patient satisfaction; Colonoscopy; Persistent adherence

Core Tip: This large-scale survey evaluated patient satisfaction with colonoscopies performed within the Hungarian population-based colorectal cancer screening program. Analysis of 4010 questionnaires (response rate, 40.6%) showed that overall patient satisfaction with colonoscopy was very high, yet procedure-related discomfort and pain remained important challenges. Satisfaction is crucial for continued adherence to screening programs; thus, targeted quality improvements may promote sustained long-term participation. The results suggest that overall satisfaction may be further improved by optimizing pain management, sedation practices, post-procedural recovery conditions, and communication between healthcare professionals and patients.

INTRODUCTION

Colorectal cancer (CRC) is an ideal target for secondary prevention because, in the majority of cases, it develops through the malignant transformation of polyps. This time-consuming process provides an opportunity to prevent carcinoma through polypectomy, while early cancer detection and advances in therapy have substantially improved cure rates and overall survival. The importance of screening is further highlighted by the fact that CRC remains the third most common malignancy worldwide in terms of incidence and accounts for nearly 10% of all cancer-related deaths[1].

Population-based organized screening programs, in which colonoscopy plays a pivotal role, have been implemented in an increasing number of countries. Their effectiveness fundamentally depends on achieving high participation rates within the target population and ensuring sustained adherence to the program. The optimal screening rate that could substantially improve disease epidemiology cannot yet be determined with certainty due to limited evidence. Nevertheless, the National Colorectal Cancer Roundtable has set an aspirational target of 80% screening coverage[2]. After achieving sufficient up-to-date screening rates, the United States has observed a reduction of more than 50% in incidence and over 25% in mortality within 15 years of the program’s introduction[3].

Persistent adherence is strongly associated with participants’ experiences and satisfaction throughout the screening program, which are influenced by all phases and components of the screening process, including the screening model (one- or two-step approach), the modality used (stool testing, computed tomography colonography, sigmoidoscopy, colonoscopy, or irrigoscopy), operational factors (appointment scheduling, waiting times, travel distance), and the quality of communication and interaction with healthcare professionals[4,5]. Colonoscopy is a minimally invasive procedure that inevitably involves some degree of patient discomfort during bowel preparation, the procedure itself, and the post-procedural recovery period. The procedure also carries a risk of complications, particularly when therapeutic interventions are involved. Previous studies have identified multiple determinants of patient satisfaction, such as patient comfort, pain and anxiety management, the professionalism and interpersonal behavior of endoscopy staff, communication with the physician about the procedure and results, the physical environment, waiting times for appointments and procedures, and the discharge process[6-8]. Taken together, these findings highlight that evaluating participants’ satisfaction is a crucial aspect of assessing the quality of screening services and an important means of enhancing adherence to screening programs[5].

In Hungary, the population-based organized CRC screening program was launched in 2018. The program has a two-step structure, consisting of an initial fecal immunochemical test, followed by a colonoscopy for positive cases. To support program optimization, enhance patient satisfaction, and promote adherence, a nationwide questionnaire survey was conducted in 2020 among individuals who had undergone a screening colonoscopy. The current study aimed to analyze the survey data to evaluate patient satisfaction and identify its influencing factors.

MATERIALS AND METHODS

Study design and invitation of participants

This multicenter, questionnaire-based national survey was conducted between January 2021 and November 2023 among participants in the Hungarian population-based CRC screening program. The Hungarian National Center for Public Health and Pharmacy (NNGYK), the coordinator of the screening program, developed the questionnaire and distributed it to 55 endoscopy units across 50 qualified institutions involved in the screening; participation by the endoscopy units was voluntary. During the study period, staff at participating institutions provided all patients with an anonymous questionnaire available in both paper and online formats. All eligible participants were invited, and the final sample size was determined by the number of returned questionnaires. Paper questionnaires were mailed to NNGYK, where they were archived and manually entered into the database by administrative staff. Data from online submissions were recorded directly into the central registry.

The study protocol was approved by the Scientific Research Ethics Committee of the Hungarian Medical Research Council (ETT TUKEB Registration No. IV/609-2/2020/EKU) and endorsed by the Regional Research Ethics Committee (RKEB Registration No. 56/2020 SZTE). Staff at the endoscopy units verbally informed patients about the purpose of the survey, emphasizing that the data would be used for scientific research and quality improvement. This information was also provided in written form on the questionnaire. Patients were assured that the questionnaire was anonymous and that strict confidentiality would be maintained during data processing. No sensitive personal information that could lead to patient identification was collected. The study was conducted in accordance with the Declaration of Helsinki.

Questionnaire design and purposes of the study

The self-administered, non-validated, institutionally developed questionnaire, created by a professional advisory panel supporting the CRC screening program, consisted of 25 items. Five questions gathered information about the screening procedure (date of the colonoscopy and date of questionnaire completion) and basic demographic data (gender, age, and type of residence). Twelve questions assessed various aspects of the screening colonoscopy and related factors - such as procedure-related pain or discomfort, overall satisfaction, communication skills of the medical staff, and the experience of the endoscopy staff - using a 5-point semi-quantitative scale. An additional seven items were formatted as yes/no questions. Finally, respondents were invited to share their opinions and comments in an open-ended free-text field (Supplementary material).

Questionnaires that were unsuitable for evaluating the colonoscopy quality were excluded from the analysis. Specifically, this included responses containing only demographic information and those in which only questions related to the general practitioner were answered. The latter was likely completed before the colonoscopy and not finalized afterward.

The primary objective of this study was to assess patient satisfaction with screening colonoscopy procedures conducted within the Hungarian population-based CRC screening program. To achieve this, both overall satisfaction and satisfaction with specific elements of the screening process were evaluated. These included the quality of information provided by general practitioners, the adequacy of pre-procedure information given at the endoscopy unit, communication between patients and medical staff; characteristics of the examination itself (e.g., perceived pain and the patient’s subjective assessment of staff professionalism), and post-procedure factors, such as the clarity of information received regarding results and the availability of rest and recovery facilities.

The secondary objective was to identify factors associated with procedure-related discomfort or pain, as well as overall patient satisfaction with the screening colonoscopy. For predictor identification, responses rated 1-3 on the 5-point Likert scale were categorized as indicating insufficient quality, whereas ratings of 4 or 5 were considered to reflect adequate quality. No changes to study outcomes were made after study commencement.

Statistical analysis

Statistical analysis was conducted using R Statistical Software (version 4.2.1; R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were used to summarize the clinical characteristics of patients and survey responses. Categorical variables are presented as n (%), while continuous variables are described using mean ± SD or median with interquartile range, as appropriate. Multivariate logistic regression was applied to examine associations between potential influencing factors and overall patient satisfaction, as well as procedure-related discomfort or pain. A P-value of < 0.05 was considered statistically significant.

RESULTS

During the study period, a total of 15202 screening colonoscopies were performed within the Hungarian population-based CRC screening program across 55 endoscopy units at 50 institutions. Of these, 32 endoscopy units participated in the survey by returning at least one completed questionnaire to NNGYK, resulting in a site participation rate of 58.18%. These participating institutions performed 9867 screening colonoscopies (825 in 2021, 5067 in 2022, and 3975 in 2023), representing 64.91% of all examinations conducted during the study period. A total of 4061 questionnaires were received. Of these, 16 were excluded because they contained only demographic data, and an additional 35 were excluded because they only addressed information provided by general practitioners without evaluating the endoscopic procedure. As a result, 4010 questionnaires were included in the final analysis, yielding a patient-level response rate of 40.64% within the screening population. The questionnaire completion rate has decreased slightly over the years from 53.58% in 2021 to 41.21% in 2022 and 37.23% in 2023.

Among the respondents, 1665 patients (41.52%) belonged to the 50-61 age group, and 2328 patients (58.05%) to the 62-70 age group (Table 1). Fifteen respondents were outside the target screening age range, and two did not report their age. Residents of the capital city of Budapest were under-represented, comprising only 98 participants (2.44%). Additionally, a slight male predominance was observed, with 2228 male respondents (55.56%). Regarding sedation, 2266 patients (61.42%) received analgesic sedation, and 197 (5.22%) received general anesthesia (with propofol sedation). However, approximately 10% of respondents did not provide information on sedation (Supplementary Figure 1).

Table 1 Clinical and demographic data of study populations, n (%).

Demographic data of enrolled patients
Gender
Male	1777 (44.31)
Female	2228 (55.56)
No response	5 (0.12)
Age categories
50-53 years	536 (13.37)
54-57 years	556 (13.87)
58-61 years	573 (14.29)
62-65 years	935 (23.32)
66-70 years	1393 (34.74)
Outside the target screening age	15 (0.37)
No response	2 (0.05)
Residence of the patient
Capital city	98 (2.44)
County capital/large city	1274 (31.77)
Small town	1329 (33.14)
Village	1299 (32.39)
No response	10 (0.25)
Sedation
Analgosedation	2266 (56.51)
General anesthesia	197 (4.91)
No sedation	1124 (28.03)

Patient satisfaction with screening colonoscopy

Overall, 85.9% of patients (n = 3445) reported high satisfaction (scores 4-5) with the information about colonoscopy provided by their general practitioner. In addition, 90.3% (n = 3444) reported having the opportunity to ask specialist questions before the examination; however, only 21.0% (n = 843) had specific questions they wished to ask. Among respondents, 95.9% (n = 3613) reported satisfaction (scores 4-5) with the answers received from the endoscopy unit staff. A small proportion (3.7%, n = 147) stated that the screening colonoscopy process was explained by someone other than the performing specialist. A total of 98.48% of respondents (n = 3878) rated the physician’s communication as excellent, and 98.40% (n = 3865) gave the same rating to the specialist staff’s communication skills.

The experience of the endoscopy unit staff was rated as good or very good (score 4-5) by 98.45% of respondents, and 97.66% (n = 3765) were satisfied with the overall examination site. Despite this, 9.96% (n = 392) of respondents rated the colonoscopy as painful (score 1-2), and 24.80% (n = 1320) described it as moderately painful. Nevertheless, 96.81% of patients were overall satisfied with the procedure (scores 4-5).

The specialist explained the examination results to 94.42% of respondents (n = 3183); however, 15.94% (n = 639) did not answer this question. A total of 97.46% of patients (n = 3729) considered the information they received sufficient, and 97.24% (n = 3634) reported having all their questions answered. In the event of a repeat procedure, 98.21% of patients (n = 3851) preferred to see the same endoscopist again, while only 22 patients (0.57%) wished to avoid doing so.

A total of 371 respondents (9.25%) did not use the recovery room in the endoscopy unit, while an additional 263 respondents (6.56%) did not respond to this question. Among the respondents, 76.10% (n = 2569) were very satisfied with the recovery room, while 17.30% (n = 584) rated it as good. The mean scores for the indicators evaluated on a 5-point scale are illustrated in Figure 1.

Figure 1  Mean values with standard deviation for questions assessing respondents’ satisfaction with screening colonoscopy.

Factors associated with procedure-related discomfort and overall patient satisfaction

In male respondents (61.40% vs 68.32%, P < 0.001) and those over 61 years (62.48% vs 67.18%, P < 0.001), the rate of painless screening colonoscopy was significantly higher; however, gender and age did not affect overall patient satisfaction. Sedation was associated with lower patient-reported pain and discomfort on a 1-5 Likert scale (71.48% vs 50.88%, P < 0.001); both analgosedation (71.08% vs 50.98%, P < 0.001) and general anesthesia (76.17% vs 50.98%, P < 0.001) were significantly more beneficial in terms of pain control than un-sedated procedures. In addition, subjective perception of procedure-related pain improved significantly when the endoscopist personally provided the preprocedural information, and when the perceived competence of the endoscopy unit staff was rated as appropriate (Table 2, Figure 2A). Notably, there was a substantial difference in sample size between groups providing positive vs negative evaluations of these factors.

Figure 2 Multivariable logistic regression analysis of factors associated with procedure-related discomfort or pain and overall patient satisfaction (odds ratios with 95% confidence intervals). A: Multivariable logistic regression analysis of factors associated with procedure-related discomfort or pain (odds ratios with 95% confidence intervals); B: Multivariable logistic regression analysis of factors associated with overall patient satisfaction (odds ratios with 95% confidence intervals). ^aP < 0.05, indicate variables significantly associated with the outcome in the multivariable model. OR: Odds ratio; CI: Confidence interval.

Table 2 Factors associated with procedure-related discomfort or pain, n (%).

	Painless examination (scores 4-5)	P value
Gender		< 0.001
Male (n = 2184)	1492 (68.32)
Female (n = 1746)	1072 (61.40)
Age of patient		< 0.001
≤ 61 years (n = 1639)	1024 (62.48)
> 61 years (n = 2279)	1531 (67.18)
Residence		0.756
Capital/large city (n = 1344)	869 (64.66)
Small city/village (n = 2581)	1691 (65.52)
Use of sedation		< 0.001
Yes (n = 2451)	1752 (71.48)
No (n = 1120)	571 (50.98)
Information provided by general practitioner		0.054
Scores 1-3 (n = 453)	259 (57.17)
Scores 4-5 (n = 3386)	2253 (66.54)
Preprocedural information provided by the endoscopist		0.002
Yes (n = 3398)	2256 (66.39)
No (n = 360)	202 (56.11)
Communication skills of endoscopist		0.466
Scores 1-3 (n = 154)	49 (31.82)
Scores 4-5 (n = 3561)	2408 (67.62)
Communication skills of endoscopy unit staff		0.384
Scores 1-3 (n = 61)	22 (36.07)
Scores 4-5 (n = 3852)	2531 (65.71)
Experience of endoscopy unit staff		0.026
Scores 1-3 (n = 63)	21 (33.33)
Scores 4-5 (n = 3838)	2526 (65.82)

Overall patient satisfaction increased when patients subjectively perceived the endoscopy unit staff as well-prepared and experienced, and when the endoscopist discussed the examination results with adequate detail (Table 3, Figure 2B). A strong, significant association was also observed regarding the quality of the recovery room (81.98% vs 98.16%, P < 0.001), the quality of the communication of the endoscopy unit staff (42.67% vs 97.69%, P < 0.001), and procedure-associated discomfort (92.83% vs 98.84%, P = 0.002). Sedation was associated with higher overall satisfaction in the univariate analysis; however, neither sedation nor sedation type remained an independent predictor in the multivariate logistic regression model.

Table 3 Factors associated with overall patient satisfaction, n (%).

	Overall patient satisfaction (scores 4-5)	P value
Gender		0.240
Male (n = 2151)	2088 (97.07)
Female (n = 1701)	1641 (96.47)
Age of patient		0.332
≤ 61 years (n = 1612)	1559 (96.71)
> 61 years (n = 2229)	2160 (96.90)
Residence		0.915
Capital/large city (n = 1326)	1285 (96.91)
Small city/village (n = 2522)	2441 (96.79)
Use of sedation		0.231
Yes (n = 2391)	2340 (97.87)
No (n = 1086)	1023 (94.20)
Information provided by general practitioner		0.159
Scores 1-3 (n = 442)	397 (89.82)
Scores 4-5 (n = 3354)	3279 (97.76)
Preprocedural information provided by the endoscopist		0.842
Yes (n = 3509)	3422 (97.52)
No (n = 139)	115 (82.73)
Communication skills of endoscopist		0.194
Scores 1-3 (n = 59)	32 (54.24)
Scores 4-5 (n = 3740)	3653 (97.67)
Communication skills of endoscopy unit staff		< 0.001
Scores 1-3 (n = 60)	25 (42.67)
Scores 4-5 (n = 3731)	3645 (97.69)
Experience of endoscopy unit staff		0.013
Scores 1-3 (n = 58)	21 (36.21)
Scores 4-5 (n = 3746)	3660 (97.70)
Painfulness of colonoscopy		0.002
Scores 1-3 (n = 1311)	1217 (92.83)
Scores 4-5 (n = 2494)	2465 (98.84)
Results explained by performing endoscopist		0.950
Yes (n = 3082)	3007 (97.57)
No (n = 185)	162 (87.67)
Post-procedure information quality		0.083
Scores 1-3 (n = 93)	53 (56.99)
Scores 4-5 (n = 3609)	3534 (97.92)
All questions answered		0.042
Yes (n = 3627)	3561 (98.18)
No (n = 100)	53 (53.00)
Satisfaction with recovery room		< 0.001
Scores 1-3 (n = 222)	182 (81.98)
Scores 4-5 (n = 3147)	3089 (98.16)

DISCUSSION

In colonoscopy-based screening programs, patients’ experiences with the procedure play a pivotal role in their long-term adherence; therefore, regular and comprehensive assessments of patient satisfaction are essential. In this study, we examined the experiences and satisfaction levels of individuals who underwent screening colonoscopy within the Hungarian population-based screening program, initiated in 2018, using a self-administered questionnaire. The key strengths of our study are its nationwide scope and representative nature, supported by a high response rate (two-thirds of individuals who underwent colonoscopy in the participating endoscopic units completed the questionnaire). In terms of sample size, this is one of the largest studies to date assessing patient satisfaction with CRC screening and/or colonoscopy. An additional advantage is the comprehensive coverage of multiple dimensions of colonoscopy care, including the referring general practitioner’s role, the endoscopy procedure, and pre- and post-procedural care and information.

Our anonymous questionnaire survey reflects the high quality of care provided in the colonoscopy component of the Hungarian population-based CRC screening program. This is likely due to the program’s strict participation criteria; only endoscopic units that have undergone prior quality assessment and meet clearly defined standards are eligible, and within these units, screening colonoscopies may be performed only by professionals with adequate experience and sufficient annual procedure volumes. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines for screening colonoscopy recommend that national programs define minimum experience requirements for endoscopists, while accounting for quality assurance. They emphasize that both annual procedure volume and lifetime experience should be considered[9]. In the United Kingdom, the Bowel Cancer Screening Program requires a minimum lifetime experience of 1000 colonoscopies and at least 150 screening procedures annually. However, current perspectives emphasize that the number of procedures alone is insufficient to guarantee a high-quality colonoscopy. Therefore, regular performance monitoring of screening endoscopists is recommended using key quality indicators, such as cecal intubation rate, withdrawal time, polyp detection rate, and complication rates[10-12]. In the Hungarian screening program, eligibility requires at least three years of professional experience and a minimum annual volume of 150 colonoscopies. However, in the five years since the program’s implementation, individual performance audits of participating endoscopists have not yet been conducted. This delay is partly attributable to the coronavirus disease 2019 pandemic, which emerged shortly after the program’s launch and substantially disrupted its operation for nearly two years. During this period, screening invitations were temporarily suspended, and the number of participating institutions and endoscopists decreased considerably due to infection, age-related vulnerability, and workforce reallocation, thereby limiting both screening activity and auditing capacity.

High patient satisfaction scores similar to those observed in our study have also been reported in CRC screening program surveys and surveys of other health and preventive services[5,13,14]. Several studies have emphasized that in voluntary, self-administered, post-intervention patient satisfaction surveys, individuals with the highest level of satisfaction are more likely to demonstrate the highest willingness to participate[5,15,16]. A Swiss study comparing response rates and satisfaction levels in 717 post-hospitalization surveys found that more satisfied patients were more likely to respond, potentially causing an upward bias in overall satisfaction scores[17]. In the present study, the response rate exceeded two-thirds, which likely reduced the impact of response bias and supports the representativeness of our findings; however, response bias cannot be excluded and may have contributed to the exceptionally high satisfaction scores observed.

Our study demonstrates that communication plays a critical role in overall patient satisfaction. The quality of information provided by the endoscopy unit staff, as well as the communication skills of the physician and assistants, showed significant correlations with these two outcome measures. Importantly, both the quality of communication and its source mattered. Specifically, information conveyed personally by the endoscopist reduced reports of examination-related pain. These findings are consistent with those of several previously published studies[18-20]. In addition to communication, other studies concluded that patient satisfaction is also influenced by the control of procedure-related pain and discomfort, anxiety levels, waiting times before the examination, the quality of bowel preparation, and basic demographic factors such as gender, age, and educational attainment[14,21,22].

Our findings also confirm that procedure-related pain is a strong predictor of overall patient satisfaction with colonoscopy. While an appropriate endoscopic technique is essential for minimizing discomfort, sedation plays a key role in controlling this; nevertheless, in our cohort, sedation was administered in only two-thirds of cases. Current ESGE guidelines do not define target sedation rates for either diagnostic or screening colonoscopy[9,23]. The ESGE survey on sedation practices in gastrointestinal endoscopy found that the rate of un-sedated diagnostic colonoscopies in the respondents’ clinical practice was only 13.4%, which is substantially lower than in our cohort (38.58%)[24]. Moderate sedation with midazolam, optionally supplemented with opioids, can be safely provided by endoscopists with experienced assistance, even in outpatient settings[25]. Evidence from a large cohort study involving 44794 patients indicates that propofol-based sedation is associated with higher patient satisfaction, increased polyp detection, and improved cecal and terminal ileal intubation rates[26]. However, its use is limited by the requirement for anesthesiology support, which is not routinely available in many countries, including Hungary.

Our study has several major limitations related to the anonymous, self-administered nature of the survey, including the fact that the questionnaire was institutionally developed and was not formally validated or pilot-tested prior to use, which may affect the generalizability and reliability of the findings. In addition, response bias cannot be excluded, as patients with more positive experiences may have been more likely to complete the questionnaire, potentially leading to an overestimation of satisfaction levels. The survey did not include questions about detected abnormalities or procedural outcomes, such as polyp or carcinoma detection, the need for polypectomy or other endoscopic interventions, or subsequent procedures including computed tomography imaging, repeat endoscopy, or surgery. Owing to the anonymous design, these clinical outcomes could not be linked to individual respondents. In theory, the outcome of the examination could have influenced the individuals’ subjective experience and satisfaction; however, this potential association could not be evaluated in our study. Moreover, although sedation was categorized as analgosedation, general anesthesia, or no sedation, the lack of detailed data on specific agents, dosages, and depth of sedation precluded a more refined analysis of the differential impact of sedation modalities on patient-reported outcomes. Another significant disadvantage of the study is the relatively low participation rate among endoscopic units (58.18%), which does not ensure comprehensive and geographically uniform national coverage, leading to underrepresentation of the capital. Center-specific differences in patient characteristics and procedural practice may influence patient experience, and the findings should be generalized with caution.

CONCLUSION

The nationwide questionnaire survey conducted among patients participating in the Hungarian CRC screening program revealed predominantly positive feedback across nearly all program components. Given the high response rate, the results are considered representative and indicate a generally high quality of care. Communication between endoscopists, endoscopy unit staff, and patients - especially regarding communication skills and the clarity and completeness of information provided - has emerged as a key determinant of overall patient satisfaction and requires increased attention. Examination-related discomfort and pain also proved to be important predictors of satisfaction, and sedation plays a crucial role in controlling them. Increasing sedation rates and implementing non-pharmacological interventions may offer promising solutions for improvement. Furthermore, improving the availability and quality of recovery rooms is essential.

ACKNOWLEDGEMENTS

The authors would like to express their sincere gratitude to the colleagues and staff participating in the colorectal cancer screening program implemented within the framework of the project EFOP-1.8.1-VEKOP-15-2016-00001, “Comprehensive Public Health Screenings”, operating under the Hungarian National Center for Public Health and Pharmacy.