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Hernández G, Gimeno-García AZ, Quintero E. Strategies to Improve Inadequate Bowel Preparation for Colonoscopy. Front Med (Lausanne) 2019; 6:245. [PMID: 31781565 PMCID: PMC6857107 DOI: 10.3389/fmed.2019.00245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022] Open
Abstract
Bowel cleansing is one of the most important parameters included in the evaluation of colonoscopy quality. The available evidence suggests that inadequate bowel preparation reduces the diagnostic yield of colorectal neoplasia and increases post-colonoscopy colorectal cancer risk. Nowadays, up to 30% of patients referred for colonoscopy have a poor bowel cleansing. Recently, several studies have analyzed the risk factors for inadequate bowel cleansing as well as the strategies to optimize bowel preparation. In this review, we have focused on summarizing the available evidence in this field.
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Affiliation(s)
- Goretti Hernández
- Servicio de Gastroenterología, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Santa Cruz de Tenerife, Spain
| | - Antonio Z Gimeno-García
- Servicio de Gastroenterología, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Santa Cruz de Tenerife, Spain
| | - Enrique Quintero
- Servicio de Gastroenterología, Hospital Universitario de Canarias, Instituto Universitario de Tecnologías Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Santa Cruz de Tenerife, Spain.,Departamento de Medicina Interna, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
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52
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Schooley B, San Nicolas-Rocca T, Burkhard R. Cloud-based multi-media systems for patient education and adherence: a pilot study to explore patient compliance with colonoscopy procedure preparation. Health Syst (Basingstoke) 2019; 10:89-103. [PMID: 34104428 DOI: 10.1080/20476965.2019.1663974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Technology based patient education and adherence approaches are increasingly utilized to instruct and remind patients to prepare correctly for medical procedures. This study examines the interaction between two primary factors: patterns of patient adherence to challenging medical preparation procedures; and the demonstrated, measurable potential for cloud-based multi-media information technology (IT) interventions to improve patient adherence. An IT artifact was developed through prior design science research to serve information, reminders, and online video instruction modules to patients. The application was tested with 297 patients who were assessed clinically by physicians. Results indicate modest potential (43.4% relative improvement) for the IT-based approach for improving patient adherence to endoscopy preparations. Purposively designed cloud-based applications hold promise for aiding patients with complex medical procedure preparation. Health care provider involvement in the design and evaluation of a patient application may be an effective strategy to produce medical evidence and encourage the adoption of adherence apps.
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Affiliation(s)
- Benjamin Schooley
- Health Information Technology, University of South Carolina, College of Engineering and Computing, Columbia, SC, USA
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Trasolini R, Nap-Hill E, Suzuki M, Galorport C, Yonge J, Amar J, Bressler B, Ko HH, Lam ECS, Ramji A, Rosenfeld G, Telford JJ, Whittaker S, Enns RA. Internet-Based Patient Education Prior to Colonoscopy: Prospective, Observational Study of a Single Center’s Implementation, with Objective Assessment of Bowel Preparation Quality and Patient Satisfaction. J Can Assoc Gastroenterol 2019; 3:274-278. [PMID: 33241180 PMCID: PMC7678736 DOI: 10.1093/jcag/gwz026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Nonpharmacologic factors, including patient education, affect bowel preparation for colonoscopy. Optimal cleansing increases quality and reduces repeat procedures. This study prospectively analyzes use of an individualized online patient education module in place of traditional patient education. Aims To determine the effectiveness of online education for patients, measured by the proportion achieving sufficient bowel preparation. Secondary measures include assessment of patient satisfaction. Methods Prospective, single-center, observational study. Adults aged 19 years and over, with an e-mail account, scheduled for nonurgent colonoscopy, with English proficiency (or someone who could translate for them) were recruited. Demographics and objective bowel preparation quality were collected. Patient satisfaction was assessed via survey to assess clarity and usefulness of the module. Results Nine hundred consecutive patients completed the study. 84.6% of patients achieved adequate bowel preparation as measured by Boston bowel preparation score ≥ 6 and 90.1% scored adequately using Ottawa bowel preparation score ≤7. 94.2% and 92.1% of patients rated the web-education module as ‘very useful’ and ‘very clear’, respectively (≥8/10 on respective scales). Conclusions Our analysis suggests that internet-based patient education prior to colonoscopy is a viable option and achieves adequate bowel preparation. Preparation quality is comparable to previously published trials. Included patients found the process clear and useful. Pragmatic benefits of a web-based protocol such as time and cost savings were not formally assessed but may contribute to greater satisfaction for endoscopists and patients.
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Affiliation(s)
- Roberto Trasolini
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Estello Nap-Hill
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Matthew Suzuki
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Cherry Galorport
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Jordan Yonge
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Jack Amar
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Hin Hin Ko
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Eric C S Lam
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Alnoor Ramji
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Gregory Rosenfeld
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Jennifer J Telford
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Scott Whittaker
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
| | - Robert A Enns
- Division of Gastroenterology, Department of Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
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Özer Etik D, Suna N, Gündüz C, Bostan A, Özdemir A, Gürel BY, Yenişekerci E, Boyacıoğlu AS. Can a 1-day clear liquid diet with a split -dose polyethylene glycol overcome conventional practice patterns during the preparation for screening colonoscopy? TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:817-825. [PMID: 31258137 DOI: 10.5152/tjg.2019.19071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND/AIMS A successful screening colonoscopy is closely linked to the quality of a bowel preparation. In this study, we aimed to determine the impact of a 1-day clear liquid diet (CLD) compared to a 3-day combined diet (CMD) accompanied by a split-dose regimen of polyethylene glycol and electrolyte lavage solution (PEG-ELS) for screening colonoscopy. MATERIALS AND METHODS This was a prospective, randomized, endoscopist-blinded study. Patients referred for screening colonoscopy were randomized to four groups as a 1-day CLD+PEG-ELS vs. a 1-day CLD+sulfate free (SF)-PEG-ELS and a 3-day CMD+PEG-ELS vs. a 3-day CMD+SF-PEG-ELS. An assessment of the quality of colon cleaning, tolerability to the preparation, and symptoms related to the preparation were recorded. RESULTS A total of 506 patients were enrolled in this study. The quality of bowel preparation was significantly inferior in the CMD+PEG-ELS group than CLD+PEG-ELS (p=0.004) and CMD+SF-PEG-ELS groups (p=0.007). There were no statistical differences among the groups in terms of the polyp detection rate. With respect to an easy rating of diet following and the consumption of laxative, there were no significant differences among the four groups. Gastric fullness and nausea/vomiting were pointed out much more, especially in the SF-PEG-ELS users (p=0.008 and p=0.004, respectively). CONCLUSION A 1-day CLD was not inferior to a 3-day CMD for colonoscopy preparation in terms of bowel cleaning, the polyp detection rate, and patient tolerance.
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Affiliation(s)
- Diğdem Özer Etik
- Department of Gastroenterology, Başkent University School of Medicine, Ankara, Turkey
| | - Nuretdin Suna
- Department of Gastroenterology, Başkent University School of Medicine, Ankara, Turkey
| | - Cemre Gündüz
- Department of Internal Disease, Başkent University School of Medicine, Ankara, Turkey
| | - Ahmet Bostan
- Başkent University School of Medicine, Ankara, Turkey
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Restall G, Michaud V, Walker JR, Waldman C, Bernstein CN, Park J, Wittmeier K, Singh H. Patient Experiences with Colonoscopy: A Qualitative Study. J Can Assoc Gastroenterol 2019; 3:249-256. [PMID: 33241177 PMCID: PMC7678735 DOI: 10.1093/jcag/gwz016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 06/11/2019] [Indexed: 12/18/2022] Open
Abstract
Background Patient perspectives have important roles in improving the quality of colonoscopy services. The purpose of this qualitative study was to obtain the perspectives of patients who recently had undergone colonoscopy procedures, about their experiences with bowel preparation, the procedure itself, and communication of follow-up results and recommendations. Methods We recruited adults who had undergone a colonoscopy, to participate in semistructured interviews. Interviews were audiotaped, transcribed and analyzed using inductive qualitative methods. Results Twenty-four adults (58% female) with an average age of 53.8 years participated. Results were categorized within the themes of bowel preparation, the colonoscopy procedure and communication of the results. Participants appreciated having clear consistent plain language messages about bowel preparation. Some participants experienced additional challenges to understanding, and navigating, colonoscopy procedures. At the time of the procedure, positive and reassuring interactions with, and between, members of the health care team, in addition to management of physical pain and discomfort, were important. Participants wanted clear and timely information about the results of their test. Conclusions Understanding patients' needs for information and support can promote higher quality colonoscopy services. Our findings suggest that quality indicators should include: patients' perspectives of the clarity of bowel instructions; the need for supports that are not routinely provided; the extent to which concerns about the procedure are addressed; interactions with the endoscopy team; the endoscopy team's interactions with each other; comfort during the procedure, and the timeliness and clarity of results and follow-up instructions. These indicators should be included in annual patient surveys.
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Affiliation(s)
- Gayle Restall
- Department of Occpational Therapy, College of Rehabilitation Sciences, Rady Faulty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Valerie Michaud
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John R Walker
- Department of Clinical Health Psychology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Celeste Waldman
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason Park
- Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristy Wittmeier
- Department of Pediatrics, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Sharara AI, Bou Daher H. Bowel Cleansing Strategies After Suboptimal Bowel Preparation. Clin Gastroenterol Hepatol 2019; 17:1239-1241. [PMID: 30625406 DOI: 10.1016/j.cgh.2018.12.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/18/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Halim Bou Daher
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Strategies to optimise the quality of bowel cleansing. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:326-338. [PMID: 31027972 DOI: 10.1016/j.gastrohep.2019.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 12/17/2022]
Abstract
Colonoscopy is the gold standard procedure for detecting neoplastic lesions of the colon and its efficiency is closely linked to the quality of the procedure. Adequate bowel preparation is a crucial factor in achieving the recommended quality indicators, but poor preparation has been reported in up to 30% of outpatients referred for colonoscopy. Consequently, over recent years, a number of studies have developed strategies to optimise bowel cleansing by improving adherence and tolerance to and the efficacy of the bowel preparation. Moreover, the identification of risk factors for inadequate bowel cleansing has led to tailored bowel preparation strategies being designed, with promising results. We aimed to review studies that assessed risk factors for inadequate bowel preparation and strategies to optimise bowel cleansing in patients at high risk of having poor preparation.
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Inadequate colonoscopy preparation: Is it time to send out an SMS? Gastrointest Endosc 2019; 89:514-517. [PMID: 30784498 DOI: 10.1016/j.gie.2018.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 02/08/2023]
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Bernstein MT, Kong J, Sriranjan V, Reisdorf S, Restall G, Walker JR, Singh H. Evaluating Information Quality of Revised Patient Education Information on Colonoscopy: It Is New But Is It Improved? Interact J Med Res 2019; 8:e11938. [PMID: 30785412 PMCID: PMC6401670 DOI: 10.2196/11938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/27/2018] [Accepted: 12/09/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Previous research indicates that patients and their families have many questions about colonoscopy that are not fully answered by existing resources. We developed revised forms on colonoscopy bowel preparation and on the procedure itself. OBJECTIVE As the goal of the revised materials is to have improved information relative to currently available information, we were interested in how revised information compared with what is currently available in terms of information quality and patient preference. METHODS Participants were asked to review one at a time the Revised and Current versions of Colonoscopy bowel preparation instructions (study 1) and About Colonoscopy (study 2). The order of administration of the Revised and Current versions was randomly counterbalanced to assess order effects. Respondents rated each form along the following dimensions: amount, clarity, trustworthiness, readability and understandability, how new or familiar the information was, and reassurance. Participants were asked which form they preferred and 4 questions about why they preferred it. Open-ended questions asked participants to describe likes and dislikes of the forms and suggestions for improvement. RESULTS The study 1 and study 2 samples were similar. Overall, in study 1, 62.4% preferred the Revised form, 28.1% preferred the Current form, and 6.7% were not sure. Overall, in study 2, 50.5% preferred the Revised form, 31.1% preferred the Current form, and 18.4% were not sure. Almost 75% of those in study 1 who received the Revised form first, preferred it, compared with less than half of those who received it first in study 2. In study 1, 75% of those without previous colonoscopy experience preferred the Revised form, compared with more than half of those who had previously undergone a colonoscopy. The study 1 logistic regression analysis demonstrated that participants were more likely to prefer the Revised form if they had viewed it first and had no previous experience with colonoscopy. In study 2, none of the variables assessed were associated with a preference for the Revised form. In comparing the 2 forms head-to-head, participants who preferred the Revised form in study 1 rated it as clearer compared with those who preferred the Current form. Finally, many participants who preferred the Revised form indicated in the open-ended questions that they liked it because it had more information than the Current form and that it had good visual information. CONCLUSIONS This study is one of the first to evaluate 2 different patient education resources in a head-to-head comparison using the same participants in a within-subjects design. This approach was useful in comparing revised educational information with current resources. Moving forward, this knowledge translation approach of a head-to-head comparison of 2 different information sources could be taken to develop and refine information sources on other health issues.
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Affiliation(s)
- Matthew Tyler Bernstein
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, MB, Canada
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - James Kong
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Vaelan Sriranjan
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Sofia Reisdorf
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Gayle Restall
- Department of Occupational Therapy, University of Manitoba, Winnipeg, MB, Canada
| | - John Roger Walker
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, MB, Canada
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Harminder Singh
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
- Section of Gastroenterology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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Desai M, Nutalapati V, Bansal A, Buckles D, Bonino J, Olyaee M, Rastogi A. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E216-E224. [PMID: 30705956 PMCID: PMC6338550 DOI: 10.1055/a-0796-6423] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/27/2018] [Indexed: 02/07/2023] Open
Abstract
Abstract
Introduction Smartphone-based applications (apps) have been used to improve the quality of bowel preparation (prep) but the success rates have been variable. We have performed a systematic review and meta-analysis to evaluate the impact of smartphone apps on bowel preparation.
Methods Electronic databases (MEDLINE, Embase, CINAHL and Cochrane) were reviewed for eligible studies of smartphone apps versus standard education before colonoscopy. The following outcomes were analyzed: pooled rate of adequacy of bowel prep among both arms and Boston bowel preparation score (BBPS) when reported. Pooled analysis was reported as odds ratio (OR) or mean difference in random effect model with Review Manager 5.3 (P ≤ 0.05 for statistical significance).
Results Six studies were eligible with smartphone app (810 patients) vs. standard education (855 patients, control group) for bowel prep. The smartphone app group had a higher proportion of adequate bowel prep compared to the control group: 87.5 % vs 77.5 % (five studies), pooled OR 2.67; 95 %CI 1.00 – 7.13 with P = 0.05. There was substantial heterogeneity in studies with I
2 = 78 %. When analysis was limited to randomized controlled trials (RCTs), smartphone app users had a numerically higher rate of bowel cleansing: 87.1 % vs 76.9 %; however, pooled OR was not statistically significant (OR 2.66, 95 %CI 0.92 – 7.69, P = 0.07). When studies using BBPS were evaluated (n = 3), smartphone app users had higher mean scores (better bowel prep) with a mean difference of 0.9 (95 %CI 0.5 – 1.3), which was statistically significant (P < 0.01).
Conclusion The smartphone app is a novel educational tool that can assist in achieving adequate and better bowel cleansing before colonoscopy.
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Affiliation(s)
- Madhav Desai
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Venkat Nutalapati
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Ajay Bansal
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Daniel Buckles
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - John Bonino
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Mojtaba Olyaee
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Amit Rastogi
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
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Abstract
PURPOSE OF REVIEW Colonoscopy is recognizably, the best colon cancer prevention test, provided the quality of the preparation is adequate for detection of precancerous polyps but also allowing for accurate identification of margins, thereby facilitating complete endoscopic resection. As there are many aspects effecting colon prep outcomes, it is timely to review new standards for optimizing outcomes, including product selection based on patient demographics. RECENT FINDINGS New national guidelines have set a minimum quality threshold for adequacy and also defined a split day delivery for oral options as the "standard of care". Several new prep options have been recently released and these data are discussed. SUMMARY Optimizing the quality of colon preps has major implications for clinical practice. Clinicians must recognize new targets for standard of care, providing the best approach for each individual patient, considering variable factors which may otherwise compromise success.
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Kim B, Kim BC, Kim J, Oh HJ, Ryu KH, Park BJ, Sohn DK, Hong CW, Han KS. Quality of Bowel Preparation for Colonoscopy in Patients with a History of Abdomino-Pelvic Surgery: Retrospective Cohort Study. Yonsei Med J 2019; 60:73-78. [PMID: 30554493 PMCID: PMC6298899 DOI: 10.3349/ymj.2019.60.1.73] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/24/2018] [Accepted: 11/07/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Prior abdomino-pelvic (AP) surgery makes colonoscopy difficult and can affect bowel preparation quality. However, bowel preparation quality has been found to vary according to prior AP surgery type. We examined the relationship of prior AP surgery type with bowel preparation quality in a large-scale retrospective cohort. MATERIALS AND METHODS In the health screening cohort of the National Cancer Center, 12881 participants who underwent screening or surveillance colonoscopy between June 2007 and December 2014 were included. Personal data were collected by reviewing patient medical records. Bowel preparation quality was assessed using the Aronchick scale and was categorized as satisfactory for excellent to good bowel preparation or unsatisfactory for fair to inadequate bowel preparation. RESULTS A total of 1557 (12.1%) participants had a history of AP surgery. The surgery types were colorectal surgery (n=44), gastric/small intestinal surgery (n=125), appendectomy/peritoneum/laparotomy (n=476), cesarean section (n=278), uterus/ovarian surgery (n=317), kidney/bladder/prostate surgery (n=19), or liver/pancreatobiliary surgery (n=96). The proportion of satisfactory bowel preparations was 70.7%. In multivariate analysis, unsatisfactory bowel preparation was related to gastric/small intestinal surgery (odds ratio=1.764, 95% confidence interval=1.230-2.532, p=0.002). However, the other surgery types did not affect bowel preparation quality. Current smoking, diabetes, and high body mass index were risk factors of unacceptable bowel preparation. CONCLUSION Only gastric/small intestinal surgery was a potential risk factor for poor bowel preparation. Further research on patients with a history of gastric/small intestinal surgery to determine appropriate methods for adequate bowel preparation is mandatory.
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Affiliation(s)
- Bun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
| | - Jeongseon Kim
- Department of Cancer Biomedical Science, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hyun Jin Oh
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kum Hei Ryu
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bum Joon Park
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Center for Cancer Prevention and Detection, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Tan L, Lin ZC, Ma S, Romero L, Warrier S. Bowel preparation for colonoscopy. Hippokratia 2018. [DOI: 10.1002/14651858.cd006330.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lynn Tan
- Monash University; Faculty of Medicine, Nursing & Health Sciences; 1-131 Wellington Road Clayton Victoria Australia 3168
| | - Zhiliang Caleb Lin
- The Alfred Hospital; Surgical Services; 55 Commercial Road Melbourne Victoria Australia 3004
| | - Stefan Ma
- Ministry of Health Singapore; Epidemiology and Disease Control Division, Public Health Group, Ministry of Health; 16 College Road, College of Medicine Building Singapore Singapore Singapore 169854
| | - Lorena Romero
- The Alfred Hospital; The Ian Potter Library; 55 Commercial Road Melbourne Victoria Australia 3000
| | - Satish Warrier
- Alfred Health; Colorectal Department; 55 Commercial Road Melbourne Victoria Australia 3004
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Zhang QX, Li J, Zhang Q, Li Y, Lei CH, Shang BX, Guan XS, Zhang Q. Effect of Education by Messaging Software on the Quality of Bowel Preparation for Colonoscopy. Chin Med J (Engl) 2018; 131:1750-1752. [PMID: 29998899 PMCID: PMC6048928 DOI: 10.4103/0366-6999.235881] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Qing-Xia Zhang
- Department of Pharmacy, The Second Hospital of Jingzhou City, Jingzhou, Hubei 434000, China
| | - Jie Li
- Department of Gastroenterology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434000, China
| | - Qin Zhang
- Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
| | - Yi Li
- Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
| | - Cong-Han Lei
- Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
| | - Bai-Xue Shang
- Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
| | - Xiao-Shuang Guan
- Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
| | - Qing Zhang
- Department of Gastroenterology, First Affiliated Hospital of Yangtze University; Department of Internal Medicine, Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
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Gálvez M, Zarate AM, Espino H, Higuera-de la Tijera F, Awad RA, Camacho S. A short telephone-call reminder improves bowel preparation, quality indicators and patient satisfaction with first colonoscopy. Endosc Int Open 2017; 5:E1172-E1178. [PMID: 29202000 PMCID: PMC5698010 DOI: 10.1055/s-0043-117954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/03/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Addition of a reminder program to conventional indications improves colonoscopy. The aim of this study was to evaluate the effectiveness of a short telephone call reminder (STCR) on a patient's first colonoscopy. PATIENTS AND METHODS One day before colonoscopy, we made a STCR of < 10 minutes to 141 randomly selected patients of 258 recruited. The STCRs informed patients about the procedure date, indications for taking laxatives, and dietetic requirements. Questions were clarified only when patients asked directly. We evaluated bowel preparation, quality indicators, and patient satisfaction. Data were expressed as mean ± SD and percentages. Statistical differences were evaluated by Student's t and Chi squared tests; alpha = 0.05. All authors had access to the study data and reviewed and approved the final manuscript. RESULTS The STCR group had better bowel preparation which was demonstrated by higher completion frequency (97.16 % vs. 82.05 %), in less time (4.52 ± 3.06 vs. 5.38 ± 3.03 hours) intake of laxative, and higher Boston's scale (7.66 ± 2.42 vs. 5.2 ± 1.65). Quality indicators of colonoscopy were better in patients that received a STCR [cecal intubation rate: 100.00 % vs. 87.18 %; polyp detection: 42.55 % vs. 9.4 %; and cecal arrival time (min): 12.09 ± 3.62 vs. 15.09 ± 5.02]. STCR patients were more satisfied (97.87 % vs. 55.56 %) and would repeat colonoscopy (21.99 % vs. 11.11 %). CONCLUSIONS A simple additional step such as a STCR improves quality of bowel preparation, quality indicators, and satisfaction of patients undergoing their first colonoscopy. Clinical trial registry in Mexico City General Hospital: DI/16/107/3/108.
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Affiliation(s)
- Marisol Gálvez
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Angel Mario Zarate
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Hector Espino
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Fátima Higuera-de la Tijera
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Richard Alexander Awad
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
| | - Santiago Camacho
- Endoscopy Unit of Gastroenterology Service, Mexico City General Hospital “Dr Eduardo Liceaga”, Mexico City, Mexico
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66
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Lee YJ, Park KS. Can Patient Education with a Smartphone Application Improve the Quality of Bowel Preparation for Colonoscopy? Clin Endosc 2017; 50:412-414. [PMID: 29017291 PMCID: PMC5642055 DOI: 10.5946/ce.2017.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/19/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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67
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Ho SB, Hovsepians R, Gupta S. Optimal Bowel Cleansing for Colonoscopy in the Elderly Patient. Drugs Aging 2017; 34:163-172. [PMID: 28214970 DOI: 10.1007/s40266-017-0436-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colonoscopy is an important diagnostic and screening tool for colorectal cancer detection and prevention, and adequate bowel preparation is critical for successful colonoscopy. Complications related to colonoscopy, either directly or indirectly related to the procedure, are increased in elderly patients, and the risks and benefits of colonoscopy procedures need to be carefully considered in these patients. Recent studies have shown that 4 L polyethylene glycol with a split preparation is safe and effective for elderly patients, and is the preferred preparation for patients with medical comorbidities. Preparations containing sodium phosphate are generally not recommended for the elderly because of increased renal complications. In addition, a low-residue diet may aid in tolerance and willingness to undergo the procedure compared with a clear liquid diet, with comparable bowel preparation adequacy. Risk factors for inadequate bowel preparations include poor adherence to split preparation instructions or volume of solution ingested, and certain patient-related medications and comorbidities, such as diabetes, elevated body mass index, and antidepressant or narcotic use. Methods for achieving safe and adequate bowel preparations in the elderly include clear instructions, reminder calls, and case management for potential confounding patient-related factors.
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Affiliation(s)
- Samuel B Ho
- VA San Diego Healthcare System and University of California, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA.
| | - Rita Hovsepians
- VA San Diego Healthcare System and University of California, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
| | - Samir Gupta
- VA San Diego Healthcare System and University of California, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
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68
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Liu Z, Zhang MM, Li YY, Li LX, Li YQ. Enhanced education for bowel preparation before colonoscopy: A state-of-the-art review. J Dig Dis 2017; 18:84-91. [PMID: 28067463 DOI: 10.1111/1751-2980.12446] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 12/27/2016] [Accepted: 01/04/2017] [Indexed: 12/11/2022]
Abstract
Colonoscopy remains the mainstay in diagnosing and monitoring colorectal cancer and other colorectal lesions. The diagnostic efficiency of colonoscopy greatly depends on the quality of bowel preparation, which is closely associated with the patient's compliance with the preparation instructions. In addition, the procedural requirements of bowel preparation are often complex and difficult for patients to comprehend and memorize, especially those with lower health literacy and motivation. Therefore, in recent years, many educational methods have been developed, such as educational booklets, cartoon visual aids, educational videos, short message service, telephone, social media and smart phone applications. These educational methods have significantly improved compliance with the instructions for bowel preparation and ultimately promoted the visualization of the colon in patients undergoing colonoscopy.
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Affiliation(s)
- Zhu Liu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Shandong University Qilu Hospital, Jinan, Shandong Province, China
| | - Ming Ming Zhang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Shandong University Qilu Hospital, Jinan, Shandong Province, China
| | - Yue Yue Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Shandong University Qilu Hospital, Jinan, Shandong Province, China
| | - Li Xiang Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Shandong University Qilu Hospital, Jinan, Shandong Province, China
| | - Yan Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Shandong University Qilu Hospital, Jinan, Shandong Province, China
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Abstract
OPINION STATEMENT The adenoma detection rate (ADR), i.e., the proportion of average risk patients with at least one adenoma detected during screening colonoscopy, is inversely associated with the development of interval colorectal cancer. Increasing the ADR is therefore an important proxy for increase in quality and efficacy of (screening) colonoscopy. Several potentially modifiable factors, such as, procedural and technological factors, and quality improvement programs, and their effect on the ADR will be reviewed. Procedural factors, such as, bowel preparation, withdrawal time, and position changes of the patient are associated with the ADR. While the relation of others, such as inspection during insertion, use of antispasmodic agents, and second inspection in the proximal colon, with the ADR is not completely clear. Many new colonoscopy technologies have been evaluated over recent years and are still under evaluation, but no unequivocal positive effect on the ADR has been observed in randomized trials that have mostly been performed by experienced endoscopists with high baseline ADRs. Several quality improvement programs have been evaluated and seem to have a positive effect on endoscopists' ADR. Increase in ADR is important for the protective benefit of colonoscopy. There are now extensive methods to measure, benchmark, and improve ADR but increased awareness of these is critical. We have provided an overview of potential factors that can be used to increase personal ADRs in every day practice.
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Affiliation(s)
- Eelco C Brand
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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MacArthur KL, Leszczynski AM, Jacobson BC. Enhancing bowel preparation instructions: Is the bang worth the buck, or are we stuck with the muck? Gastrointest Endosc 2017; 85:98-100. [PMID: 27986119 DOI: 10.1016/j.gie.2016.06.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/17/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Kristin L MacArthur
- Section of Gastroenterology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Anna M Leszczynski
- Section of Gastroenterology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Brian C Jacobson
- Section of Gastroenterology, Boston University Medical Center, Boston, Massachusetts, USA
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Elvas L, Brito D, Areia M, Carvalho R, Alves S, Saraiva S, Cadime AT. Impact of Personalised Patient Education on Bowel Preparation for Colonoscopy: Prospective Randomised Controlled Trial. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:22-30. [PMID: 28848777 PMCID: PMC5553375 DOI: 10.1159/000450594] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/30/2016] [Indexed: 01/10/2023]
Abstract
Background Adequate bowel preparation is one of the most important quality factors of colonoscopy. Our goal was to analyse the impact of personalised patient education on bowel cleansing preparation for colonoscopy. Methods We performed a single-blinded, single-centre, prospective randomised trial, where patients were either allocated to a control group, where they received some predefined oral and written information on bowel preparation from the gastroenterologist, or to an intervention group, where patients received additional personalised instructions for bowel preparation and diet from a nurse. The primary outcome was the quality of bowel preparation (Aronchick scale). Results A total of 229 patients were randomised; 113 to the control group and 116 to the intervention group. In intention-to-treat analysis, bowel preparation was adequate in 62% (95% CI 53-70) of colonoscopies in the intervention group and in 35% (95% CI 26-44) of colonoscopies in the control group (p < 0.001). The absolute risk reduction was 27%, the relative risk was 1.77, and the number needed to treat was 4. Subgroup analysis showed a significant impact of personalised education in patients under 65 years (67 vs. 35%; p < 0.001), in males (60 vs. 33%; p = 0.003), in those with higher educational levels (68 vs. 37%; p = 0.002), in those living in urban areas (68 vs. 40%; p = 0.004), and in those with previous colonoscopy (68 vs. 40%; p = 0.001). Risk factors for inadequate preparation were: male gender (OR = 2.1; 95% CI 1.1-4.1), diabetes mellitus (OR = 3.8; 95% CI 1.2-11.6), chronic constipation (OR = 3.7; 95% CI 1.7-8.2), absence of prior abdominal surgery (OR = 2.2; 95% CI 1.2-4.1), and being in the control group (OR = 2.5; 95% CI 1.4-4.4). Conclusions Personalised patient education on bowel preparation for colonoscopy significantly improved the quality of bowel preparation.
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Affiliation(s)
- Luís Elvas
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
| | - Daniel Brito
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
| | - Miguel Areia
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal.,CINTESIS - Center for Research in Health Technologies and Information Systems, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rita Carvalho
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
| | - Susana Alves
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
| | - Sandra Saraiva
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
| | - Ana T Cadime
- Department of Gastroenterology, Portuguese Oncology Institute, Coimbra, Portugal
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Kurlander JE, Sondhi AR, Waljee AK, Menees SB, Connell CM, Schoenfeld PS, Saini SD. How Efficacious Are Patient Education Interventions to Improve Bowel Preparation for Colonoscopy? A Systematic Review. PLoS One 2016; 11:e0164442. [PMID: 27741260 PMCID: PMC5065159 DOI: 10.1371/journal.pone.0164442] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Bowel preparation is inadequate in a large proportion of colonoscopies, leading to multiple clinical and economic harms. While most patients receive some form of education before colonoscopy, there is no consensus on the best approach. AIMS This systematic review aimed to evaluate the efficacy of patient education interventions to improve bowel preparation. METHODS We searched the Cochrane Database, CINAHL, EMBASE, Ovid, and Web of Science. Inclusion criteria were: (1) a patient education intervention; (2) a primary aim of improving bowel preparation; (3) a validated bowel preparation scale; (4) a prospective design; (5) a concurrent control group; and, (6) adult participants. Study validity was assessed using a modified Downs and Black scale. RESULTS 1,080 abstracts were screened. Seven full text studies met inclusion criteria, including 2,660 patients. These studies evaluated multiple delivery platforms, including paper-based interventions (three studies), videos (two studies), re-education telephone calls the day before colonoscopy (one study), and in-person education by physicians (one study). Bowel preparation significantly improved with the intervention in all but one study. All but one study were done in a single center. Validity scores ranged from 13 to 24 (maximum 27). Four of five abstracts and research letters that met inclusion criteria also showed improvements in bowel preparation. Statistical and clinical heterogeneity precluded meta-analysis. CONCLUSION Compared to usual care, patient education interventions appear efficacious in improving the quality of bowel preparation. However, because of the small scale of the studies and individualized nature of the interventions, results of these studies may not be generalizable to other settings. Healthcare practices should consider systematically evaluating their current bowel preparation education methods before undertaking new interventions.
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Affiliation(s)
- Jacob E. Kurlander
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
- Veterans Affairs Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States of America
| | - Arjun R. Sondhi
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Rd, Ann Arbor, 48105, MI, United States of America
| | - Stacy B. Menees
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
- Veterans Affairs Ann Arbor Health Care System, 2215 Fuller Rd, Ann Arbor, MI, 48105, United States of America
| | - Cathleen M. Connell
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, 3790 SPH I, 1415 Washington Heights, Ann Arbor, MI, 48109, United States of America
| | - Philip S. Schoenfeld
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Rd, Ann Arbor, 48105, MI, United States of America
| | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, United States of America
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Rd, Ann Arbor, 48105, MI, United States of America
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