Factors influencing quality of bowel preparation for colonoscopy

Rates of Suboptimal Preparation for Colonoscopy Differ Markedly Between Providers: Impact on Adenoma Detection Rates

GOALS

We sought to determine if providers who have higher standards for optimal bowel preparation might be more fastidious in their examination of the colon and, therefore, have higher adenoma detection rates (ADRs).

BACKGROUND

ADRs are a reliable and objective marker of colonoscopy performance. Suboptimal bowel preparation impacts upon adenoma detection; however, physicians have varying standards for grading bowel preparation.

STUDY

Endoscopy reports of patients who underwent screening colonoscopy in 2011 at 1 academic medical center were reviewed. Bowel preparations labeled "fair," "poor," or "unsatisfactory" were considered suboptimal. The ADR was calculated for each endoscopy provider and was correlated with the provider's suboptimal preparation rate. Logistic regression was used to determine independent predictors of adenoma detection.

RESULTS

1649 examinations from 11 separate gastroenterologists were included. Preparation was suboptimal in 22% of examinations overall. The rate of suboptimal preparations varied widely among providers, ranging from 3% to 40%. Overall ADR was 23%, with a range of 13% to 31%. Providers' suboptimal preparation rate was not significantly correlated with ADR (r=-0.22, P=0.51). After adjusting for age and sex, adenoma detection was not associated with provider suboptimal preparation rate (P=0.28).

CONCLUSIONS

Rates of suboptimal preparation vary widely between providers, but were not correlated with ADR. This suggests that a high suboptimal preparation rate is not a marker of higher quality standards and expectations by the provider. The impact of physician personality traits on colonoscopy performance requires further study.

A delayed onset of bowel activity after the start of conventional polyethylene glycol predicts inadequate colon cleansing before colonoscopy: A prospective observational study

BACKGROUND

Evaluation of factors correlating with the quality of bowel preparation (QBP) is critical to ensure high-quality colonoscopy.

OBJECTIVES

We sought to determine whether the time interval between the start of conventional polyethylene glycol (PEG) ingestion and the onset of bowel activity is predictive of QBP.

METHODS

Consecutive adult outpatients attending colonoscopy were prospectively assessed. Data including demographics, medical history, time of starting/completion of PEG and time when bowel activity started were recorded. The QBP was assessed according to the Ottawa bowel preparation score (OBPS); inadequate QBP was OBPS ≥7.

RESULTS

A total of 171 patients (92 males, mean age: 60.5 years) complying with preparation instructions were included. The median OBPS was 5 (range: 1-13) and 57 (33.3%) had inadequate QBP. The median interval between the initiation of PEG and the onset of bowel activity was 60 min (range: 9-300 min). Patients (n = 52, 30.4%) with a delayed (>90 min) onset of bowel activity had poorer QBP (p = 0.0001). In multivariate analysis, male gender (OR: 2.38, p = 0.03), the interval between the end of preparation and the start of colonoscopy (OR: 1.94, p = 0.02) and time to onset of bowel activity >90 min (OR: 3.38, p = 0.004) were predictive of inadequate QBP.

CONCLUSION

The time interval between the initiation of PEG ingestion and the onset of bowel activity is predictive of the QBP. Our data support "on demand" intensification of bowel preparation in patients with a delayed onset of purgative response to PEG.

What Influences the Quality of Prevention Colonoscopy?

Background

Colorectal cancer still has a high incidence and mortality. Although colonoscopy is considered as gold standard of colorectal cancer screening, there still exists an unsatisfactory level of adenomas missed in screening and surveillance colonoscopy. Furthermore, patients bear the burden of potentially unpleasant and painful examination and preparation procedures.

Method

A search of the literature using PubMed was carried out, supplemented by a review of the programs of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW) 2011-2013.

Results

Several new approaches to colonoscopy were described: water, CO₂ and cap colonoscopy, and application of spasmolytics such as hyoscine butylbromide and glucagon. The use of these methods does not necessitate the purchase of new endoscopes. They are feasible and safe, facilitate achieving the aim of more comfort and less pain, and perhaps allow lower doses of sedatives to be used. However, a clear effect on procedure time is lacking. Furthermore, the published data do not consistently answer the question of whether these techniques have a positive impact on the most important goal, the better detection of carcinoma precursors.

Conclusion

More efforts to optimize bowel preparation have to be made to improve visualization of the mucosal surface. The most reliable criteria for the quality of screening and surveillance colonoscopy remain a minimum cecal intubation rate of >90%, a withdrawal time of at least 6 or better 9 min, and an adenoma detection rate of >20%. These results should be achieved with a complication rate lower than 1%, including polypectomy.

Using segmented regression analysis of interrupted time series data to assess colonoscopy quality outcomes of a web-enhanced implementation toolkit to support evidence-based practices for bowel preparation: a study protocol

BACKGROUND

While there is convincing evidence on interventions to improve bowel preparation for patients, the evidence on how to implement these evidence-based practices (EBPs) in outpatient colonoscopy settings is less certain. The Strategies to Improve Colonoscopy (STIC) study compares the effect of two implementation strategies, physician education alone versus physician education plus an implementation toolkit for staff, on adoption of three EBPs (split-dosing of bowel preparation, low-literacy education, teach-back) to improve pre-procedure and intra-procedure quality measures. The implementation toolkit contains a staff education module, website containing tools to support staff in delivering EBPs, tailored patient education materials, and brief consultation with staff to determine how the EBPs can be integrated into the existing workflow. Given adaptations to the implementation plan and intentional flexibility in the delivery of the EBPs, we utilize a pragmatic study to balance external validity with demonstrating effectiveness of the implementation strategies.

METHODS/DESIGN

Participants will include all outpatient colonoscopy physicians, staff, and patients from a convenience sample of six endoscopy settings. Aim #1 will explore the relative effect of two strategies to implement patient-level EBPs on adoption and clinical quality outcomes. We will assess the change in level and trends of clinical quality outcomes (i.e., adequacy of bowel preparation, adenoma detection) using segmented regression analysis of interrupted time series data with two groups (intervention and delayed start). Aim #2 will examine the influence of organizational readiness to change on EBP implementation. We use a PRECIS diagram to reflect the extent to which each indicator of the study was pragmatic versus explanatory, revealing a largely pragmatic study.

DISCUSSION

Implementation challenges have already motivated several adaptations to the original plan, reflecting the nature of implementation in real-world healthcare settings. The pragmatic study responds to the evolving needs of its healthcare partners and allows for flexibility in intervention delivery, thereby informing clinical decision-making in real-world settings. The current study will provide information about what works (intervention effectiveness), for whom it works (influence of Medicaid versus other insurance), in which contexts it works (setting characteristics that influence implementation), and how it works best (comparison of implementation strategies).

Low-residue breakfast during the preparation for colonoscopy using a polyethylene glycol electrolyte solution: a randomised non-inferiority trial

Goals

To test the hypothesis that the use of a low-residue breakfast (LRB) the day prior to colonoscopy was not inferior to consuming clear fluids alone (CFD) in patients undergoing outpatient colonoscopy with a polyethylene glycol (PEG) bowel preparation.

Background

Optimal colon cleansing is essential for complete visualisation of the mucosa during colonoscopy. Few studies have examined the effect of diet on the quality of bowel cleansing or tolerance in patients using a PEG bowel preparation for colonoscopy.

Methods

Randomised, single-blinded non-inferiority trial. Adult patients scheduled for outpatient colonoscopy with PEG solution were randomised to an LRB followed by clear fluids or CFD using either a traditional or split-dose PEG solution for bowel preparation. The primary outcome was colon cleansing based on the Ottawa Bowel Preparation Score (OBPS).

Results

On an intention-to-treat (ITT) basis, a total of 109 and 105 patients were included in the CFD and LRB arms, respectively, with 116 and 98 patients, respectively, for the per-protocol (PP) analysis. Although there was no difference in the mean total OBPS between the CFD or LRB arms in either the ITT or PP analysis, the threshold for non-inferiority was not met. Patient acceptance of the regimens was higher in the LRB arm than in the CFD arm in the ITT and PP analyses.

Conclusions

This study failed to show the non-inferiority of an LRB in patients receiving bowel preparation with a PEG-based solution. A CFD should be prescribed when using a PEG bowel preparation.

Trial registration number

This trial is registered at ClinicalTrials.gov (NCT01454388).

Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score

BACKGROUND

Adequate bowel preparation is important for optimal colonoscopy. It is important to identify patients at risk for inadequate bowel preparation because this allows taking precautions in this specific group.

OBJECTIVE

To develop a prediction score to identify patients at risk for inadequate bowel preparation who may benefit from an intensified bowel cleansing regimen.

DESIGN

Patient and colonoscopy data were prospectively collected, whereas clinical data were retrospectively collected for a total of 1996 colonoscopies in participants who received split-dose bowel preparation. Multivariate logistic regression analyses were conducted in a random two-thirds of the cohort to develop a prediction model. Validation and evaluation of the discriminative power of the prediction model were performed within the remaining one-third of the cohort.

SETTING

Four centers, including one academic and three medium-to-large size nonacademic centers.

PATIENTS

Consecutive colonoscopies in November and December 2012. Mean age was 57.3 ± 15.9 years, 45.8% were male and indications for colonoscopy were screening and/or surveillance (27%), abdominal symptoms and/or blood loss and/or anemia (60%), inflammatory bowel disease (9%), and others (4%).

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

Inadequate bowel preparation defined as Boston Bowel Preparation Scale score <6.

RESULTS

A total of 1331 colonoscopies were included in the development cohort, of which 172 (12.9%) had an inadequate bowel preparation. Independent factors included in the prediction model were American Society of Anesthesiologists Physical Status Classification System score ≥3, use of tricyclic antidepressants, use of opioids, diabetes, chronic constipation, history of abdominal and/or pelvic surgery, history of inadequate bowel preparation, and current hospitalization. The discriminative ability of the scale was good, with an area under the curve of 0.77 in the validation cohort.

LIMITATIONS

Study design partially retrospective, no data on patient compliance.

CONCLUSION

We developed a validated, easy-to-use prediction scale that can be used to identify subjects with an increased risk of inadequate bowel preparation with good accuracy.

Split-dose vs same-day reduced-volume polyethylene glycol electrolyte lavage solution for morning colonoscopy

AIM: To compare same-day whole-dose vs split-dose of 2-litre polyethylene glycol electrolyte lavage solution (PEG-ELS) plus bisacodyl for colon cleansing for morning colonoscopy.

METHODS: Consecutive adult patients undergoing morning colonoscopy were allocated into two groups i.e., same-day whole-dose or split-dose of 2-litre PEG-ELS. Investigators and endoscopists were blinded to the allocation. All patients completed a questionnaire that was designed by Aronchick and colleagues to assess the tolerability of the bowel preparation regime used. In addition, patients answered an ordinal five-value Likert scale question on comfort level during bowel preparation. Endoscopists graded the quality of bowel preparation using the Boston bowel preparation scale (BBPS). In addition, endoscopists gave an overall grading of the quality of bowel preparation. Cecal intubation time, withdrawal time, total colonoscopy time, adenoma detection rate and number of adenomas detected for each patient were recorded. Sample size was calculated using an online calculator for binary outcome non-inferiority trial. Analyses was based upon intent-to-treat. Significance was assumed at P-value < 0.05.

RESULTS: Data for 295 patients were analysed. Mean age was 62.0 ± 14.4 years old and consisted of 50.2 % male. There were 143 and 152 patients in the split-dose and whole-dose group, respectively. Split-dose was as good as whole-dose for quality of bowel preparation. The total BBPS score was as good in the split-dose group compared to the whole-dose group [6 (6-8) vs 6 (6-7), P = 0.038]. There was no difference in cecal intubation rate, cecal intubation time, withdrawal time, total colonoscopy time and adenoma detection rate. Median number of adenoma detected was marginally higher in the split-dose group [2 (1-3) vs 1 (1-2), P = 0.010]. Patients in the whole-dose group had more nausea (37.5% vs 25.2%, P = 0.023) and vomiting (16.4% vs 8.4%, P = 0.037), and were less likely to complete the bowel preparation (94.1% vs 99.3%, P = 0.020). Patients in the split-dose group were less likely to refuse the same bowel preparation regime (6.3% vs 13.8%, P = 0.033) and less likely to want to try another bowel preparation regime (53.8% vs 78.9%, P < 0.001).

CONCLUSION: Splitting reduced-volume PEG-ELS for morning colonoscopy is as effective as taking the whole dose on the same morning but is better tolerated and preferred by patients.

Quality bowel preparation for surveillance colonoscopy in patients with inflammatory bowel disease is a must

Colonoscopy is routinely performed in patients with inflammatory bowel disease (IBD) for surveillance of dysplasia. Thorough bowel preparation is necessary to facilitate lesion detection. Patients with IBD do not have poorer bowel preparation outcomes but may have decreased preparation tolerance affecting adherence to surveillance protocols. A low-fiber prepreparation diet may improve preparation tolerance without affecting preparation quality. The standard preparation regimen should consist of split-dose administration of a polyethylene glycol-based purgative. Low-volume, hyperosmolar purgatives may be considered in patients with previous preparation intolerance, heightened anxiety, stenotic disease, or dysmotility. Appropriate patient education is critical to enhance preparation quality.

Prescreening with FOBT Improves Yield and Is Cost-Effective in Colorectal Screening in the Elderly

Background. Utilization of colonoscopy for routine colorectal cancer (CRC) screening in the elderly (patients over 75) is controversial. This study was designed to evaluate if using fecal occult blood test (FOBT) to select patients for colonoscopy can improve yield and be a cost- effective approach for the elderly. Methods. Records of 10,908 subjects who had colonoscopy during the study period were reviewed. 1496 (13.7%) were ≥75 years. In 118 of these subjects, a colonoscopy was performed to evaluate a positive FOBT. Outcomes were compared between +FOBT group (F-Group) and the asymptomatic screening group (AS-Group). The cost-effectiveness was also calculated using a median estimated standardized worldwide colonoscopy and FOBT cost (rounded to closest whole numbers) of 1000 US $ and 10 US $, respectively. Results. 118/1496 (7.9%) colonoscopies were performed for evaluation of +FOBT. 464/1496 (31%) colonoscopies were performed in AS-Group. In F-Group, high risk adenoma detection rate (HR-ADR) was 15.2%, and 11.9% had 1-2 tubular adenomas. In comparison, the control AS-Group had HR-ADR of 19.2% and 17.7% had 1-2 tubular adenomas. In the FOBT+ group, CRC was detected in 5.1% which was significantly higher than the AS-Group in which CRC was detected in 1.7% (P = 0.03). On cost-effectiveness analysis, cost per CRC detected was significantly lower, that is, 19,666 US $ in F-Group in comparison to AS-Group 58,000 US $ (P < 0.05). There were no significant differences in other parameters among groups. Conclusion. Prescreening with FOBT to select elderly for colonoscopy seems to improve the yield and can be a cost-effective CRC screening approach in this subset. The benefit in the risk benefit analysis of screening the elderly appears improved by prescreening with an inexpensive tool.

Rural-urban differences in the long-term risk of colorectal cancer after adenoma removal: a population-based study

BACKGROUND

We investigated the impact of municipality of residence on colonoscopic surveillance and colorectal cancer risk after adenoma resection in a French well-defined administrative area.

METHODS

This registry-based study included all patients residing in Côte d'Or (n=5769) first diagnosed with colorectal adenomas between January 1, 1990, and December 31, 1999. Information about colonoscopic surveillance and colorectal cancer incidence was collected until December 31, 2003.

RESULTS

A rural place of residence reduced the probability of colonoscopic surveillance in men [HR=0.89 (95%CI: 0.79-0.99), p=0.041] and in patients without family history of colorectal cancer [HR=0.91(0.82-0.99), p=0.044]. After a median follow-up of 7.7 years, 87 patients developed invasive colorectal cancer. After advanced adenoma removal, the standardized incidence ratio for colorectal cancer was 3.03 (95%CI: 1.92-4.54) for rural patients and 1.87 (95%CI: 1.26-2.66) for urban patients compared with the general population. The risk of colorectal cancer was higher in rural patients than in urban ones only after removal of the initial advanced adenoma [HR=1.73 (95%CI: 1.01-3.00, p=0.048)]. Further adjustment for surveillance colonoscopy, physician location, and other confounders had little impact on these results.

CONCLUSION

The increased risk of subsequent colorectal cancer after advanced adenoma removal in French rural patients was not explained by a lower rate of colonoscopic surveillance. The role of socio-economic and environmental factors requires further exploration.

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]

INTRODUCTION

Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate.

PATIENTS AND METHODS

A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed.

RESULTS

The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83.

CONCLUSIONS

In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.