Effect of physician-delivered patient education on the quality of bowel preparation for screening colonoscopy

Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Smartphone Application Versus Standard Instruction for Colonoscopic Preparation: A Randomized Controlled Trial

OBJECTIVE

To compare smartphone application (Colonoscopic Preparation) instructions versus paper instructions for bowel preparation for colonoscopy.

BACKGROUND

Adhering to bowel preparation instructions is important to ensure a high-quality colonoscopy.

PATIENTS AND METHODS

This randomized controlled trial included individuals undergoing colonoscopy at a tertiary care hospital. Individuals were randomized (1:1) to receive instructions through a smartphone application or traditional paper instructions. The primary outcome was the quality of the bowel preparation as measured by the Boston Bowel Preparation Score. Secondary outcomes included cecal intubation and polyp detection. Patient satisfaction was assessed using a previously developed questionnaire.

RESULTS

A total of 238 individuals were randomized (n = 119 in each group), with 202 available for the intention-to-treat analysis (N = 97 in the app group and 105 in the paper group). The groups had similar demographics, indications for colonoscopy, and type of bowel preparation. The primary outcome (Boston Bowel Preparation Score) demonstrated no difference between groups (Colonoscopic Preparation app mean: 7.26 vs paper mean: 7.28, P = 0.91). There was no difference in cecal intubation ( P = 0.37), at least one polyp detected ( P = 0.43), or the mean number of polyps removed ( P = 0.11). A higher proportion strongly agreed or agreed that they would use the smartphone app compared with paper instructions (89.4% vs 70.1%, P = 0.001).

CONCLUSIONS

Smartphone instructions performed similarly to traditional paper instructions for those willing to use the application. Local patient preferences need to be considered before making changes in the method of delivery of medical instructions.

A comprehensive intervention to enhance inpatient colon preparation quality for colonoscopy

BACKGROUND

Adequate colon preparation is a critical component of high-quality colonoscopy especially for inpatients undergoing colonoscopy for acute indications. Inpatient colonoscopy has a high incidence of inadequate preparations. We report implementation of a multifaceted quality improvement intervention to improve inpatient colonoscopy preparations.

METHODS

Bowel preparation quality from inpatient colonoscopies performed for the 12 months prior to the comprehensive intervention were compared to colonoscopies performed for 12 months following the intervention. The intervention had multiple components including: 1) EMR-based colonoscopy preparation order set; 2) automated EMR alerts prompting nursing assessment of preparation progress; 3) standardized nursing charting processes for tracking preparation progress; and 4) standardized education for nursing staff and ordering providers on adequate colon preparation, assessment of colon preparation quality, and use of the above processes; and print and video patient education materials.

RESULTS

Two hundred thirty-eight inpatient colonoscopies were performed in the preintervention assessment period and 163 colonoscopies in the postintervention period. Median preintervention Boston Bowel Preparation Score (BBPS) was 6 and 26% of patients had inadequate colon preparation. Median postintervention BBPS was 8 with 16% inadequate colon preparation (P=0.016). The postintervention group had less ASA class I patients and used a lower dose of fentanyl than the preintervention group. There were no other significant differences between the pre- and postintervention groups.

CONCLUSIONS

Implementation of a comprehensive colon preparation quality intervention resulted in significantly improved inpatient colon preparation quality and decreased frequency of inadequate preparations. The intervention consisting of an EMR-based order-set, nursing alerts and charting process, and patient education materials is continually being refined.

Effect of nurse-performed enhanced patient education on colonoscopy bowel preparation quality

OBJECTIVE

to evaluate the effect of nurse-performed enhanced patient education sessions on adequate bowel preparation and cecal intubation rates.

METHOD

a prospective, quasi-experimental, comparative study with a quantitative approach. The intervention group (n=150) received education enhanced by a visual presentation and reminder calls. The control group (n=156) received the clinic's standard written instructions. Adequate bowel preparation rates and other colonoscopy quality indicators were compared between the groups.

RESULTS

Boston Bowel Preparation scale scores and adequate bowel preparation rates were higher in the intervention group than in the control group (respectively, 6.76±2.1 vs. 5.56±2.4, p=0.000, and 80% vs. 69.2%, p=0.031). The cecal intubation rates were higher in the intervention group (80% vs. 67.3%, p=0.012). Due to inadequate bowel preparation, unsuccessful cecal intubation rates were 0% in the intervention group and 17.6% in the control group. Biopsy rates were higher in the intervention group (28% vs. 13.3%, p=0.002).

CONCLUSION

the nurse-performed enhanced patient education sessions increase adequate bowel preparation rates and, in parallel, cecal intubation rates. To reach the colonoscopy quality standards recommended in the guidelines, it is suggested that patient education be supported by different training tools and given by health professionals.

The Impact of Patient Education Level on Split-Dose Colonoscopy Bowel Preparation for CRC Prevention

INTRODUCTION

AGA guidelines emphasize split-dose bowel preparation (BP) to ensure high-quality colonoscopy for the prevention of colorectal cancer (CRC). Split dose results in higher-quality preparation, but understanding instructions might be more difficult. Lower education levels may negatively influence BP quality. The confounding role of education level on BP quality was investigated.

METHODS

This was a cross-sectional study of 60 patients given split-dose BP. Patients consented and were asked three Likert scale questions based on BP instructions before the procedure. Compliance was self-reported. BP adequacy and the number of adenomas were recorded. BP was characterized as adequate (excellent, good) or inadequate (fair, poor). Data was analyzed with chi-square, odds ratio, Mann-Whitney, and regression analysis.

RESULTS

Thirty-one (52%) patients were high school graduates, 21 (38%) completed some college, and 6 (10%) were college graduates. College-educated patients had adequate BP (72%) more often than high school graduates (51%) (p = 0.02). Adenoma findings were not significantly different. The Likert scale mean ranks for patient understanding and reviewing of instructions were comparable between the two groups. Patient rating of scheduler explanations of the importance of following instructions was significantly better in the college group (mean ranks 2.59 and 1.83, respectively; p = 0.018).

DISCUSSION

Patient education level significantly affected the success of BP. Split BP can be more complex to comprehend, and instructions should consider patient education level. Specific intervention programs should be implemented to advise patients with less education that poor preparation may result in missed advanced neoplasias and subsequent procedures.

Multimedia based education on bowel preparation improves adenoma detection rate: Systematic review & meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Colorectal cancer (CRC) is the third most common cause of cancer worldwide. Studies have shown a strong association between screening colonoscopy and a reduced risk of death from colorectal cancers. The incidence of poor bowel preparation has been reported in up to 25% cases. We conducted a systematic review and comprehensive meta-analysis to evaluate the effect of patient education using multimedia platforms on adenoma detection rate and adequacy of bowel preparation.

METHODS

Multiple databases were searched through May 2020 for studies that reported the efficacy of multimedia education (smartphone app and online audio-visual aids) in improving quality of bowel preparation and its effect on adenoma detection rate (ADR). Meta-analysis was performed to determine whether multimedia based patient education (MM) helps improve ADR and bowel preparation quality as compared to controls (CT).

RESULTS

We included 13 randomized controlled trials with a total of 3754 patients. Eight studies reported outcomes on ADR and 12 reported on adequacy of bowel preparation. Overall ADR was higher in patients receiving multimedia based education as compared to CT (risk ratio (RR) 1.25, confidence interval (CI) 1.01-1.56, P = 0.04). A higher proportion of patients receiving multimedia based education achieved adequate bowel preparation (RR 1.2, CI 1.1-1.3, P = 0.001). In patients with mean age over 50 years, ADR was better in MM cohort as compared to controls (RR 1.3, CI 1.1-1.6, P = 0.001).

CONCLUSION

Pre-colonoscopy patient education using multimedia based platforms seems to improve ADR and the adequacy of bowel preparation.

Effect of physician-provided education on the quality of bowel preparation

BACKGROUND AND STUDY AIMS

Inadequate bowel preparation in patients scheduled for colonoscopy is an important problem. In our study, we aimed to investigate the effect of physician-provided bowel preparation education on the quality of bowel preparation and process.

PATIENTS AND METHODS

A total of 150 outpatients who were referred to Kocaeli University Medical Faculty Hospital Gastroenterology Unit for colonoscopy between May 2019 and October 2019 were enrolled in our prospective, endoscopist-blinded study. Patients were divided into two groups. Group 1 (education group) included 73 patients who received 10 minutes of verbal information from a physician in addition to a written information form. Group 2 (control group) included 75 patients who received information from a medical secretary in addition to a written information form. During colonoscopy, the quality of bowel preparation was assessed using the Boston bowel preparation scale (BBPS). A BBPS score = 5 was considered adequate bowel preparation. The mean BBPS score, polyp detection rate, cecal intubation rate and time, and procedure time were also evaluated.

RESULTS

The rate of adequate bowel preparation (BBPS score = 5) was 90.4% and 74.7% in groups 1 and 2, respectively (p = 0.021). The odds ratio for having a BBPS score = 5 in the education group was 3.199 compared with the control group (95% confidence interval = 1.254-8.164; p = 0.015). The cecal intubation rates were 91.8% and 88% in groups 1 and 2, respectively (p > 0.05). The cecal intubation time, procedure time, and adenoma detection rates were similar between the groups. The relationships of age, education level, sex, diabetes mellitus, medicine use, procedure time, and intraabdominal surgery with inadequate bowel preparation were analysed using a logistic regression model. Univariate and multivariate analyses revealed no significant factors associated with inadequate bowel preparation.

CONCLUSIONS

Patient education on the bowel preparation process via a physician improved the quality of bowel preparation.

Quality Improvement of Bowel Preparation for Screening Colonoscopies: A Study of Hospital Team Resource Management in Taiwan

BACKGROUND AND OBJECTIVES

This study aimed to investigate the impact of patient education using a medical team resource management (TRM) method on the adequacy of bowel preparation.

METHODS

The study setting was a single hospital in northern Taiwan, and a total of 2104 (884 female, 1220 male) healthy subjects who underwent a health checkup colonoscopy screening were enrolled before and after the application of the TRM program intervention. The efficacy of the TRM intervention and the factors affecting bowel preparation were estimated using multivariate logistic regression.

RESULTS

The prevalence of adequate bowel preparation improved significantly from the preintervention period to the postintervention and validation periods, which had prevalence of 79.0%, 81.3%, and 84.0%, respectively. Using the preintervention period prevalence as a reference, the adjusted odds ratios (aORs) for adequate bowel preparation in the postintervention and validation periods were 2.199 (95% confidence interval [CI]: 1.538-3.142) and 2.035 (1.525-2.716), respectively. Men had a lower probability of adequate cleansing than women (aOR = 0.757; 95% CI = 0.598-0.957), and purgative containing polyethylene glycol had a lower probability of adequate cleansing than purgative containing sodium phosphate (aOR = 0.366; 95% CI: 0.277-0.483).

CONCLUSIONS

Bowel preparation quality for colonoscopy could be improved by enhancing patient education via TRM, and we suggest that effective quality improvement schemes should be proposed for health-screening programs.

Smartphone Application to Reinforce Education Increases High-Quality Preparation for Colorectal Cancer Screening Colonoscopies in a Randomized Trial

BACKGROUND & AIMS

Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, rates of inadequate preparation are still high. We investigated the effects of reinforced patient education using a smartphone application software (APP) for colonoscopy preparation in participants in a CRC screening program.

METHODS

We performed a prospective, endoscopist-blinded study of 500 patients undergoing split-dose bowel preparation for CRC screening or surveillance colonoscopies at multiple centers in Germany, from November 2017 through January 2019. Participants (n = 500) were given oral and written instructions during their initial appointment and then randomly assigned (1:1) to groups that received reinforced education starting 3 days before the colonoscopy (APP group) or no further education (controls). The primary outcome was quality of bowel preparation according to the Boston bowel preparation scale. Secondary outcomes included polyp and adenoma detection rates, compliance with low-fiber diet, split-dose laxative intake, perceived discomfort from the preparation procedure.

RESULTS

The mean Boston bowel preparation scale score was significantly higher in the APP-group (7.6 ± 0.1) than in the control group (6.7 ± 0.1) (P < .0001). The percentage of patients with insufficient bowel preparation was significantly lower in the APP group (8%) than in the control group (17%) (P = .0023). The adenoma detection rate was significantly higher in the APP group (35% vs 27% in controls) (P = .0324). Use of the APP was accompanied by a lower level of non-compliance with correct laxative intake (P =.0080) and diet instructions (P = .0089). The APP group reported a lower level of discomfort during preparation (P < .0001).

CONCLUSIONS

In a randomized trial, reinforcing patient education with a smartphone application optimized bowel preparation in the 3 days before colonoscopy, increasing bowel cleanliness, adenoma detection, and compliance in patients undergoing CRC screening or surveillance. ClinicalTrials.gov no: NCT03290157.

Ward nurses-focused educational intervention improves the quality of bowel preparation in inpatients undergoing colonoscopy: A CONSORT-compliant randomized controlled trial

BACKGROUND

Adequate bowel preparation is essential for the detection of pathological lesions during colonoscopy. However, it has been found to be inadequate in approximately 20% to 30% of colonoscopy examinations. Educational interventions focused on health staff, such as physicians and nurses, may improve the patients' understanding of the bowel preparation instructions, and consequently, increase the quality of bowel preparation.

OBJECTIVES

To investigate whether enhanced education of ward nurses could improve the bowel preparation quality in inpatients undergoing colonoscopy.

DESIGN

This was a single-center randomized controlled study.

METHODS

A total of 190 consecutive inpatients scheduled to undergo colonoscopy from March 2019 to March 2020 were randomized to the educated (nurses with enhanced education) or control group (nurses without enhanced education). We assessed the bowel preparation quality using the Boston bowel preparation scale.

RESULTS

There were 89 patients in the educated group and 101 patients in the control group. The proportion of colonoscopies with adequate bowel preparation was 83.1% in the educated group and 69.3% in the control group. Patients' compliance with bowel preparation in the educated group was superior to that in the control group. Furthermore, significantly better sleep quality was found in the educated group. The multivariate logistic regression analysis identified the ward nurses-focused enhanced educational intervention as a risk factor for bowel preparation quality.

CONCLUSIONS

The ward nurses-focused educational intervention improved the bowel preparation quality and reduced the adverse event rates in inpatients undergoing colonoscopy.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry under number ChiCTR2000030366.

Determination of the Effectiveness of Informing With the Guidance of an Education Booklet in Patients Undergoing Colonoscopy-A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of precolonoscopy information with the guidance of an education booklet on anxiety and bowel preparation adequacy in patients undergoing colonoscopy.

DESIGN

A randomized controlled study.

METHODS

The education group was informed face to face by the researcher with the guidance of the colonoscopy education booklet and provided the education booklet. The control group received usual care.

FINDINGS

The mean state and trait anxiety scores of the patients in the education group were found to be significantly lower than the control group. In the education group, the bowel preparation adequacy was determined to be higher compared with the control group.

CONCLUSIONS

Informing patients with the guidance of the education booklet before the colonoscopy decreased patients' state and trait anxiety levels and increased their bowel preparation adequacy.

Bowel Preparation for Colonoscopy in 2020: A Look at the Past, Present, and Future

PURPOSE OF THIS REVIEW

Colorectal cancer is the third most common cancer in the USA. Colonoscopy is considered the gold standard for colorectal cancer screening and can offer both diagnosis and therapy. The bowel preparation remains a significant barrier for patients who need to undergo colonoscopy and is often cited as the most dreaded aspect of the colonoscopy process. Inadequate bowel preparations still occur in 10-25% of colonoscopies, and this in turn can lead to increased procedural times, lower cecal intubation rates, and shorter interval between colonoscopies. From a quality standpoint, it is imperative that we do what we can to decrease the rate of inadequate bowel preparations. This review will focus on recent data regarding bowel preparation and offers a glimpse into what may be coming in the future.

RECENT FINDINGS

Recent advances in the field have been made to improve tolerability of bowel preparations and allow for more adequate colonoscopies. Newer, lower volume, flavored preparations, the use of adjuncts, and using split-dose preparations all can help with tolerability, compliance, and, in turn, preparation quality. Edible bowel preparations may become available in the near future. Early data on the use of artificial intelligence for assessment of preparation quality has been promising. Additionally, utilization of smartphone technology for education prior to the bowel preparation has also been shown to improve the adequacy of bowel preparations.

CONCLUSIONS

Ongoing efforts to improve the tolerability and palatability of colonoscopy bowel preparations are important from a quality improvement standpoint to ensure the adequacy of colonoscopy. Incorporating patient-specific factors and comorbidities is also an essential aspect of improving the quality of bowel preparation. Leveraging technology to better communicate with and educate patients on the bowel preparation process is likely to play a larger role in the coming years.

Effect of Short Message Service Use on Bowel Preparation Quality in Patients Undergoing Colonoscopy

This study aimed to determine the effect of SMS use on the bowel preparation quality and satisfaction in patients who underwent colonoscopy. This study was conducted as an experimental-control study with 200 patients who had received colonoscopy in the endoscopy unit of a university hospital in Eastern Thrace of Turkey between December 1, 2016, and June 30, 2017. All patients received a standard bowel preparation. The SMS was sent in addition to the standard bowel preparation to patients in an SMS group. In the SMS group, patients were informed about the standard bowel preparation practices via SMS 3 days before colonoscopy. "Patient identification," "bowel preparation quality," and "patient satisfaction" forms were used for data collection. Chi-square and independent sample t tests were used in data analysis. The average age of the participants was 57.57 ± 12.37 years, and it was determined that most of the participants were male (64.5%) and had colonoscopy experience (55%). The bowel preparation quality was significantly higher in the SMS group than in the no-SMS group (p = .044), and most patients (91%) were "very satisfied" with being informed via SMS. Sending SMS about bowel preparation practices to colonoscopy patients improves bowel preparation quality and patient satisfaction. Integrating SMS into standard care may help patients manage the bowel preparation process.

Strategies to Improve Inadequate Bowel Preparation for Colonoscopy

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.

Cloud-based multi-media systems for patient education and adherence: a pilot study to explore patient compliance with colonoscopy procedure preparation

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.

Improving the quality and acceptance of colonoscopy preparation by reinforced patient education with short message service: results from a randomized, multicenter study (PERICLES-II)

BACKGROUND AND AIMS

Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, the rates of inadequate preparation are still high. We investigated the effects of reinforcing patient education and guidance by using the short message service (SMS).

METHODS

In this prospective, endoscopist-blinded, multicenter study, standard instructions pertaining to split-dose preparation were provided in a verbal and written format to all patients during the initial appointment. Patients were randomly assigned (1:1) to a group that received reinforced education starting 4 days before the colonoscopy (SMS group) or to the control group which did not receive further education. The primary outcome was the percentage of insufficient preparation results (Boston Bowel Preparation Scale [BBPS] score <6). The secondary outcomes included quality of bowel preparation according to the BBPS, polyp and adenoma detection rates, and patients' perceived discomfort in the preparation procedure.

RESULTS

The percentage of patients with insufficient bowel preparation was significantly lower in the SMS group (9%) than in the control group (19%) (P = .0013). The mean BBPS score was significantly higher in the SMS group (7.4 ± 0.1) than in the control group (6.5 ± 0.1) (P < .0001). Each colon segment had significantly higher BBPS scores in the SMS group. The adenoma detection rate and number of detected adenomas in the right segment of the colon were higher in the SMS group. SMS messages were accompanied by a lower level of discomfort during preparation (numeric rating scale) (5.2 SMS vs 5.8 controls) (P = .0042).

CONCLUSIONS

Reinforced patient education by using SMS messages during the 4 days before colonoscopy increased bowel cleanliness, adenoma detection in the right segment of the colon, and reduced discomfort. (Clinical trial registration number: NCT02272036.).

Effect of Sending Educational Video Clips via Smartphone Mobile Messenger on Bowel Preparation before Colonoscopy

BACKGROUND/AIM

We aimed to evaluate the efficacy of sending educational video clips via smartphone mobile messenger (SMM) on enhancing bowel preparation before colonoscopy.

METHODS

This was a prospective, endoscopist-blinded, randomized controlled study. Patients in the SMM group received two video clips sent via SMM that explained the diet and regimen for bowel preparation, whereas those in the control group did not receive any video clips. We compared the quality of bowel preparation between the two groups, which was assessed by an endoscopist using the Ottawa scale.

RESULTS

Between August and November 2014, 140 patients in the SMM group and 141 patients in the control group underwent colonoscopic examination. The total Ottawa score of the SMM group was significantly lower than that of the control group (5.47±1.74 vs. 5.97±1.78, p=0.018). These results were particularly prominent in the younger age group; the total Ottawa score of patents in the SMM group aged <40 years was significantly lower than that of patients in the control group aged <40 years (5.10±1.55 vs. 6.22±2.33, p=0.034).

CONCLUSION

We demonstrated that sending educational video clips via SMM could result in better bowel preparation, especially in the younger age group.

Barriers and Facilitators to a Good Bowel Preparation for Colonoscopy in Children: A Qualitative Study

BACKGROUND

A well-visualized colon during colonoscopy has a direct impact on interpretation of findings and need for repeat procedure. Studies have been conducted in the adult population to assess factors contributing to improved bowel preparation. The primary aim of this study was to determine barriers and facilitators to good preparation in children.

METHODS

A qualitative descriptive approach was utilized. Children age 2 to 18 years old, and their parents were recruited from the McMaster University Gastroenterology clinic from May 2015 to January 2016. Semistructured interviews were conducted assessing the understanding of the preparation protocol, and the compliance and tolerability of the preparation. A thematic analysis was conducted.

RESULTS

Eleven families participated (7 children and 14 parents). Fifty percent of the children were under 11 years of age, and 73% were undergoing bowel preparation for the first time. Participants identified 26 subthemes, which were categorized into 4 broad themes. Barriers included confusion regarding mixing of the preparation and allowable diet during the preparation day, as well as lack of clarity on expected stool end goals. Facilitators included ease of access of the gastroenterology team, small volume of liquid mixed with the preparation, few adverse effects, and the provision of an understandable handout. Parental motivation to achieve a good outcome was also a facilitator.

CONCLUSIONS

This is the first qualitative study focusing on children undergoing a home bowel preparation for a colonoscopy. Being able to identify barriers and facilitators will allow gastroenterologists to improve the quality of bowel preparation and overall experience for the pediatric population.

Adherence to CRC Screening and Surveillance Guidelines when Using Split-Dose Bowel Preparation

Goal

To prospectively assess physician recommendations for repeat colonoscopy in an average-risk screening cohort.

Background

Endoscopists' adherence to colorectal cancer screening and surveillance guidelines for repeat colonoscopy have not been well characterized. Furthermore, little is known about patient and colonoscopy factors that are associated with endoscopists' nonadherence to guideline recommendation.

Study

This is a prospective cohort of average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. The primary outcome was assessment of physician recommendations for repeat colonoscopy.

Results

462 participants were prospectively enrolled. 13.6% (62) had guideline-inconsistent recommendations. 89% of the guideline-inconsistent recommendations were for an earlier interval. Endoscopists' reports cited suboptimal bowel preparation as the most common reason for earlier repeat colonoscopy. On multivariable analysis, patient split-dose preparation noncompliance was significantly associated with guideline-inconsistent recommendation (OR = 2.7) even after adjusting for other patient or bowel preparation-related characteristics. Additionally, increased odds of guideline-inconsistent recommendation were associated with older age (>70 years old), higher BMI, having 3 or more polyps, having had at least two previous colonoscopies, suboptimal bowel preparation, and having taken at least 12 hours till clear bowel movement.

Conclusions

Gastroenterologists are adherent to CRC screening and surveillance guidelines. Suboptimal bowel preparation is the most frequently cited factor in endoscopy reports leading to deviation from guidelines. Continued emphasis on optimization of bowel preparation, particularly patient compliance to split-dose regimen, is needed.

Educational strategies for colonoscopy bowel prep overcome barriers against split-dosing: A randomized controlled trial

BACKGROUND

A split-dose (SD) regimen is crucial for colonoscopy quality. Compliance with SD for early morning colonoscopy is generally poor. The present study evaluated whether pre-colonoscopy counselling, in addition to a dedicated leaflet, might increase SD uptake.

METHODS

Consecutive 50-69-year-old patients undergoing screening colonoscopy before 10 a.m. were randomized to either receive written information only on bowel preparation (Written Group, WG) or written and oral instructions (Written and Oral Group, WaOG). The leaflet strongly encouraged SD adoption. The primary endpoint was the number of patients adopting SD in each group. The secondary endpoints were predictors of SD uptake, compliance with preparation schemes and cleansing adequacy.

RESULTS

A total of 286 patients (143 WG, 143 WaOG) were enrolled (mean age 59.6 ± 6.1 years, men 49.3%). SD was adopted by 114 and 125 patients in the WG and WaOG, respectively (79.7% versus 87.4%, p = 0.079). No significant differences were observed for the proportion of patients with full compliance with preparation scheme (97.9% versus 97.2%, p = 0.99) and of procedures with adequate bowel cleansing (95.6% versus 95.1%, p = 0.77). At multivariate analysis, a > 1 h travel time to the endoscopy service was inversely correlated with SD uptake (odds ratio (OR) 0.30, 95% confidence interval (CI) 0.09-0.98).

CONCLUSIONS

Our leaflet guaranteed satisfactory uptake of SD and excellent adherence to the preparation scheme for early morning colonoscopy. Its use might marginalize the need for additional oral instructions, particularly in open-access settings.

Bowel Preparation for a Better Colonoscopy Using Polyethylene Glycol or C-lax: A Double Blind Randomized Clinical Trial

BACKGROUND

Ideal bowel preparation regimen for a suitable colonoscopy should be safe, and well tolerated, and should rapidly clear gastrointestinal tract. Soluble polyethylene glycol (PEG) is the most common cleansing drug and Senna or C-Lax (Cassia angustifolia Vahl) is an alternative herbal one. This study was designed to compare the efficacy of PEG and C-lax in bowel preparation.

METHODS

In this randomized double blind trial (registry number in IRCT.ir: IRCT201601161264N7), 320 patients were randomly assigned in PEG or C-lax groups. PEG solution was prepared from 5×70 gr sachets in 20×250cc water (250 ml every 15 minutes), prescribed 24h before the colonoscopy. In the other group 3×60 ml C-lax syrup glasses (each containing 90 mg senozid B) was given in two divided doses (1.5 glasses of 250cc every 12 hours), 24h before the colonoscopy. Ottawa score was used to evaluate the quality of bowel preparation. Chi-square test, Student t test, MannWhitney test and multivariate analysis were used to analyze the data.

RESULTS

Of these patients with the mean (SD) age of 50 (15.16) years, 162 (50.8%) were men. Mean (SD) Ottawa score was 2.57 (0.2) and 3.15 (0.31) in the PEG and C-lax group, respectively (p value = 0.81). Multivariate analysis showed that less opium consumption (p < 0.001) and higher educational level (p =0.005) were associated with better bowel preparation.

CONCLUSION

C-Lax is non-inferior to PEG solution in cleansing colon. The quality of bowel preparation was lower in opium consumers and better in those with higher educational level.

Enhanced education for bowel preparation before colonoscopy: A state-of-the-art review

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.

A Customized Mobile Application in Colonoscopy Preparation: A Randomized Controlled Trial

OBJECTIVES

Adherence with diet and prescribed purgative is essential for proper cleansing with low-volume bowel preparations. The aim of this work was to assess the effect of a customized mobile application (App) on adherence and quality of bowel preparation.

METHODS

One hundred and sixty (160) eligible patients scheduled for elective colonoscopy were randomly assigned to paper (control) or App-based instructions. The preparation consisted of low-fiber diet for 2 days, clear fluids for one day and split-dose sodium picosulfate/magnesium citrate (SPS). Before colonoscopy, information was collected regarding adherence with, and utility of the provided instructions. The colonoscopists, blinded to assignment, graded bowel preparation using the Aronchick, Ottawa, and Chicago preparation scales. The primary endpoint was adherence with instructions. Quality of preparation was a secondary endpoint.

RESULTS

No difference in overall adherence or bowel cleanliness was observed between the study arms. Adherence was reported in 82.4% of App vs. 73.4% of controls (P=0.40). An adequate bowel preparation on the Aronchick scale was noted in 77.2 vs. 82.5%, respectively (P=0.68). Mean scores on the Ottawa and Chicago scales were also similar. Gender, age, time of colonoscopy, and BMI did not influence preparation or adherence. Compliance with the clear fluid diet component was noted in 94% of patients with BMI<30 vs. 77% with BMI≥30 (P<0.01). SPS was well tolerated by 81.9% of patients. The App was user-friendly and received higher overall rating in this respect than paper instructions (P<0.01).

CONCLUSIONS

SPS is well tolerated and effective for bowel cleansing regardless of instruction method. Customized smartphone applications are effective, well-accepted and could replace standard paper instructions for bowel preparation.ClinicalTrials.gov: NCT02410720.

Impact of Personalised Patient Education on Bowel Preparation for Colonoscopy: Prospective Randomised Controlled Trial

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.

How Efficacious Are Patient Education Interventions to Improve Bowel Preparation for Colonoscopy? A Systematic Review

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.

Development and Testing of an Automated 4-Day Text Messaging Guidance as an Aid for Improving Colonoscopy Preparation

Background

In gastroenterology a sufficient colon cleansing improves adenoma detection rate and prevents the need for preterm repeat colonoscopies due to invalid preparation. It has been shown that patient education is of major importance for improvement of colon cleansing.

Objective

Objective of this study was to assess the function of an automated text messaging (short message service, SMS)–supported colonoscopy preparation starting 4 days before colonoscopy appointment.

Methods

After preevaluation to assess mobile phone usage in the patient population for relevance of this approach, a Web-based, automated SMS text messaging system was developed, following which a single-center feasibility study at a tertiary care center was performed. Patients scheduled for outpatient colonoscopy were invited to participate. Patients enrolled in the study group received automated information about dietary recommendations and bowel cleansing during colonoscopy preparation. Data of outpatient colonoscopies with regular preparation procedure were used for pair matching and served as control. Primary end point was feasibility of SMS text messaging support in colonoscopy preparation assessed as stable and satisfactory function of the system. Secondary end points were quality of bowel preparation according to the Boston Bowel Preparation Scale (BBPS) and patient satisfaction with SMS text messaging–provided information assessed by a questionnaire.

Results

Web-based SMS text messaging–supported colonoscopy preparation was successful and feasible in 19 of 20 patients. Mean (standard error of the mean, SEM) total BBPS score was slightly higher in the SMS group than in the control group (7.3, SEM 0.3 vs 6.4, SEM 0.2) and for each colonic region (left, transverse, and right colon). Patient satisfaction regarding SMS text messaging–based information was high.

Conclusions

Using SMS for colonoscopy preparation with 4 days’ guidance including dietary recommendation is a new approach to improve colonoscopy preparation. Quality of colonoscopy preparation was sufficient and patients were highly satisfied with the system during colonoscopy preparation.

Body mass index and quality of bowel preparation: Real life vs. clinical trials

BACKGROUND AND STUDY AIMS

Obesity is a recognised risk factor for poor bowel preparation in retrospective studies whilst corresponding data in prospective trials are marginally reported. Aims are to evaluate the relation between body mass index (BMI) and preparation quality in retrospective and interventional prospective settings and within a single centre.

PATIENTS AND METHODS

Data from a recent colorectal cancer screening registry were retrospectively analysed for the relation between BMI and adequacy of preparation. Patients were categorised as underweight (BMI<20kg/m(2)), normal (20-25kg/m(2)), overweight (25-30kg/m(2)), and obese (>30kg/m(2)). Data from a recent prospective colon preparation trial were similarly analysed.

RESULTS

541 registry patients were included. Multivariate analysis showed BMI to be an independent risk factor for inadequate preparation. Obesity was associated with odds ratio (OR) of 5.3 [95% confidence interval (CI) 1.4-19.8; p=0.01] compared to normal BMI. A significant difference was also noted in underweight but otherwise healthy individuals (OR=11.1, 95% CI 2-60; p=0.005). In the prospective study of 195 patients, obese patients had comparable rates of inadequate preparation to normal-weight individuals (OR=0.7, 95% CI 1.1-3.96; p=0.68). Underweight patients had a significantly worse preparation compared to normal BMI individuals (OR=8, 95% CI 1.1-58; p=0.04).

CONCLUSIONS

In real life, bowel preparations in obese individuals have a lower quality in comparison to normal individuals. This finding is not replicated in clinical trials. This discrepancy is likely the result of focused patient education suggesting that this is primarily a dietary compliance phenomenon. Underweight individuals appear to have worse quality of preparation independent of study design or setting.

Improved Bowel Preparation with Multimedia Education in a Predominantly African-American Population: A Randomized Study

Background and Aim. Inadequate bowel preparation is a major impediment in colonoscopy quality outcomes. Aim of this study was to evaluate the role of multimedia education (MME) in improving bowel preparation quality and adenoma detection rate. Methods. This was an IRB-approved prospective randomized study that enrolled 111 adult patients undergoing outpatient screening or surveillance colonoscopy. After receiving standard colonoscopy instructions, the patients were randomized into MME group (n = 48) and control group (n = 46). The MME group received comprehensive multimedia education including an audio-visual program, a visual aid, and a brochure. Demographics, quality of bowel preparation, and colonoscopy findings were recorded. Results. MME group had a significantly better bowel preparation in the entire colon (OR 2.65, 95% CI 1.16-6.09) and on the right side of the colon (OR 2.74, 95% CI 1.12-6.71) as compared to control group (p < 0.05). Large polyps (>1 cm) were found more frequently in the MME group (11/31, 35.5% versus 0/13; p < 0.05). More polyps and adenomas were detected in MME group (57 versus 39 and 31 versus 13, resp.) but the difference failed to reach statistical significance. Conclusion. MME can lead to significant improvement in the quality of bowel preparation and large adenoma detection in a predominantly African-American population.

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy: A multicentre prospective regional study

BACKGROUND

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy is often unsatisfactory. No study has investigated the inpatient or outpatient setting as cause of inadequate cleansing.

AIMS

To assess degree of bowel cleansing in inpatients and outpatients and to identify possible predictors of poor bowel preparation in the two populations.

METHODS

Prospective multicentre study on consecutive colonoscopies in 25 regional endoscopy units. Univariate and multivariate analysis with odds ratio estimation were performed.

RESULTS

Data from 3276 colonoscopies were analyzed (2178 outpatients, 1098 inpatients). Incomplete colonoscopy due to inadequate cleansing was recorded in 369 patients (11.2%). There was no significant difference in bowel cleansing rates between in- and outpatients in both colonic segments. In the overall population, independent predictors of inadequate cleansing both at the level of right and left colon were: male gender (odds ratio, 1.20 [1.02-1.43] and 1.27 [1.05-1.53]), diabetes mellitus (odds ratio, 2.35 [1.68-3.29] and 2.12 [1.47-3.05]), chronic constipation (odds ratio, 1.60 [1.30-1.97] and 1.55 [1.23-1.94]), incomplete purge intake (odds ratio, 2.36 [1.90-2.94] and 2.11 [1.68-2.65]) and a runway time >12h (odds ratio, 3.36 [2.40-4.72] and 2.53 [1.74-3.67]).

CONCLUSIONS

We found no difference in the rate of inadequate bowel preparation between hospitalized patients and outpatients.

Adenoma detection rates in an opportunistic screening colonoscopy program in Iran, a country with rising colorectal cancer incidence

Background

Data on the quality of colonoscopies in populations with rising colorectal cancer (CRC) incidence is scarce. We aimed to calculate the adenoma detection rates (ADR), and assess the quality of colonoscopies in an opportunistic screening colonoscopy program in Iran.

Methods

All the colonoscopy and pathology reports of asymptomatic adults over age 50 who underwent screening colonoscopy between June 2007 and March 2013 were reviewed. The colonoscopy quality indicators including ADR were calculated, and patient factors associated with the adenoma detection were determined.

Results

A total of 713 asymptomatic adults aged 50 years and older who underwent their first-time screening colonoscopy were included in this study. ADR and advanced-ADR were 33.00% (95% CI: 29.52-36.54) and 13.18% (95% CI: 10.79-15.90), respectively. We observed a significantly higher rate of cecal intubation in patients with fair or better bowel preparation compared to those with poor prep, 90.00% vs. 70.45%, respectively (P < 0.001). Bowel preparation (adjusted OR: 2.49, 95% CI: 1.75-3.55), older age (≥60) (adjusted OR: 1.70, 95% CI: 1.22-2.36), and male gender (adjusted OR: 1.39, 95% CI: 1.01-1.92) were associated with the adenoma detection.

Conclusions

Our ADR in both genders meets and exceeds the recommended colonoscopy quality benchmarks. The polyp and adenoma detection rates in the current study are comparable to those reported from Western countries where the incidence of CRC is traditionally high. These data are in line with the epidemiologic transition of CRC in Iran.