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Online Educational Video Improves Bowel Preparation and Reduces the Need for Repeat Colonoscopy Within Three Years

      Abstract

      Purpose

      Unsatisfactory bowel preparation has been reported in up to 33% of screening colonoscopies. Patients' lack of understanding about how a good bowel preparation can be achieved is one of the major causes. Patient education has been explored as a possible intervention to improve this important endpoint and has yielded mixed results. We compared the proportion of satisfactory bowel preparations and adenoma detection rates between patients who viewed and did not view an educational video on colonoscopy.

      Methods

      An educational video on colonoscopy, accessible via the Internet, was issued to all patients with planned procedures between 2010 and 2014. Viewing status of the video was verified through a unique code linked to each patient's medical record. Excellent, good, or adequate bowel preparations were defined as “satisfactory,” whereas fair, poor, or inadequate bowel preparations were defined as “unsatisfactory.”

      Results

      A total of 2530 patients undergoing their first outpatient screening colonoscopy were included; 1251 patients viewed the educational video and 1279 patients did not see the video. Multivariate analysis revealed higher rates of satisfactory bowel preparation in the educational video group (92.3% [95% confidence interval [CI], 84.8-96.3] vs 87.4% [95% CI, 76.4-93.7], P <.001). Need for a repeat colonoscopy within 3 years was also higher in patients who did not see the video (6.6% [95% CI, 2.8-14.7] vs 3.3% [95% CI 1.3-7.8], P <.001).

      Conclusion

      Patient-centered educational video improves bowel preparation quality and may reduce the need for an earlier repeat procedure in patients undergoing screening colonoscopy.

      Keywords

      Clinical Significance
      • Preprocedural educational video improves the quality of bowel preparation in outpatient screening colonoscopies.
      • Preprocedural educational video lowers the need for repeat colonoscopy due to poor bowel preparation.
      Despite the recent decreases in incidence and mortality,
      • Espey D.K.
      • Wu X.C.
      • Swan J.
      • et al.
      Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska natives.
      colon cancer remains the third most common cause of cancer-related deaths among both men and women in the US.

      American Cancer Society. Cancer Facts and Figures 2008. Available at: http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2008/index. Accessed July 11, 2016.

      Colonoscopy remains the gold standard test for colorectal cancer screening, and colorectal cancer screening programs reduce mortality.
      • Espey D.K.
      • Wu X.C.
      • Swan J.
      • et al.
      Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska natives.
      • Stock D.
      • Paszat L.F.
      • Rabeneck L.
      Colorectal cancer mortality reduction associated with having at least 1 colonoscopy within the past 10 years among a population-wide cohort of screening age.
      Proper preprocedure bowel purgation plays an integral role to this effect, yet inadequate bowel preparation plagues about a quarter of all colonoscopies in the US.
      • Harewood G.C.
      • Sharma V.K.
      • de Garmo P.
      Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia.
      This not only has been shown to increase the procedural duration, but it leads to higher costs due to need for repeated examinations at earlier intervals.
      • Rex D.K.
      • Imperiale T.F.
      • Latinovich D.R.
      • Bratcher L.L.
      Impact of bowel preparation on efficiency and cost of colonoscopy.
      In addition, it has also been associated with a reduction in polyp detection rates by up to 50%.
      • Prakash S.R.
      • Verma S.
      • McGowan J.
      • et al.
      Improving the quality of colonoscopy bowel preparation using an educational video.
      A meta-analysis confirmed an increase of 5% in adenoma detection rate in colonoscopies with high- and intermediate-quality bowel preparation as compared with those with inadequate bowel preparation.
      • Clark B.T.
      • Rustagi T.
      • Laine L.
      What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate.
      Evidence suggests that patients' lack of understanding about the complex procedural requirements is one of the major cited reasons behind inadequate bowel preparation.
      • Chung Y.W.
      • Han D.S.
      • Park K.H.
      • et al.
      Patient factors predictive of inadequate bowel preparation using polyethylene glycol: a prospective study in Korea.
      Nguyen and Wieland
      • Nguyen D.L.
      • Wieland M.
      Risk factors predictive of poor quality preparation during average risk colonoscopy screening: the importance of health literacy.
      showed that about 18% of the patients with poor bowel preparation failed to follow instructions on dietary restriction and timing of preparation. Therefore, a number of interventions to improve patient education and understanding of the procedure have been reported in the literature. These include the use of instructional leaflets, telephonic instructions,
      • Abuksis G.
      • Mor M.
      • Segal N.
      • et al.
      A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department.
      visual aids,
      • Calderwood A.H.
      • Lai E.J.
      • Fix O.K.
      • Jacobson B.C.
      An endoscopist-blinded, randomized, controlled trial of a simple visual aid to improve bowel preparation for screening colonoscopy.
      educational booklets,
      • Spiegel B.M.
      • Talley J.
      • Shekelle P.
      • et al.
      Development and validation of a novel patient educational booklet to enhance colonoscopy preparation.
      and one-on-one discussions with a health care provider.
      • Rosenfeld G.
      • Krygier D.
      • Enns R.A.
      • Singham J.
      • Wiesinger H.
      • Bressler B.
      The impact of patient education on the quality of inpatient bowel preparation for colonoscopy.
      The results of these studies have been variable and inconsistent.
      Our study aimed to assess the impact of viewing an educational video on adequate bowel preparation rates and adenoma detection rates in patients undergoing outpatient screening colonoscopies at a tertiary care hospital and its satellite locations in Cleveland, Ohio.

      Methods

      Study Design

      This historical cohort study utilized a prospectively maintained database ProVation (Minneapolis, Minn) and electronic medical record system to review over 35,000 consecutive outpatient colonoscopies done at Cleveland Clinic and its satellite facilities between 2010 and 2014. The study was approved by the institutional review board at Cleveland Clinic.

      Educational Intervention

      All patients undergoing outpatient colonoscopy at Cleveland Clinic receive an educational packet via mail and a preprocedure telephone call as means of educating them about the procedure. Additionally, a standardized educational video, accessible via the Internet, entailing details on the importance of detecting colonic polyps and appropriate steps for achieving adequate bowel cleansing, was issued to all patients with planned colonoscopies between 2010 and 2014. This video is a product of Emmi Solutions (Chicago, Ill), which is a health care communications company that designs technology-based solutions to deliver superior patient engagement. The video comprised 8 sections lasting a total of 30 minutes. Viewing status of the video was verified through a unique Internet-based code attached to each patient's medical record number. All subjects who started watching the educational video and completed at least one section were included in the video group, while all others who did not start watching the video, or started it but did not complete at least one section, were included in the nonvideo group. Data, including initiation and completion of the video linking to each medical record, were provided by Emmi Solutions. Emmi was not involved in any other aspect of data collection, study design, or manuscript writing.

      Inclusion and Exclusion Criteria

      Patients who were age 40 years or older undergoing their first outpatient screening colonoscopy were included in the study. Patients were excluded if the indication of procedure was other than screening, if the patient had a history of inflammatory bowel disease, colon cancer or colonic stricture, if the patient had a prior colonoscopy, or if the bowel preparation quality was not reported in the procedure note. Figure 1 is a flow diagram of all the patients that were reviewed for our study and then included for the final analysis.

      Sample Size Calculation

      Institutional data at Cleveland Clinic were reviewed for mean adenoma detection rates between the years 2011 and 2012, which were estimated to be about 27%. Because our study also included satellite locations, we took the mean adenoma detection rates as 25%. A prior study done at our institution showed an unsatisfactory bowel preparation (poor and fair) in 13.6% of all the colonoscopies.
      • Rai T.
      • Navaneethan U.
      • Gohel T.
      • et al.
      Effect of quality of bowel preparation on quality indicators of adenoma detection rates and colonoscopy completion rates.
      For power calculation, we took this percentage as 15%. To confirm our hypothesis that the educational video would increase the adenoma detection rate by 5%, with a confidence level of 95% and a power of 80%, a total of 2500 subjects and, for an increase in adequate bowel preparation rate by 5%, a total of 1812 subjects, respectively, was needed. Thus, a total of at least 2500 patients were included in our study groups to enable us to test both of the aforementioned hypotheses.

      Outcomes

      The primary endpoints for this study were bowel preparation quality and adenoma detection rates. All procedures used the Aronchick scale to grade bowel preparation quality, which was reported only after efforts to remove residual effluent and fecal debris were completed. Bowel preparation grades of excellent (>95% of mucosa seen), good (clear liquid covering up to 25% of mucosa, but >90% of mucosa seen), and adequate were taken as satisfactory, whereas fair (semisolid stool could not be suctioned, but >90% of mucosa seen), poor (semisolid stool could not be suctioned and <90% of mucosa seen), and inadequate (repeat preparation needed) were taken as unsatisfactory. As part of a sensitivity analysis, a second definition for satisfactory bowel preparation was also considered, where excellent, good, adequate, and “fair” preparation grades were defined as satisfactory, while poor and inadequate were taken as unsatisfactory. Adenoma detection rate was defined as the percentage of colonoscopies that detected one or more adenomas.
      Secondary outcomes included the need for repeat colonoscopy because of unsatisfactory bowel preparation, total procedure duration, right-sided adenoma detection rate (proportion of colonoscopies with one or more adenoma in cecum), ascending colon, hepatic flexure or transverse colon, advanced adenoma detection rates (proportion of procedures with one or more adenomas that were 10 mm or greater, had a villous component or had high-grade dysplasia), and adenoma density (number of detected adenomas per procedure).

      Statistical Analysis

      Data are presented as mean ± standard deviation, median [25th, 75th percentiles], or frequency (%). A univariate analysis was performed to assess differences between subjects who viewed the educational video and those who did not; analysis of variance or the nonparametric Kruskal-Wallis tests were used to assess differences in continuous variables, and Pearson's chi-squared tests or Fisher's exact tests were used for categorical factors.
      For all outcomes, generalized linear mixed models were used to assess differences between the 2 groups; models with random intercepts nested within endoscopists were fit. Generalized linear mixed models with a binary distribution and a logit link were used to model bowel preparation quality (adequate vs inadequate), presence of any adenomas, presence of adenomas on the right side of the colon, and repeat procedure because of poor preparation. A generalized linear mixed model with a Poisson distribution and a log link was used to assess differences in rate of adenomas detected between the 2 groups. Lastly, for procedure duration and total dose of anesthetics, the natural logarithm of each outcome was modeled and a generalized linear mixed model with a normal distribution and an identity link was used to assess differences between the 2 groups.
      Three different models were fit for each outcome:
      • 1.
        Unadjusted.
      • 2.
        Model 1: Adjusting for age, sex, race, body mass index, income, and bowel preparation quality for outcome other than quality or repeat endoscopy because of quality.
      • 3.
        Model 2: Adjusting for age, sex, race, body mass index, income, preparation quality (if outcome other than quality or repeat endoscopy because of quality), communication prior to procedure, history of abdominal/pelvic surgery, family history of colon cancer, type of bowel preparation used, interval from appointment to procedure, time of procedure (AM vs PM), location of procedure (family health center vs main campus), and endoscopist's specialty.
      For outcomes other than bowel preparation quality or repeat endoscopies, the interaction between group and bowel preparation quality was assessed and included in the models if P <.10. SAS (version 9.4; SAS Institute, Cary, NC) was used for all analyses, and a P <.05 was considered statistically significant.

      Results

      Patient Demographics

      A total of 2530 patients undergoing screening colonoscopy were included in the analysis: 1251 patients (49.5%) were included in the video group and 1279 patients (50.5%) were included in the nonvideo group. Of the 1251 subjects who started viewing the video, 92.2% (n = 1153) viewed more than 6 sections (median of 8 sections [8, 8]), and 7.8% (n = 98) viewed ≤6 sections (median of 4 sections [2, 6]) and (Table 1).
      Table 1Demographics and Clinical Characteristics
      FactorOverall (N = 2530)Noneducational Video Group (n = 1279)Educational Video Group (n = 1251)P-Value
      nSummarynSummarynSummary
      Age (y)253051.6 ± 2.2127951.9 ± 2.5125151.4 ± 1.9<.001
      Analysis of variance.
      Sex253012791251.002
      Pearson's chi-squared test.
       Male1186 (46.9)639 (50.0)547 (43.7)
       Female1344 (53.1)640 (50.0)704 (56.3)
      Ethnicity248212541228<.001
      Pearson's chi-squared test.
       White1990 (80.2)936 (74.6)1054 (85.8)
       Black438 (17.6)292 (23.3)146 (11.9)
       Other54 (2.2)26 (2.1)28 (2.3)
      BMI244729.1 ± 6.4123329.4 ± 6.3121428.8 ± 6.4.013
      Analysis of variance.
      Average annual income (based on ZIP code)2513$60,408.6 ± $30,353.41268$57,490.4 ± $28,965.91245$63,380.8 ± $31,438.5<.001
      Analysis of variance.
      Ordering physician252912781251.84
      Pearson's chi-squared test.
       PCP2296 (90.8)1155 (90.4)1141 (91.2)
       Gastroenterologist165 (6.5)89 (7.0)76 (6.1)
       Colorectal surgeon28 (1.1)14 (1.1)14 (1.1)
       Other40 (1.6)20 (1.6)20 (1.6)
      Preprocedure communication25301915 (75.7)1279976 (76.3)1251939 (75.1).46
      Pearson's chi-squared test.
      Prior abdominal/pelvic surgery2530711 (28.1)1279341 (26.7)1251370 (29.6).10
      Pearson's chi-squared test.
      Family history of CRC2520337 (13.4)1272162 (12.7)1248175 (14.0).34
      Pearson's chi-squared test.
      CRC in first-degree relative2512200 (8.0)1269105 (8.3)124395 (7.6).56
      Pearson's chi-squared test.
      Bowel prep (nonexclusive)
       PEG-Golytely24491808 (73.8)1235916 (74.2)1214892 (73.5).70
      Pearson's chi-squared test.
       Moviprep2449467 (19.1)1235212 (17.2)1214255 (21.0).016
      Pearson's chi-squared test.
       SUPREP24491 (0.04)12350 (0.0)12141 (0.08).50
      Fisher's exact test.
       PREPOPIK24493 (0.12)12351 (0.08)12142 (0.16).62
      Fisher's exact test.
       Reglan244935 (1.4)123522 (1.8)121413 (1.1).14
      Pearson's chi-squared test.
       Loperamide24491 (0.04)12351 (0.08)12140 (0.0).99
      Fisher's exact test.
       Dulcolax24494 (0.16)12351 (0.08)12143 (0.25).37
      Fisher's exact test.
       Other bowel prep2449174 (7.1)1235110 (8.9)121464 (5.3)<.001
      Pearson's chi-squared test.
      Values presented as Mean ± SD or n (column %).
      BMI = body mass index; CRC = colorectal cancer; PCP = primary care physician.
      Analysis of variance.
      Pearson's chi-squared test.
      Fisher's exact test.
      The subjects who viewed 6 or fewer sections of video (n = 98) had a significantly longer interval between viewing video and procedure (39 [15, 58] vs 27 [9, 52]; P = .027) and poorer patient tolerance to procedure (5% vs 0.57%; P <.001) as compared with those who saw more than 6 sections. Because there was no significant difference in any of the outcomes of interest, the 2 groups were combined for the final analysis.
      Subjects who viewed the educational video were more likely to be of female sex, white race, and a higher income area. In addition, subjects who saw the video were more likely to have used an ascorbic acid-enriched polyethylene glycol-based preparation (Moviprep; Salix Pharmaceuticals, Raleigh, NC). The median number of days between watching the video and the procedure was 28 [10.0, 53.0]. Subjects who started viewing the video were more likely to have the procedure done at a satellite location and receive fentanyl for anesthesia.

      Bowel Preparation Quality and Adenoma Detection Rates

      Subjects who watched the educational video had significantly higher rates of satisfactory bowel preparation (P <.001) and hence, lower rates of need for repeat procedure mainly because of inadequate bowel preparation (P <.001) (Table 3). This association remained significant on multivariate analysis. There was no significant difference in any of the other outcomes of interest, and bowel preparation quality was not found to significantly modify (interact) with any of the associations. Despite an improvement in bowel preparation, adenoma detection rates between the 2 groups were similar on both univariate and multivariate analyses.
      Adenoma detection rates were >25% in colonoscopies with bowel preparations rated as excellent, good, and fair, and were markedly lower in colonoscopies with poor bowel preparations in both the studied groups, as expected (Figure 2). The adenoma detection rates in procedures with poor bowel preparation in the educational video group were higher as compared with those in the noneducational group, but this difference remained statistically nonsignificant (Figure 2).
      Figure thumbnail gr1
      Figure 1Patients included in the final analysis. GI = gastrointestinal.
      Figure thumbnail gr2
      Figure 2Adenoma detection rates stratified according to bowel preparation quality: univariable generalized linear mixed model analysis. n = sample size.

      Results for Low Performing Endoscopists

      A sub-analysis of patients (n = 588) who had their procedures done by one of 37 low-yielding (adenoma detection rates <25% over the last 3 years based on institutional data) endoscopists (49% gastroenterologists, 35% colorectal surgeons, 13% general surgeons, and 3% family practitioners) revealed similar results with improvement in bowel preparation in the educational video group, with no significant change in adenoma detection rates (Table 4). We were unable to present Model 2 for repeat endoscopy in this subgroup analysis as there were only 50 patients who had repeat endoscopies, with around 20 variables in that model.

      Procedure Details

      Table 2 lists the details of all colonoscopy procedures done on subjects that were included in our study. These colonoscopies were performed by one of a total of 114 endoscopists, all of whom were employed at Cleveland Clinic; 54% of these endoscopists were gastroenterologists, 27% were colorectal surgeons, 14% were general surgeons, and 4% were family practitioners. Number of procedures per endoscopist in the included patients ranged between 1 and 158, with a median of 12 [3, 29]. The procedures were performed at either the main Cleveland Clinic campus or one of its 18 satellite locations.
      Table 2Procedure Details
      FactorOverall (N = 2530)Non-Educational Video Group (n = 1279)Educational Video Group (n = 1251)P-Value
      nSummarynSummarynSummary
      Days since appointment253056.0 [33.0, 98.0]127954.0 [30.0, 98.0]125156.0 [36.0, 98.0].031
      Kruskal-Wallis test.
      Days since preprocedure communication19157.0 [6.0, 8.0]9767.0 [5.5, 8.0]9397.0 [6.0, 8.0].12
      Kruskal-Wallis test.
      Days since viewing video124128.0 [10.0, 53.0]0124128.0 [10.0, 53.0]
      Procedure time252712781249.48
      Pearson's chi-squared test.
       Morning1719 (68.0)861 (67.4)858 (68.7)
       Afternoon808 (32.0)417 (32.6)391 (31.3)
      Procedure duration (min)99919.0 [14.0, 25.0]40019.0 [14.0, 25.0]59919.0 [14.0, 25.0].93
      Kruskal-Wallis test.
      Location of procedure252212731249.001
      Pearson's chi-squared test.
       Satellite location1818 (72.1)881 (69.2)937 (75.0)
       Main campus704 (27.9)392 (30.8)312 (25.0)
      Endoscopist's specialty253012791251.23
      Pearson's chi-squared test.
       Gastroenterologist1558 (61.6)787 (61.5)771 (61.6)
       Colorectal surgeon740 (29.2)376 (29.4)364 (29.1)
       Surgeon216 (8.5)112 (8.8)104 (8.3)
       Family practitioner16 (0.63)4 (0.31)12 (0.96)
      Endoscopist's ADR236111851176.35
      Pearson's chi-squared test.
       Normal-High ADR (≥25%)1773 (75.1)880 (74.3)893 (75.9)
       Low ADR (<25%)588 (24.9)305 (25.7)283 (24.1)
      Type of anesthesia (nonexclusive)
       Midazolam25302446 (96.7)12791234 (96.5)12511212 (96.9).57
      Pearson's chi-squared test.
       Fentanyl25301611 (63.7)1279785 (61.4)1251826 (66.0).015
      Pearson's chi-squared test.
       Diazepam253010 (0.40)12796 (0.47)12514 (0.32).55
      Pearson's chi-squared test.
       Benadryl253010 (0.40)12796 (0.47)12514 (0.32).55
      Pearson's chi-squared test.
       Meperidine2530809 (32.0)1279432 (33.8)1251377 (30.1).050
      Pearson's chi-squared test.
       General anesthesia253072 (2.8)127941 (3.2)125131 (2.5).27
      Pearson's chi-squared test.
       Other anesthesia253027 (1.1)127915 (1.2)125112 (0.96).60
      Pearson's chi-squared test.
      Midazolam used (mg)24454.0 [3.0, 5.0]12334.0 [3.0, 5.0]12124.0 [3.0, 5.0].015
      Kruskal-Wallis test.
      Fentanyl used (μg)1610100.0 [75.0, 100.0]784100.0 [75.0, 100.0]826100.0 [75.0, 100.0].081
      Kruskal-Wallis test.
      Meperidine used (mg)80975.0 [50.0, 100.0]43275.0 [50.0, 100.0]37775.0 [50.0, 100.0].55
      Kruskal-Wallis test.
      Total dose of anesthetics (mg)25295.1 [4.1, 54.0]12785.1 [4.1, 65.5]12515.1 [4.1, 53.0].89
      Kruskal-Wallis test.
      Difficulty251312681245.44
      Pearson's chi-squared test.
       Difficult111 (4.4)52 (4.1)59 (4.7)
       Not difficult2402 (95.6)1216 (95.9)1186 (95.3)
      Patient tolerance of procedure227011181152.087
      Pearson's chi-squared test.
       Well/fair2239 (98.6)1098 (98.2)1141 (99.0)
       Poor/very poor31 (1.4)20 (1.8)11 (0.95)
      Values presented as Median [P25, P75] or n (column %).
      Kruskal-Wallis test.
      Pearson's chi-squared test.

      Discussion

      Efforts aimed at improving quality indicators of colonoscopies, such as adenoma detection rate and cecal intubation rates, target achieving satisfactory bowel preparation quality as one of the important goals. To our knowledge, this is the largest study that assessed the effect of an educational intervention in the form of a video on patients undergoing screening colonoscopies. Subjects who completed the viewing of the video had significantly higher rates of satisfactory bowel preparation rates as compared with the subjects who did not see the video. Our study results are in accordance with the findings of 2 prospective studies that evaluated the impact of an instructional video on 101 and 133 subjects, respectively, who were undergoing colonoscopy at small outpatient centers and showed an increment in the proportion of adequate bowel preparations
      • Prakash S.R.
      • Verma S.
      • McGowan J.
      • et al.
      Improving the quality of colonoscopy bowel preparation using an educational video.
      • Cho Y.Y.
      • Kim H.O.
      Effects of a patient educational video program on bowel preparation prior to colonoscopy.
      along with improving knowledge about dietary restriction prior to the colonoscopy and ingestion of colon cleansing solutions.
      • Cho Y.Y.
      • Kim H.O.
      Effects of a patient educational video program on bowel preparation prior to colonoscopy.
      Even though a meta-analysis showed only a decrement of <1% in adenoma detection rates in patients with intermediate-quality (fair) bowel preparation as compared with high-quality (excellent and good) bowel preparation,
      • Clark B.T.
      • Rustagi T.
      • Laine L.
      What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate.
      smaller studies have shown concerns for missed adenomas and early repeat colonoscopies due to fair bowel preparation.
      • Menees S.B.
      • Kim H.M.
      • Elliott E.E.
      • Mickevicius J.L.
      • Graustein B.B.
      • Schoenfeld P.S.
      The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy.
      Hence, any reported fair preparation in our study was included under the “satisfactory” category as well as the “unsatisfactory” category as a part of the sensitivity analysis mentioned above, thus enabling us to effectively counter this variable (Table 3). Rate of unsatisfactory bowel purgation remained significantly different in both analyses, which strengthened our confidence on the positive impact of an instructional video on this quality parameter for colonoscopies.
      Table 3Primary Outcomes for All Procedures Univariable and Multivariable Generalized Linear Mixed-Model Analysis
      OutcomeModelnNoneducational Video GroupEducational Video GroupP-Value
      Satisfactory bowel preparation (%) (Excellent + Good)Unadjusted253084.1 (80.1-87.4)91.1 (88.4-93.3)<.001
      Model 1238885.7 (79.6-90.3)91.3 (87.0-94.2)<.001
      Model 2231687.4 (76.4-93.7)92.3 (84.8-96.3)<.001
      Satisfactory bowel preparation (%) (Excellent + Good + Fair)Unadjusted253094.2 (92.0-95.8)97.8 (96.6-98.6)<.001
      Model 1238895.4 (90.8-97.8)98.0 (95.7-99.1)<.001
      Model 2231695.9 (91.5-98.0)98.2 (96.1-99.2)<.001
      Adenoma detection rates (%)Unadjusted253030.7 (27.5-34.0)29.3 (26.2-32.7).48
      Model 1238827.4 (22.2-33.3)26.9 (21.7-32.8).79
      Model 2231628.5 (20.9-37.6)27.8 (20.3-36.8).71
      Right-sided adenomas found (%)Unadjusted250118.5 (16.0-21.4)19.4 (16.7-22.3).59
      Model 1236015.7 (11.7-20.7)17.1 (12.8-22.5).34
      Model 2228915.3 (10.0-22.7)16.6 (10.9-24.4).4
      Advanced adenoma found (%)Unadjusted252329.2 (26.0-32.6)28.0 (24.9-31.4).54
      Model 1238226.5 (21.4-32.4)26.2 (21.1-32.1).88
      Model 2231127.7 (20.0-36.8)27.5 (19.9-36.6).92
      Adenoma densityUnadjusted25300.50 (0.46-0.54)0.45 (0.42-0.49).11
      Model 123880.44 (0.37-0.52)0.43 (0.36-0.51).58
      Model 223160.42 (0.33-0.54)0.40 (0.31-0.51).36
      Procedure duration (min)Unadjusted99819.3 (18.0-20.7)19.7 (18.4-21.1).42
      Model 194118.2 (16.6-19.9)18.7 (17.1-20.4).34
      Model 291218.7 (16.0-21.8)19.3 (16.6-22.5).29
      Need for repeat endoscopy within 3 years (%)Unadjusted25307.3 (5.3-9.9)3.3 (2.2-4.9)<.001
      Model 123887.6 (4.7-12.3)3.7 (2.1-6.4)<.001
      Model 223166.6 (2.8-14.7)3.3 (1.3-7.8)<.001
      Total dose of anesthetics (mg)Unadjusted25297.3 (5.4-9.8)7.8 (5.8-10.5).31
      Model 123877.3 (5.2-10.2)7.9 (5.6-11.1).29
      Model 223156.3 (3.6-10.9)6.9 (4.0-11.9).24
      n = total subjects used for model.
      Data presented as rate (95% confidence interval [CI]) for number of adenomas/procedure; mean (95% CI) for procedure duration and total dose of anesthetics; and % (95% CI) otherwise.
      Model 1 adjusts for age-sex, race, body mass index (BMI), income and bowel preparation quality for outcome other than quality or repeat scope because of prep quality.
      Model 2 adjusts for age, sex, race and BMI, income, preparation quality (if outcome other than quality or repeat scope because of quality), telephone call prior to procedure, history of abdominal/pelvic surgery, family history of colon cancer, type of bowel preparation used, interval from appointment to procedure, time of procedure (AM vs PM), location of procedure (family health center vs main campus) and endoscopist's specialty.
      Table 4Primary Outcomes for Procedures Performed by Low Yielding Endoscopists: Univariable and Multivariable Generalized Linear Mixed-Model Analysis
      OutcomeModelnNoneducational Video GroupEducational Video GroupP-Value
      Satisfactory bowel preparation (%) (Excellent + Good)Unadjusted58882.1 (72.7-88.8)89.6 (82.7-94.0).008
      Model 156385.2 (71.6-93.0)90.9 (81.1-95.9).028
      Model 254698.6 (0.00-100.0)99.2 (0.00-100.0).013
      Adenoma Detection Rate (%)Unadjusted58825.9 (19.4-33.7)26.7 (19.8-34.9).85
      Model 156324.8 (14.6-39.0)26.4 (15.6-41.1).69
      Model 254623.3 (0.00-100.0)22.9 (0.00-100.0).91
      Any right sided adenomas found (%)Unadjusted58314.1 (9.5-20.4)14.5 (9.6-21.2).9
      Model 155813.0 (6.1-25.7)14.1 (6.6-27.7).71
      Model 254212.4 (0.00-100.0)12.3 (0.00-100.0).98
      Any advanced adenoma found (%)Unadjusted58725.3 (18.7-33.1)25.6 (18.8-33.9).92
      Model 156224.5 (14.2-38.8)26.1 (15.2-40.8).7
      Model 254621.9 (0.00-100.0)21.4 (0.00-100.0).88
      Adenoma DensityUnadjusted5880.33 (0.25-0.44)0.38 (0.28-0.51).35
      Model 15630.32 (0.20-0.51)0.37 (0.23-0.60).27
      Model 25460.28 (0.00-4,091,085.8)0.30 (0.00-4,423,233.7).59
      Procedure duration (minutes)Unadjusted27818.6 (16.1-21.5)18.6 (16.0-21.6).99
      Model 126616.5 (13.3-20.4)16.8 (13.7-20.7).75
      Model 225716.5 (13.2-20.7)18.3 (14.8-22.5).14
      Need for repeat endoscopy within 3 years (%)Unadjusted5889.0 (5.1-15.5)4.9 (2.4-9.5).045
      Model 15638.3 (4.5-14.9)4.7 (2.3-9.5).078
      n = total subjects used for model.
      Data presented as rate (95% confidence interval [CI]) for number of adenomas/procedure; mean (95% CI) for procedure duration and total dose of anesthetics; and % (95% CI) otherwise.
      Importantly, the group that did not see the video was more likely to get an earlier surveillance colonoscopy within the next 3 years, as compared with the group that saw the video, which correlates with higher rates of successful bowel purgation in these subjects. Even though a cost–benefit analysis was not done in our study, earlier intervals of surveillance colonoscopy for indications that can be avoided (ie, unsuccessful bowel preparation) increases resource utilization, posing a challenge to the burgeoning costs of our health care system.
      Our study is novel, as it looks at the direct impact of an educational intervention on adenoma detection rates, which has not been examined in any prior literature. Many prior studies have shown an improvement in adenoma detection rate after improvement in bowel preparation,
      • Clark B.T.
      • Rustagi T.
      • Laine L.
      What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate.
      but betterment in bowel preparation did not translate into an increment in adenoma detection rate in our endeavor. Interestingly, another study done at Cleveland Clinic also showed no difference in adenoma detection rates between colonoscopies grouped according to the quality of bowel cleansing.
      • Rai T.
      • Navaneethan U.
      • Gohel T.
      • et al.
      Effect of quality of bowel preparation on quality indicators of adenoma detection rates and colonoscopy completion rates.
      One possible explanation is that mean adenoma detection rates at Cleveland Clinic are higher than the nationally recommended adenoma detection rate of 25%,
      • Rex D.K.
      • Schoenfeld P.S.
      • Cohen J.
      • et al.
      Quality indicators for colonoscopy.
      which potentially leaves less room for improvement with better bowel preparation rates. To test our aforementioned hypothesis, a subgroup analysis on procedures done by low-performing endoscopists (with mean adenoma detection rates <25% based on annual institutional data) was done, but differences in adenoma detection rates failed to reach statistical significance on both univariate and multivariate analysis. It is imperative to note that adenoma detection rates were higher than 25% in this population as well, which would have made it difficult to show an improvement in adenoma detection rates when considering these procedures with a lower expected mean adenoma detection rate. It is also likely that during the proceduralist's efforts to remove all residual effluent during colonoscopies with good and fair preparations, more time was spent inspecting the colon, thus improving chances of visualizing a colonic polyp/adenoma, as evident in Figure 2. Interestingly, adenoma detection rates were lower in the educational video group in procedures with poor bowel preparations, but a small sample size of only 104 colonoscopies and statistical insignificance preclude any definite conclusions from being drawn, and this finding can likely be attributed to chance.
      Our study had several limitations. Firstly, all procedures done at Cleveland Clinic reported bowel preparation in Aronchick scale, which, unlike other validated tools for reporting bowel preparation (such as the Boston Bowel Preparation Scale and Ottawa Scale), has substantial inter-observer reliability
      • Parmar R.
      • Martel M.
      • Rostom A.
      • Barkun A.N.
      Validated scales for colon cleansing: a systematic review.
      and does not include information on different segments of the colon. Despite this, the Aronchick scale is the most widely used tool for reporting bowel preparation quality, and we believe our results are applicable to most of the colonoscopy centers. Secondly, we were unable to include data on impact of the educational video on patient satisfaction. Nevertheless, improvement in bowel preparation quality can be interpreted as an indirect indicator of increased subjective understanding of the necessary prerequisites for the procedure as a result of watching the video. Thirdly, this is a retrospective study, which raises the possibility of a selection bias in our studied population. There were some baseline differences, including sex, race, and income bracket in our 2 groups of interest, as evident in Table 1. It can be argued that patients who see the video are also likelier to be more compliant and thus will be better at following bowel preparation instructions. Even though all the potential confounders cannot be accounted for, we did conduct a multivariate analysis after adjustment for all possible factors that could have affected the probability of any of our subjects to see the video, the most important of which were age, sex, ethnicity, annual income, family history of colon cancer, and any other preprocedural communication (Table 3). Fourthly, our study only included patients undergoing their first screening colonoscopy. Prior studies have shown that patients who are hospitalized
      • Spiegel B.M.
      • Bolus R.
      • Harris L.A.
      • et al.
      Characterizing abdominal pain in IBS: guidance for study inclusion criteria, outcome measurement and clinical practice.
      or who undergo colonoscopy for indications other than screening (like constipation)
      • Yadlapati R.
      • Johnston E.R.
      • Gregory D.L.
      • Ciolino J.D.
      • Cooper A.
      • Keswani R.N.
      Predictors of inadequate inpatient colonoscopy preparation and its association with hospital length of stay and costs.
      have lower rates of adequate bowel preparation, and the effect of watching the educational video on colonoscopy outcomes in these patients still remains to be established.

      Conclusion

      Our results reveal that a patient-centered educational video may lead to improved bowel preparation quality and may reduce the need for an earlier repeat procedure in patients undergoing their first screening colonoscopy. Thus, we present a cost-effective and easy-to-implement intervention that translates to improved quality outcomes for outpatient colonoscopies. Studies testing our hypotheses in a more controlled setting are needed to confirm these findings. Educational interventions other than an educational video will also be worth exploring as inexpensive methods of improving patients' awareness and understanding of this important cancer screening procedure.

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