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Requests for reprints should be addressed to Maged K. Rizk, MD, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A30, Cleveland, OH 44195.
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.
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.
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.
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.
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.
Am J Gastroenterol.2014; 109 (quiz 1724): 1714-1723
Evidence suggests that patients' lack of understanding about the complex procedural requirements is one of the major cited reasons behind inadequate bowel preparation.
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,
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.
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).
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 1Patients included in the final analysis. GI = gastrointestinal.
Figure 2Adenoma detection rates stratified according to bowel preparation quality: univariable generalized linear mixed model analysis. n = sample size.
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.
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
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,
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.
Am J Gastroenterol.2014; 109 (quiz 1724): 1714-1723
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
Satisfactory bowel preparation (%) (Excellent + Good + Fair)
Unadjusted
2530
94.2 (92.0-95.8)
97.8 (96.6-98.6)
<.001
Model 1
2388
95.4 (90.8-97.8)
98.0 (95.7-99.1)
<.001
Model 2
2316
95.9 (91.5-98.0)
98.2 (96.1-99.2)
<.001
Adenoma detection rates (%)
Unadjusted
2530
30.7 (27.5-34.0)
29.3 (26.2-32.7)
.48
Model 1
2388
27.4 (22.2-33.3)
26.9 (21.7-32.8)
.79
Model 2
2316
28.5 (20.9-37.6)
27.8 (20.3-36.8)
.71
Right-sided adenomas found (%)
Unadjusted
2501
18.5 (16.0-21.4)
19.4 (16.7-22.3)
.59
Model 1
2360
15.7 (11.7-20.7)
17.1 (12.8-22.5)
.34
Model 2
2289
15.3 (10.0-22.7)
16.6 (10.9-24.4)
.4
Advanced adenoma found (%)
Unadjusted
2523
29.2 (26.0-32.6)
28.0 (24.9-31.4)
.54
Model 1
2382
26.5 (21.4-32.4)
26.2 (21.1-32.1)
.88
Model 2
2311
27.7 (20.0-36.8)
27.5 (19.9-36.6)
.92
Adenoma density
Unadjusted
2530
0.50 (0.46-0.54)
0.45 (0.42-0.49)
.11
Model 1
2388
0.44 (0.37-0.52)
0.43 (0.36-0.51)
.58
Model 2
2316
0.42 (0.33-0.54)
0.40 (0.31-0.51)
.36
Procedure duration (min)
Unadjusted
998
19.3 (18.0-20.7)
19.7 (18.4-21.1)
.42
Model 1
941
18.2 (16.6-19.9)
18.7 (17.1-20.4)
.34
Model 2
912
18.7 (16.0-21.8)
19.3 (16.6-22.5)
.29
Need for repeat endoscopy within 3 years (%)
Unadjusted
2530
7.3 (5.3-9.9)
3.3 (2.2-4.9)
<.001
Model 1
2388
7.6 (4.7-12.3)
3.7 (2.1-6.4)
<.001
Model 2
2316
6.6 (2.8-14.7)
3.3 (1.3-7.8)
<.001
Total dose of anesthetics (mg)
Unadjusted
2529
7.3 (5.4-9.8)
7.8 (5.8-10.5)
.31
Model 1
2387
7.3 (5.2-10.2)
7.9 (5.6-11.1)
.29
Model 2
2315
6.3 (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.
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,
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.
Am J Gastroenterol.2014; 109 (quiz 1724): 1714-1723
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.
One possible explanation is that mean adenoma detection rates at Cleveland Clinic are higher than the nationally recommended adenoma detection rate of 25%,
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
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
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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Swan J.
et al.
Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska natives.
Colorectal cancer mortality reduction associated with having at least 1 colonoscopy within the past 10 years among a population-wide cohort of screening age.
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.
Am J Gastroenterol.2014; 109 (quiz 1724): 1714-1723
Conflict of Interest: The authors disclose no financial conflict.
Authorship: We verify that all authors had access to the data that were collected for the study. The first and second authors wrote the first draft of the manuscript, which was subsequently revised and edited by all other authors.
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