A randomized controlled trial of four precolonoscopy bowel cleansing regimens

BACKGROUND:

The ideal bowel cleansing regimen for colonoscopy has yet to be determined.

OBJECTIVE:

To compare the cleansing efficacy, and patient tolerability and safety of four bowel preparation regimens.

METHODS:

A total of 834 patients undergoing outpatient colonoscopy were randomly assigned to one of four regimens: 4 L polyethylene glycol (PEG); 2 L PEG + 20 mg bisacodyl; 90 mL of sodium phosphate (NaP); or two sachets of a commercially available bowel cleansing solution (PSMC) + 300 mL of magnesium citrate (M). The primary outcome measure was cleansing efficacy, which was scored by blinded endoscopists using the Ottawa Bowel Preparation Scale. Secondary outcome measures were bowel preparation quality according to time of colonoscopy, and patient tolerability and safety.

RESULTS:

The mean total cleansing score was significantly worse in the NaP group compared with the other three groups (P<0.0001). The mean cleansing scores were worse in patients who underwent morning versus afternoon colonoscopy, a finding that was consistent in all four groups. PSMC + M was the best tolerated regimen. No clinically significant mean changes in creatinine or electrolyte levels were identified, although a significantly higher proportion of patients in the NaP group developed hypokelemia (P<0.0001).

CONCLUSIONS:

2 L PEG + 20 mg bisacodyl, or PSMC + M was as efficacious as 4 L PEG and superior to NaP for bowel cleansing. A short interval between the completion of bowel preparation and the start of colonoscopy (ie, ‘runway time’), irrespective of bowel preparation regimen, appeared to be a more important predictor of bowel cleanliness than the cathartic agents used.     

The impact of patient education on the quality of inpatient bowel preparation for colonoscopy

BACKGROUND:

For patients requiring colonoscopy while admitted to hospital, achieving adequate cleansing of the colon is often difficult.

OBJECTIVES:

To assess the impact of patient education, in the form of both counselling and written instructions, on bowel cleanliness at colonoscopy.

METHODS:

A total of 38 inpatients at a tertiary care hospital in Vancouver, British Columbia, who were referred to the gastroenterology service for colonoscopy were enrolled in the present study. Sixteen patients were randomly assigned to the intervention group, while 22 patients comprised the control group. Both groups received a clear liquid diet and 4 L of a commercially available bowel preparation. The intervention group also received a brief counselling session and written instructions outlining the methods and rationale for bowel preparation before colonoscopy. Bowel cleanliness was assessed by the endoscopist using a five-point rating scale.

RESULTS:

The two groups were similar with respect to demographics, the indication for colonoscopy and findings at colonoscopy. The median bowel cleanliness scores in the control group and the enhanced-instruction group were 3.0 and 2.0, respectively (P=0.001).

CONCLUSION:

Patient counselling and written instructions are inexpensive, safe and simple interventions. Such interventions are an effective means of optimizing colonoscopy preparation in the inpatient setting.     

Timing and frequency of bowel activity in patients ingesting sodium picosulphate/magnesium citrate and adjuvant bisacodyl for colon cleansing before colonoscopy

BACKGROUND:

Despite the wealth of research investigating bowel cleansing efficacy, there are very little data on the timing or frequency of bowel movements after each agent is ingested.

OBJECTIVE:

To examine the effect of each component of a three-day combined sodium picosulphate/magnesium citrate (PSLX) and bisacodyl regimen on the timing and frequency of bowel activity in patients undergoing colonoscopy.

METHODS:

Outpatients booked for colonoscopy were asked to complete a diary of their bowel preparation that tracked the timing of bowel movements. Bowel preparation quality was assessed using the Ottawa Bowel Preparation Scale. Bowel activity was compared with baseline and correlated with colon cleansing. Subgroup analysis was performed examining the effect of timing of the procedure and split-dose regimens.

RESULTS:

One hundred patients undergoing colon cleansing received bisacodyl 10 mg at 17:00 three days and two days before the day of colonoscopy. In one group, both sachets of PSLX were given the night before colonoscopy, while the second group, whose colonoscopies were scheduled after 11:00, ingested one sachet the night before and the second sachet at 06:00 on the day of colonoscopy. Patients had a mean of 1.7 bowel movements per day in the seven days before starting the cleansing regimen. Both doses of bisacodyl tablets resulted in a significant increase in the mean number of bowel movements compared with baseline (3.3/day first dose; 3.8/day second dose [P=0.03 and 0.001, respectively]). Each dose of PSLX also resulted in a significant increase in bowel movement frequency compared with baseline, with means of 4.4, 6.3 and 4.5 bowel movements after each dose. The mean time to the final bowel movement following the second sachet of PSLX was 8.9 h when taken the night before, and 3.9 h when taken the morning of the procedure. Bowel preparation quality significantly correlated with bowel frequency when total bowel movements were considered and when only the effects of bisacodyl were accounted for (P<0.01 for each).

DISCUSSION:

These data demonstrate that the addition of bisacodyl before PSLX ingestion has a significant additive effect on bowel frequency and correlates with bowel cleansing quality. The timing of the resulting bowel movements have practical implications for sleep and travel times to endoscopy suites.     

A multicentre, observational study of sodium picosulfate and magnesium citrate as a precolonoscopy bowel preparation

BACKGROUND:

Sodium picosulfate with magnesium citrate (PSMC) has been available as a precolonoscopy bowel preparation in Canada since 2005. A high patient acceptability and preference appears to have contributed to its wide adoption across the country. Despite its frequent use, there are relatively few published studies of this product, especially reports regarding its use in routine clinical practice. Moreover, to date, there have been no Canadian studies of any kind.

OBJECTIVE:

To conduct a preliminary evaluation of PSMC by prospectively collecting data describing its effectiveness.

METHODS:

In the present multicentre, observational study, sequential patients used PSMC according to each institution’s standard colonoscopy protocol. Differences in bowel cleansing protocols included dose timing, fluid intake, dietary restrictions and administration of bisacodyl. During colonoscopy, preparation quality was rated separately for the right and left sides of the colon.

RESULTS:

Of the 613 patients entered, 606 were evaluable for efficacy. For the right and left colon, respectively, 93.0% and 96.2% of preparations were rated either ‘excellent’ or ‘adequate’. In the 334 patients who received adjunctive bisacodyl and the 272 patients who did not, the results were similar: for the right and left colon, 92.3% and 97.1% of those who did not, and 93.4% and 95.7% of those who did receive bisacodyl, respectively, were rated either ‘excellent’ or ‘adequate’.

CONCLUSIONS:

Despite the differences in bowel cleansing protocols used at each hospital (including an additional laxative), PSMC consistently yielded a high percentage of positive ratings for efficacy.     

A Clear Liquid Diet Is Not Mandatory for Polyethylene Glycol-Based Bowel Preparation for Afternoon Colonoscopy in Healthy Outpatients

Background/Aims

A dietary regimen consisting of a clear liquid diet (CLD) for at least 24 hours is recommended for colonoscopy preparation. However, this requirement results in problems in patient compliance with bowel preparation. The aim of this study was to evaluate the efficacy of a CLD compared with a regular diet (RD) for colonoscopy preparation using a polyethylene glycol (PEG) solution.

Methods

This was a multicenter, randomized, investigator-blind prospective study. A total of 801 healthy outpatients undergoing afternoon colonoscopy were randomized to either a CLD or RD in addition to a 4 L PEG regimen.

Results

The quality of bowel cleansing was not different between the CLD and RD groups in terms of the proportion with excellent or good preparation. In addition, no significant differences were observed between the two groups for polyp and adenoma detection rates and overall adverse events. Good compliance with bowel preparation was higher in the RD group than in the CLD group.

Conclusions

A CLD for a full day prior to colonoscopy should not be mandatory for PEG-based bowel preparation. Dietary education concerning the avoidance of high-fiber foods for 3 days before colonoscopy is sufficient, at least for healthy outpatients.     

Rate of serious complications of colonoscopy in Quebec

BACKGROUND

The rate of serious complications is one marker of the quality of colonoscopy services.

OBJECTIVE:

To estimate the rate of serious complications of colonoscopy according to colonoscopy indication and polypectomy status.

METHODS:

A prospective cohort study of patients scheduled for colonoscopy who were recruited from seven endoscopy facilities across Montreal (Quebec) was conducted. Before colonoscopy, patients completed a brief questionnaire and provided their health insurance numbers. Colonoscopy indication was based on patient-reported medical history. Polypectomy status was obtained from provincial physician billing records (Régie de l’assurance maladie du Québec). Diagnoses and procedures associated with hospitalization in the 30 days following colonoscopy were obtained from the provincial hospitalization database (MedEcho).

RESULTS:

Of the 2134 patients enrolled (mean age 60.9 years, 50.1% male), 33 (1.55% [95% CI 1.06% to 2.16%]) were hospitalized within 30 days. One patient experienced bleeding following a colonoscopy that involved polypectomy and was diagnosed with carcinoma in situ of the rectum. Based on self-reported rectal bleeding in the previous six months, the colonoscopy was nonscreening. The provincial hospitalization data showed no occurrences of perforation, diverticulitis, myocardial infarction/stroke or death; thus, the rate of serious colonoscopy complications was 0.05% (95% CI 0.00% to 0.26%).

DISCUSSION:

The rate of serious colonoscopy complications requiring hospitalization was low and comparable with what is reported in the literature. The serious complication occurred subsequent to polypectomy and in a nonscreening colonoscopy.

CONCLUSION:

The findings support the relative safety of screening colonoscopy in persons without large bowel diseases and symptoms. However, future research to determine the rate of serious complications not requiring hospitalization is warranted to reassure decision makers of the safety of colonoscopy for colorectal cancer screening.     

Comparing patient and endoscopist perceptions of the colonoscopy indication

BACKGROUND

Determining whether a colonoscopy is performed for screening or nonscreening purposes can facilitate clinical practice and research. However, there is no simple method to determine the colonoscopy indication using patient medical files or health administrative databases.

OBJECTIVE

To determine patient-endoscopist agreement on the colonoscopy indication.

METHODS

A cross-sectional study was conducted among staff endoscopists and their patients at seven university-affiliated hospitals in Montreal, Quebec. The study participants were 50 to 75 years of age, they were able to understand English or French, and were about to undergo colonoscopy. Self- (endoscopist) and interviewer-administered (patient) questionnaires ascertained information that permitted classification of the colonoscopy indication. Patient colonoscopy indication was defined as the following: perceived screening (routine screening, family history, age); perceived nonscreening (follow-up); medical history that implied nonscreening; and a combination of the three preceding indications. Agreement between patient and endoscopist indications was measured using concordance and Kappa statistic.

RESULTS

In total, 702 patients and 38 endoscopists participated. The three most common reasons for undergoing colonoscopy were routine screening/regular check-up (33.8%), follow-up to a previous problem (30.2%) and other problem (24.6%). Concordance (range 0.79 to 0.85) and Kappa (range 0.58 to 0.70) were highest for perceived nonscreening colonoscopy. Recent large bowel symptoms accounted for 120 occurrences of disagreement in which the patient perceived a nonscreening colonoscopy while the endoscopist perceived a screening colonoscopy.

CONCLUSIONS

Patient self-report may be an acceptable means for rapidly assessing whether a colonoscopy is performed for screening or nonscreening purposes. Delivery of patient-centred care may help patients and endoscopists reach a shared understanding of the reason for colonoscopy.     

Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program--Endoscopy

BACKGROUND

Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.

OBJECTIVE

To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.

METHODS

A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.

RESULTS

Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).

DISCUSSION

Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.

CONCLUSION

Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.     

Qualitative study of physician perspectives on classifying screening and nonscreening colonoscopy using administrative health data: Adding practice does not make perfect

BACKGROUND:

Previously developed screening colonoscopy algorithms based on diagnostic and endoscopy procedural variables have not been sufficiently accurate for use in epidemiological and health services research.

OBJECTIVE:

To increase understanding of the administrative health database variables that could help to discern screening and nonscreening colonoscopy.

METHODS:

A qualitative study using physician focus groups was conducted in Montreal (Quebec), Calgary (Alberta) and Toronto (Ontario). Specialty-specific focus group sessions were held among family physicians and gastroenterologists – the physicians responsible for referring patients to and performing screening colonoscopy, respectively. Interview guides were developed to better understand physician clinical and billing practices. Discussions were audiotaped, transcribed verbatim and analyzed using the constant comparative approach.

RESULTS:

Forty family physicians and seven gastroenterologists participated in five focus group sessions. Patient variables included demographics (age) and medical history (colorectal cancer risk factors/symptoms, medication for colorectal cancer risk factors/symptoms, gastrointestinal disorders, severe disease). Clinical practice variables included timing of the colonoscopy (evenings, weekends, holidays, during hospitalization; same-day endoscopist consultation and colonoscopy), use of services (hospitalization, annual examination, transfer from other facility) and procedure use patterns (large bowel or other medical/surgical procedure before and subsequent to colonoscopy). However, wide variability in clinical and billing practices will likely preclude the development of a reasonably accurate screening colonoscopy algorithm. Physicians suggested adding a screening colonoscopy code to the administrative health data.

CONCLUSIONS:

Failure to acknowledge the limitations of the provincial administrative health databases to identify screening colonoscopy may lead to incorrect conclusions and the establishment of inappropriate health care policies.     

Practice and documentation of performance of colonoscopy in a central Canadian health region

OBJECTIVE:

To evaluate the reporting and performance of colonoscopy in a large urban centre.

METHODS:

Colonoscopies performed between January and April 2008 in community hospitals and academic centres in the Winnipeg Regional Health Authority (Manitoba) were identified from hospital discharge databases and retrospective review of a random sample of identified charts. Information regarding reporting of colonoscopies (including bowel preparation, photodocumentation of cecum/ileum, size, site, characteristics and method of polyp removal), colonoscopy completion rates and follow-up recommendations was extracted. Colonoscopy completion rates were compared among different groups of physicians.

RESULTS:

A total of 797 colonoscopies were evaluated. Several deficiencies in reporting were identified. For example, bowel preparation quality was reported in only 20%, the agent used for bowel preparation was recorded in 50%, photodocumentation of colonoscopy completion in 6% and polyp appearance (ie, pedunculated or not) in 34%, and polyp size in 66%. Although the overall colonoscopy completion rate was 92%, there was a significant difference among physicians with varying medical specialty training and volume of procedures performed. Recommendations for follow-up procedures (barium enema, computed tomography colonography or repeat colonoscopy) were recorded for a minority of individuals with reported poor bowel preparation or incomplete colonoscopy.

CONCLUSIONS:

The present study found many deficiencies in reporting of colonoscopy in typical, city-wide clinical practices. Colonoscopy completion rates varied among different physician specialties. There is an urgent need to adopt standardized colonoscopy reporting systems in everyday practice and to provide feedback to physicians regarding deficiencies so they can be rectified.     

Serious events in older Ontario residents receiving bowel preparations for outpatient colonoscopy with various comorbidity profiles: a descriptive, population-based study

BACKGROUND:

Polyethylene glycol-based bowel preparations (PEGBPs) and sodium picosulfate (NaPS) are commonly used for bowel cleansing before colonoscopy. Little is known about adverse events associated with these preparations, particularly in older patients or patients with medical comorbidities.

OBJECTIVE:

To characterize the incidence of serious events following outpatient colonoscopy in patients using PEGBPs or NaPS.

METHODS:

The present population-based retrospective cohort study examined data from Ontario health care databases between April 1, 2005 and December 31, 2007, including patients ≥66 years of age who received either PEGBP or NaPS for an outpatient colonoscopy. Patients with cardiac or renal disease, long-term care residents or patients receiving concurrent diuretic therapy were identified as high risk for adverse events. The primary outcome was a serious event (SE) defined as a composite of nonelective hospitalization, emergency department visit or death within seven days of the colonoscopy.

RESULTS:

Of the 50,660 outpatients ≥66 years of age who underwent a colonoscopy, SEs were observed in 675 (2.4%) and 543 (2.4%) patients in the PEGBP and NaPS groups, respectively. Among high-risk patients (n=30,168), SEs occurred in 481 (2.8%) and 367 (2.8%) of patients receiving PEGBP and NaPS, respectively.

CONCLUSIONS:

The SE rate within seven days of outpatient colonoscopy was 24 per 1000 procedures, and among high-risk patients was 28 per 1000 procedures. The rates were similar for PEGBP and NaPS. Clinicians should be aware of the risks associated with colonoscopy in older patients with comorbidities.     

Patient satisfaction with colonoscopy: A literature review and pilot study

BACKGROUND:

Current guidelines recommend that colonoscopic colorectal cancer screening be undertaken every 10 years after the age of 50 years. However, because the procedure does not meet criteria that promote screening uptake, patient satisfaction with colonoscopy may encourage repeat screening.

OBJECTIVE:

To systematically review the literature and conduct a pilot study of patient satisfaction with the colonoscopy experience.

METHODS:

All cohort studies from January 1997 to August 2008 in the MEDLINE database that measured either patient satisfaction with colonoscopy, patient willingness to return for colonoscopy under the same conditions or patient preference for colonoscopy compared with other large bowel procedures were identified. The search was supplemented by journal citation lists in the retrieved articles.

RESULTS:

Of the 29 studies identified, 15 met the inclusion criteria. Consistently, the vast majority of patients (approximately 95%) were very satisfied with their colonoscopy experience. Patient satisfaction was similar for screening and nonscreening colonoscopy. Patient willingness to return for the procedure ranged from 73% to 100%. Of the five studies that examined modality preference, three studies reported the majority of patients preferred colonography to colonoscopy and two studies reported the reverse. Our pilot study findings mirrored those of other studies that were conducted in the United States. The major limitation of the included studies was that patients who were most dissatisfied may have gone elsewhere to have their colonoscopy.

CONCLUSIONS:

Patients were very satisfied with colonoscopy. The majority were willing to return for repeat testing under the same conditions, and colonoscopy was not preferred over other modalities. However, studies were limited by methodological shortcomings.     

Different screening definitions have little impact on polypectomy rate estimates

BACKGROUND:

Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate.

OBJECTIVE:

To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications.

METHODS:

A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer.

RESULTS:

A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94.

DISCUSSION:

Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar.

CONCLUSION:

The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.     

A Korean experience of the use of Boston Bowel Preparation Scale: A Valid and Reliable Instrument for Colonoscopy-Oriented Research

Background/Aims:

Few bowel preparation scales have been validated. The Boston Bowel Preparation Scale (BBPS) is a novel bowel preparation scale in western countries. We validated the BBPS in Korean patients and assessed the relationship between the colon polyp detection rate and BBPS score.

Patients and Methods:

This study was a prospective, single-center trial. The BBPS is a 10-point scale that assesses bowel preparation after the completion of all cleansing maneuvers. We assessed three segment scores (the right side, transverse section, and left side) and total BBPS scores during screening colonoscopy. In addition, we compared the BBPS scores with clinically meaningful outcomes such as the polyp detection rate and colonoscope withdrawal times.

Results:

We enrolled 482 screening colonoscopies between January 2011 and January 2012. The mean (± standard deviation [SD]) BBPS score was 8.1 ± 1.1. Higher BBPS scores (≥8 vs <8) were associated with a higher polyp detection rate (44.9% vs. 33.0%, P = 0.042). The BBPS scores were inversely correlated with colonoscope withdrawal times (r = −0.167, P < 0.001).

Conclusions:

The BBPS is a valid and reliable measure for assessing bowel preparation during colonoscopy in Korean patients. The polyp detection rate is higher in patients with higher BBPS scores than in those with lower BBPS scores during a colonoscopic procedure.     

A Comparison of 2 L of Polyethylene Glycol and 45 mL of Sodium Phosphate versus 4 L of Polyethylene Glycol for Bowel Cleansing: A Prospective Randomized Trial

Background/Aims

Polyethylene glycol (PEG)-based gut lavage solutions are safe and effective, but require the intake of large volumes of fluid. The use of 2 L PEG plus 45 mL sodium phosphate (PEG2 plus NaP) was compared with 4 L PEG (PEG4) for bowel cleansing before colonoscopy.

Methods

Patients were randomized to the PEG2 plus NaP group or PEG4 group between January 1, 2009 and March 31, 2010. One hundred and thirty patients were included in the PEG2 plus NaP group, and 141 patients in the PEG4 group.

Results

The qualities of the bowel preparation, based on the Ottawa scale were not significantly different between the groups (4.8±2.25 for the PEG2 plus NaP group vs. 5.11±2.26 for the PEG4). In addition, there were no significant differences in side effects. Laboratory findings after bowel preparation, including electrolyte, phosphorus and creatinine levels, were within the normal ranges in both groups.

Conclusions

PEG2 plus NaP provides good cleansing that is similar to PEG4, but with a lower volume. However, because PEG2 plus NaP can cause serious side effects such as calcium deposition in the kidneys (i.e., nephrocalcinosis), this solution might be considered for the outpatients who cannot tolerate PEG4.     

A comparison of hospital and nonhospital colonoscopy: wait times, fees and guideline adherence to follow-up interval

BACKGROUND:

Although colonoscopy is increasingly performed in nonhospital facilities, studies to date examining differences between colonoscopy services in hospital and nonhospital settings have been limited, in large part, to administrative databases.

OBJECTIVES:

To describe the experiences of patients receiving colonoscopy in hospital and nonhospital settings, and to compare these settings with respect to wait times and recommended follow-up interval to the next colonoscopy.

METHODS:

A postal survey of 2000 patients, 50 to 70 years of age, from an urban academic family practice was conducted. Most recent colonoscopy was classified as either occurring in a hospital or nonhospital setting. Multivariable logistic regression analysis was used to examine the association among wait times, follow-up intervals and patient factors with respect to colonoscopy setting.

RESULTS:

Patients who underwent their most recent colonoscopy outside of a hospital were more likely to be men (P=0.01) and to have undergone more than one previous colonoscopy (P=0.02). For patients with a normal screening colonoscopy and no family history of colorectal cancer or polyps, nonhospital clinics less often recommended a 10-year follow-up interval (OR 0.13 [95% CI 0.04 to 0.47]). Reported wait times at nonhospital clinics were shorter for patients receiving screening colonoscopy (OR 2.11 [95% CI 1.28 to 3.47]), but not for symptomatic patients (OR 1.74 [95% CI 0.88 to 3.43]). For individuals attending nonhospital clinics, 10% were referred from a hospital by the same specialist performing the procedure; 31.7% reported paying a fee.

CONCLUSION:

Nonhospital clinics were far less likely to adhere to guidelines regarding follow-up intervals for low-risk patients. Given the implications for both health care costs and patient safety, further study is needed to determine the cause of this disparity.     

Does Polyethylene Glycol (PEG) Plus Ascorbic Acid Induce More Mucosal Injuries than Split-Dose 4-L PEG during Bowel Preparation?

Background/Aims

The aims of this study were to compare the bowel-cleansing efficacy, patient affinity for the preparation solution, and mucosal injury between a split dose of poly-ethylene glycol (SD-PEG) and low-volume PEG plus ascorbic acid (LV-PEG+Asc) in outpatient scheduled colonoscopies.

Methods

Of the 319 patients, 160 were enrolled for SD-PEG, and 159 for LV-PEG+Asc. The bowel-cleansing efficacy was rated according to the Ottawa bowel preparation scale. Patient affinity for the preparation solution was assessed using a questionnaire. All mucosal injuries observed during colonoscopy were biopsied and histopathologically reviewed.

Results

There was no significant difference in bowel cleansing between the groups. The LV-PEG+Asc group reported better patient acceptance and preference. There were no significant differences in the incidence or characteristics of the mucosal injuries between the two groups.

Conclusions

Compared with SD-PEG, LV-PEG+Asc exhibited equivalent bowel-cleansing efficacy and resulted in improved patient acceptance and preference. There was no significant difference in mucosal injury between SD-PEG and LV-PEG+Asc. Thus, the LV-PEG+Asc preparation could be used more effectively and easily for routine colonoscopies without risking significant mucosal injury.     

Importance of the Time Interval between Bowel Preparation and Colonoscopy in Determining the Quality of Bowel Preparation for Full-Dose Polyethylene Glycol Preparation

Background/Aims

The quality of bowel preparation (QBP) is the important factor in performing a successful colonoscopy. Several factors influencing QBP have been reported; however, some factors, such as the optimal preparation-to-colonoscopy time interval, remain controversial. This study aimed to determine the factors influencing QBP and the optimal time interval for full-dose polyethylene glycol (PEG) preparation.

Methods

A total of 165 patients who underwent colonoscopy from June 2012 to August 2012 were prospectively evaluated. The QBP was assessed using the Ottawa Bowel Preparation Scale (Ottawa) score according to several factors influencing the QBP were analyzed.

Results

Colonoscopies with a time interval of 5 to 6 hours had the best Ottawa score in all parts of the colon. Patients with time intervals of 6 hours or less had the better QBP than those with time intervals of more than 6 hours (p=0.046). In the multivariate analysis, the time interval (odds ratio, 1.897; 95% confidence interval, 1.006 to 3.577; p=0.048) was the only significant contributor to a satisfactory bowel preparation.

Conclusions

The optimal time was 5 to 6 hours for the full-dose PEG method, and the time interval was the only significant contributor to a satisfactory bowel preparation.     

Screening Colonoscopy in the US: Attitudes and Practices of Primary Care Physicians

Background

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery.

Objective

Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns.

Design

Cross-sectional analysis of data from a nationally representative survey conducted in 2006–2007.

Participants

1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists.

Main Measures

Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics.

Results

The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering.

Conclusions

PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.KEY WORDS: colorectal cancer screening, primary care physicians, colonoscopy screening practices     

Adenoma detection rates decline with increasing procedural hours in an endoscopist’s workload

BACKGROUND:

Operator fatigue may negatively influence adenoma detection (AD) during screening colonoscopy.

OBJECTIVE:

To better characterize factors affecting AD, including the number of hours worked, and the number and type of procedures performed before an index screening colonoscopy.

METHODS:

A retrospective cohort study was conducted involving individuals undergoing a screening colonoscopy at a major tertiary care hospital in Montreal, Quebec. Individuals were identified using an endoscopic reporting database; AD was identified by an electronic chart review. A hierarchical logistic regression analysis was performed to determine the association between patient- and endoscopist-related variables and AD.

RESULTS:

A total of 430 consecutive colonoscopies performed by 10 gastroenterologists and two surgeons were included. Patient mean (± SD) age was 63.4±10.9 years, 56.3% were males, 27.7% had undergone a previous colonoscopy and the cecal intubation rate was 95.7%. The overall AD rate was 25.7%. Age was associated with AD (OR 1.06 [95% CI 1.03 to 1.08]), while female sex (OR 0.44 [95% CI 0.25 to 0.75]), an indication for average-risk screening (OR 0.47 [95% CI 0.27 to 0.80]) and an increase in the number of hours during which endoscopies were performed before the index colonoscopy (OR 0.87 [95% CI 0.76 to 0.99]) were associated with lower AD rates. On exploratory univariable analysis, a threshold of 3 h of endoscopy time performed before the index colonoscopy was associated with decreased AD.

CONCLUSION:

The number of hours devoted to endoscopies before the index colonoscopy was inversely associated with AD rate, with decreased performance possibly as early as within 3 h. This metric should be confirmed in future studies and considered when optimizing scheduling practices.