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A Telephone-Based Education Program Improves Bowel Preparation Quality in Patients Undergoing Outpatient Colonoscopy
March 2015
there were a multiple choice examination querying the best diagnostic test for indeterminate bile duct strictures, potential answers might include clinical history, cholangiographic features, cytology brushings, forceps biopsies, EUS-FNA, and FISH. Although the options increase in number (every test takers nightmare), the correct answer remains “all of the above.” We should calibrate our practices accordingly.
Selected Summaries
657
Liu X, Luo H, Zhang L, et al. Telephone-based reeducation on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomised, controlled study. Gut 2014;63:125–130.
education was administered by a single physician investigator, 22–28 hours before the procedure. This intervention emphasized the importance of bowel preparation, appropriate use and side effects of the preparation, and dietary instructions. The primary outcome was the proportion of patients in each arm with adequate bowel preparation, defined as Ottawa score of <6 at the time of the procedure. Bowel preparation was considered inadequate if Ottawa score was 6, or if the colonoscopy was canceled or incomplete. Secondary outcomes included polyp detection rate, noncompliance with preparation instructions, and willingness to repeat bowel preparation. All colonoscopies were performed without conscious sedation, using identical equipment, by 4 experienced endoscopists. There were 605 patients between ages 18 and 75 randomized—305 to the intervention arm and 300 to the control arm. Baseline characteristics were similar between the 2 groups. In an intention-to-treat analysis, adequate preparation was achieved in 81.6% of intervention patients and 70.3% of control patients (P < .001), an absolute increase of approximately 11.3% and number needed to treat of 9. The polyp detection rate was also greater in the intervention group (38.0% vs 24.7%; P < .001). Patients in the control group were more likely to be noncompliant with bowel preparation than those in the intervention group (32.6% vs 9.4%; P < .001). On multivariable analysis, factors associated independently with inadequate bowel preparation included constipation, incorrect start time of preparation, and incorrect dietary restriction (P ¼ .009).
High-quality colonoscopy can markedly reduce morbidity and mortality related to colorectal cancer (N Engl J Med 2014;370:1298–1306). However, the effectiveness of colonoscopy depends on the quality of bowel preparation. Bowel preparation is inadequate in approximately 25% of patients who present for colonoscopy (Gastrointest Endosc 2005;61:378–384). Inadequate bowel preparation increases the risk of missed neoplasia (Gastrointest Endosc 2003;58:76–79). It also increases the technical difficulty of colonoscopy and reduces the efficiency of the procedure. Finally, inadequate preparation leads to more frequent colonoscopies, increasing the cumulative risk to patients, depleting limited endoscopic resources, and increasing health care expenditures. Thus, effective interventions to increase the quality of bowel preparation could have important clinical and economic benefits. In this randomized, controlled trial, Liu et al studied the impact of a telephone-based educational intervention to improve bowel preparation quality on the day before outpatient colonoscopy (Gut 2014;63:125–130). The study was conducted at a single endoscopy center in China. Before the procedure, all patients received standard bowel preparation instructions, which included nurse-directed education and a booklet with written instructions. Bowel preparation consisted of 2 sachets of PEG-ELP in 2 L of water or 90 mL sodium phosphate in 1.5 L water. Once the procedure was scheduled, the patients were assigned randomly to receive telephone-based education (the intervention) versus usual care (control). Telephone-based
Comment. Investigators have long known that the effectiveness of colonoscopy is linked intimately to bowel preparation quality (Gastrointest Endosc 2003;58:76–79). Furthermore, bowel preparation quality depends on patient adherence to the preparation regimen. It is, therefore, natural to seek methods to improve bowel preparation quality through enhanced education. A recent United States Multi-Society Task Force consensus guideline on bowel cleansing for colonoscopy acknowledged the fundamental importance of adherence to bowel preparation instructions and called for standardization and validation of educational interventions to improve preparation quality (Gastroenterology 2014;147:903–924). This study adds to a growing body of literature on this topic, which includes studies testing a variety of delivery platforms for patient education on bowel preparation. Investigators have examined educational approaches ranging from one-on-one teaching by nurses or physicians to educational pamphlets and, more recently, smartphone applications. Unfortunately, educational interventions remain underutilized. The advantage of a telephone-based intervention is that it is potentially scalable (eg, most patients will have access to a telephone). If such an intervention could be scripted and automated (eg, through interactive voice response), it could be centralized and performed at a relatively low cost. Overall, the study was well executed. Strengths include successful blinding and randomization and use of an intention-to-treat analysis, all of which enhance the study’s
NABEEL S. KORO B. JOSEPH ELMUNZER GREGORY A. COTÉ Department of Medicine Division of Gastroenterology & Hepatology Medical University of South Carolina Charleston, South Carolina
A TELEPHONE-BASED EDUCATION PROGRAM IMPROVES BOWEL PREPARATION QUALITY IN PATIENTS UNDERGOING OUTPATIENT COLONOSCOPY
658
Selected Summaries
internal validity. Many studies on this topic have used less robust study designs, such as pre–post or other quasiexperimental approaches. Despite these strengths, the study may have limited external validity (ie, generalizability) for several reasons. First, it was performed at a single center in China, where practice patterns and patient adherence may differ from the United States. For instance, sodium phosphate, which is no longer used in the United States, was utilized in approximately one-fourth of patients in the study, and split preparation (now the standard of care) was not utilized. Additionally, although telephone interventions are generally feasible, the use of a physician to deliver the intervention also limits the study’s generalizability. It is not clear whether delivery of the intervention by nonphysicians would have the same effect. Nonetheless, it is important to note that this was an efficacy study that aimed to determine whether the educational intervention improved bowel preparation in a controlled setting (rather than an effectiveness study that aimed to determine whether the intervention was effective in usual practice).
Gastroenterology Vol. 148, No. 3
In summary, this study demonstrates that a telephonebased, physician-delivered educational intervention can improve colonoscopy preparation and other measures of colonoscopy quality in an experimental context. As the US health care system becomes increasingly focused on the quality, efficiency, and value of health care, interventions to improve colonoscopy quality and efficiency will assume greater importance. Future studies are needed to determine whether such interventions are feasible and effective in realworld practice. ARJUN R. SONDHI JACOB E. KURLANDER Department of Internal Medicine University of Michigan Medical School AKBAR K. WALJEE SAMEER D. SAINI Department of Internal Medicine University of Michigan Medical School and Veterans Affairs Center for Clinical Management Research Ann Arbor, Michigan
there were a multiple choice examination querying the best diagnostic test for indeterminate bile duct strictures, potential answers might include clinical history, cholangiographic features, cytology brushings, forceps biopsies, EUS-FNA, and FISH. Although the options increase in number (every test takers nightmare), the correct answer remains “all of the above.” We should calibrate our practices accordingly.
Selected Summaries
657
Liu X, Luo H, Zhang L, et al. Telephone-based reeducation on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomised, controlled study. Gut 2014;63:125–130.
education was administered by a single physician investigator, 22–28 hours before the procedure. This intervention emphasized the importance of bowel preparation, appropriate use and side effects of the preparation, and dietary instructions. The primary outcome was the proportion of patients in each arm with adequate bowel preparation, defined as Ottawa score of <6 at the time of the procedure. Bowel preparation was considered inadequate if Ottawa score was 6, or if the colonoscopy was canceled or incomplete. Secondary outcomes included polyp detection rate, noncompliance with preparation instructions, and willingness to repeat bowel preparation. All colonoscopies were performed without conscious sedation, using identical equipment, by 4 experienced endoscopists. There were 605 patients between ages 18 and 75 randomized—305 to the intervention arm and 300 to the control arm. Baseline characteristics were similar between the 2 groups. In an intention-to-treat analysis, adequate preparation was achieved in 81.6% of intervention patients and 70.3% of control patients (P < .001), an absolute increase of approximately 11.3% and number needed to treat of 9. The polyp detection rate was also greater in the intervention group (38.0% vs 24.7%; P < .001). Patients in the control group were more likely to be noncompliant with bowel preparation than those in the intervention group (32.6% vs 9.4%; P < .001). On multivariable analysis, factors associated independently with inadequate bowel preparation included constipation, incorrect start time of preparation, and incorrect dietary restriction (P ¼ .009).
High-quality colonoscopy can markedly reduce morbidity and mortality related to colorectal cancer (N Engl J Med 2014;370:1298–1306). However, the effectiveness of colonoscopy depends on the quality of bowel preparation. Bowel preparation is inadequate in approximately 25% of patients who present for colonoscopy (Gastrointest Endosc 2005;61:378–384). Inadequate bowel preparation increases the risk of missed neoplasia (Gastrointest Endosc 2003;58:76–79). It also increases the technical difficulty of colonoscopy and reduces the efficiency of the procedure. Finally, inadequate preparation leads to more frequent colonoscopies, increasing the cumulative risk to patients, depleting limited endoscopic resources, and increasing health care expenditures. Thus, effective interventions to increase the quality of bowel preparation could have important clinical and economic benefits. In this randomized, controlled trial, Liu et al studied the impact of a telephone-based educational intervention to improve bowel preparation quality on the day before outpatient colonoscopy (Gut 2014;63:125–130). The study was conducted at a single endoscopy center in China. Before the procedure, all patients received standard bowel preparation instructions, which included nurse-directed education and a booklet with written instructions. Bowel preparation consisted of 2 sachets of PEG-ELP in 2 L of water or 90 mL sodium phosphate in 1.5 L water. Once the procedure was scheduled, the patients were assigned randomly to receive telephone-based education (the intervention) versus usual care (control). Telephone-based
Comment. Investigators have long known that the effectiveness of colonoscopy is linked intimately to bowel preparation quality (Gastrointest Endosc 2003;58:76–79). Furthermore, bowel preparation quality depends on patient adherence to the preparation regimen. It is, therefore, natural to seek methods to improve bowel preparation quality through enhanced education. A recent United States Multi-Society Task Force consensus guideline on bowel cleansing for colonoscopy acknowledged the fundamental importance of adherence to bowel preparation instructions and called for standardization and validation of educational interventions to improve preparation quality (Gastroenterology 2014;147:903–924). This study adds to a growing body of literature on this topic, which includes studies testing a variety of delivery platforms for patient education on bowel preparation. Investigators have examined educational approaches ranging from one-on-one teaching by nurses or physicians to educational pamphlets and, more recently, smartphone applications. Unfortunately, educational interventions remain underutilized. The advantage of a telephone-based intervention is that it is potentially scalable (eg, most patients will have access to a telephone). If such an intervention could be scripted and automated (eg, through interactive voice response), it could be centralized and performed at a relatively low cost. Overall, the study was well executed. Strengths include successful blinding and randomization and use of an intention-to-treat analysis, all of which enhance the study’s
NABEEL S. KORO B. JOSEPH ELMUNZER GREGORY A. COTÉ Department of Medicine Division of Gastroenterology & Hepatology Medical University of South Carolina Charleston, South Carolina
A TELEPHONE-BASED EDUCATION PROGRAM IMPROVES BOWEL PREPARATION QUALITY IN PATIENTS UNDERGOING OUTPATIENT COLONOSCOPY
658
Selected Summaries
internal validity. Many studies on this topic have used less robust study designs, such as pre–post or other quasiexperimental approaches. Despite these strengths, the study may have limited external validity (ie, generalizability) for several reasons. First, it was performed at a single center in China, where practice patterns and patient adherence may differ from the United States. For instance, sodium phosphate, which is no longer used in the United States, was utilized in approximately one-fourth of patients in the study, and split preparation (now the standard of care) was not utilized. Additionally, although telephone interventions are generally feasible, the use of a physician to deliver the intervention also limits the study’s generalizability. It is not clear whether delivery of the intervention by nonphysicians would have the same effect. Nonetheless, it is important to note that this was an efficacy study that aimed to determine whether the educational intervention improved bowel preparation in a controlled setting (rather than an effectiveness study that aimed to determine whether the intervention was effective in usual practice).
Gastroenterology Vol. 148, No. 3
In summary, this study demonstrates that a telephonebased, physician-delivered educational intervention can improve colonoscopy preparation and other measures of colonoscopy quality in an experimental context. As the US health care system becomes increasingly focused on the quality, efficiency, and value of health care, interventions to improve colonoscopy quality and efficiency will assume greater importance. Future studies are needed to determine whether such interventions are feasible and effective in realworld practice. ARJUN R. SONDHI JACOB E. KURLANDER Department of Internal Medicine University of Michigan Medical School AKBAR K. WALJEE SAMEER D. SAINI Department of Internal Medicine University of Michigan Medical School and Veterans Affairs Center for Clinical Management Research Ann Arbor, Michigan