Abstract 9 A Good Bowel Prep, Can We as Physicians do Better?

Abstract

Colorectal cancer (CRC) is a leading cause of cancer death in the US and high-quality colonoscopy is key to efficient CRC screening and detection. Previous studies indicated that 18% to 31% of patients have inadequate bowel preparation. It has been reported that nearly 20% of patients with poor bowel preparation fail to follow instructions. We hypothesized that educating physicians who order colon purgatives with general tips on good quality bowel cleansing will improve the adequacy of preparation by helping to choose the most appropriate protocol tailored to each patients’ medical comorbidities. The aim of this quality improvement project was to determine whether a teaching intervention for ordering primary care physicians improves the patient’s bowel preparation quality and changes prescribing habits. This was a prospective cohort study. Physicians ordering colonoscopies in primary care practices were provided with a brief informational session regarding the available bowel cleansing agents and useful tips for a good bowel prep. Patients undergoing a screening or diagnostic colonoscopy 3 months prior to the intervention and 3 months after completion of the teaching intervention were identified by reviewing endoscopy records. Outpatient charts were reviewed to record demographics and additional data on patient factors. Differences between continuous variables were assessed using analysis of variance for multiple group comparisons or the Student t-test for comparisons between the 2 groups. The χ2 test was used to assess differences in distributions of categorical variables. A total of 192 patients underwent screening or diagnostic colonoscopies 3 months preceding the teaching intervention compared with 175 patients afterwards. Gender, body mass index, ethnicity, and patient factors (Table 1) were comparable between the 2 groups, except for a slightly older population (mean age, 64.8 vs 60.8 years) present in the pre-intervention group. Bowel prep quality overall was good in both groups as assessed by the total Boston Bowel Prep Score (BBPS, 6.64 vs 6.66) and only 9 compared with 8 patients who had inadequate preparation (BBPS < 5) pre- and post-intervention, respectively (NS). Additional measures of quality, such as segmental BBPS scores and withdrawal time, did not show a marked improvement after intervention. The majority of physicians prescribed large volume purgatives (GoLytely, MoviPrep) with the preferred split dosing (Table 2). In a multivariate analysis, only patient factors were predictive of inadequate bowel preparation quality (BBPS <5) (P = .0029). Inadequate bowel preparation is a common problem with potential impact on colorectal cancer screening quality. In our cohort, provider education had no measurable impact on bowel prep quality, which was already adequate in most patients before our proposed intervention. However, our negative findings on the role of provider education may not translate into all practice settings. Furthermore, patient-related risk factors were predictive of worse bowel prep quality, indicating the importance of tailoring our colon prep prescribing practices by these parameters to achieve high-quality colonoscopy.Table 1Pre-InterventionPost-InterventionP valueMeanStd DevMeanStd DevAge (y)64.779.8260.8310.19<.001BMI28.074.8227.825.13.63GenderN% totalN% total.72 Female9826.70%8623.43% Male9425.61%8924.25%Ethnicity.07 White16444.69%15141.14% Black41.09%51.36% Asian30.82%102.72% Hispanic133.54%61.63% Other82.18%30.82%Patient factors.45 Type 2 diabetes mellitus246.76%195.35% Narcotic use10.28%51.41% Constipation154.23%113.10% Prior colon surgery30.85%20.56% BBPS (total score)6.641.266.661.30.88 BBPS < 5 inadequate92.47%82.19%.94 BBPS ≥ 5 inadequate18149.59%16745.75% BBPS right2.120.532.140.56.71 BBPS transverse2.350.532.310.51.44 BBPS left2.180.562.250.51.22 Number of polyps1.741.951.602.11.51 Cecal intubation10.557.7011.537.61.22 Withdrawal in13.507.1714.539.23.24Procedure Time25.259.8926.2912.78.39 Open table in a new tab Table 2Pre-InterventionPost-InterventionN% totalN% totalBowel prep used.19 GoLytely6317.17%6617.98% MoviPrep12734.60%10528.61% Suprep00.00%30.82% Prepopik20.54%10.27%Split dose?.19 Yes16645.23%15943.32% No267.08%164.36% Open table in a new tab