Improvement in Adenoma Detection Rate in a High Risk Population Using Two Simple Interventions

Abstract

Introduction: High quality colonoscopy is associated with favorable adenoma detection rates (ADR) and polyp detection rates (PDR), which improve outcomes related to colorectal cancer. Inadequate bowel preparation limits colonoscopy by impairing visualization, increasing cost, and decreasing PDR and ADR. Barriers to adequate bowel preparation include Medicaid health insurance, non-English primary language, lower educational background or health literacy, low patient motivation, and increased time to procedure. Using a Plan Do Study Act (PDSA) model, we implemented a split-dose bowel regimen and multi-lingual educational booklet, and achieved >90% prep adequacy. Here, we report the effect of improved bowel preparation on ADR in a diverse, high-risk population at a New York City public hospital. Methods: In 1/2014 we implemented a split-dose bowel preparation regimen (cycle 1). In 8/2014, we implemented a visual multi-language educational booklet in English, Spanish and Chinese (cycle 2). Individual patient data on polyps found and histopathology was collected during inception of the interventions from October 2013 to December 2014. Hospital data was collected for years 2013 and 2015, which included number of screening, colonoscopies and adenomas detected. Chi-square testing was performed in R (version 3.3.1) to evaluate the difference in ADR pre and post interventions. Results: There was an overall upward trend noted in PDR and ADR from October 2013 to December 2014 through each intervention cycle (Figure 1). Within this group, patients were similar in age (median = 57; p=0.56). Across the hospital, there were 1345 screening colonoscopies with 320 adenomas detected in 2013. Post intervention (2015) there was 1555 colonoscopies with 424 adenomas detected. An ADR of 24% was achieved in 2013 versus 27% in 2015 (p=0.0331).Figure 1Conclusion: Split-dose bowel preparation combined with a multi-language educational booklet to improve bowel preparation is associated with improved PDR and ADR in a high risk, ethnically diverse population. Utilizing the PDSA cycle we made a significant impact on two important quality markers, preparation adequacy and ADR.