Rate Of Inadequate Bowel Preparation Research Articles

Screening and Colonoscopy Quality Measures: Ethnic Disparities and Impact on Patients' Outcome.

Recent reports have confirmed the improving trends in colorectal cancer (CRC) incidence and outcomes. Still, disparities in incidence and mortality in CRC continue to persist between major ethnic groups despite the provision of widespread screening and improved care. We aimed to outline, from an endoscopic point of view, ethnic disparities in major endoscopic measures concerned with CRC screening and detection and track their impact on patients' outcomes. We reviewed electronic reports of patients referred for colonoscopy procedures over 20 years. We compared demographic, clinical, and endoscopic findings between major ethnic population groups in Israel. In addition, trends of screening utilization, bowel preparation, and polyp detection rates were tracked, and the incidence of CRC diagnosis was followed. A total of 51307 patients had undergone colonoscopies, of whom 16% were Arabs, and 84% were Jewish. The procedures performed for CRC screening throughout the study period were significantly lower in Arabs (5% vs. 13.1%; P < 0.0001). In parallel, for most of the follow-up period, the Arab patients had higher rates of inadequate bowel preparation (overall: 19.9% vs. 12%; P < 0.001) and a lower polyp detection rate (16.7% vs. 22.5%; P < 0.0001). Expectedly, the incidence of CRC has steadily decreased in the Jewish group, while an adverse pattern of increasing incidence was documented in the Arab patient during the follow-up period. Characterized by lower screening utilization and poor bowel preparation, the incidence of CRC development in Arab patients is increasing, while improving trends of CRC were observed in their Jewish counterparts.

Improving bowel preparation for colonoscopy with a smartphone application driven by artificial intelligence

Optimal bowel preparation is a prerequisite for a successful colonoscopy; however, the rate of inadequate bowel preparation remains relatively high. In this study, we establish a smartphone app that assesses patient bowel preparation using an artificial intelligence (AI)-based prediction system trained on labeled photographs of feces in the toilet and evaluate its impact on bowel preparation quality in colonoscopy outpatients. We conduct a prospective, single-masked, multicenter randomized clinical trial, enrolling outpatients who own a smartphone and are scheduled for a colonoscopy. We screen 578 eligible patients and randomize 524 in a 1:1 ratio to the control or AI-driven app group for bowel preparation. The study endpoints are the percentage of patients with adequate bowel preparation and the total BBPS score, compliance with dietary restrictions and purgative instructions, polyp detection rate, and adenoma detection rate (secondary). The prediction system has an accuracy of 95.15%, a specificity of 97.25%, and an area under the curve of 0.98 in the test dataset. In the full analysis set (n = 500), adequate preparation is significantly higher in the AI-driven app group (88.54 vs. 65.59%; P < 0.001). The mean BBPS score is 6.74 ± 1.25 in the AI-driven app group and 5.97 ± 1.81 in the control group (P < 0.001). The rates of compliance with dietary restrictions (93.68 vs. 83.81%, P = 0.001) and purgative instructions (96.05 vs. 84.62%, P < 0.001) are significantly higher in the AI-driven app group, as is the rate of additional purgative intake (26.88 vs. 17.41%, P = 0.011). Thus, our AI-driven smartphone app significantly improves the quality of bowel preparation and patient compliance.

Influencing factors for the quality of bowel preparation with polyethylene glycol electrolyte powder combined with diet control before colonoscopy in children

To investigate the influencing factors for the quality of bowel preparation before colonoscopy in children and the association of the interval from the last administration of laxative to the start of colonoscopy (shortly referred to as waiting time) with the quality of bowel preparation. A retrospective analysis was performed for the children who were admitted to the Department of Gastroenterology, Children's Hospital of Nanjing Medical University, from January to November 2020, and received bowel preparation with polyethylene glycol electrolyte powder combined with diet control before colonoscopy. According to the score of Boston bowel preparation scale, they were divided into two groups: adequate bowel preparation group (n=337) and inadequate bowel preparation group (n=30). Related data were collected from the children in both groups, including general information, possible influencing factors for the quality of bowel preparation, adverse reactions associated with bowel preparation, duration of colonoscopy, and postoperative diagnosis. Univariate and multivariate analyses were used to explore the influencing factors for the quality of bowel preparation. The univariate analysis showed that age, body weight, and waiting time were associated with inadequate bowel preparation (P<0.05). The multivariate analysis showed that older age (OR=2.155, 95%CI: 1.087-4.273, P=0.028) and longer waiting time (OR=1.559, 95% CI: 1.191-2.041, P=0.001) were independent risk factors for inadequate bowel preparation. The receiver operating characteristic (ROC) curve analysis showed that the cut-off value of waiting time was 5.5 hours in determining whether bowel preparation was adequate or not, with a sensitivity of 90.0%, a specificity of 50.7%, and an area under the ROC curve of 0.708. After grouping based on waiting time, it was found that the incidence rate of inadequate bowel preparation in the ≥5.5 hours group was significantly higher than that in the <5.5 hours group [14.0% (27/193) vs 1.7% (3/174), P<0.001]. For children who use polyethylene glycol electrolyte powder combined with diet control for bowel preparation, older age is an independent risk factor for inadequate bowel preparation before colonoscopy, which may be associated with an insufficient dose of polyethylene glycol in older children. Longer waiting time is also an independent risk factor for inadequate bowel preparation, and it is recommended that the waiting time should not exceed 5.5 hours.

Effects of a Personalized Smartphone App on Bowel Preparation Quality: Randomized Controlled Trial.

BackgroundAdequate bowel preparation is essential for the visualization of the colonic mucosa during colonoscopy. However, the rate of inadequate bowel preparation is still high, ranging from 18% to 35%; this may lead to a higher risk of missing clinically relevant lesions, procedural difficulties, prolonged procedural time, an increased number of interval colorectal carcinomas, and additional health care costs.ObjectiveThe aims of this study are to compare bowel preparation instructions provided via a personalized smartphone app (Prepit, Ferring B V) with regular written instructions for bowel preparation to improve bowel preparation quality and to evaluate patient satisfaction with the bowel preparation procedure.MethodsEligible patients scheduled for an outpatient colonoscopy were randomized to a smartphone app group or a control group. Both the groups received identical face-to-face education from a research physician, including instructions about the colonoscopy procedure, diet restrictions, and laxative intake. In addition, the control group received written information, whereas the smartphone app group was instructed to use the smartphone app instead of the written information for the actual steps of the bowel preparation schedule. All patients used bisacodyl and sodium picosulfate with magnesium citrate as laxatives. The quality of bowel preparation was scored using the Boston Bowel Preparation Scale (BBPS) by blinded endoscopists. Patient satisfaction was measured using the Patient Satisfaction Questionnaire-18.ResultsA total of 87 patients were included in the smartphone app group and 86 in the control group. The mean total BBPS score was significantly higher in the smartphone app group (mean 8.3, SD 0.9) than in the control group (mean 7.9, SD 1.2; P=.03). The right colon showed a significantly higher bowel preparation score in the smartphone app group (mean 2.7, SD 0.5 vs mean 2.5, SD 0.6; P=.04). No significant differences were observed in segment scores for the mean transverse colon (mean 2.8, SD 0.4 vs mean 2.8, SD 0.4; P=.34) and left colon (mean 2.8, SD 0.4 vs mean 2.6, SD 0.5; P=.07). General patient satisfaction was high for the smartphone app group (mean 4.4, SD 0.7) but showed no significant difference when compared with the control group (mean 4.3, SD 0.8; P=.32).ConclusionsOur personalized smartphone app significantly improved bowel preparation quality compared with regular written instructions for bowel preparation. In particular, in the right colon, the BBPS score improved, which is of clinical relevance because the right colon is considered more difficult to clean and the polyp detection rate in the right colon improves with improvement of bowel cleansing of the right colon. No further improvement in patient satisfaction was observed compared with patients receiving regular written instructions.Trial RegistrationClinicalTrials.gov NCT03677050; https://clinicaltrials.gov/ct2/show/NCT03677050

A108 ARE INPATIENTS STILL MORE LIKELY TO FAIL BOWEL PREPARATION IN THE SPLIT-DOSE ERA? FINDINGS FROM 47, 292 COLONOSCOPIES IN THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Abstract Background Prior studies before the widespread use of split-dose bowel preparation have shown a high rate of inadequate bowel preparation in hospitalized patients. Whether this is still true in the era of split-dose bowel preparation is unknown. Aims To determine the impact of inpatient status on bowel preparation quality in the contemporary era of split-dose bowel preparation. Methods The Southwest Ontario Colonoscopy cohort consists of all inpatient and outpatient colonoscopies performed between April 2017 and Oct 2018 at 21 hospitals serving a large geographic health region. Procedures done in patients &amp;lt; 18 years of age or by an endoscopist performing &amp;lt;50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed. The primary outcome was adequate bowel preparation, defined on an ordinal scale as “good” or “fair” rather than “poor”. Secondary outcomes included adenoma detection rate (ADR), sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), and cecal intubation rate (CIR). Results A total of 47,292 colonoscopies were performed by 75 physicians (36.2% by gastroenterologists, 60% by general surgeons, 4% others), of which 1,690 were inpatients (3.6%). Inpatients were older (mean 66.8 years vs 60.2 years, p&amp;lt;0.0001), more co-morbid (≥ASA grade 3, 53.6% vs 23.7%, p&amp;lt;0.0001), performed for symptomatic indications (95.7% vs 48.6%, p&amp;lt; 0.0001), have trainee involvement (47% vs 11.6% p&amp;lt;0.001), and less likely to receive split-dose bowel preparation (71.7% vs 91.6% p&amp;lt;0.001). On crude analysis, inpatients were less likely to have adequate bowel preparation (86.2% vs 97.6% p&amp;lt;0.001). On multi-variable analysis, inpatients had lower odds of achieving adequate bowel preparation (OR=0.41, 95% CI 0.33 - 0.50, p&amp;lt;0.001), lower ADR (OR=0.47, 95% CI 0.40 - 0.55, p&amp;lt;0.001), lower PDR (OR=0.54, 95% CI 0.47 - 0.61 p&amp;lt;0.001) and lower CIR (OR = 0.43, 95% CI 0.35 - 0.54, p&amp;lt;0.001). Conclusions In the era of split-dose bowel preparation, inpatient status is still an important predictor of inadequate bowel preparation with resultant lower quality outcome metrics. Funding Agencies None

Volume of fluid consumption during preparation for colonoscopy is possibly the single most important determinant of bowel preparation adequacy.

BackgroundThe effectiveness and safety of colonoscopy are directly dependent on the quality of bowel preparation. Multiple risk factors for inadequate bowel preparation (IBP) have been identified; however, IBP is still reported in 20-30% of cases in most studies. We aimed to identify modifiable predictors of the adequacy of bowel preparation using sodium picosulfate, and to recommend easily modifiable parameters to increase the success rate of colonoscopies.MethodsThis was a single-center observational study of adult outpatients referred for an elective colonoscopy. Patients were interviewed prior to colonoscopy; volume of liquids consumed was calculated as number of 200-mL cups showed to the patient. Additional information, including medical history, diagnoses and regular medications, was procured from patients’ medical records. Univariate and multivariate regression analyses were performed to identify factors significantly associated with IBP in a subgroup analysis of high-risk patients.ResultsThe rate of IBP in 1172 subjects was 19.4%. This rate decreased as fluid consumption increased, with a further drop associated with shorter intervals from end of preparation to colonoscopy. Drinking < 1.4 L significantly increased the risk of IBP (odds ratio [OR] 3.62, 95% confidence interval [CI] 2.65-4.95), while drinking ≥2 L was associated with adequate preparation (OR 0.09, 95%CI 0-0.42). These associations were stronger in high-risk individuals.ConclusionGreater fluid intake and short interval to colonoscopy are easily modifiable parameters that can substantially reduce the rate of IBP, especially among high-risk individuals.

S0270 Repeat Endoscopies in Patients With Suboptimal Bowel Prep in a Safety Net Setting

INTRODUCTION: Colorectal cancer is the 3rd leading cause of death in the US. Colonoscopy is the most commonly used diagnostic tool in our arsenal and more than 15 million are performed annually in the US. In 2012, The US Multi-Society Task Force on Colorectal Cancer guidelines for the first time mentioned poor preparation and recommended repeat examination within 1 year in most cases of poor bowel preparation. METHODS: We performed a retrospective review of inpatient and outpatient electronic health records at Dell Seton Medical Center and CommUnityCare (CUC), a large safety net health care system in Austin, Texas to describe rates of inadequate bowel preparation. We identified 1709 eligible patients between ages 50 and 75 within the safety net system who had evidence of colonoscopy within the past 10 years. 204 of 1709 (12%) patients had suboptimal bowel prep, identified as fair or poor. Each chart was reviewed to determine what the recommended interval was for repeat testing was, whether it was performed, and whether any further intervention was necessary. RESULTS: Of the 204 patient who had suboptimal prep, 109 (53%) were deemed to be in need of a colonoscopy or fecal immunochemical test (FIT) as no follow-up was done.Those patients were classified into increased risk (personal or family history of CRC, adenomatous polyps or polyps with dysplasia or FIT positive) or average risk (no risk factors). Average risk patients were sent FIT test kits, while increased risk patients were contacted and scheduled for colonoscopies. Of the 109, 67 (61%) were deemed to need FIT testing, 24 (22%) were in need of colonoscopies now, 9 (8%) were in need of colonoscopies in the future, 6 (5%) patients were out of CUC system, and 3 (3%) were >75 years old and over age of recommended screening. Of the 41 patients overdue for colonoscopy that we were able to contact, 4 (0.1%) of those patients were found with cancer or high-grade dysplasia. CONCLUSION: Healthcare providers must be aware of patients with poor bowel prep, particularly in a safety net setting. Poorly prepared colons result in a longer cecal intubation time, a lower cecal intubation rate, higher adenoma miss rate (AMR), as well as increase in total costs to healthcare system. Therefore, gastroenterologists should develop a call back or a reminder system and should educate patients about need for repeat colonoscopies in those poor prep.Figure 1.: Schematic Representation of Follow-up for Patients with History of Poor Prep Colonoscopy.

S3088 Single Center Evaluation of Patient and Healthcare System Related Factors Influencing Inadequate Bowel Preparation Rates

INTRODUCTION: Colonoscopy is the most effective test for the detection and prevention of colorectal cancer. However, studies report 20 to 40 percent of colonoscopies have inadequate bowel preparation (IBP). Having high rates of IBP lead to challenges including those of quality, safety, economic and most notably, patient experience which have consequences that increase rate of aborted procedures, failure to reschedule, missed detection of polyps and cancer. Many institutions have a triage process to determine both patient and healthcare system related predictors contributing to poor rates. Understanding this, we dedicated efforts to identify the IBP rate in our center as well as factors that influence it. METHODS: Outpatient Colonoscopy procedure data were collected from Provation® and Athena® electronic medical records from December 31, 2018 to December 31, 2019. IBP is defined as presence of any form of stool that precludes visualization and require a repeat colonoscopy within a year. Patient factors included age, gender, if English is a primary language, presence or absence of more than 2 comorbidities, constipation, and Medicaid insurance. Healthcare system-related factors included procedures booked in private vs fellows clinic, morning vs afternoon procedure, month vs after a month, directly vs after consultant visit, and repeat procedures. RESULTS: A total of 1505 colonoscopies were performed and 175 (11.6%) had IBP. Of these, 42.3% were initial colonoscopies, 56.6% had prior colonoscopies performed and only 14.3% returned for repeat colonoscopy. IBP was seen in 62.9% of screening colonoscopies and 36.6% of diagnostic colonoscopies (Figure 1). The most common prep used was Golytely®. Healthcare system-related factors are displayed in Figure 2, and patient-related factors are displayed in Figure 3, respectively. CONCLUSION: Poor colonoscopy preparation is an ongoing issue that affects both the patient and healthcare system alike in many aspects. We sought to evaluate our centers colonoscopy preparation rates. There was no single patient related factor that contributed to significant IBP rate. However, within the system, procedures booked a month after the visit carried a high rate of poor preparation. This is likely due to the inherent memory recall issue, which our institution has now incorporated a patient phone call 48 hours in advance to explain preparation.Figure 1.: Indication for colonoscopy.Figure 2.: Healthcare system-related factors leading to inadequate bowel preparation.Figure 3.: Patient-related factors leading to inadequate bowel preparation.

Comparing the Real-World Effectiveness of High- Versus Low-Volume Split Colonoscopy Preparations: An Experience Through the British Columbia Colon Cancer Screening Program.

BackgroundThe British Columbia Colon Screening Program (BCCSP) is a population-based colon cancer screening program. In December 2018, physicians in Vancouver, Canada agreed to switch from a low-volume split preparation to a high-volume polyethylene glycol preparation after a meta-analysis of studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates.AimsTo compare the quality of bowel preparation and neoplasia detection rates using a high-volume split preparation (HVSP) versus a low-volume split preparation (LVSP) in patients undergoing colonoscopy in the BCCSP.MethodsA retrospective review of patients undergoing colonoscopy through the BCCSP at St. Paul’s Hospital from July 2017 to November 2018 and December 2018 to November 2019 was conducted. Inclusion criteria included age 50 to 74 and patients undergoing colonoscopy through the BCCSP. Variables collected included patient demographics and bowel preparation quality. Rates of bowel preparation and neoplasia detection were analyzed using chi-squared test.ResultsA total of 1453 colonoscopies were included, 877 in the LVSP group and 576 in the HVSP group. No statistically significant difference was noted between rates of inadequate bowel preparation (LVSP 3.6% versus HVSP 2.8%; P = 0.364). Greater rates of excellent (48.4% versus 40.1%; P = 0.002) and optimal (90.1% versus 86.5%; P = 0.041) bowel preparation were achieved with HVSP. The overall adenoma detection rate was similar between the two groups (LVSP 53.1% versus HVSP 54.0%; P = 0.074). LVSP demonstrated higher overall sessile serrated lesion detection rate (9.5% versus 5.6%; P = 0.007).ConclusionsCompared to LVSP, HVSP was associated with an increase in excellent and optimal bowel preparations, but without an improvement in overall neoplasia detection.

Mo1747 ONE WEEK POLYETHYLENE GYCOL (PEG) 3350 FOLLOWED BY SPLIT DOSE PEG ELECTOLYTE SOLUTION WITH OR WITHOUT ASCORBIC ACID IMPROVED COLONOSCOPY BOWEL PREPARATION IN PATIENTS WITH CONSTIPATION: A QUALITY IMPROVEMENT PROJECT AT A LARGE VETERANS AFFAIRS HOSPITAL

High quality bowel preparation is crucial for an effective examination of the colon during colonoscopy. Diabetes, chronic constipation, spinal cord injury, and the use of medications such as narcotics and tricyclic antidepressants are well known predictors of inadequate bowel preparation. The 2014 US Multi-Society Task Force guidelines do not recommend the use of a specific bowel regimen in high risk patients, and limits its statement to the favorable use of additional purgatives in this group of patients (weak recommendation, low quality evidence). We aimed to identify the rate of inadequate bowel preparation in high risk patients and to compare the efficacy of different types of bowel preparations in this population. We identified colonoscopies (n=3651) performed at our institution between January 2019 until November 2019. Patients at high risk for inadequate preparation were identified by specific ICD-10 codes for constipation, diabetes or spinal cord injury or by review of outpatient pharmacy orders for narcotics, antidepressants or laxatives. Bowel preparation adequacy was reported according to the 4- point Boston Bowel Preparation Scale. Mid-P Exact test was used to compare the rates of poor bowel preparation in constipated patients according to the bowel preparation received. The majority of patients were male (92.3%) with a mean age of 64.2+10.4. Approximately 65% of patients received a split dose PEG electrolyte solution with ascorbic acid (Moviprep), 25% received 1 week of PEG 3350 (Miralax) prior to a split dose Moviprep or PEG electrolyte solution (Golytely), and 9.5% prepped with Golytely. Overall, 680 colonoscopies (18.6%) had inadequate bowel preparation of which 235 (6.4%) were deemed poor. A total of 2166 colonoscopies (59.3%) were performed on high risk patients (table). Among high risk patients, the rate of inadequate bowel preparation was 24.5% (figure). In a subgroup analysis on patients with constipation who were prescribed laxatives (n=984), the rate of poor bowel preparation was significantly reduced in patients who received 1 week of Miralax followed by split dose Moviprep or Golytely (13.9%) compared to Split dose Moviprep or Golytely alone (19.9%) OR= 0.65( 95% CI: 0.46-0.91, p=0.006). High risk patients have an increased rate of inadequate bowel preparation. One week of Miralax followed by split dose Moviprep or Golytely reduced the rate of poor bowel preparation in constipated patients on laxatives. If proven beneficial in large randomized controlled trials, this method of preparation will reduce repeated colonoscopies and wasted capacity in endoscopy unit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Factors affecting bowel preparation adequacy and procedural time.

Background and AimPoor bowel preparation results in difficult colonoscopies, missed lesions, and repeat procedures. Identifying patient risk factors for poor bowel preparation, such as prolonged runway time and prolonged cecal intubation, will aid in interventions prior to a procedure.MethodsThis was a retrospective, single‐center analysis of 3 295 colonoscopies performed between May 2012 and November 2014. Indications for colonoscopy included gastrointestinal bleed and anemia, change in bowel habits, for screening, and others (including planning re‐anastomoses, abdominal distension, family history and angioectasias). Data were collected from medical charts and endoscopy reports. Comparisons between patient factors and runway time were made with adequacy of bowel preparation as the primary outcomes.ResultsMale and diabetic patients had statistically higher rates of inadequate bowel preparation and prolonged cecal intubation times. A previous history of abdominal surgery also demonstrated prolonged cecal intubation. A runway time of ≤7.63 h was associated with higher rates of adequate bowel preparation by multivariate analysis. The optimal time frame is 3–6 h for the highest success rates.ConclusionPatient risk factors for inadequate bowel preparation or prolonged cecal intubation should signal clinicians to intervene prior to colonoscopy. A runway time between 3 and 6 h is optimal for adequate bowel preparation. This may involve further patient education, along with work flow optimization, to facilitate ideal runway times. Future studies should explore how to avoid repeat endoscopies using protocols enforcing this timeframe.

Modifiable Factors Associated with Quality of Bowel Preparation Among Hospitalized Patients Undergoing Colonoscopy

Inadequate bowel preparation (IBP) is a common problem in hospitalized patients; however, little is known about how to prevent IBP. In a large, multihospital system, we evaluated the association between modifiable factors and IBP rate. We reviewed data from adult (≥18 years) inpatients undergoing colonoscopy between January 2011 and June 2017. Colonoscopies performed in the intensive care unit or lacking descriptions of bowel preparation quality were excluded. Multivariate logistic regression analysis was performed to identify factors associated with IBP. A counterfactual analysis was performed to assess the potential contribution of modifiable factors to IBP. Of 8,819 patients that were included (median age of 64 years; 50.5% female), 51% had IBP. Patients with IBP stayed in the hospital one day longer than those with adequate bowel preparation (P < .001). Modifiable factors associated with IBP include opiate use within three days of colonoscopy (OR, 1.31; 95% CI, 1.18, 1.45), colonoscopy performed after 12:00 pm (OR, 1.25; 95% CI, 1.1, 1.41), and solid diet the day before colonoscopy (OR, 1.37; 95% CI, 1.18, 1.59). In the counterfactual analysis, if all patients avoided these three conditions, adjusted IBP rates were reduced by 5.6%. Among hospitalized patients undergoing colonoscopy, IBP rates are high and associated with an increased length of stay. Avoiding opiates before colonoscopy, performing colonoscopy before noon, and maintaining patients on a liquid diet or nil per os might significantly reduce IBP rates.

Which Patient-Related Factors Determine Optimal Bowel Preparation?

Adequate bowel cleansing before colonoscopy is a simple concept but the high rate of inadequate or incomplete bowel cleanliness and its consequences have been the subject of many studies, guidelines, and meta-analysis. The complexity resides in all the factors surrounding preparation intake such as type and regimen of bowel preparation, diets, compliance, and also patient-related factors that all influence quality of the bowel preparation. The purpose of this review is to focus specifically on patient-related factors and their challenges. Patients with lower GI bleeding are excluded from this review. Patient factors that may be associated with a poor bowel preparation were searched for in the literature. With regard to patient's characteristics, higher age, male gender, and socio-economic status (lower income, Medicaid, and lower education) were all associated with higher rates of inadequate bowel preparation. Comorbidities such as inflammatory bowel disease (IBD), in-patients, body mass index (BMI), cirrhosis, constipation, and neurological condition as well as some pharmacotherapy were also associated with inadequate bowel preparation. Studies identifying predictive patient factors as well as those studying these patients in particular showed variability in the strength of the patient factor associations. Patients taking tricyclic antidepressant, narcotics, and those with neurological conditions were identified to have a stronger association with worse bowel cleanliness. Those can be implemented with the current recommendations of split-dosing. Identifying individual factors that can impact the quality of bowel cleanliness can be challenging. Some have been well-studied in the literature such as age, in-patient status, or constipation and others such as male gender or higher BMI have required more studies to clearly conclude on any possible association. In many studies, simple recommendations like walking 30min during the preparation, and additional instructions or support have also been added to instructions to improve motility and compliance.

Our Center Experience in Improving Colonic Preparation for Screening Colonoscopy: Quality Improvement Project

Introduction: Inadequate bowel preparation limits the efficacy of screening colonoscopy, leads to significant healthcare cost, increases the risk of complications, and lowers compliance among patients. Well written and communicated instructions are essential in achieving proper bowel preparation. The aim of our quality improvement project was to decrease the rate of inadequate bowel preparations for screening colonoscopies at Cleveland Clinic Florida by providing education to ordering providers and improving written instructions for bowel preparation. Methods: We performed a retrospective analysis of all pre-intervention patients who underwent screening colonoscopy at our center from November 15, 2016 through January 10, 2017. The first part of our intervention was to assess the knowledge of axillary staff and ordering providers in form of a survey and to educate them on new recommendations for bowel preparation. The second part of our intervention was to modify the written bowel prep instructions to include new recommendations on following the split dose bowel prep or same day bowel prep. Due to our large Spanish speaking population, we included Spanish instructions as well. We performed a prospective analysis of all patients undergoing screening colonoscopy post-intervention from March 15, 2017 to May 10, 2017. We included patient demographics, ordering department, department performing colonoscopy, and the quality of the bowel preparation. Our primary endpoint was the rate of incomplete, canceled and re-scheduled colonoscopies in the pre-intervention vs post-intervention period. We measured the odds ratio for the cancelation rate and rescheduling rate for both groups. Results: A total of 2,478 patients underwent screening colonoscopy at our center from November 2016 until May 2017. Out of 1,032 patients in the pre-intervention group, 106 (10.3%) had inadequate preparation or were cancelled due to issues with preparation. From the 1,446 patients in the post-intervention group, 97 patients (6.7%) had inadequate preparation or were cancelled. Screening colonoscopies were significantly less likely to be re-scheduled (OR 0.66; p<.001) or cancelled (OR 0.61; p<0.01) due to bowel preparation after our intervention. Conclusion: Our study shows that providing education to staff and enhancing bowel preparation instructions can significantly decrease the rate of inadequate bowel preparation. This leads to improved utilization of resources, patient satisfaction and decrease in healthcare cost.1098 Figure 1 No Caption available.

Modifiable Factors Associated With Inadequate Bowel Preparation Quality in Patients With Inadequate Bowel Preparation on Index Outpatient Colonoscopy

Introduction: Inadequate bowel preparation (IBP) reduces the efficacy of colonoscopy. While it is often necessary to have a repeat colonoscopy in this setting, research has demonstrated that having IBP on index colonoscopy increases the risk of IBP on the second colonoscopy. After adjusting for other factors associated with bowel preparation quality, we identified and assessed the impact of modifiable factors associated with IBP on the second colonoscopy. Methods: Records of all patients with IBP who underwent at least 2 outpatient colonoscopies in the Cleveland Clinic between Jan 2011 and June 2017 identified. Information about patient demographics, clinical, and colonoscopic factors were obtained. Multivariable logistic regression was performed to identify factors associated with IBP on second colonoscopy. Next using this model, a counter-factual analysis was performed whereby hypothesized changes in the modifiable factors were applied to the study population. The effect of such hypothesized changes on IBP rate was computed. Results: Overall, N=4,677 outpatients had IBP on the first colonoscopy (50% male, mean age 60 years). On the second colonoscopy, 32% of these patients had IBP. Modifiable factors inversely associated with IBP on the second colonoscopy include: having colonoscopy performed before noon (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71, 0.94), use of low volume ( Conclusion: In patients who have IBP on initial colonoscopy, scheduling the second colonoscopy in the morning, using low volume bowel preparation, and repeating the colonoscopy the next day were all associated with improved outcomes. Indeed, our model predicts that instituting all of these changes would have resulted in a 15% decrease in the rate of IBP of patients undergoing repeat colonoscopy compared to patients in whom the opposite of these changes was instituted.220_A Figure 1 No Caption available.220_B Figure 2 No Caption available.

Tu1033 RISK FACTORS FOR INADEQUATE BOWEL PREPARATION IN PATIENTS WITH FUNCTIONAL CONSTIPATION

Constipation is a common reason of poor bowel preparation, which negatively influences the quality of colonoscopy. The risk factors associated with inadequate bowel preparation in constipated patients remains unclear. The aim of this study was to investigate the high-risk factors which might influence the quality of bowel preparation in patients with functional constipation. In this multicenter, prospective cohort study, consecutive patients with functional constipation who underwent colonoscopy between May 2016 and April 2017 were enrolled. Standard split-dose of 4 Liter (L) polyethylene glycol (PEG) was used for bowel preparation. Patient-related and procedure-related parameters were recorded. The primary outcome was adequate rate of bowel preparation, defined as Boston Bowel Preparation Scale (BBPS) ≥6 with each segment ≥2. Risk factors for inadequate bowel preparation were screened by multivariate logistic regression analysis. A total of 199 patients with functional constipation were included. 78.4% of them were female. Adequate bowel preparation was found in 62.8% (125/199) of patients. At multivariate analysis, Bristol stool form scale (BSFS) 1 (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.11-4.56; P = 0.008), no or mild pain during defecation (OR 4.14, 95% CI 1.22-13.97; P=0.022), and starting-to-defecation interval more than 4h (OR 3.10, 95% CI 1.17-8.22; P=0.023) were independent risk factors for inadequate bowel preparation in patients with constipation. For patients with non-, 1, 2 or 3 risk factors, the rates of inadequate bowel preparation were 11%, 23%, 49%, and 65% respectively (P＜0.001). With standard preparation regime, more than 1/3 of patients with functional constipation had inadequate bowel cleansing. BSFS 1, no or mild pain during defecation, and starting-to-defecation interval more than 4h were identified as independent risk factors for inadequate bowel preparation in constipated patients.Tabled 1Multivariate analysis of the association between potentially significant factors and inadequate bowel preparationInadequate rate, n (%)OR (95% CI)P valueUnmarried6/9 (66.7%)4.24 (0.87-20.81)0.075Past alcohol intake1/11 (9.1%)0.17 (0.02-1.52)0.113Duration of constipation ≥4 years44/130 (33.8%)0.55 (0.26-1.16)0.119BSFS score 150/110 (45.5%)2.25 (1.11-4.56)0.024No or mild pain during defecation70/174 (40.2%)4.14 (1.22-13.97)0.022Stools ≤3 times per week31/104 (29.8%)1.31 (0.65-2.64)0.45Using purgatives ≥2 times per week22/77 (28.6%)0.87 (0.42-1.78)0.695Starting-to-defecation interval ≥4h20/32 (62.5%)3.10 (1.17-8.22)0.023Vomiting19/36 (52.8%)2.89 (0.91-14.32)0.113Nausea41/84 (48.8%)1.56 (0.79-3.05)0.199Stools ≤2 times after 1st PEG23/45 (51.1%)1.37 (0.60-3.13)0.454BSFS, Bristol stool form scale; PEG, polyethylene glycol; OR, odds ratio; CI, confidence interval. Open table in a new tab

923 ADJUSTED COMPARISON OF COMMERCIAL BOWEL PREPARATIONS BASED ON INADEQUACY OF BOWEL PREPARATION IN OUTPATIENT SETTINGS

Adequate bowel preparation is important for effective colonoscopic examination. Although limited research has identified commercial bowel preparations (CBP) associated with inadequate bowel preparation (IBP) it does not adjust for multiple known risk factors associated with IBP. In this study, after adjusting for many factors previously identified to affect IBP, various commercial bowel preparations are compared with each other. After obtaining permission from Institutional Review Board, all ambulatory colonoscopies performed within the Cleveland Clinic system (Jan 2011-Aug 2017) were reviewed. Risk factors previously noted to affect IBP were identified: age, gender, race, body mass index, payor status, Primary spoken language (English v. other), diabetes, cirrhosis, dementia, stroke, constipation, coronary artery disease, heart failure, opiate use, timing of colonoscopy (AM v. PM, day of the week, month of the year), colonoscopy location, endoscopist specialty, distance from home to colonoscopy location, individual providers, and when CBP was picked up by patient. Differences in IBP by specific CBP--SUPREP (Su), OsmoPrep (Os), PREPOPIK (Pr), NuLYTELY (Nu), GoLYTELY (Go), CoLyte (Co), MoviPrep (Mo), GaviLyte (Ga), HalfLytely (Ha), and TriLyte (Tr)--were calculated and significance was assessed using chi-square analysis. Multivariate analysis was performed. N=140,912 colonoscopies were reviewed. Overall IBP was noted 19.5% of colonoscopies. Bar-graph demonstrating IBP by various CBPs is noted (Figure 1). After adjusting for risk factors of ABP. Compared to Su, Os (OR=2.68), Pr (OR=1.94), Go (OR=2.09), Co (OR=1.94), Mo (OR=2.22), Ga (OR=1.88), and Ha (OR=3.52) had significantly increased risk of IBP. Next, compared to Nu, Os (OR=2.46), Pr (OR=1.78), Co (OR=1.78), Mo (OR=2.04), Ga (OR=1.73), Ha (OR=3.23) had significantly increased risk of IBP. Further, compared to Pr, Mo (OR=1.15) and Ha (OR=1.68) had increased odds of IBP. Compared to Go, Mo (OR=1.06) and Ha (OR=1.68) had increased risk of IBP. Only comparisons, where p<0.05 are listed above. Refer to Table 1 complete set comparisons. Adjusting for many patient characteristics, procedural factors, and risk factors associated with IBP, CBPs can be arranged in the following order from lowest to highest rates of IBP: (Su and Nu comparable efficacy), Os, Pr, (Co & Go have comparable efficacy), Ga, Tr, and Ha. While further evaluation is necessary to evaluate the efficacy of preparations used infrequently, this large study on bowel preparations has significant impact with respect to improving adenoma detection rate (as IBP worsens ABP), and prevent recurrent IBP--along with the significant patient discomfort and financial burden associated with it.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The incidence of and risk factors for inadequate bowel preparation in elderly patients: A prospective observational study.

Background/Aim:We conducted a prospective observational study to identify the incidence of and risk factors for inadequate bowel preparation in elderly Chinese patients.Patients and Methods:We enrolled 240 outpatients over 60 years of age scheduled for elective colonoscopy at our university hospital between November 2016 and April 2017. We recorded patient demographics, bowel preparation data, and clinical characteristics. Factors associated with inadequate bowel preparation were identified by multivariate logistical regression analysis.Results:The rate of inadequate bowel preparation was 34.6%. Factors associated with inadequate bowel preparation were a history of abdominal surgery (OR, 2.617; CI, 1.324–5.174; P = 0.006), chronic constipation (OR, 3.307; CI, 1.551–7.054; P = 0.002), non-compliance with dietary instructions (OR, 2.239; CI, 1.122–4.471; P = 0.022), non-compliance with polyethylene glycol (PEG) dosage (OR, 4.576; CI, 1.855–11.287; P = 0.001), walking <30 minutes during preparation (OR, 2.474; CI, 1.261–4.855; P = 0.008), interval between PEG ingestion and the onset of bowel activity (OR, 1.025; CI, 1.010–1.040; P = 0.001), and a last stool that was not clear and watery (OR, 4.191; CI, 1.529–11.485; P = 0.005).Conclusion:The incidence of adequate bowel preparation in elderly patients is not optimal. Walking <30 minutes during the PEG ingestion period may be a surrogate for bowel preparation failure. Future studies should identify elderly patients at risk for poor bowel preparation and develop interventions to improve outcomes in this population.

Factors Influencing the Adequacy of Bowel Preparation in Patients With Developmental Disabilities.

BackgroundThe rate of inadequate bowel preparation in the general population is approximately 23%. As more individuals with developmental disabilities enter late adulthood, a concomitant rise in endoscopic procedures for this population, including screening colonoscopies, is anticipated. However, there are sparse data on the adequacy of bowel preparation in patients with developmental disabilities.MethodsA retrospective analysis of 91 patients with developmental disabilities who underwent colonoscopy from 2006 to 2014 was performed. Bowel preparation adequacy from these procedures was evaluated, together with other data, including age, developmental disability diagnoses, procedure type, indication and setting.ResultsMean age at the time of endoscopy was 52.6 ± 13.4 years, with an age range of 18 - 74 years. Inadequate bowel preparation was found in approximately 51% of documented cases. Outpatients were more likely to have adequate bowel preparation compared to inpatients, with an odds ratio of 2.75 (95% confidence interval: 1.14 - 6.62, P = 0.022). No other major factors identified had any statistically significant influence on the adequacy of bowel preparation.ConclusionOver half of patients with developmental disabilities undergoing colonoscopy had inadequate bowel preparations in our study, which is more than twice the rate for the general population. Furthermore, outpatients were 2.75 times more likely to have adequate bowel preparation compared to inpatients. Further studies are recommended to improve endoscopic practices for this patient population.

Cost Effectiveness of Screening Colonoscopy Depends on Adequate Bowel Preparation Rates - A Modeling Study.

BackgroundInadequate bowel preparation during screening colonoscopy necessitates repeating colonoscopy. Studies suggest inadequate bowel preparation rates of 20–60%. This increases the cost of colonoscopy for our society.AimThe aim of this study is to determine the impact of inadequate bowel preparation rate on the cost effectiveness of colonoscopy compared to other screening strategies for colorectal cancer (CRC).MethodsA microsimulation model of CRC screening strategies for the general population at average risk for CRC. The strategies include fecal immunochemistry test (FIT) every year, colonoscopy every ten years, sigmoidoscopy every five years, or stool DNA test every 3 years. The screening could be performed at private practice offices, outpatient hospitals, and ambulatory surgical centers.ResultsAt the current assumed inadequate bowel preparation rate of 25%, the cost of colonoscopy as a screening strategy is above society’s willingness to pay (<$50,000/QALY). Threshold analysis demonstrated that an inadequate bowel preparation rate of 13% or less is necessary before colonoscopy is considered more cost effective than FIT. At inadequate bowel preparation rates of 25%, colonoscopy is still more cost effective compared to sigmoidoscopy and stool DNA test. Sensitivity analysis of all inputs adjusted by ±10% showed incremental cost effectiveness ratio values were influenced most by the specificity, adherence, and sensitivity of FIT and colonoscopy.ConclusionsScreening colonoscopy is not a cost effective strategy when compared with fecal immunochemical test, as long as the inadequate bowel preparation rate is greater than 13%.