Meta-analysis: The effect of patient education on bowel preparation for colonoscopy

Background and study aims: The proportion of outpatients with inadequate bowel preparation before colonoscopy is high owing to patient unawareness of its importance and poor adherence to instructions. This meta-analysis aimed to determine the effect of educational intervention on the quality of bowel preparation before colonoscopy.

Patients and methods: A comprehensive literature review identified randomized controlled trials measuring the effect of educational intervention on the quality of bowel preparation. Two reviewers independently screened relevant articles, extracted data, and assessed the risk of bias. The primary outcome was the quality of each bowel preparation before colonoscopy, using a particular assessment scale. The secondary outcomes were polyp detection rates during the procedure and the need for a repeat colonoscopy due to incomplete examination.

Results: Nine randomized controlled trials were included in this meta-analysis. In all, 2885 patients were enrolled, with 1458 receiving education and 1427 assigned to the control group. An educational intervention before colonoscopy significantly improved bowel preparation (relative risk [RR] = 1.22; 95 % confidence interval [CI], 1.10 – 1.36), however, no significant differences were identified in polyp detection rates (RR = 1.14; 95 %CI 0.87 – 1.51) or the need for repeat colonoscopy (RR = 0.52; 95 %CI 0.25 – 1.04) between the groups. Asymmetry in the appearance of the funnel plot and the result of Egger test (P < 0.001) suggested that publication bias existed.

Conclusions: Evidence from these randomized controlled trials shows that a brief counseling session with patients before colonoscopy ensures better bowel preparation. However, evidence is insufficient to assess improvements in polyp detection rate and avoidance of a repeat colonoscopy. Despite these encouraging observations, this meta-analysis had some limitations, including potential publication bias and significant heterogeneity of the types of bowel purgatives. These results should be interpreted with caution.

• References

• 1 Grassini M, Verna C, Battaglia E et al. Education improves colonoscopy appropriateness. Gastrointest Endosc 2008; 67: 88-93
• 2 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
• 3 Zauber AG, Winawer SJ, O'Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 4 Froehlich F, Wietlisbach V, Gonvers JJ et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005; 61: 378-384
• 5 Ziv Y, Scapa E. A new colonic lavage system to prepare the colon for colonoscopy: a retrospective study. Tech Coloproctol 2013; 17: 39-44
• 6 Calderwood AH, Lai EJ, Fix OK et al. An endoscopist-blinded, randomized, controlled trial of a simple visual aid to improve bowel preparation for screening colonoscopy. Gastrointest Endosc 2011; 73: 307-314
• 7 Byrne MF. The curse of poor bowel preparation for colonoscopy. Am J Gastroenterol 2002; 97: 1587-1590
• 8 Rex DK, Imperiale TF, Latinovich DR et al. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol 2002; 97: 1696-1700
• 9 Park JS, Sohn CI, Hwang SJ et al. Quality and effect of single dose versus split dose of polyethylene glycol bowel preparation for early-morning colonoscopy. Endoscopy 2007; 39: 616-619
• 10 Siddiqui AA, Yang K, Spechler SJ et al. Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel-preparation quality. Gastrointest Endosc 2009; 69: 700-706
• 11 Chan WK, Saravanan A, Manikam J et al. Appointment waiting times and education level influence the quality of bowel preparation in adult patients undergoing colonoscopy. BMC Gastroenterol 2011; 11: 86
• 12 Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 2011
• 13 Liberati A, Altman DG, Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
• 14 Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996; 17: 1-12
• 15 Liu X, Luo H, Zhang L et al. Telephone-based re-education 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
• 16 Park J, Kim TO, Seo EH. The Effectiveness of Short Message Service (Sms) From a Mobile Phone to Assure the Preparation-to-Colonoscopy (PC) Interval for Bowel Preparation for Afternoon Colonoscopy: a Randomized Control Study. Gastrointest Endosc 2013; 77: AB517
• 17 Pillai A, Menon RV, Oustecky D et al. Educational Colonoscopy Video Enhances Bowel Prep Quality and Comprehension in an Inner City Population. Gastrointest Endosc 2013; 77: AB510
• 18 Tae JW, Lee JC, Hong SJ et al. Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy. Gastrointest Endosc 2012; 76: 804-811
• 19 Spiegel BM, Talley J, Shekelle P et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Am J Gastroenterol 2011; 106: 875-883
• 20 Ahn SB, Son BK, Kim SH et al. Education Card Improve the Tolerance of Large Volume PEG Solution in Colonoscopy. Gastrointest Endosc 2011; 73: AB434
• 21 Shaikh AA, Hussain SM, Rahn S et al. Effect of an educational pamphlet on colon cancer screening: a randomized, prospective trial. Eur J Gastroenterol Hepatol 2010; 22: 444-449
• 22 Modi C, Depasquale JR, Digiacomo WS et al. Impact of patient education on quality of bowel preparation in outpatient colonoscopies. Qual Prim Care 2009; 17: 397-404
• 23 Sondhi AR, Kurlander JE, Waljee AK et al. A telephone-based education program improves bowel preparation quality in patients undergoing outpatient colonoscopy. Gastroenterology 2015; 148: 657-658
• 24 Chiu HM, Lin JT, Lee YC et al. Different bowel preparation schedule leads to different diagnostic yield of proximal and nonpolypoid colorectal neoplasm at screening colonoscopy in average-risk population. Dis Colon Rectum 2011; 54: 1570-1577
• 25 Seo EH, Kim TO, Park MJ et al. Optimal preparation-to-colonoscopy interval in split-dose PEG bowel preparation determines satisfactory bowel preparation quality: an observational prospective study. Gastrointest Endosc 2012; 75: 583-590
• 26 Voiosu T, Ratiu I, Voiosu A et al. Time for individualized colonoscopy bowel-prep regimens? A randomized controlled trial comparing sodium picosulphate and magnesium citrate versus 4-liter split-dose polyethylene glycol. . J Gastrointestin Liver Dis 2013; 22: 129-134
• 27 Hassan C, Bretthauer M, Kaminski MF et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2013; 45: 142-150
• 28 Park WG, Triadafilopoulos G. Colonoscopy appropriateness: education is important to identify the right patient, at the right time, for the right reason. Gastrointest Endosc 2008; 67: 94-96
• 29 Hong SN, Sung IK, Kim JH et al. The Effect of the Bowel Preparation Status on the Risk of Missing Polyp and Adenoma during Screening Colonoscopy: A Tandem Colonoscopic Study. Clin Endosc 2012; 45: 404-411
• 30 Rex DK. Optimal bowel preparation--a practical guide for clinicians. Nat Rev Gastroenterol Hepatol 2014; 11: 419-425