Most patients survive colon cancer if the cancer is found early, and a colonoscopy is the only test that can identify and remove polyps from the entire colon. However, the effectiveness of the procedure depends as much on what happens in the hours before the patient comes in for the exam as it does on the skill of the health care team.
Patients scheduled to undergo the test receive instructions on how to empty their colon by using purgative medications and following rigid dietary restrictions. Good preparation helps the doctors clearly see the colon walls during the procedure and improves their ability to identify polyps. But up to a quarter of patients still undergo the exam with inadequate bowel preparation, which can limit the effectiveness of the procedure and lead to missed polyps and incomplete or aborted procedures.
“For the technicians performing a colonoscopy, a clean colon is like driving along a country road with a clear sky and the sun shining,” said Dr. Brennan M.R. Spiegel, study author and director of the UCLA–VA Center for Outcomes Research and Education. “A dirty colon is like driving through a snowstorm with very limited visibility. Good preparation before a colonoscopy is key to a successful procedure.”
Reporting in the April 12 online edition of the American Journal of Gastroenterology, the UCLA–VA team addressed these concerns by first asking patients what information would help them better prepare for a colonoscopy. Based on these findings, the team developed a user-friendly booklet that was then tested with patients.
“Unlike every other screening test in medicine, the ability of the colonoscopy to reduce the risk for cancer is associated with the physical preparation by the patients themselves,” said Spiegel, an associate professor of medicine in the division of digestive diseases at the VA Greater Los Angeles Healthcare System and the David Geffen School of Medicine at UCLA. “The worse the prep is, the fewer polyps we can identify and remove.”
In preparing the booklet, the team first met with patients to glean knowledge, attitudes and beliefs that might drive inadequate colonoscopy preparation. Researchers then created the educational booklet using high-quality visual elements, such as pictures of what patients can and cannot eat during colonoscopy preparation. The booklet also included a section on frequently asked questions and a checklist and calendar for when to take purgatory medications to cleanse and clear the bowel. Researchers ran the draft booklet by another group of patients before finalizing it.
Next, the team tested the effectiveness of the booklet by sending it to a group of 216 patients at a single VA hospital a week ahead of their scheduled colonoscopy procedures. A control group of 220 patients received the normal preparation instructions.
Researchers found that patients given the booklet were far more likely to arrive for their colonoscopy with a “good” preparation than patients who had received the usual preparation instructions (68 percent vs. 46 percent).
For every 3.3 booklets that were sent out, researchers found that there was one additional “good” or better preparation, compared with the control group. Booklet use increased the odds of good colonoscopy preparation by 3.7 times.
The next step in the research is to study the impact of the booklet on outcomes such as polyp yield, as well as the overall cost of care.
According to Spiegel, poor colonoscopy preparation can lead to the canceling of procedures and rescheduling and repeating tests, which not only costs money but also inconveniences the patient. The booklet might save resources and lower the burden on patients by minimizing the need for them to come back a second time.
“The booklet is inexpensive, easy to hand out and can be used for anyone preparing for a colonoscopy,” Spiegel said. “Since a successful colonoscopy is so dependent upon proper bowel prep, we hope that the booklet may ultimately help improve polyp detection and reduce cancer incidence.”
To obtain a free electronic version of the booklet:
• Select the publication category “Other Health Services.”
• Choose the booklet version of the two PDF copies of “Getting Ready for Your Colonoscopy.”
• Contact Jennifer Talley (firstname.lastname@example.org) if you need help obtaining the booklet.
Bound paper copies are available for purchase through SLACK Publishing (www.slackinc.com).
The study was funded by a Veteran’s Affairs Health Services Research and Development Grant, a Career Development Transition Award, and a Veterans Affairs Merit Award. Development of the educational booklet was supported in part by an educational grant from Salix Pharmaceuticals to the CURE Digestive Diseases Research Center Foundation.
Institutions involved in the study included the department of medicine, division of digestive diseases, David Geffen School of Medicine at UCLA; the department of medicine, VA Greater Los Angeles Healthcare System; the department of health services, UCLA School of Public Health; the CURE Digestive Diseases Research Center; and the UCLA–VA Center for Outcomes.
Other study authors included Jennifer Talley, M.S.P.H.; Dr. Paul Shekelle; Dr. Nikhil Agarwal; Bradley Snyder; Roger Bolus, Ph.D.; Nicole Kurzbard; Dr. Michael Chan; Dr. Andrew Ho; Dr. Mark Kaneshiro; Dr. Kristina Cordasco; and Dr. Hartley Cohen.