Abstract
Background and Aims
Split-dose bowel preparation is associated with improved mucosal visualization and patient tolerance, becoming a standard of care. However, quality measures data associated with this preparation are limited. At our academic tertiary-care facility, we aim to study the effect of changing from single- to split-dose preparation on colonoscopy quality measures.
Methods
A retrospective cohort study with quality indicators was conducted using electronic medical record data. Cases were identified via ICD9 code V76.51, “Special screening for malignant neoplasms of colon.” Single-dose preparation data was collected from 9/1/13 to 8/31/14. Split-dose preparation was implemented 11/2014, and data were collected from 1/1/15 to 8/31/15.
Results
A total of 1602 colonoscopies in the single-dose group and 1061 colonoscopies in the split-dose group were analyzed. The Boston Bowel Preparation Scale was significantly improved in the split-dose group 8.64 ± SD 1.25 versus 8.25 ± SD 1.61, p < 0.001. There was no significant difference in adenoma detection rate 40.7% (95% CI 37.8–43.7%) versus 40.5% (95% CI 38.1–42.9%), p = 0.92; however, the rate for recommending an early repeat examination due to an inadequate bowel preparation was significantly decreased to 3.9% (95% CI 2.7–5.0%) versus 8.9% (95% CI 1.52–2.97%), p < 0.001.
Conclusion
While split-dose preparation significantly improves overall bowel cleanliness, there is no significant adenoma detection rate improvement with high baseline rate, suggesting a threshold which may not improve with enhanced preparations. Split-dose preparation significantly reduces the frequency with which inadequate preparation prompts an early repeat examination, which has important clinical implications on performance, costs, and patient experience, providing further evidence supporting split-dose preparation use.
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References
Corley D, Jensen C, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med.. 2014;370:1298–1306.
Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med.. 2013;369:1095–1105.
Brenner H, Hoffmeister M, Arndt V, Stegmaier C, Altenhofen L, Haug U. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst. 2010;102:89–95.
Nakao S, Sucandy I, Fassler S, Kim S, Soo DM. Colorectal cancer following negative colonoscopy: is 5-year screening the correct interval to recommend? Surg Endosc. 2013;27:768–773.
Kaminski M, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and risk of interval cancer. N Engl J Med.. 2010;362:1795–1802.
Kilgore T, Abdinoor A, Szary NM, et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Gastrointest Endosc. 2011;73:1240–1245.
Rex D, Schoenfeld P, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc.. 2015;81:31–53.
American Society for Gastrointestinal Endoscopy. Quality indicators for GI endoscopic procedures. Gastrointest Endosc. 2015;81:31–53.
Kahi CJ, Anderson JC, Waxman I, et al. Highdefinition chromocolonoscopy versus high-definition white light colonoscopy for average-risk colorectal cancer screening. Am J Gastroenterol. 2010;105:1301–1307.
Lai E, Calderwood A, Doros G, Fix O, Jacobson B. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc. 2009;69:620–625.
Kahi C, Vemulapalli K, Johnson CS, Rex D. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc.. 2014;79:448–454.
Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med.. 2009;150:1–8.
Enestvedt B, Tofani C, Laine LA, Tierney A, Fennerty MB. 4-Liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2012;10:1225–1231.
Unger R, Amstutz S, Seo DH, Huffman M, Rex DK. Willingness to undergo split-dose bowel preparation for colonoscopy and compliance with split-dose instructions. Dig Dis Sci.. 2010;55:2030–2034.
Gurudu SR, Ramirez FC, Harrison ME, Leighton JA, Crowell MD. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Gastrointest Endosc. 2012;76:603–608.
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.
Riegert M, Nandwani M. Enhancing the quality of colonoscopy through split-dose bowel preparation. Gastroenterol Nurs. 2014;37:148–154.
Cohen B, Tang R, Groessl E, Herrin A, Ho S. Effectiveness of a simplified “patient friendly” split dose polyethylene glycol colonoscopy prep in Veterans Health Administration patients. J Interv Gastroenterol. 2012;2:177–182.
Rosty C, Hewett DG, Brown IS, Leggett BA, Whitehall VL. Serrated polyps of the large intestine: current understanding of diagnosis, pathogenesis, and clinical management. J Gastroenterol.. 2013;48:287–302.
Lu FI, van Niekerk de W, Owen D, Tha SP, Turbin DA, Webber DL. Longitudinal outcome study of sessile serrated adenomas of the colorectum: an increased risk for subsequent right-sided colorectal carcinoma. Am J Surg Pathol.. 2010;34:927–934.
Barclay R, Vicari J, Doughty A, Johanson J, Greenlaw R. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med.. 2006;355:2533–2541.
Rex D, Imperiale T, Latinovich D, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol. 2002;97:1696–1700.
Rex D, Cutler CS, Lemmel GT, Rahmani EY, Clark DW, Helper DJ. Colonic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology. 1997;112:24–28.
Radaelli F, Paggi S, Hassan C, Senore C, et al. Split dose preparation for colonoscopy increases adenoma detection rate: a randomized control trial in an organised screening programme. Gut. 2017;66:270–277.
Jia H, Pan Y, Guo X, Zhao L, et al. Water exchange method significantly improves adenoma detection rate: a multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112:568–576.
Cadoni S, et al. Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial. Endoscopy. 2017;49:456–467.
Hsieh YH, et al. Prospective multicenter randomized controlled trial demonstrating water exchange (WE), but not water immersion (WI), significantly increases adenoma detection compared with air insufflation (AI) even in propofol sedated patients. GIE. 2017;86:192–201.
Radaelli F, Paggi S, Repici A, Gullotti G, et al. Barriers against split-dose bowel preparation for colonoscopy. Gut.. 2017;66:1428–1433.
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Wang, L., Sprung, B.S., DeCross, A.J. et al. Split-Dose Bowel Preparation Reduces the Need for Early Repeat Colonoscopy Without Improving Adenoma Detection Rate. Dig Dis Sci 63, 1320–1326 (2018). https://doi.org/10.1007/s10620-017-4877-3
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DOI: https://doi.org/10.1007/s10620-017-4877-3