Andrew Ho

Development and validation of a novel patient educational booklet to enhance colonoscopy preparation.

OBJECTIVES:The success of colonoscopy depends on high-quality bowel preparation by patients; yet inadequate preparation is common. We developed and tested an educational booklet to improve bowel preparation quality.METHODS:We conducted patient cognitive interviews to identify knowledge and belief barriers to colonoscopy preparation. We used these interviews to create an educational booklet to enhance preparatory behaviors. We then prospectively randomized patients scheduled for outpatient colonoscopy at a VA Medical Center to receive usual instructions vs. the booklet before colonoscopy. Patients in both groups received standard pharmacy instructions for single-dose bowel preparation; the protocol did not specify which purgatives to prescribe. The primary outcome was preparation quality based on blinded ratings using the validated Ottawa score. We performed bivariate analyses to compare mean scores between groups using a t-test, and logistic regression to measure the booklet effect on preparation quality, adjusting for potential confounders.RESULTS:A total of 436 patients were randomized between arms. In an intention-to-treat analysis of the primary outcome, mean Ottawa scores were superior in patients allocated to booklet vs. controls (P=0.03). An intention-to-treat analysis of the secondary outcome revealed a “good” preparation in 68 vs. 46% of booklet and control patients, respectively (P=0.054). In a per-protocol analysis limited to patients who actually received the booklet, preparation was good in 76 vs. 46% patients, respectively (P<0.00001). Regression analysis revealed that booklet receipt increased the odds of good preparation by 3.7 times (95% confidence interval=2.3–5.8).CONCLUSIONS:Provision of a novel educational booklet considerably improves preparation quality in patients receiving single-dose purgatives. The effect of the booklet on split-dose purgatives remains untested and will be evaluated in future research.

Diagnostic Yield of Endoscopy for Weight Loss: Results of a Comparative Cohort Study vs. Non-Weight Loss Controls

Background: Gastroenterologists are commonly asked to perform pan-endoscopy in patients with weight loss. This request is based on historical series revealing a high prevalence of GI causes of involuntary weight loss (Lankisch J Int Med 2001). However, in the absence of specific GI symptoms or signs, such as bleeding, dysphagia, diarrhea, constipation, or anemia, the yield of endoscopy may be low and its appropriateness unclear. We studied patients referred for endoscopy because of weight loss, and evaluated the yield of endoscopy vs. non-weight loss controls. Methods: We performed a retrospective analysis of patients referred to the endoscopy unit of a University-based VA medical center from 2000-2010 with a primary indication of weight loss. We excluded patients who would otherwise qualify for endoscopy regardless of weight loss, such as those with positive fecal occult blood, iron deficiency, previous imaging study with a colonic abnormality, familial GI cancer syndrome, GI bleeding, or prior colon cancer. Although we allowed for diarrhea and constipation, we performed a sensitivity analysis in which this sub-group was also excluded. We gathered data on patient characteristics, duration and amount of weight loss, body mass index (BMI), and endoscopy findings. We calculated the proportion of cases in which an explanatory luminal diagnosis was identified by endoscopy, and compared this to the yield in 2 age and sex-matched control groups: 1) group undergoing screening colonoscopy; and 2) group undergoing diagnostic colonoscopy for a non-weight loss indication. We conducted separate analyses for colonoscopy and upper endoscopy (EGD). We employed chi-squared for pairwise comparisons. Results: There were 95 colons and 61 EGDs identified (mean age=65; 93% male; BMI=23). Patients lost a mean of 22 lbs over a 9 month average period. The Figure reveals the diagnostic yield of the study groups. Two of the 95 colonoscopy patients (2.1%) had primary colon cancer and 3 had colitis as the explanation for weight loss. The screening colonoscopy control group resulted in no colon cancers, and the diagnostic colonoscopy control group revealed 4 cancers (4.2%) and 1 case of colitis (1.1%). After excluding diarrhea and constipation, there was 1 case of colitis (1.8%) and no cancer. There were no significant differences among any pair-wise comparisons. Of the EGD cases, there was 1 gastric cancer (1.6%); the non-weight loss control EGDs revealed 2 gastric cancers (3.3%) (p=NS). Conclusion: In the absence of other GI “red flag” features, patients with weight loss rarely harbor an underlying luminal disease; there is no difference in diagnostic yield of endoscopy vs. age and sex-matched controls. These data suggest that pan-endoscopy for weight loss is unlikely to be cost-effective in the absence of other concurrent indications for a GI procedure.