Colonoscopy is the most effective test for the detection and prevention of colorectal cancer, the second leading cause of cancer death in the United States. An estimated 14 million colonoscopies are performed in the United States every year. About 20 to 40 percent of these colonoscopies have inadequate bowel preparation according to multiple studies.
Inadequate bowel preparation is costly to the patient, the health care system, and society.
In one study, poor bowel preparation lowers the detection of colon polyps by over 40 percent. This can increase the risk of developing colorectal cancer if the patient fails to repeat the procedure in a timely fashion. The need for repeated procedures increases the risk of complications and its attendant costs. Discomfort and other adverse events may be associated with poor bowel preparation due to longer procedure time and poor visualization of the colon wall. In the unlikely event that a perforation occurs during colonoscopy, poor bowel preparation can lead to fecal contamination of the abdominal cavity and need for colostomy. Often the cost of the purgative is borne by the patient. The cost of transportation is also borne by the patient. Patients are usually required to be accompanied by an adult. The wages of the patient and the accompanying adult is often lost for that day, especially for low-income hourly-paid workers.
Inadequate bowel preparation increases the time it takes to complete a colonoscopy due to time spent cleaning and suctioning the colon wall. This leads to increased time spent by providers (gastroenterologists, nurses, technicians, anesthesiologists) on a procedure thereby reducing the overall number of procedures performed during the work hours. This may also lead to increased need for medications used in sedation and increased use of other resources.
The societal cost of inadequate bowel preparation is enormous. Inadequate bowel preparation can lead to increased morbidity and mortality from colorectal cancer as a result of aborted procedures, failure to reschedule, missed lesion and interval colorectal cancer. Repeat procedures increase the cost of colonoscopy. There is lost productivity associated with attendance at colonoscopy for the patient and the accompanying adult. Costs associated with inadequate bowel preparation represent an opportunity cost for other essential health care needs and non-health care societal needs.
The solution to inadequate bowel preparation requires involvement of the patient, the provider, and the health care system. The patient is the focal point and solution to inadequate bowel preparation starts with the patient. Patients should be empowered with tools to enhance bowel preparation. Empowerment begins with education.
- Patients should be informed of the importance and implication of bowel preparation before colonoscopy is scheduled.
- Most patients do not understand colonoscopy instructions. Bowel preparation instructions should be available in the primary language of the patient. The instructions should be simple and available in written and video formats.
- A reminder system should be adopted to engage and activate patients a day before the procedure. Reminder tools include patient navigators, telephone calls, and mobile device apps.
- To assure adequate bowel preparation before a patient shows up for a colonoscopy, there must be a way for the patient to check their level of preparedness at home. The rectal effluent is a simple way to check the level of preparedness. Other non-invasive and easy-to-use technologies should be developed for home use. The information from this bowel preparedness check must be actionable. Patients must be able to use this information to continue or escalate their bowel preparation.
- Currently, there is little incentive for patients to have adequate bowel preparation. An incentive program, financial and non-financial should be developed to encourage bowel preparation.
The adequacy of bowel preparation impacts quality measures in colonoscopy such as cecal intubation rate (ability to reach the end of the colon), adenoma detection rate (ability to detect precancerous polyps), withdrawal time, and appropriate surveillance interval.
These quality measures are now part of the Physician Quality Reporting System (PQRS) that is linked to payment reforms in health care. Therefore, providers must also take an active role in preventing inadequate bowel preparation. Providers should be able to identify patients at risk for inadequate bowel preparation.
Clinical decision tool to identify at risk population and recommend intensive bowel preparation regimen should be developed. The additional therapy may be in form of educational instructions or medication. The clinical decision tool may be embedded in the electronic medical records for easier use.
Finally, in the event that inadequate bowel preparation is only identified during colonoscopy, salvage therapies should be available to improve bowel preparation if possible.
Adewale Ajumobi is a gastroenterology fellow and editor, Bowel Preparation Guide.