Overcoming barriers against split-dose bowel preparation

Last Updated: 2016-04-29

By Will Boggs MD

NEW YORK (Reuters Health) - Several interventions are needed to improve patient compliance with split-dose bowel preparation regimens for colonoscopy, researchers from Italy report.

"The systematic implementation of split dosing as the routine preparation for colonoscopy represents a simple strategy to improve the effectiveness of colorectal cancer prevention," Dr. Franco Radaelli from Valduce Hospital, Como, Italy told Reuters Health by email.

"As most of the barriers against split-dosing adoption can be addressed, organizational or educational interventions are strongly warranted," he added.

Split-dose regimens, where the first half of the bowel preparation is administered the evening before colonoscopy and the second half is administered on the morning of the procedure, provide a higher quality of bowel preparation and an increase in the detection of significant lesions, so most official guidelines now recommend them over the single-dose, evening-before regimens.

The adoption of these regimens, however, remains suboptimal, especially for morning colonoscopies.

Dr. Radaelli and colleagues surveyed 1,447 patients presenting to 19 open-access endoscopy centers in Italy in an effort to assess the actual uptake of a split-dose regimen and to identify patient-related barriers to its implementation.

Most patients (61.7%) chose a split-dose regimen, and the rest (38.3%) chose a day-before regimen, according to the April 19th online report in Gut.

Female gender, low education level, working status, and a longer time travel to the endoscopy unit were associated with a lower uptake of the split-dose regimen, whereas patients scheduled later in the morning were more likely to choose the split-dose regimen.

More than three quarters of patients (77.6%) said their choice of bowel preparation was driven exclusively by the information provided in an information leaflet. In this group, the higher guarantee of adequate colon cleansing, better tolerability, and less interference with job activity during the day before colonoscopy were cited as the reasons for choosing the split-dose regimen.

Fear of bowel movements before traveling and reluctance to get up early in the morning were the most common barriers to choosing the split-dose regimen.

The rest of the patients (22.4%) said the referring physician or other persons influenced their choice. Those advised by a GI specialist were more likely to choose split-dose regimens, whereas those advised by pharmacists were more likely to choose day-before regimens.

Cecal intubation was more commonly achieved in the split-dose group (97.5%) than in the day-before group (95.5%), and at least one polyp was found in more split-dose patients (45.0%) than in day-before patients (35.6%).

Bowel prep was rated as adequate in 92.2% of split-dose patients, compared with only 75.7% of day-before patients.

"Patient education is of outmost importance," Dr. Radaelli said. "In the present study, patients were given only written instructions on bowel prep, in accordance with standard practice in most Italian endoscopy centers. However, it is conceivable that the addition of verbal instructions to reinforce the advantages of split-dose over day-before regimens might enhance split-dose uptake."

"Education campaigns should target healthcare providers (primary care physicians and pharmacists) to increase their awareness of the importance of split-dosing for a high-quality colonoscopy," he said.

"Conversely," Dr. Radaelli concluded, "in a patient-centered care system, where patients' preferences and expectations are of paramount importance, organizational measures likely represent the most effective strategy to improve the low split-dose uptake for early morning colonoscopy. This target can be achieved by remodeling colonoscopy timetables, by scheduling outpatient colonoscopies in the second part of the morning, and by anticipating other endoscopy procedures (i.e., upper GI endoscopy, in-patients)."

Dr. Ala Sharara from American University of Beirut Medical Center in Lebanon told Reuters Health by email, "Our group was in fact the first to suggest, study, and publish a randomized controlled trial on the effect of split-dosing the preparation."

He expressed surprise that "some patients continue to choose the day-before regimen despite receiving information about the superiority of a split-dose regimen in terms of quality of bowel preparation and colonoscopy outcomes."

"Patients should not be given the choice between a superior strategy and a clearly inferior one that is associated with lower quality and higher cost," Dr. Sharara said. "Physicians should emphasize the advantages of the split-dose regimen and insist on the need for compliance, including the rapid ingestion of the morning dose (over 1-1.5 hours to be completed 2-2.5 hours before the scheduled appointment) as well as adjust the endoscopy schedule accordingly to match those with the shortest commute with the earlier appointments."

SOURCE: http://bit.ly/1O0Lvml

Gut 2016.