Ashish Malhotra, MD
Pre-procedural Quality in Colonoscopy
ASHISH MALHOTRA, MDAssistant Professor of Medicine
University of Minnesota/Minneapolis VAMCAnnual ACG Meeting- 2016
Las Vegas, NV, USA
OUTLINE
How to maximize the quality of the bowel prep
How to reduce patient no-shows
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Why A Good Prep is Important
• More missed lesions
• Longer procedures
• More repeat colonoscopies
Chokshi RV Gastrointest endosc 2012; 75 (6):1197-203Clark BT Am J gastroenterol 2014; 109 (11):1714-23
Bernstein C, Gastrointest Endosc. 2005 Jan;61(1):72-5.
Menees SB Gastrointest endosc 2013; 78 (3):510-6Lieberman DA Gastroenterol 2012; 143:844-857
Bowel Preparation in Colonoscopy
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Let’s Start With the Prep
Prep Solution +
PsychologyPsychology
Physiology +
In Other Words
Prep Quality
Prep Quality
Prep RegimenPrep Regimen
Psychological Factors
Psychological Factors
Biological Factors
Biological Factors
Physician’s assessmentPhysician’s assessment
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Prep Quality
Prep Quality
Prep RegimenPrep Regimen
Psychological Factors
Psychological Factors
Biological FactorsBiological Factors
Physician’s assessmentPhysician’s assessment
Prep Regimen• Type
• Volume
• Timing
• Diet
Gold Standard 4L Peg ELSLow Volume 2L
Split Dose3-7 Hours from last purgative dose
Low-residue diet
Iso-osmoticHyper-osmotic Sweetser S, Mayo clin proc 2015;90 (4):520-26
Enestvedt BK, Clin gastroenterol hepatol 2012;10(11)1225-31
Siddiqui AA, Gastrointest endosc 2012;75(3):583-590
Park DI, J gastroenterol hepatol 2009;24(6):988-991
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Prep Quality
Prep Quality
Prep RegimenPrep Regimen
Psychological Factors
Psychological Factors
Biological Factors
Biological Factors
Physician’s assessmentPhysician’s assessment
Biological Factors Affecting Prep
• Biological Factors History of chronic constipation Use of constipating medications Diabetes mellitusObesity History of inadequate prep History of colonic resection Neurological diseaseCurrent hospitalization
Malhotra A, Shaukat A Pract Gastroenterol 2016; in press
What do We do: Avoid Low Volume Preps
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Relationship Between Inadequate Prep and BSFS
1414
343425
17.6
10
6.4
8.3
% Inadequate Prep
Malhotra A et al. Colorectal Dis. 2016 Feb;18(2):200-4
Prep Quality
Prep Quality
Prep RegimenPrep Regimen
Psychological Factors
Psychological Factors
Biological Factors
Biological Factors
Physician’s assessmentPhysician’s assessment
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Psychological Factors Affecting Prep
• Factors: Lower educational level Low health literacy Low patient activation English not first language Living aloneMedicaid insurance Unmarried
Malhotra A, Shaukat A Pract Gastroenterol 2016; in press
What do We do: Intensify Education
Tested Educational Tools
Kang X et al; ClinGastroenterolHepatol. 2016 Mar;14(3):429-435
Kang X et al; ClinGastroenterolHepatol. 2016 Mar;14(3):429-435
Liu X et al; Gut. 2014; 63(1):125-30.
Liu X et al; Gut. 2014; 63(1):125-30.
Shieh TY et al; GastroenterolRes Pract. 2013:570
Shieh TY et al; GastroenterolRes Pract. 2013:570
Lee YJ et al; Endoscopy. 2015 Nov;47(11):1018-27
Lee YJ et al; Endoscopy. 2015 Nov;47(11):1018-27
Prakash SR et al; Can J Gastroenterol. 2013 Dec;27(12):696-700
Prakash SR et al; Can J Gastroenterol. 2013 Dec;27(12):696-700
Lebwohl B et al; J Clin Gastroenterol. 2011 May-Jun;45(5)
Lebwohl B et al; J Clin Gastroenterol. 2011 May-Jun;45(5)
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
The Final Component
Prep Quality
Prep Quality
Prep RegimenPrep Regimen
Psychological Factors
Psychological Factors
Biological Factors
Biological Factors
Physician’s assessmentPhysician’s assessment
Does Ugliness Lie in the Eyes of the Beholder?
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
What is Considered Optimal Prep?• Preparation is adequate if 5mm lesions can be detected (MSTF guidelines).
• Terms used to commonly characterize bowel preparation include excellent, good, fair, and poor.
• These terms lack standardized definitions raising concerns about the subjectivity of grading.
Physicians Role in Grading Bowel Prep
The rates of SPR ranged from 14.3% to 53.8% among 13 trial endoscopists
The rates of SPR ranged from 3% to 42% among 11 study endoscopists
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Suboptimal Prep Rate for Each Physician Each Year-MVAMC Data
Simple Algorithm to Improve Quality of Bowel Preparation
Patient before colonoscopy
Perfusion problems? : CHF, liver
cirrhosis, CKD
Biological predictors present?
Psychological predictors present?
PEG-ELS Avoid nephrotoxic agents
More aggressive split or same day prep
Split prep, intensify education: navigation if possible
Use a standard validated scale to assess prep quality ?
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Compliance to Colonoscopy Appointment
Interventions to Reduce Patient Absenteeism for Elective Procedures
ationing demandestructuring referral processeminder systemevised scheduling
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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Ashish Malhotra, MD
Thank You Very MuchQuestions/Comments
ACG 2016 Annual Scientific Meeting Copyright 2016 American College of Gastroenterology
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