Spiegel BM (VA Greater Los Angeles Healthcare System; Sepulveda HSR&D COE), Shekelle P
(VA Greater Los Angeles Healthcare System; Sepulveda HSR&D COE), Talley J
(VA Greater Los Angeles Healthcare System; Sepulveda HSR&D COE), Chan M
(David Geffen School of Medicine, UCLA), Cohen H
(VA Greater Los Angeles Healthcare System )
Colonoscopy is the gold standard for colorectal cancer (CRC) screening because it can find and remove pre-malignant polyps and reduce subsequent CRC. Yet up to 60% of veterans presenting to colonoscopy have inadequate bowel preparation, and those with poor preps have fewer polyps found, more incomplete exams, and higher costs of care vs. patients with acceptable bowel preparation. We sought to develop and test an educational booklet designed to improve bowel preparation quality in veterans undergoing colonoscopy.
We performed cognitive interviews in 20 veterans, 10 gastroenterologists, and 5 GI nurses to identify patient knowledge, attitude, and belief (KAB) deficits hypothesized to drive inadequate colonoscopy preparation. We then created a novel educational booklet, based on the Health Beliefs Model, aimed at addressing KAB deficits to improve desired preparatory behaviors. In concert with a psychometrician and health literacy expert, we developed a color booklet containing text and visual elements designed to address modifiable KAB domains. The booklet was iteratively revised with feedback from 60 patients. We then performed a controlled before and after study to compare bowel preparation quality, measured on a standard 7-point Likert scale ( > = 6 is “good”), in veterans undergoing screening colonoscopy at the West L.A. VA during 2 consecutive months: 1 without and 1 with the booklet. Patients in both time periods received standard pharmacy instructions. We performed chi-squared analyses to compare the proportion achieving a “good” prep between groups, and logistic regression to measure the impact of the booklet on prep quality, adjusting for age, sex, race, BMI, and type of prep.
61% vs. 45% of patients had a good prep in the booklet (N = 63) and control (N = 93) groups, respectively (p = 0.04). In multivariable regression analysis, receipt of the booklet increased the odds of a good prep by 1.9 times (95% CI = 1.1-3.4).
Provision of a novel educational booklet improves bowel preparation quality in veterans undergoing screening colonoscopy.
VA has committed extensive resources to ensuring use of screening colonoscopy in veterans. These resources are undermined if patients cannot effectively evacuate their bowels and ensure maximum test effectiveness. This simple intervention improves preparation quality, and, although untested, may ultimately improve polyp detection.