Impact of a Novel Patient Educational Booklet on Achievement of Quality Indicators in Screening Colonoscopy Project Summary/Abstract Project Background: Colorectal cancer (CRC) is the second leading cause of cancer death in the U.S. Colonoscopy is the gold standard for CRC screening because it can find and remove pre-malignant polyps - a maneuver that reduces subsequent CRC. The VA has committed extensive resources to ensuring use of screening colonoscopy. Yet there is less attention to whether the VA is adhering to published quality indicators (QIs) for colonoscopy and, if not, how to improve quality. We have shown that achievement of key QIs in VA, including polyp detection and incomplete exam rates, depends on the thoroughness of patient preparation for the test, including proper use of purgatives and dietary restrictions. Moreover, up to 60% of Veterans presenting to colonoscopy have inadequate bowel preps, and those with poor preps have fewer polyps found, more incomplete exams, and higher costs of care. This suggests that improving quality will require improving patient preparation. Unlike other commonly available cancer screening tests, colonoscopy is unique because its effectiveness depends on careful and committed physical preparation by the patient - not just the skill of an examiner or accuracy of a laboratory. In order to achieve colonoscopy QIs, patients must effectively evacuate their bowels. Yet poor preps are common. To improve bowel preps and thus achievement of QIs, we first performed a series of cognitive interviews in patients and providers to identify knowledge, attitude, and belief deficits hypothesized to drive inadequate patient preps. We then created a novel patient educational booklet to address these deficits. In a controlled pilot study, we found that 61% vs. 45% of patients had a good prep in the booklet (N=63) &control (N=93) groups, respectively (p=0.04). Project Objectives: We now propose to conduct a 12-month, randomized, controlled trial to compare colonoscopy quality in a group of patients exposed to the previously pilot-tested educational booklet vs. a control group not exposed to the booklet. The primary outcome will be bowel prep quality. Secondary outcomes will include adherence with key QIs, including polyp detection and completed exam rates, along with measuring resource utilization. We hypothesize that the intervention, which is based on the Health Belief Model, will improve polyp detection and reduce incomplete exams by improving preparation for the test. These benefits will occur while reducing the need for repeated exams, and will save costs vs. usual practice control. Project Methods: The primary outcome will be bowel prep quality (Ottowa Scale). Secondary outcomes will be adherence with QIs, including: (1) proportion of exams identifying >1 polyp, (2) proportion of exams identifying "advanced polyps," and (3) proportion of exams completed. We will also evaluate the impact on relevant resource utilization. The unit of randomization will be patients presenting for screening colonoscopy. We will 516 patients over a 12-month period to meet our required sample size for cluster-adjusted analyses. We will perform bivariate and cluster-adjusted multivariate models to compare outcomes between groups.
- Relevance of Proposed Research to Veterans Health The VA has committed extensive resources to ensuring use of screening colonoscopy in eligible Veterans. Yet there is relatively less attention to measuring and improving quality of the colonoscopies themselves. In order to achieve colonoscopy quality indicators (QIs), patients must effectively evacuate their bowels prior to colonoscopy. Yet up to 60% of Veterans presenting to colonoscopy have inadequate bowel preps, and we have shown that those with poor preps have fewer polyps found, more incomplete exams, and higher costs of care vs. patients with acceptable bowel preparation. In preparation for this study, we created and pilot tested a novel educational booklet to address patient knowledge, attitude, and belief deficits regarding colonoscopy preparation. We now propose a randomized, controlled trial to compare achievement of colonoscopy QIs in a group of patients exposed to the educational booklet vs. a control group not exposed to the booklet. If the proposed intervention were successful, it would increase bowel preparation quality, improve colonoscopy yield for polyps, reduce the rate of aborted procedures, reduce the need for rescheduled colonoscopies, and potentially shorten wait time for screening colonoscopy.