Introduction
The U.S. Multi-Society Task Force recommends repeat colonoscopy within 1 year of an exam with inadequate bowel preparation.1 Prior studies show that endoscopists’ recommendations for timing of colonoscopy in this context are variable.2,3 One factor that may influence endoscopists’ willingness to recommend early repeat colonoscopy is concern about patients’ willingness to repeat the preparation and procedure at a short interval. The aim of this study was to assess patient preferences for timing of repeat colonoscopy using a hypothetical suboptimal bowel preparation scenario.
Methods
Previously, we reported results from a multiple-choice survey to assess split-dose bowel preparation compliance among patients aged 50–74 years presenting for average-risk screening colonoscopy at Michigan Medicine between 2011–2013.4 Patients completed surveys prior to their colonoscopies. For this study, we analyzed questions on patient preferences for repeat colonoscopy in the context of suboptimal bowel preparation. Questions asked respondents about the interval at which they would want a repeat colonoscopy (answer choices: <1, 1, 3, 5, 10, >10 years), certainty about their decision, and how worried they were about colorectal cancer (CRC). The primary outcome was likelihood of following a physician’s recommendation to repeat a colonoscopy within 1 year. Response options for decision certainty, worry about CRC, and likelihood of following a physician’s recommendation were reported on unidirectional Likert-type scales ranging from 1 (“not at all”) to 7 (“extremely”). Only the endpoints of the scale were labelled. We used multivariable ordered logistic regression to identify factors associated with likelihood of following recommendations for repeat colonoscopy within 1 year. We adjusted for age, race, gender, body mass index (BMI), self-reported health status, education level, whether the colonoscopy was the first screening exam, and worry about CRC. Analyses were performed using Stata 14.1 statistical package (StataCorp, College Station, Texas).
Results
Five hundred and fifty-eight out of six hundred and forty-three (response rate=87%) patients completed the subset of questions and met eligibility criteria. Mean age was 56 years (±6.7). 49% were men, and 87% were white, with average BMI 28.8 mg/kg2 (±5.8). 33% had a post-graduate or graduate degree, and 93% reported good or very good health. 65% were undergoing their first screening colonoscopy.
When told to imagine being notified that they had a suboptimal bowel preparation, 45% reported wanting to wait >1 year for their next colonoscopy. Reported certainty in this decision was high (75% reported ≥5 out of 7). However, when asked how likely they would be to follow a physician’s recommendation to repeat colonoscopy within 1 year, 80% reported that they intended to follow this recommendation (responses ≥5 out of 7).
In the regression analysis (Table 1), age was associated with lower likelihood of following recommendations for repeat colonoscopy within 1 year (adjusted odds ratio (OR) 0.96 per one-year increase in age; 95% CI 0.93–0.99). Worry about CRC was associated with greater likelihood of following a recommendation to repeating colonoscopy within 1 year (OR 1.25; 95% CI 1.14–1.38). No other factors were significantly associated with likelihood of following physicians’ recommendations to repeat colonoscopy within 1 year, although there was a non-significant trend for respondents undergoing their first colonoscopy to state a higher likelihood of following this recommendation.
Table 1.
Factors Associated with Likelihood of Following Physicians’ Recommendations to Repeat Colonoscopy within 1 Year of Exam with Suboptimal Bowel Preparation
| Adjusted* | |||
|---|---|---|---|
| Independent Variable | OR | 95% CI | p-value |
| Age (per year increase) | 0.96 | 0.93 to 0.99 | 0.004 |
| Race | |||
| Caucasian | Ref | ||
| African American | 1.53 | 0.71 to 3.28 | 0.28 |
| Asian-American/Pacific Islander | 0.87 | 0.35 to 2.14 | 0.76 |
| American Indian/Alaskan Native | 0.28 | 0.04 to 2.17 | 0.23 |
| Gender | |||
| Male | Ref | ||
| Female | 1.18 | 0.83 to 1.66 | 0.36 |
| BMI (per mg/kg2)** | 1.00 | 0.999 to 1.00 | 0.81 |
| Self-Reported Health Status | |||
| Excellent | Ref | ||
| Very Good | 0.84 | 0.54 to 1.31 | 0.44 |
| Good | 0.73 | 0.44 to 1.22 | 0.23 |
| Fair | 0.70 | 0.30 to 1.66 | 0.42 |
| Poor | 0.35 | 0.09 to 1.28 | 0.11 |
| Highest Level of Education | |||
| Did not complete High School | Ref | ||
| Completed High School | 1.05 | 0.31 to 3.51 | 0.94 |
| Some College or specialty training | 0.85 | 0.27 to 2.67 | 0.77 |
| Graduated from College | 0.67 | 0.21 to 2.11 | 0.49 |
| Post Graduate/Graduate Degree | 0.79 | 0.25 to 2.53 | 0.70 |
| First Colonoscopy | 1.44 | 0.94 to 2.21 | 0.09 |
| Worried about CRC** | 1.25 | 1.14 to 1.38 | <0.001 |
Adjusted for age, race, gender, BMI, self-reported health status, level of education, whether colonoscopy was first exam, and how worried respondents were about CRC
BMI=body mass index; CRC=colorectal cancer
Discussion
While a significant minority of patients express a desire to wait longer than 1 year for repeat colonoscopy after suboptimal bowel preparation, most are willing to follow a physician recommendation for repeat colonoscopy within 1 year. Increasing age was associated with lower likelihood of following this recommendation, and more worry about CRC was associated with higher likelihood of following this recommendation.
Suboptimal bowel preparation is associated with interval CRC.5 Endoscopists often recommend repeat colonoscopy intervals of greater than 1 year in this setting.3,6 This study highlights that most patients are willing to follow endoscopists’ recommendations for early repeat colonoscopy. Physicians should therefore feel comfortable recommending a repeat exam within 1 year of suboptimal preparation, as guidelines suggest, in order to prevent interval CRC.
Limitations of our study include its single-center, hypothetical-scenario design, which may not reflect actual perceptions, and a high education level, which may limit generalizability. Strengths include administration of the survey prior to patients undergoing colonoscopy with a majority undergoing their first colonoscopy, which limit prior experiences from impacting patients’ responses.
In conclusion, our study highlights that endoscopists should feel confident following guidelines to recommend repeat colonoscopy within 1 year of suboptimal preparation.
Acknowledgments
Stacy Menees received support from the Michigan Institute for Clinical and Health Research T2 grant. Jennifer Maratt and Marc Piper received support from the National Institute of Health T32 DK062708 grant.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Conflicts of Interest: All authors have no conflicts of interest.
Author Contributions:
Study concept and design: Stacy Menees, Sameer Saini
Survey design: Stacy Menees, Sameer Saini, Brian Zikmund-Fisher
Acquisition, analysis, or interpretation of data: Stacy Menees, Sameer Saini, Jennifer Maratt, Marc Piper, Brian Zikmund-Fisher
Drafting of the manuscript: Stacy Menees, Sameer Saini, Jennifer Maratt, Brian Zikmund-Fisher
Statistical analysis: Jennifer Maratt, Marc Piper Study supervision: Stacy Menees, Sameer Saini
References
- 1.Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointestinal Endoscopy. 2014;80:543–562. doi: 10.1016/j.gie.2014.08.002. [DOI] [PubMed] [Google Scholar]
- 2.Chokshi RV, Hovis CE, Colditz GA, et al. Physician Recommendations and Patient Adherence After Inadequate Bowel Preparation on Screening Colonoscopy. Dig Dis Sci. 2013;58:2151–2155. doi: 10.1007/s10620-013-2642-9. [DOI] [PubMed] [Google Scholar]
- 3.Larsen M, Hills N, Terdiman J. The Impact of the Quality of Colon Preparation on Follow-Up Colonoscopy Recommendations. Am J Gastroenterology. 2011;106:2058–2062. doi: 10.1038/ajg.2011.238. [DOI] [PubMed] [Google Scholar]
- 4.Menees SB, Kim HM, Wren P, et al. Patient compliance and suboptimal bowel preparation with split-dose bowel regimen in average-risk screening colonoscopy. Gastrointestinal Endoscopy. 2014;79:811–820.e3. doi: 10.1016/j.gie.2014.01.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lebwohl B, Kastrinos F, Glick M, et al. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointestinal Endoscopy. 2011;73:1207–1214. doi: 10.1016/j.gie.2011.01.051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hillyer GC, Basch CH, Lebwohl B, et al. Shortened surveillance intervals following suboptimal bowel preparation for colonoscopy: Results of a national survey. Int J Colorectal Dis. 2012;28:73–81. doi: 10.1007/s00384-012-1559-7. [DOI] [PMC free article] [PubMed] [Google Scholar]