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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