Evidence-Based and Patient-Centered Medicine with Shared Decision Improves Colonoscopy Efficacy in Poor Bowel Preparation Patients

This article refers to:

Effect and Tolerability of Same-Day Repeat Colonoscopy

Daily clinical practice originates ideas that may be overlooked by most doctors even though these ideas are fundamental in medical research and they are the main driver of evidence-based and patient-centered medicine. Consider the opinion and interests of patients has shown a reduction on costs and anxiety of medical procedures and an increasing in the attachment [1]. In apparently healthy people, but at risk and at whom we need to perform scrutiny procedures, the benefit for them would be unclear. Here we require new approaches linked to patient-centered medicine.

In the case of colorectal cancer (CRC), which is the third cause of cancer-related death worldwide, early detection is essential to reduce the cost of the disease. In 2014, the direct medical costs of CRC were up to $14 billion in the United States. Although there are distinct approaches; such as fecal immunochemical tests, which reduce the cost in about five times, but also the adenoma detection rate decreases to 1.6% compared with the 23.6%, the colonoscopy is still the gold standard for early diagnosis and potentially treatment of cancerous lesions by removing it during the procedure. Consequently, performing a colonoscopy properly has become a priority as a therapeutic/diagnostic tool to reduce the health-related cost of CRC [2].

This invasive procedure requires to carry out an adequate bowel preparation because the correct visualization of the mucosa is indispensable to identify a lesion. We know that up to 20% of patients undergoing colonoscopy have poor bowel preparation that decrease adenoma rate detection and increase the costs by 12–22 %. This problem is more serious in populations with concomitant diseases such as slow transit constipation that do not respond to standard doses of laxatives. This patients with poor bowel preparation are subjected to be reprogramed to undergo a new colonoscopy another day with the consequences over losing the working-day, time, the intake of a new laxative, the cost of the second colonoscopy, as well as repeating the fear and distress of taking a new preparation to [3]. In this scenario the use of a second dose of laxative can have a deep impact on the detection of adenomas, the quality standards, and patient satisfaction [4].

This problem was addressed in the article referred by this comment [5]. The authors recruited 60 patients referred to colonoscopy and who had poor bowel preparation (Boston Scale <2) in the programmed colonoscopy. Six out of 10 patients reported having followed the instructions to the letter, 5 out of 10 had constipation and 6 out of 10 had no co-morbidities that could affect the preparation of the study. This is the most frequent scenario in routine clinical practice. They were offered the option to take a second dose of laxative and repeat the study that same day in the afternoon. Eighty percentage of the patients with the second dose achieved adequate bowel preparation, so the second colonoscopy was performed without complications. This success rate is important because they report a 16% benefit compared with reported of 20% of poor bowel preparation, decreasing the need to re-schedule in only the 4% of colonoscopies. They show an increase in the Boston scale and the quality indicators. The adenoma detection rate increased from 1.6 to 26.6%. They mention that 91.7% found it beneficial and 96.7% would repeat it if necessary. Unfortunately, they did not perform a comparison arm or report the number of successful studies during the recruitment period, making it impossible to make an adequate estimate of the prevalence in their center of inadequate bowel preparation. Nor do they mention the prevalence of patients reprogramed for poor bowel preparation in their center to know if this second colonoscopy could have similar results. Even with these limitations, the idea is great because it offers an alternative for patients with poor bowel preparation for eliminating the need to be cited on another occasion.

This work involved evidence-based and patient-centered medicine with shared decision. The result of the article supports the notion that this type of maneuvers must be on the standard care. We can improve the outcomes incorporating minimal maneuvers on standardized procedures; for example; a short telephone call one day previous, taking patient satisfaction into account and involving them in making decisions [6]. This can avoid secondary expenses with the subsequent attachment to their appointments for colonoscopy.

On the broader vision, this approaches has effects on the screening for CRC [7]. For example, the actual guideline of screening proposes begin screening at 50 years old, [8] but recent reports support the need to initiate at younger age [9]. This implies that our target population grows, involving patients in more productive ages and therefore needing to avoid losing working days.

Finally, we need to perform focused studies that assess the influence of these rescue measures for poor intestinal preparation in the number needed for screening and the number of adenomas to be removed in different regions and different populations that allow homogeneity in the findings, generalize the results and implement custom measures to different populations that decrease the worldwide health-related cost of CRC [10].

Declaration of Interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.