Patient education for colonoscopy in the time of computers: are you ready, player one?

Patient education has been recognized as an important quality parameter for colonoscopy [1], as the preparation for this examination is not straightforward and encompasses several steps: patients have to follow a recommended diet and correctly take the bowel prep, generally in a split-dose or same-day regimen, which may be difficult to follow without proper instructions. In general terms, communicating something to a person means making that person understand the content of your speech, which is generally possible if the other person can relate to the object of understanding. This relies on the capability to mentally figure it, or at least to compare it to a past experience [2]. In human history, as well as in medicine, the written word has been the basis for the process of education, through books and their much leaner, modern versions, such as leaflets. However, paralleling what is currently happening with social networks, the written word has been progressively replaced by images, and these latter by videos. This is not unexpected, if we consider that a video engages both the sense of sight and hearing, and has in its motion another reason for its superiority over still images and words.

In this issue of Endoscopy, Veldhuijzen et al. [3] evaluated the impact of patient education for colonoscopy on the adequacy of colon cleansing through a web-based platform including videos and explanatory text. This novel educational methodology was compared with traditional nurse counselling in a non-inferiority, multicenter randomized controlled trial (RCT), finally including more than 200 patients per group. The findings are highly interesting as the computer-based education (CBE) performed similarly to the nurse counselling in terms of bowel preparation adequacy (93 % vs. 94 % in the per-protocol analysis) and achieved a much lower sickness absence leave (5 % vs. 28 %) [3]. Furthermore, the anxiety levels of patients at baseline and before colonoscopy were similar between the groups. Lastly, around 20 % of patients in the CBE group requested additional information on the preparation for colonoscopy, mostly by phone call, and only 3 % needed an outpatient visit.

There are a few implications that can be derived from this study. First, the CBE tested in this study worked well, achieving a high success rate in terms of a “hard” endpoint, namely the adequacy of colon cleansing. This study expands previously reported data from other RCTs [4] [5], but provides a slightly larger study size, although it does not confirm the superiority of CBE over nurse-based patient education; nevertheless, adequate bowel cleansing was achieved in over 90 % of patients in both groups. Therefore, the CBE seems to perform well when provided along with high quality endoscopy services and is in line with the ESGE quality standards for colonoscopy.

Second, this technological aid seems to be appropriate and timely if we consider the context of the current COVID-19 pandemic. Indeed, ESGE recommended in a recent position statement that online care should be provided if feasible, possibly including video and audio documentation if this is to replace an outpatient clinic visit [6]. In fact, using a remote web-based education system implies that patients do not have to attend the outpatient clinic, avoiding unnecessary travel and gatherings. This would clearly represent an important aid for endoscopy services. Third, avoiding nurse visits might well lead to resource sparing, in terms of economic savings and reallocation of personnel.

“computer-based education (CBE) seems to perform well when provided along with high quality endoscopy services and is in line with the ESGE quality standards for colonoscopy.”

Nevertheless, further research is needed in order to expand our knowledge on the potential of CBE in the field of colonoscopy. Of note, patient co-morbidities and factors known to impact on the quality of bowel preparation were not assessed by Veldhuijzen and co-workers [3], thereby limiting the external validity of the study findings, especially for “hard-to-prepare” subjects. A recent prospective multicenter study [7], including more than 1600 hospitalized patients, found that providing both written and oral instructions significantly increased the adequacy of bowel preparation, estimating a 6 % rise in adequate colon cleansing if applied to the whole study population. Therefore, it might be interesting to provide the CBE to “hard-to-prepare” patients in order to assess whether a better understanding of the preparation for colonoscopy could lead to better bowel cleansing for this group. Furthermore, the CBE requires that patients are familiar with computers or at least smartphones, which is not always the case for the elderly. Therefore, it seems important to identify the category of people who might benefit most from this innovation.

Another point that remains to be elucidated is the lower incidence of sickness absence leave for the CBE group (5 % vs. 28 %) [3], for which an explanation was not given by the authors. Recent prospective data on more than 1000 patients scheduled for colonoscopy found that their working activity was significantly affected by the preparation for the examination in 22 % of cases, being more markedly impacted by a same-day vs. a split-dose regimen (i. e. 35 % vs. 20 %), and by high- vs. low-volume prep (24 % vs. 20 %) [8]. Such information, along with the type of work performed by the included patients, was not provided by Veldhuijzen et al. [3], meaning that the finding of the CBE impact on patients’ working activity remains only speculative at present.

In conclusion, it is likely that computer-based interaction with patients will play an increasingly important role, also boosted by the current COVID-19 pandemic. The education of patients seems to be one of the more promising fields, and studies like the one authored by Veldhuijzen and co-workers [3] are needed to fully explore its potential and to define its applicability in clinical practice.

Publication History

Article published online:
25 February 2021

• References

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