Combined written and oral information prior to gastrointestinal endoscopy compared with oral information alone: a randomized trial

The evolution of informed consent in gastroenterology

With medical litigation on the rise, physicians require a nuanced understanding of the legalities of consenting patients to reduce their liability while practising evidence-based medicine. This study aims to a) clarify the legal duties of gastroenterologists in the UK and USA when gaining informed consent and b) provide recommendations at the international and physician level to improve the consent process and reduce liability.A bibliometric analysis of the Web of Science database with the MeSH terms "gastroenterology" and "informed consent" yielded 383 articles, of which 228 were excluded due to not meeting the inclusion criteria. Of the top 50 articles, 48% were from American institutions and 16% were from the UK. Thematic analysis showed 72% of the articles discussed informed consent in relation to diagnostic procedures, 14% regarding treatment, and 14% regarding research participation.Both the USA and the UK have progressed from previously paternalistic Natanson case (1960) and Bolam test (1957), respectively, where physicians were held to the standard of a "reasonable and prudent medical doctor". The American Canterbury case (1972) and the British Montgomery case (2015) radically shifted the standard of disclosure during the consent process by requiring physicians to explain all information pertinent to a "reasonable patient".It is our recommendation that a two-pronged approach be taken; a) creation of international guidelines for consenting patients for invasive procedures in gastroenterology, and b) development of internationally standardised endoscopy consent forms containing all the details pertinent to a "reasonable patient".

Patients' Experiences With the Removal of a Ureteral Stent: Insights From In-depth Interviews With Participants in the USDRN STENTS Qualitative Cohort Study

OBJECTIVE

To describe the experiences of patients undergoing stent removal in the USDRN Study to Enhance Understanding of Stent-Associated Symptoms (STENTS), a prospective, observational cohort study of patients with short-term ureteral stent placement post-ureteroscopy.

METHODS

We conducted a qualitative descriptive study using in-depth interviews. Participants reflected on (1) painful or bothersome aspects of stent removal, (2) symptoms immediately after removal, and (3) symptoms in the days following removal. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis.

RESULTS

The 38 participants interviewed were aged 13-77 years, 55% female, and 95% White. Interviews were conducted 7-30 days after stent removal. Almost all participants (n = 31) described that they experienced either pain or discomfort during stent removal, but for most (n = 25) pain was of short duration. Many participants (n = 21) described anticipatory anxiety related to the procedure, and several (n = 11) discussed discomfort arising from lack of privacy or feeling exposed. Interactions with medical providers often helped put participants at ease, but also increased discomfort for some. Following stent removal, several participants described lingering pain and/or urinary symptoms, but these largely resolved within 24 hours. A few participants described symptoms persisting for more than a day post stent removal.

CONCLUSION

These findings on patients' experiences during and shortly after ureteral stent removal, particularly the psychological distress they experienced, identify opportunities for improvement in patient care. Clear communication from providers about what to expect with the removal procedure, and the possibility of delayed pain, may help patients adapt to discomfort.

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies

BACKGROUND

Sedation is common practice in endoscopic procedures to suppress a patient's level of consciousness while maintaining the cardio-respiratory function. Midazolam and propofol are the sedatives most frequently used for procedural sedation at the hospitals in Scandinavia. Remimazolam is a new ultra-short-acting benzodiazepine sedative and the present analysis aimed at estimating the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia.

METHOD

We developed a cost model applying a micro-costing approach that comprised the cost components that are affected by differences in the efficacy of remimazolam, midazolam and propofol, and the model estimated the cost per successful colonoscopy and bronchoscopy when using remimazolam, midazolam or propofol as sedation. A micro-costing approach was applied, and the model consisted of six stages representing the journey for patients undergoing endoscopies and was informed primarily by data from clinical studies on remimazolam.

RESULTS

We found a total cost of DKK 1,200 per successful colonoscopy procedure when using remimazolam, a total cost of DKK 1,320 when using midazolam and a total cost of DKK 1,255 when using propofol. Hence, the incremental saving per successful colonoscopy procedure of using remimazolam was estimated to be DKK 120 compared to midazolam and DKK 55 compared to propofol. The total cost per successful bronchoscopy procedure when using remimazolam was DKK 1,353 and DKK 1,724 for midazolam, resulting in an incremental saving per bronchoscopy of DKK 372 when using remimazolam. Performed sensitivity analyses identified the time in recovery as the largest contributor to uncertainty in the analyses of remimazolam compared to midazolam in colonoscopies and bronchoscopies. In the comparison of remimazolam and propofol in colonoscopies, procedure time was the largest contributor to uncertainty.

CONCLUSION

We found that procedural sedation with remimazolam was associated with economically meaningful savings compared to procedural sedation with midazolam and propofol in colonoscopies and to midazolam in bronchoscopies.

Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

The Effect of a Pre-Colonoscopy Education Program on Fear and Anxiety of Patients: A Randomized Clinical Trial Study

Background

Due to the increasing prevalence of intestinal diseases, colonoscopy is considered a safe and fast diagnostic and treatment method for these patients. According to studies, most patients waiting for a colonoscopy experience fear and anxiety. This study aimed to investigate the effect of a pre-colonoscopy education program on the fear and anxiety of patients undergoing colonoscopy.

Materials and Methods

This randomized clinical trial study was conducted on patients undergoing colonoscopy in hospitals in southeast Iran. A total of 90 participants were selected by convenient sampling and randomly assigned to two groups control (n = 45) and intervention (n = 45). The patients in the intervention group received nursing interventions before colonoscopy, while the patients in the control group received only routine care. The data were collected using a researcher-made fear of colonoscopy scale, its Cronbach's alpha coefficient (0.92), and the Spielberger State-Trait Anxiety Inventory. The data were analyzed with a Chi-square t-test and pair t-test.

Results

The data showed that anxiety and fear of colonoscopy in the patients in the intervention group significantly decreased compared to the patients in the control group (p < 0.001).

Conclusions

Using non-pharmacological methods before colonoscopy can reduce the fear and anxiety in patients who are candidates for this procedure and similar invasive procedures. The intervention performed in this study can be used together with other methods to control patients' fear and anxiety. Especially for nurses, It is recommended to do pre-colonoscopy education programs for these clients.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy Facilities: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high-quality endoscopic care in children. These standards were subcategorized into three subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards).

DISCUSSION

The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high-quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.

The Impact of Endoscopy Sedation Information Sheets on the Level of Concern Regarding Possible Awareness in Patients Undergoing Endoscopy Sedation

Sedation encompasses a continuum from complete unconsciousness to drowsiness and anxiolysis where some awareness might be expected. Most patients undergoing endoscopy sedation expect to be completely unconscious during the procedure and thus have unmet expectations regarding their state of consciousness. This study aimed to evaluate whether endoscopy sedation information sheets reduce the level of concern regarding possible awareness during endoscopy sedation at a major regional hospital. Our findings were that 28.8% of patients who received the endoscopy sedation information sheet (n = 82) were concerned about awareness during the procedure, compared to 36.5% of patients in the control group (n = 105). However, the difference was not statistically significant. We also found that the incidence of awareness was higher (13.9%) in the intervention group compared to 8.8% in the control group but, again, not statistically different. This study allowed us to elucidate the level of concern regarding possible awareness during sedation and the incidence of awareness during endoscopy sedation. This will enable future work investigating the role of endoscopy sedation information methods involving written and video material in assisting pre-procedure patient counselling.

Medical professional liability in gastroenterology: definitions, trends, risk factors, provider behaviors, and implications

Introduction: Medical professional liability (MPL) is a notable concern for many clinicians, especially in procedure-intensive specialties such as gastroenterology (GI). Comprehensive understanding of the basis for MPL claims can improve gastroenterologists' practice, lower MPL risk, and improve the overall patient care experience. This is particularly relevant in the setting of the increasing average compensation per paid GI-related MPL claim, and evolving healthcare delivery patterns and regulations.Areas Covered: MPL claims are generally grounded in the concept of negligence, a broad term that may apply to situations involving medical errors, ameliorable adverse events, inadequate informed consent and/or refusal, and numerous others. Though often not directly discussed in GI training or thereafter, there are various mechanisms and behaviors that can alter (decrease or increase) MPL risk. Additional dimensions of MPL include telemedicine, social media, and vicarious liability. We discuss these topics as well as takeaways to mitigate risk, thus reducing unnecessary clinician anxiety, promoting professional development, and optimizing healthcare outcomes.Expert Opinion: MPL risk is modifiable. Strong provider-patient relationships, through effective communication, patient reassurance, and enhanced informed consent, decrease risk, as does thorough documentation. Conversely, provider 'defensive' mechanisms intended to decrease MPL risk, including assurance and avoidance behaviors, may paradoxically increase it.

Preparing accessible and understandable clinical research participant information leaflets and consent forms: a set of guidelines from an expert consensus conference

BACKGROUND

In line with Good Clinical Practice and the Declaration of Helsinki, it is the investigator's responsibility to ensure that research participants are sufficiently informed, to enable the provision of informed consent. The Participant Information Leaflet/Informed Consent Form is key to facilitating this communication process. Although studies have indicated that clinical research Participant Information Leaflets/Informed Consent Forms are not optimal in terms of accessibility, there is little or no specific guidance available. The aim of this research was to propose and agree a set of guidelines for academic researchers and sponsors for preparing accessible and understandable Participant Information Leaflets/Informed Consent Forms.

METHODS

A literature review identified guidance for the preparation of patient-facing documents. Following critical appraisal, key recommendations were extracted and a set of recommendations which can be applied to clinical research Participant Information Leaflets/Informed Consent Forms were prepared. These recommendations were evaluated and amended by an Expert Consensus Conference consisting of a group of key stakeholders. The stakeholders included members of a Research Ethics Committee (both lay and expert), a patient advocate, experienced clinical researchers, a plain English editor and a Data Protection Officer. Consensus was reached regarding a final set of recommendations.

RESULTS

44 recommendations were agreed upon and grouped into five categories: Layout, Formatting, Content, Language and Confirming Readability. These recommendations aimed to maximize accessibility for lay participants, including readers with dyslexia, literacy or numeracy challenges, thereby improving the quality of the consent process.

CONCLUSIONS

More empirical research is needed to further improve the informed consent process for research participants. However, these recommendations are informed by the current literature and have been ratified by expert stakeholders. It is hoped that these recommendations will help investigators and sponsors to consistently and efficiently produce more accessible clinical research Participant Information Leaflets/Informed Consent Forms.

Determination of the Effectiveness of Informing With the Guidance of an Education Booklet in Patients Undergoing Colonoscopy-A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of precolonoscopy information with the guidance of an education booklet on anxiety and bowel preparation adequacy in patients undergoing colonoscopy.

DESIGN

A randomized controlled study.

METHODS

The education group was informed face to face by the researcher with the guidance of the colonoscopy education booklet and provided the education booklet. The control group received usual care.

FINDINGS

The mean state and trait anxiety scores of the patients in the education group were found to be significantly lower than the control group. In the education group, the bowel preparation adequacy was determined to be higher compared with the control group.

CONCLUSIONS

Informing patients with the guidance of the education booklet before the colonoscopy decreased patients' state and trait anxiety levels and increased their bowel preparation adequacy.

Quality of informed consent documents among US. hospitals: a cross-sectional study

OBJECTIVE

To determine whether informed consent for surgical procedures performed in US hospitals meet a minimum standard of quality, we developed and tested a quality measure of informed consent documents.

DESIGN

Retrospective observational study of informed consent documents.

SETTING

25 US hospitals, diverse in size and geographical region.

COHORT

Among Medicare fee-for-service patients undergoing elective procedures in participating hospitals, we assessed the informed consent documents associated with these procedures. We aimed to review 100 qualifying procedures per hospital; the selected sample was representative of the procedure types performed at each hospital.

PRIMARY OUTCOME

The outcome was hospital quality of informed consent documents, assessed by two independent raters using an eight-item instrument previously developed for this measure and scored on a scale of 0-20, with 20 representing the highest quality. The outcome was reported as the mean hospital document score and the proportion of documents meeting a quality threshold of 10. Reliability of the hospital score was determined based on subsets of randomly selected documents; face validity was assessed using stakeholder feedback.

RESULTS

Among 2480 informed consent documents from 25 hospitals, mean hospital scores ranged from 0.6 (95% CI 0.3 to 0.9) to 10.8 (95% CI 10.0 to 11.6). Most hospitals had at least one document score at least 10 out of 20 points, but only two hospitals had >50% of their documents score above a 10-point threshold. The Spearman correlation of the measures score was 0.92. Stakeholders reported that the measure was important, though some felt it did not go far enough to assess informed consent quality.

CONCLUSION

All hospitals performed poorly on a measure of informed consent document quality, though there was some variation across hospitals. Measuring the quality of hospital's informed consent documents can serve as a first step in driving attention to gaps in quality.

Effect of Consent and Educational Adjuncts to Consent on Patient Perceptions About Colonoscopy

BACKGROUND AND AIMS

Informed consent is a vital preprocedural step for endoscopy but there are substantial variations in its delivery. We therefore sought to assess a multifaceted intervention to improve the consent process.

METHODS

Gastroenterologists at a tertiary center were educated on the recommended components of informed consent. Following this, 3 cohorts of patients undergoing colonoscopy were surveyed before and after consent. In one cohort, the effect of optimized verbal consent alone was assessed. In the second and third groups, the effects of the addition of either a handout or a video describing colonoscopy and its risks were evaluated. The primary outcomes were the changes between preconsent and postconsent survey responses regarding confidence in understanding the procedure's purpose, likelihood of adverse events, and levels of anxiety.

RESULTS

In total, 240 patients were included with 79 to 81 patients per group. There were no significant differences among the groups' survey responses. Compared with patients receiving verbal consent alone, fewer patients in the handout and video groups increased their perceived risk of adverse events following consent, but this difference did not reach significance (P=0.08). Examining all groups together, anxiety levels changed significantly after consent (P=0.003), with 31% of patients reducing their anxiety level, 8% increasing it, and 62% having no change.

CONCLUSIONS

The consent process appears to decrease patient anxiety about colonoscopy. When used in conjunction with a high-quality verbal consent, written or video educational adjuncts provided on the day of colonoscopy likely have no effect on patient perceptions.

Effect of Education for Hypertensive Patients with Correctly Performed Self-Blood Pressure Monitoring (SBPM)

INTRODUCTION

The study objective was to assess the impact of pharmacist-led education on the patient's knowledge and skills on SBPM (self-blood pressure monitoring).

METHODS

Patient knowledge was assessed using tests and patients' skills were based on a checklist (20 parameters) completed by the researcher based on the SBPM video records. Patients taking pressure measurements were filmed for 20 days and after 6 months. After the first 10 days, patients were educated about the correct SBPM procedure. Knowledge tests were repeated three times (before/after/6 months after education).

RESULTS

All patients' knowledge and skills in the field of SBPM were improved after education. After the education, patients scored an average of 9 out of 10 points in the knowledge test (increasing an average of five points after education), six months later-an average increase of 7.36 points. Patient skills after training were rated at 17.4 out of 20 points on average (increase by an average of 5.14 points after education), six months later, there was an average of 16.23 points.

CONCLUSIONS

The study showed an increase in patients' knowledge and skills in the field of SBPM after training.

Effect of Information of Patients' Coping Style on Pregastroscopy Anxiety

Examination of the relationship between patients' coping style, pregastroscopy information, and anxiety associated with gastroscopy in China was the aim of this study. A pretest, post-test, nonrandom assignment study with a two by two design was conducted. One hundred forty-five patients who underwent initial gastroscopy without sedation were classified into 2 groups on the basis of the coping style: information seekers or information avoiders using the Information Subscale of the Krantz Health Opinion Survey (KHOS-I). All participants were given standardized procedural information about gastroscopy as routine care. Half of each group was assigned to receive additional sensory information describing what sensation they would experience and how to cooperate to alleviate the discomfort. State anxiety assessed by the State Anxiety Scale of Spielberg's State-Trait Anxiety Inventory, blood pressure, and pulse were measured at enrollment and before gastroscopy. The information seekers and avoiders who received additional sensory information experienced significantly less state anxiety after the intervention. In contrast, the information seekers and avoiders who received standardized procedural information maintained their preintervention state anxiety level. Most patients reported their preference for sensory information. In conclusion, the provision of sensory information could significantly reduce patients' pregastroscopy anxiety regardless of patients' information coping style.

Educational Colonoscopy Video Enhances Bowel Preparation Quality and Comprehension in an Inner City Population

BACKGROUND

Quality of bowel preparation and patient knowledge remains a major barrier for completing colorectal cancer screening. Few studies have tested unique ways to impact patient understanding centering on interactive computer programs, pictures, and brochures. Two studies explored instructional videos but focused on patient compliance and anxiety as endpoints. Furthermore, excessive video length and content may limit their impact on a broad patient population. No study so far has studied a video's impact on preparation quality and patient understanding of the colonoscopy procedure.

METHODS

We conducted a single blinded prospective study of inner city patients presenting for a first time screening colonoscopy. During their initial visit patients were randomized to watch an instructional colonoscopy video or a video discussing gastroesophageal reflux disease (GERD). All patients watched a 6 minutes long video with the same spokesperson, completed a demographic questionnaire (Supplemental Digital Content 1, http://links.lww.com/JCG/A352) and were enrolled only if screened within 30 days of their visit. On the day of the colonoscopy, patients completed a 14 question quiz of their knowledge. Blinded endoscopist graded patient preparations based on the Ottawa scale. All authors had access to the study data and reviewed and approved the final manuscript.

RESULTS

Among the 104 subjects enrolled in the study, 56 were in the colonoscopy video group, 48 were in GERD video group, and 12 were excluded. Overall, 48% were male and 52% female; 90% of patients had less than a high school education, 76% were African American, and 67% used a 4 L split-dose preparation. There were no differences between either video group with regard to any of the above categories. Comparisons between the 2 groups revealed that the colonoscopy video group had significantly better Ottawa bowel preparation score (4.77 vs. 6.85; P=0.01) than the GERD video group. The colonoscopy video group also had less-inadequate repeat bowel preparations versus the GERD video group (9% vs. 23%; P<0.01). The overall score on the knowledge questionnaire (Supplemental Digital Content 1, http://links.lww.com/JCG/A352) was significantly higher in the colonoscopy video group as compared with the GERD video group (12.77 vs. 11.08; P<0.001. In all patients the overall quiz score positively correlated with preparation quality (odds ratio, 2.31; confidence interval, 1.35-3.94; P<0.001).

CONCLUSIONS

Our unique population represented an overwhelmingly under-educated (85% had a high school education or less) and minority group (76% African American). They are one of the most at risk of having multiple barriers such as comprehension and reading difficulties resulting in poor preparation examinations and no shows to procedures. Our instructional video proved to be high yield in this population. The patients assigned to watch the colonoscopy video showed a significant increase in "excellent" grade adequate bowel preparation quality by >23% and a significant decrease in "inadequate" bowel preparations by almost 50%. Our study proves that an educational video can improve both comprehension with regard to all aspects of colonoscopy. ClinicalTrials.gov number, NCT02906969.

A Web-based Multimedia Program Before Colonoscopy Increased Knowledge and Decreased Anxiety, Sedation Requirement, and Procedure Time

GOALS

Assess the impact of a web-based multimedia patient engagement program on patient anxiety, perception and knowledge about the colonoscopy in addition to procedure outcomes.

BACKGROUND

The success of patients coming for a colonoscopy for colorectal cancer screening is dependent in part on patients' understanding of the preparation and of the procedure. Patients were randomized to use either our institution's standard preprocedure colonoscopy packet or a web-based multimedia patient engagement program (Emmi Solutions) before their scheduled procedure. On the day of colonoscopy, all participants completed a survey including questions to assess knowledge and perception of colonoscopy, in addition to the State Trait Anxiety Inventory. We also collected procedure data including medication doses and procedure time.

STUDY RESULTS

Patients in the experimental group correctly answered knowledge questions (82%) more often than the control group (74%) (P=0.0003). More than half (58%) of patients in the experimental group felt this intervention reduced their anxiety about the procedure, and the State Trait Anxiety Inventory anxiety score was lower in the experimental group (P=0.026). Patients who viewed the program required less midazolam (3.66 vs. 4.46 mg, P=0.0035) and total procedure time was shorter (24.8 vs. 29 min, P=0.024).

CONCLUSIONS

A web-based multimedia patient engagement program watched before colonoscopy decreased patient anxiety, medication requirements, and procedure time while increasing knowledge. This intervention could help patients understand and feel more comfortable about colonoscopy leading to increased screening rates while increasing efficiency and decreasing recovery time.

Impact of anxiety on sedative medication dosage in patients undergoing esophagogastroduodenoscopy

Introduction

Esophagogastroduodenoscopy (EGD) is a diagnostic method used in the investigation of upper gastrointestinal system diseases. A high level of anxiety of patients who undergo EGD increases the duration of the procedure and the sedation and analgesic requirements. Sedation is used to increase patient comfort and tolerance by reducing the anxiety and pain associated with endoscopic procedures.

Aim

In this study, the effect of anxiety scores on medication doses was investigated in patients who underwent EGD under sedation.

Material and methods

A psychiatrist, an endoscopist and an anesthesiologist conducted a prospective observational study blindly to investigate the effect of pre-procedural (before EGD) anxiety level on medication doses for sedation. Patients were divided into two groups, with and without additional medication doses.

Results

The study included 210 consecutive patients who underwent EGD under sedation. The average STAI-S score was 40.28 and the average STAI-T score was 40.18. There was no relationship between anxiety scores and gender (p = 0.058, p = 0.869). Statistically significant results were obtained for anxiety scores with additional sedation dosing (p < 0.05). It was observed that an additional dose of medication was affected by age, body mass index and anxiety scores (p < 0.005). Patients who were young, had a low body mass index and had high anxiety scores had significantly higher additional dose requirements.

Conclusions

The medications used for sedation during EGD may be inadequate or an additional dose of medication may be needed for patients who have higher anxiety scores, younger age, and lower body mass index.

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

A Study on the Effects of a Health Education Intervention on Anxiety and Pain During Colonoscopy Procedures

BACKGROUND

Colonoscopy is currently considered the best screening tool in the diagnosis of colon diseases. However, this procedure often causes pain and discomfort in patients, thus reducing patient willingness to undergo and comply with this procedure.

PURPOSE

This study explores the effects of providing procedure-related information to patients receiving colonoscopy in terms of anxiety and pain reduction and identifies factors that influence the pain and anxiety experienced by patients during this procedure.

METHODS

This study adopted a quasi-experimental design that targeted colonoscopy patients in outpatient clinics. Two hundred thirteen patients were recruited, with 103 patients in the experimental group and 110 in the control group. Participants were recruited between January and April 2011. All of the participants received standard care, and only those participants who were assigned to the experimental group were asked to watch "A Guide to the Colonoscopy Procedure," a multimedia health informatics CD-ROM.

RESULTS

Anxiety scores of the experimental group dropped from 48.7 ± 11.6 to 39.2 ± 8.7 after the intervention. The average pain score of the experimental group was significantly lower than that of the control group (3.8 ± 2.5 vs. 5.0 ± 2.7). Furthermore, trait anxiety, gender, and educational level were identified as the main predictors for state anxiety, and state anxiety was identified as an important predictor for pain during the colonoscopy examination.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This study found that using a multimedia health informatics CD-ROM to provide information on the colonoscopy procedure effectively reduced the examination-related anxiety and pain of patients.

Prospective evaluation of anxiety, pain, and embarrassment associated with cystoscopy and urodynamic testing in clinical practice

INTRODUCTION

We sought to prospectively assess anxiety, pain, and embarrassment associated with diagnostic cystoscopy and multi-channel urodynamic study (UDS).

METHODS

All consecutive patients undergoing diagnostic cystoscopy or UDS in our department over a period of nine months were asked to participate. Two anonymous auto-administered questionnaires were specifically designed to collect basic epidemiological data, document medical history, and assess the quality of information provided, along with prevalence and level (0-10 numerical visual analog rating scale) of anxiety, pain, and embarrassment experienced before and/or during the procedures. Statistical analysis was carried out to identify underlying factors that could have influenced patients' experience and ascertain potential correlations between anxiety, pain, and embarrassment.

RESULTS

101 and 185 patients were respectively evaluated immediately after cystoscopy and UDS. Multivariate analysis repeatedly showed statistical correlations between anxiety, pain, and embarrassment, with regard to prevalence and level of intensity in both cystoscopy and UDS populations. Males and young patients were more likely to present anxiety, pain, or embarrassment during cystoscopy and UDS. Interestingly, patients who reported having received complete information before cystoscopy were significantly more likely to experience anxiety (62.6% vs. 20.0%; p=0.009).

CONCLUSIONS

The present study demonstrated the major impact of gender and age on patients' experience. Interestingly, information provided before cystoscopy was reported to have a negative impact on patients' perception of anxiety; this could be partly prevented by optimizing the way information is provided to patients.

Provider documentation of patient education: a lean investigation

PURPOSE

The study evaluates how providers give patient education materials and identifies improvements to comply with Meaningful Use (MU) requirements.

METHODS

Thirty-eight patient-provider interactions in two health care outpatient clinics were observed.

RESULTS

Providers do not uniformly know MU patient education requirements. Providers have individual preferences and find gaps in what is available. Accessing and documenting patient education varies among providers. Embedded electronic health record (EHR) materials, while available, have technical access barriers.

CONCLUSIONS

Providers' EHR skills and knowledge levels contribute to non-standardized patient education delivery.

How Efficacious Are Patient Education Interventions to Improve Bowel Preparation for Colonoscopy? A Systematic Review

BACKGROUND

Bowel preparation is inadequate in a large proportion of colonoscopies, leading to multiple clinical and economic harms. While most patients receive some form of education before colonoscopy, there is no consensus on the best approach.

AIMS

This systematic review aimed to evaluate the efficacy of patient education interventions to improve bowel preparation.

METHODS

We searched the Cochrane Database, CINAHL, EMBASE, Ovid, and Web of Science. Inclusion criteria were: (1) a patient education intervention; (2) a primary aim of improving bowel preparation; (3) a validated bowel preparation scale; (4) a prospective design; (5) a concurrent control group; and, (6) adult participants. Study validity was assessed using a modified Downs and Black scale.

RESULTS

1,080 abstracts were screened. Seven full text studies met inclusion criteria, including 2,660 patients. These studies evaluated multiple delivery platforms, including paper-based interventions (three studies), videos (two studies), re-education telephone calls the day before colonoscopy (one study), and in-person education by physicians (one study). Bowel preparation significantly improved with the intervention in all but one study. All but one study were done in a single center. Validity scores ranged from 13 to 24 (maximum 27). Four of five abstracts and research letters that met inclusion criteria also showed improvements in bowel preparation. Statistical and clinical heterogeneity precluded meta-analysis.

CONCLUSION

Compared to usual care, patient education interventions appear efficacious in improving the quality of bowel preparation. However, because of the small scale of the studies and individualized nature of the interventions, results of these studies may not be generalizable to other settings. Healthcare practices should consider systematically evaluating their current bowel preparation education methods before undertaking new interventions.

Informed Consent for Pediatric Endoscopy

Informed consent and refusal for pediatric procedures involves a process in which the provider, child, and parents/guardians participate. In pediatric gastroenterology, many procedures are considered elective and the process generally begins with an office visit and ends with the signing of the consent document. If the process is emergent then this occurs more expeditiously and a formal consent may not be required. Information about the procedure should be shared in a way that allows a decision-making process to occur for both the parent/guardian and the child, if of assenting age.

Comparative investigation of the effectiveness of face-to-face verbal training and educational pamphlets on readiness of patients before undergoing non-emergency surgeries

BACKGROUND

The thought of having a surgery can be stressful for everyone. Providing the necessary information to the patient can help both the patient and the treatment team. This study was conducted to compare the effectiveness of face-to-face verbal training and educational pamphlets on the readiness of patients for undergoing non-emergency surgeries.

MATERIALS AND METHODS

The study was a before-after randomized clinical trial. 90 patients scheduled to undergo non-emergency surgery who referred to Shahrekord Ayatollah Kashani Hospital in 2013 were distributed randomly and gradually into two experimental groups (group of face-to-face verbal training and group of educational pamphlet) and one control group. Dependent variable of the study was pre-surgery readiness. Data analysis was carried out by using SPSS statistical software. Statistical analysis were analysis of variance (ANOVA) and correlation test.

RESULTS

Results showed that the mean scores of pre-surgery readiness in both interventional groups were significantly higher than that in the control group after the intervention (P < 0.05). However, there was no significant difference between the two experimental groups (P > 0.05).

CONCLUSIONS

Each of the methods of face-to-face verbal education and using the pamphlet could be equally effective in improving the readiness of the patients undergoing surgery. Therefore, in environments where the health care providers are facing with the pressure of work and lack of sufficient time for face-to-face verbal training, suitable educational pamphlets can be used to provide the necessary information to patients and prepare them for surgery.

Anxiety at outpatient hysteroscopy

This review summarises current understanding and research on the association between anxiety and outpatient hysteroscopy. Women undergoing hysteroscopy suffer from significant levels of anxiety, with repercussions on pain perception, success rates and satisfaction. Using validated tools such as the Spielberger State-Trait Anxiety Index (STAI) or the Hospital Anxiety and Depression Scale (HADS) in the outpatient hysteroscopy setting, average state anxiety scores similar or greater than those measured before more invasive procedures under general anaesthesia have been consistently reported. This clearly suggests a significant gap between our clinical viewpoint of what is "minimally invasive" and patients' expectations. In spite of its potential role of confounder in studies on pain-reduction interventions, we found that patient anxiety was evaluated in only 9 (13 %) out of a sample of 70 randomised controlled trials on outpatient hysteroscopy published since 1992. Factors such as trait anxiety, age, indication and the efficiency of the clinic can be correlated to state anxiety before hysteroscopy, but more robust data are needed. Promising non-pharmacological interventions to reduce anxiety at hysteroscopy include patient education, communication through traditional or multimedia approaches, interaction and support during the procedure and music listening.

Assessment of delivery methods used in the informed consent process at a safety-net hospital

BACKGROUND

Informed consent is legally and ethically required before a patient undergoes an endoscopic procedure, yet current literature suggests that patient comprehension of key components of informed consent is poor.

OBJECTIVE

To evaluate specific aspects of and patient satisfaction with the informed consent process in patients who attended an endoscopy education class versus gastroenterology clinic.

DESIGN

Prospective survey that examined all components of the informed consent process.

SETTING

Safety-net hospital.

PATIENTS

Outpatients undergoing endoscopy.

INTERVENTION

Endoscopy education class versus gastroenterology clinic.

MAIN OUTCOME MEASUREMENTS

Patient recall of the components of and satisfaction with the informed consent process.

RESULTS

A total of 301 patients completed the survey, 52.0% of whom attended and were consented in an endoscopy education class. Patients who attended an endoscopy education class reported that a greater number of individual components of the informed consent process were explained to them as compared with patients who were consented in clinic. In multivariate analysis, patients who attended an education class were more likely to recall having had the alternatives (odds ratio [OR] 4.8; 95% confidence interval [CI], 2.0-11.8), details of the procedure (OR 3.0; 95% CI, 1.3-6.8), and what to expect after the procedure (OR 3.0; 95% CI, 1.5-5.6) explained to them by a provider. These patients were more likely to know they could refuse the procedure (OR 4.1; 95% CI, 1.0-16.8), compared with patients consented in the gastroenterology clinic.

LIMITATIONS

Non-randomized trial.

CONCLUSION

Patients from a diverse, urban population who attended a multilingual endoscopy education class reported having more elements of the informed consent process explained to them compared with patients who were consented in gastroenterology clinic.

The effect of different patient education methods on quality of bowel cleanliness in outpatients receiving colonoscopy examination

AIMS

To investigate the effectiveness of an educational film intervention on the quality of bowel cleanliness of outpatients receiving colonoscopy examinations and also to understand the related factors affecting bowel cleanliness.

METHOD

This is a quasi-experimental design. One hundred four patients in the experimental group and 114 patients in the control group are the participants in this study. An 8-minute "Preparation for Bowel Cleanliness" educational film was made based on clinical experience and references to related literature. We adopted a valid Aronchick scale evaluate bowel cleanliness.

RESULTS

The patients in the experimental group had significantly better bowel cleanliness compared to the control group (80.8% vs. 48.2%, p<.001). Logistic regression showed that the experimental group, gender, and experience with colonoscopy were potentially important factors that may affect bowel cleanliness.

CONCLUSIONS

The "Preparation for Bowel Cleanliness" educational film provides simple and easy-to-follow methods for the preparation of cleaning the colon and related information.

Research methodologies in informed consent studies involving surgical and invasive procedures: time to re-examine?

OBJECTIVE

We conducted a review of informed consent studies involving surgical and invasive procedures and report the degree to which current research targets a broader scope of patient outcomes beyond comprehension.

METHODS

Using PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database, we identified 97 articles for review. Six members coded articles and generated scores of study design quality.

RESULTS

The mean quality score (10.7 out of a total score of 20) was low. Most studies were single institution-based, relying on one-time data collections. Randomly assigning subjects to study conditions, using power analysis to determine subject numbers, and reporting psychometric evidence, such as reliability and validity, were not widely reported. Most frequently targeted patient outcomes were knowledge, understanding and satisfaction. Core informed consent outcomes (e.g. capacity, voluntariness, decision making) and emotional factors (e.g. anxiety) were not extensively addressed.

CONCLUSION

Informed consent research may benefit from applying qualitative methods to more directly tap into patients' beliefs and decisions by eliciting in patients' own words their emotions and reasoning around processing informed consent content.

PRACTICE IMPLICATIONS

Research that addresses patient perspectives toward surgical interventions should tap into underexplored ethical and emotional factors that shape decision making.

Readability and content of patient information leaflets for endoscopic procedures

BACKGROUND

Informed consent requires good communication. Patient information leaflets (PILs) may be helpful, although some PILs are too hard to read for the average patient.

AIMS

We sought to examine the readability of PILs provided for patients prior to endoscopic procedures in 24 gastrointestinal and 16 respiratory departments of 24 Irish public hospitals.

METHODS

Readability, measured using the Flesch Reading Ease and the Flesch-Kincaid Grade Level scores, and content of all PILs were examined.

RESULTS

We received 61 PILs from 17 gastrointestinal and 7 respiratory departments, a response rate of 60 % (24/40). Overall, 38 (62 %) PILs met a minimum standard of a Reading Ease score of 60 or more. Only two (3 %) PILs met the optimal reading standard of being comprehensible to an average 10- to 11-year-old, while 35 (57 %) PILs would be comprehensible to an average 13- to 14-year-old. There were striking differences between PILs (and particular departments) in the amount of information given regarding potential complications-in particular, serious complications. With the exception of PILs for endoscopic retrograde cholangiopancreatography, less than half of PILs mentioned death as a possible rare outcome.

CONCLUSIONS

This study raises significant concerns about the readability and content of current Irish PILs, and it is unlikely that these issues are restricted to leaflets given prior to endoscopy. A standardised approach to developing PILs for common elective procedures, with minimum standards for readability and a uniform approach, based on current Irish legal requirements, to risk disclosure, might be helpful.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy

BACKGROUND

High-quality bowel preparation is a prerequisite for colonoscopy. Few studies have evaluated visual aids as a means of improving the quality of bowel preparation.

OBJECTIVE

To assess the effect of patient education by using cartoon visual aids on the quality of bowel preparation.

DESIGN

An endoscopist-blinded, randomized, controlled trial.

SETTING

Tertiary referral center.

SUBJECTS

Patients scheduled for screening colonoscopy in a health examination center.

INTERVENTIONS

Patients were assigned to receive the existing verbal and written instructions (group A) or a new cartoon visual educational instruction (group B) for colonoscopy.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was the quality of bowel preparation, assessed by using the Boston Bowel Preparation Scale (BBPS). Secondary endpoints were the quality of bowel preparation assessed by using the Universal Preparation Assessment Scale; insertion, withdrawal, and workup times; and polyp detection rates in the 2 groups. Logistic regression analysis was performed to determine the factors associated with poor bowel preparation according to a BBPS score less than 5.

RESULTS

Group B exhibited better bowel preparation than group A according to BBPS scores (mean BBPS score, 6.12 ± 2.19 vs 7.44 ± 1.87, P ≤ .01; median BBPS score, 6.00 ± 0.00 vs 9.00 ± 0.00, P ≤ .01; good bowel preparation for colonoscopy, BBPS score ≥5, 81.6% vs 93.1%, P = .02). Multivariate analysis revealed that older age (odds ratio 1.07, P ≤ .01) and no use of visual aids (odds ratio 3.08, P = .02) were independent factors associated with poor bowel preparation.

LIMITATIONS

Single-center study.

CONCLUSIONS

Patient education with cartoons effectively improved bowel preparation for colonoscopy.

Effects of written plus oral information vs. oral information alone on precolonoscopy anxiety

AIMS AND OBJECTIVES

To determine the effect of written plus oral information vs. oral information alone on precolonoscopy anxiety.

BACKGROUND

Information provision has been considered to reduce precolonoscopy anxiety. However, the best means to provide information before colonoscopy has not yet been determined as there is inconsistency in the outcomes of the clinical trials.

DESIGN

A two-group, pretest, post-test, prospective, quasi-experimental design with non-random assignment.

METHODS

Participants were assigned to group 1 or 2 in the study. In the enrolment all the participants completed the questionnaires to collect personal characteristics data and assessed subjects' anxiety level by the Chinese version of the State Scale of State-Trait Anxiety Inventory as baseline data. After that, subjects in group 1 received written plus oral information before colonoscopy, while those in group 2 received oral information before colonoscopy. On the day for colonoscopy all subjects completed the Chinese version of the State Scale of State-Trait Anxiety Inventory again.

RESULTS

There was no difference in state anxiety and personal characteristic between the two groups at enrolment. After the intervention, although the state anxiety scores were dropped, there were no statistical significant differences between two groups or within groups 1 and 2.

CONCLUSIONS

Information provision before colonoscopy did not reduce the anxiety level in patients directly before colonoscopy.

RELEVANCE TO CLINICAL PRACTICE

There was a trend that information had a positive effect on patients' state anxiety. Future information provision studies may need to add more interactive methods appropriately and take patients' gender, educational level and coping style into consideration.

Age, smoking and overweight contribute to the development of intestinal metaplasia of the cardia

AIM: To assess the role of Helicobacter pylori (H. pylori), gastroesophageal reflux disease (GERD), age, smoking and body weight on the development of intestinal metaplasia of the gastric cardia (IMC).

METHODS: Two hundred and seventeen patients scheduled for esophagogastroduodenoscopy were enrolled in this study. Endoscopic biopsies from the esophagus, gastroesophageal junction and stomach were evaluated for inflammation, the presence of H. pylori and intestinal metaplasia. The correlation of these factors with the presence of IMC was assessed using logistic regression.

RESULTS: IMC was observed in 42% of the patients. Patient age, smoking habit and body mass index (BMI) were found as potential contributors to IMC. The risk of developing IMC can be predicted in theory by combining these factors according to the following formula: Risk of IMC = a + s - 2B where a = 2,…6 decade of age, s = 0 for non-smokers or ex-smokers, 1 for < 10 cigarettes/d, 2 for > 10 cigarettes/d and B = 0 for BMI < 25 kg/m² (BMI < 27 kg/m² in females), 1 for BMI > 25 kg/m² (BMI > 27 kg/m² in females). Among potential factors associated with IMC, H. pylori had borderline significance (P = 0.07), while GERD showed no significance.

CONCLUSION: Age, smoking and BMI are potential factors associated with IMC, while H. pylori and GERD show no significant association. IMC can be predicted in theory by logistic regression analysis.

Risks associated with laparoscopic entry: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

The aim of these recommendations of the French National College of Gynaecologists and Obstetricians was to focus the surgeon's attention on those aspects which could allow him/her to prevent, or at least limit, the incidence of these serious complications, in the absence of a previous laparotomy or specific risk factors (obesity, gauntness, large pelvic mass or pregnancy), four widely evaluated techniques can be used in a first line approach (Grade B): blind trans-umbilical technique following creation of pneumoperitoneum with a needle, open laparoscopy (Hasson technique), left upper quadrant entry (pneumoperitoneum and insertion of the first trocar) and direct trans-umbilical trocar with no prior pneumoperitoneum. The currently existing trials do not allow one or another of these techniques to be preferred. Radially expanding insertion systems and optical trocars cannot be recommended as a first-line approach, as a consequence of their currently insufficient degree of evaluation (Grade C). Trans-umbilical (blind or open) laparoscopic entry in a slim woman must be associated with care, as a result of the proximity of the large vessels (Grade B). If a blind trans-umbilical insertion technique is decided upon, one option can be to insufflate into the left upper quadrant (professional consensus). In the case of a previous midline laparotomy, whatever the technique used, initial entry is recommended at a distance from the scars (Grade B). It is recommended to carry out micro-laparoscopy in the LUQ, because this is the most completely evaluated technique for this indication (Grade C). One option is to use open laparoscopy at a distance from the existing scars (professional consensus). During pregnancy, the insertion position of the first laparoscopic trocar will need to be adapted according to the volume of the uterus (Grade B). Starting from 14WG, trans-umbilical Veress needle insufflation is contraindicated (Grade C). Two trocar insertion techniques are thus recommended: open laparoscopy (using the trans-umbilical or supra-umbilical routes, depending on the volume of the uterus) or micro-laparoscopy via the left upper quadrant (Grade C). After the second quarter of pregnancy, with laparoscopy the patient will need to be placed on a table inclined towards her left side, in order to minimize compression of the inferior vena cava (Grade B). In the case of laparoscopy during pregnancy, the insufflation pressure must be maintained at a maximum of 12mmHg (Grade B). After 24WG, if laparoscopy is performed, it is recommended to apply open laparoscopy, above the level of the umbilicus (professional consensus). Patients must be informed of the risks inherent to the insertion of trocars during laparoscopy (vascular, bowel or bladder injury) (Grade B). The more benign the pathology requiring an operation, the more detailed the supplied information must be, including that concerning rare but serious complications (Grade B).

An endoscopist-blinded, randomized, controlled trial of a simple visual aid to improve bowel preparation for screening colonoscopy

BACKGROUND

The effect of patient education on bowel preparation for colonoscopy has not been well studied. An improvement in patient understanding of the rationale for bowel preparation before colonoscopy might enhance adherence to the prescribed bowel regimen and improve bowel preparation quality.

OBJECTIVE

To measure the effect of a simple educational intervention on the quality of bowel preparation during colonoscopy.

DESIGN

Prospective, single-center, endoscopist-blinded, randomized, controlled trial.

SETTING

Tertiary-care center.

PATIENTS

This study involved outpatients directly referred for screening colonoscopy.

INTERVENTION

Inclusion of a visual aid depicting both clean and dirty colons in addition to standard written colonoscopy instructions.

MAIN OUTCOME MEASUREMENTS

The primary outcome was the quality of the bowel preparation according to the Boston Bowel Preparation Scale (BBPS). Secondary outcomes included the need for repeat colonoscopy because of inadequate bowel preparation, insertion and withdrawal time, polyps detected, and patient tolerance of bowel preparation and colonoscopy.

RESULTS

We analyzed 492 patients given a visual aid and 477 controls. The percentage of colonoscopies with a BBPS score≥5 was similar in both groups (91% visual aid vs 89% control, P=.43). The odds ratio for having a BBPS≥5 in the visual aid group was 1.24 (95% CI, 0.83-1.87) compared with controls. Other secondary outcomes were similar between groups.

LIMITATIONS

Single-center study.

CONCLUSION

A simple card with photographs and text explaining the rationale for bowel preparation did not change the quality of bowel preparation in patients directly referred for screening colonoscopy. Future educational studies may need to include more interactive or intensive methods. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00643682.).

Analysis of patient information leaflets provided by a district general hospital by the Flesch and Flesch-Kincaid method

INTRODUCTION

Patient information leaflets (PILs) remain the most frequently used sources of medical information. There is a concern that the reading age of these leaflets may exceed patient comprehension, thus negating their beneficial effect. The 'Flesch Reading Ease' and the 'Flesch-Kincaid grade level' are established methods for providing reliable and reproducible scores of readability.

METHOD

All available hospital PILs (171) were assessed and divided into 21 departments. Microsoft Word was used to provide Flesch and Flesch-Kincaid readability statistics and compared against the national reading age and the recommended level for provision of medical information.

RESULTS

The average Flesch readability of all of the hospital's PILs is 60, with a Flesch-Kincaid grade of 7.8 (12-13 years old). There is considerable variation in the average readability between departments (Flesch readability 43.8-76.9, Flesch-Kincaid 5.4-10.2). The average scores of two departments have PILs scores suitable for patient information.

CONCLUSION

Although our PILs were well laid out and easy to read, the majority would have exceeded patient comprehension. The current advice for provision of NHS information does not highlight the importance of a recommended reading level when designing a PIL. Potentially a wide group of patients are being excluded from the benefits of a PIL.

The effects of providing pre-gastrointestinal endoscopy written educational material on patients' anxiety: a randomised controlled trial

BACKGROUND

Endoscopy is a frequently applied operation in health institutions which may cause anxiety in patients.

OBJECTIVE

The objective of this study is to determine the effects of written educational material related to the endoscopy procedure on the anxiety level of the patient before gastrointestinal endoscopy.

DESIGN

A randomised controlled trial design with two groups: case and control groups.

PARTICIPANTS

140 patients assigned randomly who applied for gastrointestinal endoscopy.

METHODS

INTERVENTION

the control group in our study consisted of 70 people who were briefly informed by the relevant unit about pre-endoscopy preparation. The case group consisted of 70 people who were also given brief information about the pre-endoscopy preparation by the relevant unit. Only the case group were also given written educational material and told orally by the researcher about the content.

MEASUREMENTS

for the collection of the data, a questionnaire form and Spielberger's State-Trait Anxiety Inventory were used.

RESULTS

A significant difference in the average state anxiety scores was found between the case and the control group (p<0.05). An important difference was found in the average state anxiety scores between the case and the control group who had not undergone endoscopy before our study (p<0.05).

CONCLUSIONS

Use of written material including detailed information to inform the patient before endoscopy was useful in lessening their anxiety level. Health professionals should evaluate the anxiety level of patients before endoscopy and educational material should be given to them to read.

Assessing the readability statistics of national consent forms in the UK

INTRODUCTION

When obtaining consent for an invasive procedure, the patient needs to understand what is happening to them in broad terms. Best medical practice advocates that written consent is given to acknowledge patient agreement. Across the UK, the Department of Health has provided standard consent forms for obtaining consent in all situations. Potentially these written sources of information may not be comprehended by patients and thus invalidate consent.

METHOD

Consent forms were assessed by the Flesch readability and Flesch-Kincaid grade formulae and compared with the national reading age, the recommended level for patient medical information, three newspaper articles and a journal article.

RESULTS

The consent forms have acceptable statistics [average Flesch readability 61.1 (range 57.2-66.1) and Flesch-Kincaid grade 7 (range 6.3-8)]. This grade, however, is above the recommended level of patient health information (Flesch-Kincaid grade 6). When the patient statements are isolated the reading statistics worsen [average Flesch readability 52.6 (range 41-62.6) and Flesch-Kincaid grade 9.6 (range 7.9-11.1)].

CONCLUSION

Consent forms should be used as adjuncts to detailed conversations, describing what a procedure involves to ensure that a patient understands, in broad terms, what is happening to them. The patient's statement section of the form may be being written at a level above patient comprehension currently and thus could invalidate any consent given. We would advocate a documented conversation with patients to ensure they have a broad understanding of the procedure and using the consent form as an adjunct to this discussion. The patient's statement section should be re-written to avoid invalidating consent.