Published online Dec 21, 2020. doi: 10.3748/wjg.v26.i47.7568
Peer-review started: September 15, 2020
First decision: November 3, 2020
Revised: November 16, 2020
Accepted: November 29, 2020
Article in press: November 29, 2020
Published online: December 21, 2020
Educative interventions with bidirectional contact to the patient have shown to improve colonoscopy attendance in colorectal cancer population screening programmes and because of its huge clinical and economic impact, they have been widely implemented. However, outside of this population programmes, educative measures to improve colonoscopy attendance have been poorly studied and no navigation interventions are usually performed.
We thought this lack of research needed attention, so we designed a randomized controlled trial to conduct an educational telephone nurse intervention with bidirectional contact directed to increase colonoscopy attendance, similar to the patient navigation carried out in the population screening setting.
The aim of the study was to determine the clinical and economic impact of this educational intervention.
We included all consecutive outpatients referred for colonoscopy from primary care centres in our health area. Patients randomized to the intervention group received a telephone call 7 d before colonoscopy appointment to eliminate socioeconomic, psychological and clinical barriers that could affect attendance. Baseline characteristics including demographics, clinical and endoscopic factors previously reported to be related to non-attendance were collected. The primary outcome was the attendance rate. The secondary outcomes included the economic impact and the potential benefit of the intervention in regard to compliance with patient preparedness protocols, cleansing adequacy, and patient satisfaction. We performed an intention-to-treat (ITT) and per-protocol (PP) analysis to measure the applicability of the telephone intervention.
A total of 738 and 746 patients were finally included in the intervention and control group (CG) respectively. Six hundred thirteen (83%) patients were contacted in the intervention group (IG). The non-attendance rate was lower in the IG, both in the ITT analysis (IG 8.4% vs CG 14.3%, P < 0.001) and in the PP analysis (4.4% vs 14.3%, P < 0.001). In a multivariable analysis, belonging to the CG increased the risk of non-attendance in both, the ITT analysis (OR 1.81, 95%CI: 1.27 to 2.58, P = 0.001) and the PP analysis (OR 3.56, 95%CI: 2.25 to 5.64, P < 0.001). There was also a significant difference in compliance with preparedness protocols [bowel cleansing: IG 61.7% vs CG 52.6% (P = 0.001), antithrombotic management: IG 92.5% vs CG 62.8% (P = 0.001), and sedation scheduling: IG 78.8% vs CG 0% (P ≤ 0.001)]. We observed a net benefit of €55600/year after the intervention. The information given before the procedure was rated as excellent by 26% (CG) and 51% (IG) of patients, P ≤ 0.001.
According to our results, non-attendance has a significant clinical and economic impact outside the population screening setting. This study proposes the necessity to routinely incorporate attendance measures into endoscopy units, not only in the population screening programmes but also in all colonoscopies. A telephone educative intervention by an endoscopy nurse seems to be a valid method.
Further multicentric studies on attendance outside colorectal cancer population screening programmes are needed. The type and percentage of undiagnosed pathology and the prognostic and therapeutic implications of the diagnostic delay in these patients have to be studied. We also do not know the effect that the intervention could have on attending future colonoscopies although the satisfaction results observed in our study are promising in this regard.