Preparation for colonoscopy in hospitalized patients.

Successful colonoscopy depends on good preparation of the colon before the procedure. Inadequate preparation may lead to cancelled or repeat procedures and compromise patient safety, quality of care, and cost effectiveness. The primary aim of this study was to isolate factors that affect preparation success, especially in older, more severely ill, bedridden patients. The secondary aim was to examine the possible differences in preparation quality between ambulatory and hospitalized patients and the impact of a staff educational program on the preparation of hospitalized patients for colonoscopy. The study group included 303 consecutive ambulatory patients and 104 hospitalized patients referred for colonoscopy between January and March 2002, before the department introduced an educational program on colonoscopy preparation, and 310 ambulatory patients and 105 hospitalized patients referred for colonoscopy between January and March 2003. All patients completed an ad hoc questionnaire, and the findings were compared between ambulatory and hospitalized patients and between patients treated before and after the educational program. Polyethylene glycol was used significantly more often for colonoscopy preparation in hospitalized patients than in ambulatory patients (53.1% versus 8.8%; P=.0001). The hospitalized group was characterized by more incomplete or repeated colonoscopies and poorer preparation quality. On multivariate analysis, the variables found to be independent predictors of good preparation were successful patient completion of the preparatory procedure according to instructions, colonoscopy performed for follow-up after polypectomy, and preparation with sodium phosphate. The educational intervention had no impact on the quality of preparation. In conclusion, sodium phosphate preparation and complete adherence to preparation instructions are the most important factors for successful colonoscopy preparation. Current preparatory methods for hospitalized and severely ill patients need to be revised.

Patient retention in a clinical trial: a lesson from the rofecoxib (VIOXX) study.

A high retention rate of patients and control subjects is an important criterion for the credibility and accuracy of prospective, randomized, controlled clinical trials. Retention and adherence depend on a combination of patient-, physician- and coordinator-related factors, and these need to be carefully evaluated to ensure success. The aim of the study was to evaluate predictive factors for patient retention in a clinical trial. Questionnaires containing items on demographic and clinical data and specific questions related to patient motivation were distributed to 31 patients participating in a clinical study comparing rofecoxib (Vioxx) and placebo for the prevention of colonic polyp recurrence. Adherence of the group with the rofecoxib study and the questionnaire was 100%. The sample included 24 men (77%) and 7 women of mean age 66+/-9 years; 90% were married, 42% were employed. A family history of colorectal cancer (CRC) was reported by 29%. The main reasons for adherence reported by the patients (on an analog scale of 0-10) were 24-hour availability of a nurse (9.2+/-1.9), the chance to prevent CRC (9.1+/-1.9), and participation in a multicenter study (9.1+/-2.2). The least important factor was support of the family physician (5.8+/-4.1). In conclusion, retention in a clinical trial mainly depends on the subject of the trial and the scientific/professional setting where it takes place, and less on the support of the family physician.

Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for long-term enteral nutrition. Though safe and technically simple, PEG has been associated with significant morbidity and mortality. AIM: We compared the outcome of strategies applied in two different periods; the original approach of PEG insertion during hospitalization (upon request), and PEG insertion 30 days after hospital discharge. METHODS: A cohort of 127 patients scheduled for PEG insertion from 1.1.1997 to 31.12.2000, was evaluated. In 61 consecutive patients admitted from 1.1.1997 to 31.12.1998 the PEG insertion was planned during hospitalization, as close to the time of the physician's request (period 1). Sixty-six consecutive patients admitted from 1.1.1999 to 31.12.2000 were scheduled for the PEG insertion 30 days after discharge (period 2). The 30-day mortality rate was calculated from the time of the request. Univariate and multivariate analyses were used to find predictive factors for 30-day mortality. RESULTS: There were 61 patients with a mean age of 78+/-13 in period 1, and 66 patients with a mean age of 77.8+/-15.5 in period 2. There was no significant difference between patients of the two periods in regard to age, sex, underlying disease, nutritional and mental status. Patients received PEG 30 days after hospital discharge had a 40% lower 30-day mortality rate than patients who received PEG during hospitalization from the time of request for PEG (P=0.01) and a 87.5% lower rate when calculated from the time of insertion (P<0.0001). In-hospital PEG insertion, bed-ridden and disorientation were found to be independent factors predictive of 30-day mortality after PEG insertion (P=0.016,P=0.001, and P=0.0005, respectively). CONCLUSION: PEG insertion during hospitalization increases mortality and should be avoided. A grace period of 30 days with nasogastric tube feeding before PEG insertion may prevent mortality and achieve a long-term enteral nutrition.