Even with text instructions, almost half miss appointment or have subpar bowel prep

While cancellations and non-attendance drive down colonoscopy rates, it appears that a text messaging protocol designed to improve colonoscopy adherence wouldn’t be helpful.

According to the results of a randomized clinical trial, published in JAMA Network Open, such a text messaging intervention involving reminders and instructions did not improve colonoscopy attendance rates or bowel preparation quality.

Colonoscopies are recommended for all individuals between the age of 50 and 75; however, testing rates have historically been suboptimal. As pointed out by study authors Nadim Mahmud, MD, MS, MPH, MSCE, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania in Philadelphia, and colleagues, the process of obtaining a colonoscopy is “complex,” as it can require patients to identify escorts, obtain bowel preparation, take time off from work, follow a clear liquid diet, and adhere to the bowel preparation as recommended.

According to Mahmud and colleagues, while the success of certain approaches to improve screening adherence — such as the use of videos and mobile applications or having nurses or trained staff contact patients directly — has been limited, the use of an automated text massaging intervention could prove more successful. Here, the authors conduced a quality improvement pilot study designed to assess the effectiveness of a one-week text messaging protocol for patients who were scheduled for outpatient colonoscopy.

The trial included 753 patients (median age 56) who were scheduled for outpatient colonoscopy at an urban academic medical center between Jan. and Sept. 2019. These patients were randomized on a 1:1 basis to receive usual care — such as written instructions or a nurse telephone call — or the intervention: usual care plus an automated series of 9 educational or reminder text messages in the week prior to scheduled colonoscopy.

The primary outcome — appointment attendance with good or excellent bowel preparation — was essentially the same in intervention (53.1%) and the control group (54.4%).

There were no significant differences between intervention and control groups in:

  • Appointment attendance rate (242 patients [65.9%] vs 262 patients [67.9%]).
  • Bowel preparation quality (excellent or good: 195 patients [81.6%] vs 210 patients [82.7%]; fair or adequate: 31 patients [13.0%] vs 28 patients [11.0%]; poor or inadequate: 13 patients [5.4%] vs 16 patients [6.3%]).
  • Appointment reschedule rate (42 patients [11.4%] vs 51 patients [13.2%]).
  • Median cancellation lead time prior to scheduled colonoscopy (4 days for both groups).

Mahmud and colleagues pointed out that previous studies evaluating text message-based interventions have had varying results concerning colonoscopy adherence. “The heterogeneity in these findings highlights several underlying challenges in affecting behavioral change,” they wrote, adding that one-size-fits-all interventions to improve colonoscopy adherence and attendance may not exist.

“Instead, there should be a focus on behavior change frameworks to design interventions, wherein discrete component constructs are investigated and addressed for a patient population,” they suggested. “This approach would emphasize processes to design a tailored intervention rather than replicating a package and may lead to improved outcomes.”

In a commentary accompanying the study, Carolyn M. Clancy, MD, George Washington University School of Medicine, Washington, D.C., and Jason A. Dominitz, MD, MHS, University of Washington School of Medicine, Seattle, noted that while text messaging can be an efficient intervention for patients scheduled for colonoscopy, it is only effective if the message is received and leads to the desired result.

“The intervention delivered in the study by Mahmud et al was not found effective, raising questions about message receipt, content, and intensity,” Clancy and Dominitz observed. For example, they noted that the messaging system gave patients the option of opting out of receiving reminder messages after getting the introductory message, and because the system was not bidirectional there was no way of determining whether the messages were received and actually read.

The study authors acknowledged additional limitations to their study, including an inability to assess bowel preparation quality using a validated scoring system, a lack of detailed assessments of patients who received prior colonoscopy, and that the manner of enrollment was changed halfway through the study, potentially leading to unanticipated heterogeneity in the response to the intervention.

“It is worthwhile to attempt to find an effective intervention for the vexing problem of colonoscopy non-attendance and inadequate bowel preparation,” Clancy and Dominitz wrote. “Future studies are urgently needed to find effective solutions to optimize colonoscopy for the health of patients and health care systems.”

  1. A text messaging intervention was not more effective than usual care in improving colonoscopy adherence.

  2. These results suggest that a one-size-fits-all solution to improve colonoscopy adherence and attendance may not exist, according to study authors.

Michael Bassett, Contributing Writer, BreakingMED™

The study authors and editorialists had no relevant relationships to disclose.

Cat ID: 16

Topic ID: 77,16,728,791,730,16,142,192,925