Microscopic colitis (MC) is a common cause of chronic diarrhea; however, the clinical course of this disease is poorly understood. We aimed to investigate how patients diagnosed with MC were treated in routine clinical practice and how their symptoms compared to patients with other causes of chronic diarrhea at one year follow-up.

We conducted a case-control study of patients undergoing outpatient colonoscopy to evaluate diarrhea. The study pathologist determined whether patients were classified as MC cases or non-MC controls. One year after colonoscopy, we interviewed cases (n = 74) and controls (n = 162) about their diagnosis, medications for diarrhea, and symptom burden.

At 1-year follow-up after colonoscopy, 10% of MC cases were unaware of the diagnosis, 60% had been prescribed a medication for diarrhea, 40% had fecal urgency, 32% had weight loss, and 21% had fecal incontinence. Among cases, 46% were treated with budesonide. Compared to cases, controls had worse symptoms based on the Microscopic Colitis Disease Activity Index score with a median score of 3.0 (interquartile range 1.9-4.2) vs 2.3 (interquartile range 1.4-3.2) at 1-year follow-up. Controls had more frequent stools, urgency, fecal incontinence, and abdominal pain.

In a cohort of patients with biopsy-confirmed MC and diarrhea controls, we found that some cases remained unaware of their diagnosis, many cases had persistent symptoms, and controls had worse symptoms than cases. These findings suggest there are opportunities to improve management of this chronic disease.

The promotion of quality and best practices in gastroenterology and endoscopy is an ongoing effort. For upper GI endoscopy, quality indicators derived from clinical studies and expert consensus have been long established but remain variably obtained. To date, data on interventions aimed to improve these indicators are scarce. We systematically reviewed the literature to identify interventions and measures demonstrated to improve the performance of previously established upper endoscopy quality indicators. We also identified evidence gaps and opportunities for improvement in this area.

Background: As doctors often fail to explain diagnoses and therapies to patients in an understandable and appropriate way, the improvement of doctor-patient communication is essential. The current medical training and examinations are focused on verbal rather than on written communication. Following the premise of "assessment drives learning", the final medical licensing examination in Germany has been further developed by the German National Institute for state examinations in Medicine, Pharmacy and Psychotherapy (IMPP). As part of the discharge management the candidates have to prepare a report for the patient that is understandable and provides them with all important information about their stay in hospital. Aim: A standardized evaluation form for formative and summative feedback has been developed and tested with regard to applicability and the assurance of test quality criteria, especially the reliability to assess the written communication skills of the students. Methodology: In an expert consensus procedure, a draft for a standardized evaluation form was developed. This form was revised after an initial trial run on patient-directed reports written by students in their last year of medical studies. Afterwards twenty-one patient-directed reports were evaluated by fourteen different examiners. The reliability was tested by calculating the generalizability-coefficient and by analysing the inter-rater reliability. Results: The first test on the evaluation of the patient-directed reports indicated the practicability of the application and the usefulness of the evaluation form as an instrument for assessing the written communication skills of students. The analyses of the inter-rater reliability showed that the degree of agreement in the evaluations was partly different between two groups of examiners. The calculated G-coefficient indicates a high reliability. The content validity of the evaluation form was given through the comprehensive medical expertise in the development process. Conclusion: Assessing written patient-directed communication is a benefit of the newly developed last part of the medical licensing examination in Germany. Continuous formative assessment and feedback based on the evaluation form is intended to improve the written communication skills of future doctors. Furthermore, a better understanding of their diagnosis and treatment as well as a trusting relationship with their doctor may empower patients in the medical decision process and lead to fewer dismissal errors in the future. For consistent use of the evaluation form a standardized training of examiners should be implemented.

Patient perspectives have important roles in improving the quality of colonoscopy services. The purpose of this qualitative study was to obtain the perspectives of patients who recently had undergone colonoscopy procedures, about their experiences with bowel preparation, the procedure itself, and communication of follow-up results and recommendations.

We recruited adults who had undergone a colonoscopy, to participate in semistructured interviews. Interviews were audiotaped, transcribed and analyzed using inductive qualitative methods.

Twenty-four adults (58% female) with an average age of 53.8 years participated. Results were categorized within the themes of bowel preparation, the colonoscopy procedure and communication of the results. Participants appreciated having clear consistent plain language messages about bowel preparation. Some participants experienced additional challenges to understanding, and navigating, colonoscopy procedures. At the time of the procedure, positive and reassuring interactions with, and between, members of the health care team, in addition to management of physical pain and discomfort, were important. Participants wanted clear and timely information about the results of their test.

Understanding patients' needs for information and support can promote higher quality colonoscopy services. Our findings suggest that quality indicators should include: patients' perspectives of the clarity of bowel instructions; the need for supports that are not routinely provided; the extent to which concerns about the procedure are addressed; interactions with the endoscopy team; the endoscopy team's interactions with each other; comfort during the procedure, and the timeliness and clarity of results and follow-up instructions. These indicators should be included in annual patient surveys.

Colonoscopy screening is an effective method of detecting and preventing colorectal cancer. Standard procedure for most colonoscopies (98%) is to use conscious sedation, which can cause short-term cognitive impairment postprocedure, including communication difficulties. In this study, we explored providers' (gastroenterology doctors and nurses) perceptions of the barriers to optimal communication with patients immediately following colonoscopy.

We conducted interviews with 61 providers across 5 clinical configurations. Interviews were transcribed and coded with NVivo version 11 software.

Themes emerged regarding barriers to optimal provider-patient communication postcolonoscopy: patient barriers (sedation and patient characteristics), caregiver barriers, and system characteristics.

Providers' perceived barriers to communication are an important topic to study. They endorsed, in particular, interventions that target the postcolonoscopy time frame when patients may still be sedated, but providers must convey important discharge and follow-up instructions.

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.

We conducted a systematic review to determine the effect of providing patients access to their medical records (electronic or paper-based) on healthcare quality, as defined by measures of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Articles indexed in PubMed from January 1970 to January 2012 were reviewed. Twenty-seven English-language controlled studies were included. Outcomes were categorized as measures of effectiveness (n=19), patient-centeredness (n=16), and efficiency (n=2); no study addressed safety, timeliness, or equity.

Outcomes were equivocal with respect to several aspects of effectiveness and patient-centeredness. Efficiency outcomes in terms of frequency of in-person and telephone encounters were mixed. Access to health records appeared to enhance patients' perceptions of control and reduced or had no effect on patient anxiety.

Although few positive findings generally favored patient access, the literature is unclear on whether providing patients access to their medical records improves quality.

The strategies used in population-based colorectal screening strategies culminate in colonoscopy and consequently the success of these programs largely depends on the quality of this diagnostic test. The main factors to consider when evaluating quality are scientific-technical quality, safety, patient satisfaction, and accessibility. Quality indicators allow variability among hospitals, endoscopy units and endoscopists to be determined and can identify those not achieving recommended standards. In Spain, the working group for colonoscopy quality of the Spanish Society of Gastroenterology and the Spanish Society of Gastrointestinal Endoscopy have recently drawn up a Clinical Practice Guideline that contains the available evidence on the quality of screening colonoscopy, as well as the basic requirements that must be met by endoscopy units and endoscopists carrying out this procedure. The implementation of training programs and screening colonoscopy quality controls are strongly recommended to guarantee the success of population-based colorectal cancer screening.

The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients' awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations.

Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed.

Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59).

Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance.

The Global Rating Scale (GRS) comprehensively evaluates the quality of an endoscopy department, providing a patient-centred framework for service improvement.

To assess patient experiences during colonoscopy and identify areas that need service improvement using the GRS.

Consecutive outpatients undergoing colonoscopy were asked to complete a pre- and postprocedure questionnaire. Questions were based on GRS items and a literature review. The preprocedure questionnaire addressed items such as patient characteristics and information provision. The postprocedure questionnaire contained questions regarding comfort, sedation, the attitude of endoscopy staff and aftercare.

The preprocedure questionnaire was completed by 1,187 patients, whereas the postprocedure part of the questionnaire was completed by 851 patients (71.9%). Fifty-four per cent of patients were first seen in the outpatient clinic. The indication for colonoscopy was explained to 85% of the patients. Sixty-five per cent of the patients stated that information about the risks of colonoscopy was provided. Sedation was used in 94% of the patients; however, 23% judged the colonoscopy to be more uncomfortable than expected. Ten per cent of patients rated the colonoscopy as (very) uncomfortable. Preliminary results of the colonoscopy were discussed with 87% of patients after the procedure. Twenty-one per cent of the patients left the hospital without knowing how to obtain their final results. Being comfortable while waiting for the procedure (OR 9.93) and a less uncomfortable procedure than expected (OR 2.99) were important determinants of the willingness to return for colonoscopy.

The present study provided evidence supporting the GRS in identifying service gaps in the quality of patient experiences for colonoscopy in a North American setting. Assessing experiences is useful in identifying areas that need improvement such as the provision of pre- and postprocedure information.

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.

One study in sedated patients demonstrated a reduction in pain score but not midazolam dosage when warm water infusion was used to manage colonic spasm. We describe pilot data with a modified warm water infusion technique. We tested the hypothesis that patients receiving even only half of the usual dose of sedation medications would have acceptable cecal intubation and tolerate the procedure well, based on retrospective review of prospectively collected data from a single Veterans Affairs (VA) medical center. Group 1 included 32 consecutive patients who received full-dose and group 2 included 43 consecutive patients who received half-dose premedication. Insertion of colonoscope was aided by warm water infusion in lieu of air insufflation. Pain scores during insertion, cecal intubation rate, and total amount of medications were monitored. The novel technique permitted equal cecal intubation rate at reduced total dose of medications. Pain scores were not significantly different. The uncontrolled nonrandomized observational nature of the data is one limitation. The nonsignificant difference in pain scores may be affected by a type II error. These pilot data suggest that insertion is feasible without air when water infusion is used. The novel technique may be a useful adjunct for minimizing the dosage of sedation medications without adversely affecting cecal intubation. Further study is needed to compare air insufflation and water infusion with regard to patient tolerance and success, particularly in the presence of an on-demand sedation policy.

Communication between patient and physician remains a central step of interaction.

15 min after receiving the results of their coronary angiography via a standard verbal report, a total of 288 patients were asked the following questions: (1) Were the results of coronary angiography explained to you? (2) Who performed your procedure? (3) Were there any narrowings in your coronary arteries? (4) Was your left ventricular ejection fraction normal? (5) What kind of therapy was recommended to you?

98.6% of the patients were informed about the results of their coronary angiography. 31.2% were able to recall the name of the interventionalist. 52.8% knew about their coronary arteries, 36.8% knew their left ventricular function, and 92.7% were able to recall the recommendations for therapy (mean 53.4% correct answers). In 14.6%, the causes of incorrect answers were related to the patient, in 85.4% to the doctor. The number of incorrect answers increased significantly in patients with complex angiographic results, cultural discordance between physician and patient, and presentation of the results by noncardiologists (p < 0.001 for all).

Communication of coronary angiography results to patients via standard verbal reports leads to frequent misunderstanding. To resolve communication problems in the cathlab as effective as possible, communication skills of physicians should be improved.

Providing a procedure report to patients after endoscopy is inconsistently practiced by clinicians.

To evaluate the effect of providing a procedure report to patients after an outpatient endoscopy.

Demographic data, including age, sex, race, and endoscopic procedures. Assessments one week after the procedure included anxiety, satisfaction, recall of endoscopic findings and recommendations, and compliance.

A prospective, randomized, single-center, investigator-blinded study. Anxiety was measured by using the Beck Anxiety Inventory; satisfaction was measured with a modified American Society for Gastrointestinal Endoscopy survey, which was validated as part of this study, and recall and compliance was measured by a patient interview, during which responses were compared with the original endoscopy report.

Single university outpatient endoscopy laboratory. Between June and September 2005, 115 patients were randomized, and 83 completed this protocol.

The two groups were equally matched, except the intervention group (received report) was older (54.4 vs 50.7 years; P = .037). Receipt of an endoscopy report reduced postprocedure anxiety (P = .001) and improved recall of findings and recommendations (P = .001 for both). Satisfaction was very high for all patients and was unaffected by receipt of a report. Patients older than 60 years had significantly lower satisfaction scores by approximately 6 points (P = .004). Some subcategories of compliance were significantly better in the intervention group, but there was no effect on the number of patients who complied with all recommendations.

Small number of patients.

The receipt of an endoscopy report at discharge reduces postprocedure anxiety, improves recall of findings and recommendations, and may increase compliance. This inexpensive and safe practice should be routinely adopted.