Background The impact of fair bowel preparation on endoscopists’ recommendations and adenoma miss rates in average-risk patients undergoing colonoscopy is unknown. Objective To assess the impact of fair bowel preparation on endoscopists’ interval colonoscopy recommendations and miss rates in colonoscopies performed within 3 years of the index colonoscopy in average-risk patients undergoing colorectal cancer screening. Design Retrospective chart review. Setting Tertiary-care center. Patients Average-risk patients undergoing index colonoscopy for colorectal cancer screening between 2004 and 2006. Intervention Colonoscopy. Main Outcome Measurements Endoscopists’ interval recommendations, adenoma miss rates. Results A total of 16,251 colonoscopy records were reviewed over a 2-year period. Of these cases, 1943 colonoscopies were performed for the sole indication of average risk or screening. Of these, fair bowel preparation was reported in 619 patients (31.9%). A repeat colonoscopy within 5 years was recommended in 70.4% of patients. The follow-up colonoscopy compliance rate within 3 years was 55.9%. Adenoma detection rates at index and follow-up colonoscopy were 20.5% and 28.2%, respectively. Of the 39 patients with follow-up colonoscopy within 3 years, the overall adenoma miss rate was 28%. Of the patients with an adenoma identified on follow-up colonoscopy, 13.6% had normal colonoscopy results on index examination. Limitations Retrospective design. Conclusion Fair bowel preparation led to a deviation from national guidelines with early repeat colonoscopy follow-up recommendations in nearly 60% of average-risk patients with normal colonoscopy results. In patients who returned for repeat colonoscopy within 3 years, the overall adenoma miss rate was 28%. Further guidelines on timing for repeat colonoscopy for fair bowel preparation are needed.

Background Although split-dose bowel regimen is recommended in colon cancer screening and surveillance guidelines, implementation in clinical practice has seemingly lagged because of concerns of patient compliance. Objectives To assess patient compliance with the split-dose bowel regimen and assess patient- and preparation process–related factors associated with compliance and bowel preparation adequacy. Design Prospective survey cohort. Setting Tertiary care setting. Patients Average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. Main Outcome Measurements Split-dose bowel regimen patient-reported compliance and bowel preparation adequacy with the Boston Bowel Preparation Scale score. Results Surveys and Boston Bowel Preparation Scale score data were completed in 462 participants; 15.4% were noncompliant with the split-dose bowel regimen, and suboptimal bowel preparation (score < 5) was reported in 16% of all procedures. White (P = .009) and married (P = .01) subjects were least likely to be noncompliant, whereas Hispanic subjects and those who reported incomes of US$75,000 or less were most likely to be noncompliant (P = .004). Participants who were noncompliant with split-dosing were less likely to follow the other laxative instructions and more likely to have their colonoscopy appointment before 10:30 am. Compliance differed by bowel preparation type (P = .003, χ2 test), with those who used MiraLAX showing the highest compliance, followed by polyethylene glycol electrolyte solution and other bowel preparations. Noncompliance with split-dose bowel preparation (odds ratio 6.7; 95% confidence interval, 3.2–14.2) was the strongest predictor of suboptimal bowel preparation. Limitations Patient self-report, performed at tertiary care center. Conclusions Overall, 1 in 7 patients do not comply with a split-dose bowel regimen. Ensuring compliance with the split-dose bowel regimen will reduce the risk of a suboptimal bowel preparation. (Gastrointest Endosc 2014;79:811-20.)

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Goal To prospectively assess physician recommendations for repeat colonoscopy in an average-risk screening cohort. Background Endoscopists' adherence to colorectal cancer screening and surveillance guidelines for repeat colonoscopy have not been well characterized. Furthermore, little is known about patient and colonoscopy factors that are associated with endoscopists' nonadherence to guideline recommendation. Study This is a prospective cohort of average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. The primary outcome was assessment of physician recommendations for repeat colonoscopy. Results 462 participants were prospectively enrolled. 13.6% (62) had guideline-inconsistent recommendations. 89% of the guideline-inconsistent recommendations were for an earlier interval. Endoscopists' reports cited suboptimal bowel preparation as the most common reason for earlier repeat colonoscopy. On multivariable analysis, patient split-dose preparation noncompliance was significantly associated with guideline-inconsistent recommendation (OR = 2.7) even after adjusting for other patient or bowel preparation-related characteristics. Additionally, increased odds of guideline-inconsistent recommendation were associated with older age (>70 years old), higher BMI, having 3 or more polyps, having had at least two previous colonoscopies, suboptimal bowel preparation, and having taken at least 12 hours till clear bowel movement. Conclusions Gastroenterologists are adherent to CRC screening and surveillance guidelines. Suboptimal bowel preparation is the most frequently cited factor in endoscopy reports leading to deviation from guidelines. Continued emphasis on optimization of bowel preparation, particularly patient compliance to split-dose regimen, is needed.