INTRODUCTION
Among cancers diagnosed in both males and females, colorectal cancer (CRC) is the second most common cancer and the third leading cause of cancer-related deaths in the United States. CRC also has the second highest cost of any cancer in the United States. Depending on the stage of CRC, average Medicare health spending ranges between 40K and 80K USD for newly diagnosed patients. The total annual medical cost of CRC care is 14.1 billion USD.[ 1 ] Colonoscopy , as the gold standard for CRC screening, is the most sensitive test and can be both diagnostic and therapeutic.[ 2 ] Colonoscopy is a safe procedure with a reported low rate of complications (2.8% of every 1,000 procedures). Due to effective screening with colonoscopy , CRC is one of the most preventable cancers in terms of incidence and mortality. Despite known effectiveness, only one in three eligible patients underwent colonoscopy .[ 3 ] Many barriers prevent effective colonoscopy procedures such as poor quality bowel preparation , non-adherence to diet and appointment, limited knowledge of the procedure, fear of embarrassment, fear of procedural pain, older age, socioeconomic status, and fear of cost.[ 4 ]
The advent of innovative mobile health technologies has facilitated communication and patient engagement during the coronavirus disease 2019 (COVID-19) era of social distancing. Mobile health applications have gained increasing interest among physicians and patients to efficiently deliver information.[ 5 , 6 ] Text messaging and mobile applications are as beneficial, if not superior, to current standards that provide information to patients and promote detailed instructions for better communication and adherence .[ 7 ] Recent trials have shown that mobile apps have improved patient adherence to bowel preparation and colonoscopy appointments.[ 8 ] The contributions of mobile technologies can overcome barriers to effective colonoscopy procedures.
This scoping review aims to evaluate the impact of smartphone application (SPA) technologies in patients undergoing elective colonoscopy to measure adherence , cost-effectiveness, bowel preparation , and quality of life .
The main research questions for the scoping review were:
What is the benefit of SPAs on the colonoscopy process in patients undergoing elective colonoscopy ?
The following research questions also guided the scoping review:
Do SPAs improve adherence to colonoscopy appointments?
Do SPAs reduce the cost burden linked to missed colonoscopy appointments?
Do SPAs increase patient compliance with the bowel preparation process?
Do SPAs improve the patient’s quality of life during the colonoscopy peri-procedural period?
METHODS
The review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for scoping review (PRISMA-ScR),[ 9 ] registered at Open Science Framework, and can be accessed with a Doi number of “10.17605/OSF.IO/ZQNVK”.
Eligibility criteria
1) All primary studies examining the impact of digital health technologies (mobile applications) on peri-procedural colonoscopy outcomes (bowel preparation , adherence , quality of life , and cost-effectiveness) were included.
2) Only studies in the English language were included.
3) Systematic reviews, meta-analysis, and narrative reviews were excluded.
4) No filters for dates and population were applied.
Types of outcome measures:
(i) Bowel preparation
(ii) Adherence
(iii) Quality of life
(iv) Cost-effectiveness
Information sources and search strategy
We searched the following electronic bibliographic databases for published papers between Jan 1, 1990 and Oct 14, 2020: Ovid Medline, Web of Science, ScienceDirect, Scopus, Cochrane Library, PubMed, and ClinicalTrials.gov. The detailed search strategy has been included in this manuscript’s supplement [Appendix 1 ]. We also conducted a manual search of the reference list and citations (until Dec 12, 2020) of the retrieved studies [Figure 1 ].
Figure 1: Inclusion and exclusion of the studies from the literature review
Study selection
Two independent reviewers (FA, LHT) independently screened all titles/abstracts retrieved by the search strategy listed in this protocol to identify articles according to the above-mentioned inclusion and exclusion criteria. In case of disagreement, a third independent reviewer (SJ) was consulted. After initial screening, full texts were obtained for further assessment.
Data extraction and data analysis
Two reviewers (FA, LHT) independently extracted the following data: the author’s name, the manuscript’s year of publication, study objectives, indications of intervention (elective colonoscopy or emergent colonoscopy , outpatient colonoscopy or inpatient colonoscopy ), study design, study age groups, number of study arms, number of study participants, and the studies’ primary and secondary outcomes. Full-text availability was obtained for all manuscripts included in the data charting and extraction processes. Special attention was given to the results section of each included article from which a descriptive summary was extracted [Table 1 ]. All included studies had two arms. Outcomes were compared between the intervention arm (SPA arm) and the control arm (written instructions or/and verbal instructions). We analyzed the features of SPAs along with the outcomes of studies [Table 2 ]. Table 2 includes outcomes with statistical significance of the individual studies. Following SPAs’ features were analyzed including language options, providing procedural education, notifications, instructions for bowel preparation , a calendar, or other multimedia content including videos or pictures. Information regarding the features of SPAs was obtained through descriptions within articles, reviewing the SPAs, and contacting authors via e-mail.
Table 1: Study and patient characteristic charting form.
Table 2: Features of SPAs and outcomes comparison
RESULTS
Search results and study characteristics
Three thousand nine hundred and seventy nine non-duplicate articles out of 6,661 studies were initially collected for the screening process. Three thousand nine hundred and fifty two articles were excluded based on the eligibility criteria. Twenty-seven articles remained for which the full text was obtained, and reviewed according to our pre-established inclusion and exclusion criteria. Two additional articles were added from the related references and underwent the above-mentioned criteria as shown in Figure 1 . A total of eight studies met our eligibility criteria and were included in the final analysis [Table 1 ].
One of the eight studies was based on a pediatric population.[ 10 ] Most of the included studies focused on the adult population. The methodology was consistently randomized controlled, prospective, single-blinded trials except for one study, which was a feasibility study.[ 11 ] Two of the eight studies were done in the United States.[ 10 , 12 ] and the remaining were internationally based. The median number of patients involved was 210 patients. In all included studies, an app (electronic)-based group was compared to a matched control arm, which represented conventional methods for colonoscopy preparation. Conventional methods were consistent in all studies with control arms, and consisted of oral and/or written (paper-based) instructions before colonoscopy . Only one study used an iPad for electronic instructions instead of an app-based smartphone intervention as a form of communication.[ 12 ] Further details of the included SPAs are presented as Appendix 2 .
Interventions
Overall, the interventions were SPAs that aimed to improve peri-procedural colonoscopy in one or more of the following ways: providing education, notifications, and instructions for bowel preparation , a calendar, or other multimedia content including videos or pictures. The applications offered a variety of language options, including English, Arabic, French, German, Spanish, Korean, and Chinese. The interventions used in each study are summarized in Table 2 .
Impact on outcomes
Outcomes of the studies were reported in terms of the intervention’s impact on one or more of the following domains: bowel preparation quality, adherence to dietary instructions/colonoscopy appointment, and patient satisfaction/quality of life .
Bowel preparation The efficacy and quality of bowel preparation largely determine a successful colonoscopy and are influenced by multiple factors such as patient education, type of bowel preparation , and patient adherence to diet and laxatives. Seven studies included bowel preparation efficacy in their main objectives.[ 8 , 10 , 11 , 13-16 ] The majority of studies used Boston Bowel Preparation Scales (BPPS) to assess bowel preparation . Three of those studies used adenoma detection rate (ADR) to power assessment of bowel preparation .[ 13 , 14 , 16 ] ADR was highly correlated with high BPPS score. One of the studies used the Aronchick scale, as well as the Ottawa Bowel preparation scale and the Chicago Bowel preparation scale.[ 8 ] The other study used the Harefield Cleansing Scale (HCS).[ 15 ]
Adherence to diet/laxatives and appointmentsAdherence to colonoscopy screening was assessed by one study.[ 12 ] The study used app (mPATH-CRC) delivered information to positively impact the completion of CRC screening, while increasing self-efficacy and resulting in cost-effectiveness for both patients and providers when compared with traditional methods. Adherence to diet and laxatives was assessed by three studies.[ 8 , 14 , 16 ]
Quality of life and patient satisfactionQuality of life and patient satisfaction during the peri-procedural period of colonoscopy were assessed by five studies. Two studies used numeric rating scales (NRSs) to assess quality of life and found digitally reinforced education via app to be less burdensome.[ 11 , 16 ] Cho et al . assessed patient satisfaction with bowel preparation in both groups by a questionnaire.[ 13 ] Satisfaction scores were significantly higher in the app group than the control group. In Sharara et al. ,[ 8 ] patients reported the app to be user-friendly and helpful.
Cost-effectiveness
Walter et al . (2021)[ 16 ] showed that app-based education delivered pre-colonoscopy was accessible and reached a broader spectrum of socioeconomic levels given its sustainability with less financial input. However, the scope of this study was limited to fully evaluate cost-effectiveness.
DISCUSSION
The main purpose of this review is to assess the impact of SPAs in the colonoscopy process. This process includes bowel preparation , adherence to diet, patient satisfaction, cost effectiveness, and compliance with appointments. Another important objective of this research is to compare studies and identify SPA features that might improve the outcomes mentioned above.
Bowel preparation is often a complex and stressful process for patients due to multiple factors including specific dietary changes, using laxatives, spending time in the bathroom, and discomfort due to bowel prep. The lack of adherence to bowel preparation and dietary instructions increased by five-fold the risk of inadequately cleansed bowels.[ 17 , 18 ] Inadequate bowel preparation were reported in up to 25% of all patients undergoing colonoscopy .[ 19 , 20 ] Inadequate bowel preparation has been associated with prolonged procedure time, incomplete examination, increased cost, and missed pathology.[ 8 , 21 , 22 ] Step-by-step guidance is often required by patients who undergo colonoscopy based on the complexity of the procedure. Continuous reinforcement and coaching in real time by smartphone apps can help to improve patients’ adherence .[ 23 ] SPAs represent accessible resources for evidence-based information and care, and can be customized to promote each patient’s active engagement in their own care. Seven studies assessed bowel preparation as an outcome. Six out of seven studies showed more adequate bowel preparation in the SPAs group compared to written or/and verbal instructions.[ 10 , 11 , 13-16 ] One study did not show a statistically significant difference between the two groups.[ 8 ] Three of those studies used ADR to power assessment of bowel preparation .[ 13 , 14 , 16 ] All of these studies revealed a correlation between high BPPS and ADR. All studies used similar methodologies and these studies are comparable to each other. Additionally, bowel preparation regimens were consistent in most of the included trials, allowing comparability, and increasing the validity of the results obtained from each of them. There was a lack of standardization between SPAs features thus it is unknown whether these results are consistent and if external generalizability can be applied. On the other hand, the methodology of each study is robust and creates confidence toward the advantage of using mobile technologies to improve the colonoscopy preparation process.
Optimal bowel preparation and adherence to diet and laxatives are the cornerstone of the colonoscopy quality. Many factors have been historically identified as possible barriers to obtaining an adequate bowel preparation . Factors such as socioeconomic and educational status may represent limitations in promoting adherence . Therefore, methods that provide continuous education and guidance to the patient throughout the colonoscopy preparation process often aim toward optimal procedure quality outcomes. Three studies included adherence to dietary instructions and laxatives as an outcome.[ 8 , 14 , 16 ] All studies showed a better adherence to dietary instruction and laxatives in the SPAs group. To improve adherence , SPAs can include features such as automatic alerts, reminders, notifications, and reviewing the instructions about bowel prep.
Understanding factors impacting patient decision regarding CRC screening is the key to improve screening rates. Based on one meta-analysis, barriers to CRC screening completion include language barriers, logistical challenges, and cultural beliefs.[ 24 ] Facilitators of CRC screening are awareness of CRC screening, attitudes toward CRC screening, and motivation for screening. One out of eight studies assessed adherence to appointments for CRC screening.[ 12 ] The study used an SPA (mPATH-CRC) as the intervention. mPATH-CRC has three components: 1) a previously validated brief decision aid about CRC screening that reviews the two most commonly recommended CRC screening tests, fecal testing for blood and colonoscopy ; 2) patient self-ordering of screening tests which triggers study personnel to enter a cosignature required order under the primary care provider’s name in the electronic health record system; and 3) follow-up electronic messages delivered by text or e-mail designed to promote screening test completion. The control program consisted of a brief video about diet and exercise that was produced by the Centers for Disease Control. Patients in the intervention group had increased CRC screening with an accompanying difference in test ordering in the arms (69% vs 32%). Understanding and addressing facilitators and barriers for CRC screening might have a positive impact on completion and adherence to the colonoscopy appointment.[ 12 ]
Patient satisfaction is an important factor for the colonoscopy process. Fear of discomfort or complications, embarrassment, an unpleasant experience with pre colonoscopy bowel cleansing preparations, and lack of informative support can make patients uncomfortable and prevent completion of the colonoscopy . Educating patients about the colonoscopy process and addressing their fears/anxiety can improve the patients’ quality of life during the process. Five studies assessed quality of life or patient satisfaction during the colonoscopy process. Two studies used NRSs to assess quality of life and found digitally reinforced education via apps to be less burdensome.[ 15 , 16 ] Cho et al assessed patient satisfaction with the bowel preparation in both groups by a questionnaire. Satisfaction scores were significantly higher in the app group than the control group.[ 13 ] Sharara et al .[ 8 ] did not use any numerical scales for patient satisfaction assessment, however, higher numbers of patients reported the SPA to be user-friendly and helpful compared to the control arm.
CRC continues to be one of the most prevalent cancers in the United States with an estimated 50,260 cases per year, representing nearly $14 billion spent on direct medical care. CRC costs during the first year of diagnosis range from $12,757 to $58,704. Screening for CRC by colonoscopy not only reduces its incidence, but also the mortality and cost burden. None of the included trials studied cost-effectiveness. Future investigations can study the impact of SPAs on cost-effectiveness.
Limitations and strengths
This study has the following limitations. First, non-English studies are excluded and that can cause a bias toward English-written articles. Second, our study focused only on SPAs, while other digital technologies (web-based, SMS, social media platforms) were not included. Third, since a considerable amount of time is required to conduct scoping reviews, more recent and relevant studies may not have been included.
Despite smartphones being commonly used, factors such as level of literacy, age and socioeconomic status, can impact the level of smartphone usage in the population. The studies are from six different countries. Some studies reported demographic data of patients; however, demographics-based outcomes are not reported in those studies. Absence of patients’ demographic-based outcomes in studies can limit generalizability of results.
Despite these limitations, this study has several strengths. First, it includes a broad database search strategy. Second, no time filters were applied in this study. Third, additional articles were added from related references and underwent inclusion and exclusion criteria. Fourth, the features of all SPAs can be easily compared with each other regarding the association between features and outcomes.
CONCLUSION
SPAs represent easy, cost-effective, user friendly, and innovative tools that can be used to improve patient-centered outcomes. Technology has been increasingly used in all aspects of life including the medical arena during the COVID-19 pandemic. We will see an increasing impact of digital technologies in the health sector in the near future. Customized SPAs can be created to improve the colonoscopy process.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
APPENDIX 1: SEARCH STRATEGY
Appendix II: The details of included smartphone applications (links and interface)
REFERENCES
1. Chen CT, Li L, Brooks G, Hassett M, Schrag D. Medicare spending for breast, prostate, lung, and colorectal cancer patients in the year of diagnosis and year of death. Health Serv Res 2018;53:2118.
2. Provenzale D, Gupta S, Ahnen DJ, Markowitz AJ, Chung DC, Mayer RJ, et al. NCCN guidelines insights: Colorectal cancer screening, version 1.2018. J Natl Compr Canc Netw 2018;16:939–49.
3. Singal AG, Gupta S, Skinner CS, Ahn C, Santini NO, Agrawal D, et al. Effect of
colonoscopy outreach vs fecal immunochemical test outreach on colorectal cancer screening completion: A randomized clinical trial. JAMA 2017;318:806–15.
4. Smith H, Brunet N, Tessier A, Boushey R, Kuziemsky C. Barriers to
colonoscopy in remote northern Canada: An analysis of cancellations. Int J Circumpolar Health 2020;79:1816678.
5. Liu C, Zhu Q, Holroyd KA, Seng EK. Status and trends of mobile-health applications for iOS devices: A developer's perspective. J Syst Softw 2011;84:2022–33.
6. Chang AY, Ghose S, Littman-Quinn R, Anolik RB, Kyer A, Mazhani L, et al. Use of mobile learning by resident physicians in Botswana. Telemed J E Health 2012;18:11–3.
7. Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin C-T. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: Randomized trial. J Med Int Res 2004;6:e64.
8. Sharara AI, Chalhoub JM, Beydoun M, Shayto RH, Chehab H, Harb AH, et al. A customized
mobile application in
colonoscopy preparation: A randomized controlled trial. Clin Transl Gastroenterol 2017;8:e211.
9. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med 2018;169:467–73.
10. Brief J, Chawla A, Lerner D, Vitola B, Woroniecki R, Morganstern J. The Impact of a smartphone app on the quality of pediatric
colonoscopy preparations: Randomized controlled trial. JMIR Pediatr Parent 2020;3:e18174.
11. Walter B, Schmid R, von Delius S. A smartphone app for improvement of
colonoscopy preparation (ColoprAPP): Development and feasibility study. JMIR
Mhealth Uhealth 2017;5:e138.
12. Denizard-Thompson NM, Miller DP, Snavely AC, Spangler JG, Case LD, Weaver KE. Effect of a digital health intervention on decreasing barriers and increasing facilitators for colorectal cancer screening in vulnerable patients. Cancer Epidemiol Biomarkers Prev 2020;29:1564–9.
13. Cho J, Lee S, Shin JA, Kim JH, Lee HS. The impact of patient education with a smartphone application on the quality of
bowel preparation for screening
colonoscopy . Clin Endosc 2017;50:479–85.
14. Guo B, Zuo X, Li Z, Liu J, Xu N, Li X, et al. Improving the quality of
bowel preparation through an app for inpatients undergoing
colonoscopy : A randomized controlled trial. J Adv Nurs 2020;76:1037–45.
15. Lorenzo-Zúñiga V, Moreno de Vega V, Marín I, Barberá M, Boix J. Improving the quality of
colonoscopy bowel preparation using a smart phone application: A randomized trial. Dig Endosc 2015;27:590–5.
16. Walter B, Frank R, Ludwig L, Dikopoulos N, Mayr M, Neu B, et al. Smartphone application to reinforce education increases high-quality preparation for colorectal cancer screening colonoscopies in a randomized trial. Clin Gastroenterol Hepatol 2021;19:331–8.e5.
17. El Bizri M, El Sheikh M, Lee GE, Sewitch MJ. Mobile health technologies supporting
colonoscopy preparation: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2021;16:e0248679.
18. Chan W-K, Saravanan A, Manikam J, Goh K-L, Mahadeva S. Appointment waiting times and education level influence the quality of
bowel preparation in adult patients undergoing
colonoscopy . BMC Gastroenterol 2011;11:1–9.
19. Menees SB, Kim HM, Elliott EE, Mickevicius JL, Graustein BB, Schoenfeld PS. The impact of fair
colonoscopy preparation on
colonoscopy use and adenoma miss rates in patients undergoing outpatient
colonoscopy . Gastrointest Endosc 2013;78:510–6.
20. Hayat U, Lee PJ, Lopez R, Vargo JJ, Rizk MK. Online educational video improves
bowel preparation and reduces the need for repeat
colonoscopy within three years. Am J Med 2016;129:1219.e1–9.
21. Ness RM, Manam R, Hoen H, Chalasani N. Predictors of inadequate
bowel preparation for
colonoscopy . Am J Gastroenterol 2001;96:1797–802.
22. Hendry P, Jenkins J, Diament R. The impact of poor
bowel preparation on
colonoscopy : A prospective single centre study of 10 571 colonoscopies. Colorectal Dis 2007;9:745–8.
23. Denberg TD, Melhado TV, Coombes JM, Beaty BL, Berman K, Byers TE, et al. Predictors of nonadherence to screening
colonoscopy . J Gen Internal Med 2005;20:989–95.
24. Honein-AbouHaidar GN, Kastner M, Vuong V, Perrier L, Daly C, Rabeneck L, et al. Systematic review and meta-study synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2016;25:907–17.
