Colonoscopies have become the mainstay for colorectal cancer (CRC) screening based on guidelines released by several different gastroenterological societies and the United States Preventive Services Task Force. When a patient older than age 50 years has a colonoscopy with normal results, it can be a challenge for the gastroenterologist to make recommendations on when the next colonoscopy should occur. In addition to following the screening guidelines, this decision is typically multifactorial and can be operator-dependent based on experience. However, bowel preparation is a crucial factor that plays an intricate role in recommending an appropriate screening interval. Consequently, one of the new quality measurements requested by the Centers for Medicare and Medicaid Services (CMS) is the recommendation of repeat colonoscopy for normal-risk patients 10 years after a normal colonoscopy.1 Therefore, bowel preparation and its interpretation will play a key role in both clinical outcomes and reimbursement in the near future.

There are several scales used to measure the quality of bowel preparation; one of the most popular of which is the Aronchick scale.2 This scale rates the quality of the bowel preparation based on the percentage of mucosa visualized during colonoscopy: more than 95% mucosa visualized, excellent; 90% to 95%, good; 80% to 90%, fair; and less than 80%, poor. In some cases, the interpretation of the bowel preparation is subjective, leading to the potential for operator-dependent variability. 

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Recently, Menees and colleagues studied the effect of bowel cleansing on screening colonoscopy interval recommendations with respect to following current guidelines.1 This retrospective review found that close to 25% of average-risk patients aged 50 years and older who had normal colonoscopy results received recommendations for follow-up colonoscopies that were not consistent with current guidelines. Based on the Aronchick scale, the patients labeled as having “fair” bowel preparation were the most likely to have follow-up colonoscopies inconsistent with screening guidelines. As the intricacies of the new health care law continue to unfold, it is reasonable to speculate that reimbursement for these inconsistent follow-up colonoscopies may be more highly scrutinized than before.

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Compliance with bowel preparation can be extremely challenging for some patients; however, this challenge provides an opportunity for both physician and patient to make significant improvements in the future. Several strategies can be implemented in order to improve compliance including split-dosing, more succinct patient instructions and reminders, improved patient education, utilization of flavor packets, and lower volume of bowel preparation. In order to meet the upcoming CRC screening requirements being enforced by the CMS and new health care law, a focus on future interventions for bowel preparation will be necessary.


  1. Menees SB, Elliott E, Govani S, et al. The impact of bowel cleansing on follow-up recommendations in average-risk patients with a normal colonoscopy. Am J Gastroenterol. 2014;109(2):148-154.
  2. Aronchick C, Lipshutz W, Wright S, et al. Validation of an instrument to assess colon cleansing [Abstract]. Am J Gastroenterol. 1999;94:2667.