Govert Veldhuijzen

175 Discussion and future perspectives practicality. We therefore recommended the D-GESQ for routine use in daily clinical practice to improve quality of patient care in daily endoscopic practice. Strengths and limitations In this thesis, we embarked on a trajectory to establish our objectives. The decisions we made in the design of our trials resulted in several strengths, but undoubtedly also several limitations. These will be discussed here for each chapter. In chapter 2 , we stated that computer assisted instruction (CAI) empowers the patient in place, pace and moment of learning, and is known to have impact on patients satisfaction. 7 The main limitation of the CAI pilot study was its non-randomized design. This was due to the unavailability of the CAI at the start of patient inclusion in March 2013. The first patients in the CAI group were included in July 2013. However, this design did not affect the score by the participating endoscopists as he/she was unaware of this information and therefore unaware of assignment over the groups whilst assessing the primary endpoint. The endoscopist scoring rate of 60% was unforeseen low, introducing some selection bias in this study. Forgetting to score this item was probably due to the endoscopist’ busy daily practice. Also, the use of patient reported questionnaires restricts medical data collection as compared to chart review. Therefore, we cannot exclude the possibility of some selection bias (such as previous experience with colonoscopy) in assessing secondary endpoints. Familiarity with the use of computers, notably by elderly patients, could have been of concern. In our cohort, 40% in the CAI group were older than 65 years. However, we did not find an age dependent effect (data not shown). Before drawing general conclusions from our results, we needed to confirm our findings in a randomized study instead of this pre – after implementation design. As we demonstrated a small difference in effect on our primary outcome of bowel preparation quality, this subsequent trial should be adequately powered to test a non-inferiority hypothesis. We published our experiences with implementation of CAI outside of the first participating hospitals in chapter 3 . The strength of this position paper was that we were able to share the problems we encountered in this phase of the thesis. But the format of a position paper posed the main limitation, as we did not use a systematic approach of the presented literature. Our position paper therefore lacked explicit criteria for article selection without evaluation of selected articles for validity. The evolution of the CAI into a computer based education (CBE) and the CBE process implantation showed that in the period 2013-2017 several important obstacles were overthrown. We demonstrated the way to safely manage patient data and privacy via the CBE platform. Also, we showed how to deal with the legal value of online reported 9