Govert Veldhuijzen

98 Chapter 5 a series of 15 text messages to patients and found that they to achieving better colonoscopy preparation. 22  In addition, digital send instructions increase appointment adherence with less same-day cancellations. 23 Trials utilizing smartphone apps showed improved bowel preparation. 24-26 An important difference with these studies using text messages via SMS of smartphone app is that our approach aimed achieve patient engagement through the use of visual 3D animation as a teaching tool to provide better insight and actual visualisation of the procedure. Also, web based solutions like ours have the benefit over smart phone apps that it is ubiquitously available on all devices (e.g. desktop computer, tablet of smartphone) without the need for users to download it first. More importantly, the fact that our CBE platformmay substitute nurse counselling, common practise in several health care services, is a novel element and relevant to policy makers. 27 Earlier, authors hypothesized that there is a “ceiling effect” of 90% adequate bowel preparation score for educational interventions that influence these scores in any endoscopy unit. 28 As a result, these interventions will be beneficial in underperforming units with scores well below the 85% benchmark advised by the U.S. Multi-Society Task Force on Colorectal Cancer Screening. 29 In several recent (non-Western) studies demonstrating improved bowel cleanliness by smart phone intervention, baseline scores in the control group were often below this point (77.2%-73.6%). 25,30 By contrast, in our four trial units (already performing well above 90% adequate bowel preparation in controls) the ceiling effect might have prevented to detect meaningful superiority differences. We therefore adopted the non-inferiority design, novel to this type of research. Initiatives in other fields utilizing the same functionality of CBE have shown that it can reduce the number of outpatient visits. For example, use of CBE improves patient self- management in inflammatory bowel disease, diabetes, asthma, and chronic obstructive pulmonary disorder. 31,32 We realize that CBE is not suitable for every patient. The patient with low (eHealth) literacy are less likely to benefit. In our trial, 3.0% of patients paid an extra visit to the hospital despite CBE. CBE should therefore be positioned as an adjunct to nurse counselling in vulnerable patient groups, as they might need an alternative access for relevant health care information. The implication of our finding is that CBE may save valuable time for the nurses and free up resources. With the growing future need for colonoscopies due to the national colorectal cancer screening programme and subsequent surveillance colonoscopies, and the current problems in recruiting nursing staff in Dutch hospitals, this is very relevant. 33,34