Review for 10.1186/s12876-023-02751-1 (2023)

Reviewer’s report
Title: 
Effect of acuity level and patient characteristics on bowel preparation
quality: a retrospective cohort study of inpatient colonoscopies
Version: 
1 
Date: 
21 Nov 2022
Reviewer's report:
Effect of acuity level and patient characteristics on bowel preparation quality: a
retrospective cohort study of inpatient colonoscopies
Manuscript Number: BMGE-D-22-00370R1
This manuscript describes a retrospective cohort study of adult patients
undergoing diagnostic colonoscopy while admitted in the hospital from Jan. 1,
2015 - June 30, 2020. The study was conducted in a single urban level 1 trauma
medical center. The research team examined the level of inpatient care between 3
units: General Medical Floor (GMF), Intensive Care Units (ICU) and Telemetry
Unit (TU) and assessed this association with bowel preparation quality, adjusting
for known and unknown predictors. The topic is relevant and interesting since
inadequate bowel preparation is common and limits visualization during
colonoscopy, which is an important screening and diagnostic tool to reduce
colorectal cancer and assess other conditions. Furthermore, colorectal cancer is
the second most common cause of cancer death in the U.S. The paper is very
well written, organized, and easy to read. The presented tables/figures were
helpful in improving understanding. 
Despite robust evidence that outpatients achieve higher quality of bowel
preparation (BPQ)
when compared to inpatients, no study has investigated patient disposition within
a
hospital as an opportunity to identify modifiable factors and setting-based
interventions
to improve BPQ. The research team proposed that a clear understanding of
patient and care level variables within the hospital could identify patients who
may benefit from enhanced pre-colonoscopy readiness assessments or different
bowel preparation protocols. Several previous papers have looked at patient
factors related to inadequate bowel preparation (IBP) in an inpatient setting and
identified patient factors such as age, having significant comorbidities, lower
socioeconomic class, opiate/TCA use, afternoon colonoscopies, etc. 
Poola, S., Jampala, N., Tumin, D., & Ali, E. (2020). Factors influencing inpatient
colonoscopy bowel preparation quality. Minerva gastroenterologica e
dietologica, 66(3), 194-200. https://doi.org/10.23736/S1121-421X.20.02657-4
Yadlapati, R., Johnston, E. R., Gregory, D. L., Ciolino, J. D., Cooper, A., &
Keswani, R. N. (2015). Predictors of Inadequate Inpatient Colonoscopy
Preparation and Its Association with Hospital Length of Stay and Costs.
Digestive diseases and sciences, 60(11), 3482-3490.
https://doi.org/10.1007/s10620-015-3761-2
The conclusions are consistent with the evidence and arguments presented. The
aim of this study was to investigate the association between the quality of bowel
preparation and predictors stratified by acuity level of inpatient care between the
General Medical Floor (GMF), Telemetry Unit (TU), and Intensive Care Units
(ICU). The study team hypothesized that ICU patients had worse quality of
bowel preparation, and the ICU setting was found to be an independent predictor
for IBP. Findings also indicated that patients with prior opioid and laxative use
may be more likely to have inadequate bowel preparation in an inpatient setting.
The study does provide greater detail around inpatients that undergo diagnostic
colonoscopy. 
of IBP.
The author is not disagreeing significantly with the current academic consensus.
One specific aspect of this work does conflict with prior findings in that "age
was not identified as a risk factor for IBP in this study, but it was in prior work
(below)":
McNabb-Baltar, J., Dorreen, A., Al Dhahab, H., Fein, M., Xiong, X., O' Byrne,
M., Ait, I., Martel, M., & Barkun, A. N. (2016). Age Is the Only Predictor of
Poor Bowel Preparation in the Hospitalized Patient. Canadian journal of
gastroenterology & hepatology, 2016, 2139264.
The authors suggestions that difficulty following instructions and older age may
contribute less 
to BPQ in inpatient procedures and more in outpatient
colonoscopies seem plausible. 
Major Flaws
N/A
Minor Flaws
It has been acknowledged that clinicians and researchers continue to use a
variety of bowel preparation quality measures, including nonvalidated scales,
leading to potential confusion and difficulty when comparing quality results
among clinicians and across clinical trials:
Kastenberg, D., Bertiger, G., & Brogadir, S. (2018). Bowel preparation quality
scales for colonoscopy. World journal of gastroenterology, 24(26), 2833-2843.
https://doi.org/10.3748/wjg.v24.i26.2833
I would be interested in hearing the authors perspectives on their decision not to
use a validated BPQ scale such as the Ottawa or Boston bowel prep scale. 
Declaration of competing interests
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
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Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
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