Toward high-quality bowel preparation in Italy: insights from a nationwide cross-sectional survey of endoscopists

Abstract

Background:

Understanding endoscopists’ perspectives and routine practice offers opportunities to improve bowel cleansing for colonoscopy.

Objective:

To elucidate Italian endoscopists’ perceptions of bowel preparation quality, focusing on defining high-quality cleansing (HQC) and its perceived benefits in clinical practice and for diagnostic outcomes.

Design:

Nationwide, cross-sectional, web-based survey.

Methods:

A nationwide, web-based cross-sectional survey was undertaken in Italy between August and September 2024 among gastroenterologists with special interest in endoscopy. Participants were recruited via telephone screening; of 498 gastroenterologists contacted, 150 respondents completed an online questionnaire; analyses were descriptive.

Results:

The survey results revealed that all respondents (100%) routinely evaluate and document cleansing in the endoscopy report and almost all (99%) used validated scales. The majority (72%) of endoscopists aimed for HQC, which they defined as a segment score of ⩾8–9 on the Boston Bowel Preparation Scale or ‘excellent’ on the Aronchick scale. Almost all (93%) considered HQC important in every colonoscopy regardless of indication. All respondents considered that HQC allows higher identification rates for adenomas and sessile serrated lesions, reduces procedure time, and improves overall clinical efficiency; 99% considered that HQC allows for more appropriate surveillance intervals. On a scale of 1–10 to rate confidence with the diagnostic reliability of the exam (1 = not at all confident, 10 = very confident), the respondents’ levels of confidence improved with high-quality bowel preparation; mean scores were 2.1 with inadequate preparation, 6.6 with good cleansing and 9.2 with high-quality bowel cleansing.

Conclusion:

The survey revealed that the vast majority of Italian endoscopists consider HQC essential across all clinical indications. The results support the transition from ‘good’ to ‘high-quality’ cleansing as the new standard in clinical colonoscopy practice.

Plain language summary

High-quality bowel preparation in Italy

Understanding endoscopists’ perspectives and routine practice offers opportunities to improve bowel cleansing for colonoscopy. A survey of Italian endoscopists was conducted to elucidate perceptions of bowel preparation quality, focusing on defining high-quality cleansing (HQC) and its benefits in clinical practice and for diagnostic outcomes. The survey results revealed that all respondents (100%) routinely evaluate and document cleansing in the endoscopy report and almost all (99%) used validated scales. The majority (72%) of endoscopists aimed for HQC, which they defined as a segment score of ⩾8–9 on the Boston Bowel Preparation Scale or “excellent” on the Aronchick scale. Almost all (93%) considered HQC important in every colonoscopy regardless of indication. All respondents considered that HQC allows higher identification rates for adenomas and sessile serrated lesions, reduces procedure time, and improves overall clinical efficiency; 99% considered that HQC allows for more appropriate surveillance intervals. On a scale of 1 to 10 to rate confidence with the diagnostic reliability of the exam (1 = not at all confident, 10 = very confident), the respondents’ levels of confidence improved with high-quality bowel preparation; mean scores were 2.1 with inadequate preparation, 6.6 with good cleansing, and 9.2 with high-quality bowel cleansing. The survey revealed that the vast majority of Italian endoscopists consider HQC essential across all clinical indications. The results support the transition from “good” to “high-quality” cleansing as the new standard in clinical colonoscopy practice.

Keywords

adenoma detection rate bowel preparation colonoscopy colorectal cancer screening quality colonoscopy

Introduction

Colonoscopy plays a pivotal role in the prevention of colorectal cancer (CRC) and significantly decreases CRC incidence and mortality.^1,2 However, its success is highly dependent on the quality of bowel preparation. Bowel preparation quality is associated with two key performance measures for colonoscopy, namely adenoma detection rate (ADR) and caecal intubation rate.³ Inadequate or suboptimal bowel preparation leads to unnecessary costs and patient inconvenience as the examination has to be repeated or the subsequent surveillance examination has to be rescheduled at a shorter-than-usual interval.^4–7

To ensure validity and reliability of bowel preparation quality, clinical guidelines recommend documenting the adequacy of the preparation using validated scales,^5,8 including the Boston Bowel Preparation Scale (BBPS),⁹ the Aronchick scale,^10,11 the Ottawa Bowel Preparation Scale,¹² the Harefield Cleansing Scale¹³ and the Chicago Bowel Preparation Scale.¹⁴ These scales are inherently subjective and are heavily influenced by the operator’s preferences and experience.^15–17 The BBPS and the Aronchick scale are both commonly used in clinical practice, whereas the other scales have been mainly adopted in clinical trials;^15,18 current guidelines recommend the BBPS as the preferred scale.^7,19 The BBPS is the most extensively validated bowel cleansing score, with a score of ⩾2 in each colon segment correlating with adequate preparation.²⁰ Patients with adequate bowel preparation scores should have intervals for the next screening or surveillance examination that are consistent with current screening or post-polypectomy surveillance guidelines. United States (US)-based⁸ and European-based⁵ guidelines have recommended that patients with inadequate preparation should have their examination repeated within 1 year.^5,8

There is ongoing debate about whether high scores of bowel preparation indicating ‘high-quality’ rather than merely ‘good’ preparation are associated with improved colonoscopy outcomes. There is also no clear consensus on how to define high-quality cleansing (HQC).²¹ Various researchers have examined the impact of HQC on colonoscopy outcomes.^3,10,22 HQC ensures optimal mucosal visualisation, minimises the risk of missing potentially malignant lesions^4,23–25 and reduces the cost burden associated with procedures repeated at shorter intervals.^4–6 In 2016, a clinical study demonstrated that HQC is significantly more effective than intermediate-quality cleansing in detecting sessile serrated polyps (SSPs).²⁶ Similarly, in 2020, a study confirmed a significantly higher ADR was obtained with HQC than with good preparation.²⁷ In a large population-based screening programme database in Austria, compared with HQC, the probability of adenoma detection was significantly reduced with fair rather than poor and inadequate- bowel preparation at screening colonoscopy.¹⁷ Fair bowel preparation also significantly increased the risk of mortality from post-colonoscopy CRC (PCCRC) compared with HQC.¹⁷ Despite methodological differences in these three studies, they all highlight the importance – if not the necessity – of achieving high-quality preparation.²⁸

Since these findings suggest that HQC is probably better than adequate bowel preparation for screening colonoscopies, this leads to the central question of what practising gastroenterologists/endoscopists do in the real world. Understanding endoscopists’ perspectives on HQC offers valuable insights into current challenges and opportunities to improve bowel cleansing for colonoscopy. To investigate this further, an exploratory, nationwide, cross-sectional survey was conducted among Italian endoscopists to assess perceptions of bowel preparation quality, focusing on defining HQC and identifying its perceived benefits in clinical practice and for diagnostic outcomes.

Methods

Survey questionnaire and advisory board meeting

An exploratory, cross-sectional, web-based survey (online questionnaire) was conducted to describe endoscopists’ self-reported practices and perceptions regarding bowel preparation quality. The nationwide survey was carried out in Italy between 27 August and 26 September 2024 among gastroenterologists with a special interest in endoscopy and was administered by Ipsos (Milan, Italy), a research agency specialising in healthcare and social research. Survey questions were developed with the help of a Key Opinion Leader in colonoscopy and finalised by Ipsos. The survey responses were compiled and analysed at a meeting held on 12 December 2024 that involved 10 gastroenterologists with special interest in endoscopy from leading Italian hospitals and outpatient clinics (the authors), all of whom are experts in their fields and have amassed many years of experience in assessing bowel preparation quality for colonoscopies based on both clinical and research.

Selection of endoscopists

Gastroenterologists with endoscopic expertise were recruited by telephone by interviewers from Ipsos trained in health surveys who verified eligibility against predefined screening criteria. Eligible participants were aged ⩽65 years, had ⩾5 years’ experience performing colonoscopies, worked predominantly in public hospitals, accredited private hospitals or public outpatient clinics (excluding those practising predominantly in private practice), and performed ⩾200 colonoscopies per year. To reflect routine clinical practice and limit selection bias towards academically visible early adopters, we excluded endoscopists classified as ‘opinion leaders’, operationally defined as those who had served as speakers at national/international colonoscopy conferences and/or had authored colonoscopy-related publications within the previous 2 years. We also excluded physicians not meeting the minimum volume and setting criteria described above. Of the 498 gastroenterologists contacted by telephone, 150 met the eligibility criteria and completed the survey; 328 did not meet screening criteria and 20 declined participation. Given the self-reported nature of survey data, potential selection and response biases are addressed in the Limitations section.

Survey data collection

The survey consisted of a structured questionnaire comprising 11 closed-ended questions and one 10-point Likert scale item (Supplemental Material). The survey was structured into two sections: section (1) had questions pertaining to the endoscopist’s demographic and professional background, the clinical setting, the number of procedures conducted and their routine practice; and section (2) had questions related to the endoscopist’s evaluation of, and response to, bowel preparation, and how they assess, define and emotionally react to varying levels of bowel cleansing quality. Finally, the survey respondents rated their sense of confidence with the diagnostic reliability of the exam with varying bowel cleansing qualities, using a Likert scale ranging from 1 (not at all confident) to 10 (very confident) based on the quality of bowel preparation. No objective validation (e.g. audit of endoscopy reports) was performed.

Statistical analysis

Statistical analysis was descriptive. Categorical variables were summarised as frequencies and percentages, and continuous variables as means. No inferential tests or multivariable adjustments were performed, given the exploratory nature of the study.

The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies.²⁹

Results

Survey respondents

The 150 respondents had a mean age of 53.4 years and 21.8 years of professional experience, primarily in public hospitals (76%), with most respondents based in the northwestern (31%) or southern (32%) regions of Italy (Table 1).

Table 1.

Demographic and clinical practice characteristics of the Italian physicians who completed the survey.^a.

Variable	N = 150
Age, years
⩽45	24%
46–55	22%
56–60	22%
61–65	26%
Mean	53.4
Years in profession
5–15	27%
16–20	19%
21–25	18%
>25	36%
Mean	21.8
Geographical area of Italy
Northwest	31%
Northeast	17%
Centre	20%
South and Islands	32%
Primary workplace
Public hospital	76%
Private accredited hospital	22%
Private hospital	1%
Local Health Authority clinic	1%
Number of colonoscopies performed per year
200–499	30%
500–549	20%
550–599	27%
⩾600	23%
Mean	589

Data are presented as percentage of physicians, unless specified otherwise.

Eligible participants were gastroenterologists with endoscopic expertise, aged ⩽65 years, with ⩾5 years of experience performing colonoscopies, working in public hospitals, accredited private hospitals, or public outpatient clinics, and performing ⩾200 colonoscopies per year.

Desired quality of bowel preparation

Most physicians (86%) reported that they aim for HQC in their routine clinical practice. Very few reported that they targeted a good level of cleansing (8%) or one sufficient to perform the examination (6%). Almost all respondents (93%) considered HQC important in every colonoscopy, regardless of indication; the remaining 7% deemed it essential only for selected indications, such as faecal immunochemical test (FIT)-positive CRC screening programmes (Table 2).

Table 2.

Evaluation, definition and response to bowel preparation reported by the Italian physicians who completed the survey.

Variable	N = 150
Use of validated scales
Yes	99%
No	1%
Aim of bowel preparation
Optimal (high-quality) cleansing	86%
Good cleansing	8%
Sufficient cleansing to address the clinical question	6%
Definition of adequate bowel preparation
Meets validated criteria in bowel preparation quality scales (BBPS score ⩾2; ‘fair’ rating on the Aronchick scale)	83%
Ensures clear mucosal visibility with minimal washing and suctioning	13%
A cleansing quality that allows confident diagnosis	4%
Definition of high-quality bowel preparation
High scores (BBPS 8–9; ‘excellent’ rating on the Aronchick scale)	81%
Optimal visualisation without washing and suctioning	10%
Supports a confident diagnosis by the endoscopist	9%
Benefits of high-quality cleansing
Higher adenoma detection rate	100%
Higher sessile serrated lesion detection rate	100%
Reduced examination time and improved efficiency	100%
Better appropriateness of surveillance intervals	99%
Importance of optimal bowel preparation
In every colonoscopy	93%
Mainly for certain indications (e.g. a positive FIT result for screening colonoscopy)	7%

Data are reported as percentage of patients.

BBPS, Boston Bowel Preparation Scale; FIT, faecal immunochemical test.

Assessment and definition of bowel preparation quality

All respondents (100%) reported routinely evaluating and documenting bowel cleansing in the endoscopy report; almost all (99%) reported that they use validated bowel preparation quality scales (Table 2).

Most (83%) endoscopists defined good cleansing according to definitions of validated scales, in particular as a segment score of ⩾2 on the BBPS or an ‘at least fair’ on the Aronchick rating.^9,11 A further 13% defined it as mucosa visibility without excessive washing or suction, and 4% defined it as providing sufficient clarity to make a reliable diagnosis. HQC was defined by 81% of endoscopists as BBPS scores of 8–9 or ‘excellent’ on the Aronchick scale.^9,11 Ten per cent associated HQC with optimal visualisation of the mucosa without needing washing and suctioning, while 9% defined it as enabling a confident diagnosis by the endoscopist.

Benefits of high-quality bowel preparation

The physicians agreed that HQC is associated with several benefits including higher ADR and SSL detection rates (100% of respondents, respectively), more appropriate surveillance intervals (99%), reduced examination time (100%) and enhanced endoscopy efficiency (100%).

Confidence with the diagnostic reliability of the exam was higher with HQC than with good cleansing (mean score of 9.2 vs 6.6) and was lowest with inadequate preparation (mean score of 2.1; Figure 1).

Figure 1.

Confidence scores among endoscopists after performing colonoscopies with different bowel cleansing qualities. Confidence scores were rated on a 10-point scale, where 1 = not at all confident and 10 = very confident, based on the quality of bowel preparation.

Discussion

The survey findings indicate that assessment of bowel preparation quality is a systematic practice amongst the Italian endoscopists surveyed. This finding agrees with the results of another recent nationwide Italian survey, which reported that 93.9% of participating endoscopists stated that they used the BBPS for assessing bowel preparation quality.³⁰ This is an improvement over colonoscopy practice in Italy from around 20 years ago, when a survey found that only 108 (39.0%) of the 278 participating endoscopy centres were systematically reporting the quality of bowel cleansing.³¹

The majority of endoscopists distinguished between adequate bowel preparation and HQC, with their interpretations aligning with current standards,^5,7,8,19 where HQC corresponds with BBPS scores of 8–9 or a rating of ‘excellent’ on the Aronchick scale.^9,11 In addition, the survey findings indicated that nearly all Italian endoscopists consider HQC to be essential across all clinical indications, with perceived beneficial impacts on ADRs, SSL detection, surveillance interval accuracy and overall colonoscopy efficiency.

Importantly, current guidelines endorse a performance target for endoscopy units of good bowel preparation (defined as a BBPS score of ⩾6, with each segment score ⩾2) in ⩾90% of all colonoscopies and ⩾95% of screening colonoscopies.^5,7,19 In contrast, the current survey findings revealed that most endoscopists consider HQC as a priority in their clinical practice and experience; they want not only excellent preparation but also optimal bowel preparation (i.e. without the need for excessive washing) immediately prior to initiating colonoscopy, which extends beyond the concept of total BBPS scores of 8–9. Clearly, endoscopists in real-world clinical practice in Italy aim to achieve a standard of bowel preparation that exceeds key performance measures recommended by current guidelines.

HQC makes the endoscopist feel more relaxed about the results of the procedure, whereas suboptimal preparation reduces the endoscopist’s level of diagnostic confidence. This finding is important, as it highlights the psychological and operational value associated with bowel preparation, indicating a paradigm shift from ‘adequate’ to ‘high-quality’ cleansing.

Achieving high-quality bowel cleansing may also improve procedural efficiency by reducing the need for repeat colonoscopies and optimising the organisation of endoscopy services. Previous analyses have suggested that improved cleansing quality may contribute to more efficient use of healthcare resources.^32–35

Importantly, although the literature cites clinical and economic advantages associated with HQC, several barriers exist including conceptual, organisational and economic considerations that prevent the achievement of HQC in clinical practice.^{15–17,24,36–38} For example, the lack of a standard definition for HQC and the fact that the quality of colonoscopy procedures and their interpretation is provider-dependent.^15–17 A systematic literature review has identified a lack of consistent use of standardised measures of adequate bowel cleansing, with some studies using validated scales such as the BBPS or Aronchick scale, while many other studies have used unvalidated rating scales or they have not reported how bowel preparation was assessed.³² Introducing procedure standardisation, quality assurance standards and key performance indicators could reduce discrepancies in outcomes between different endoscopists, and potentially result in HQC.^24,36–38

Efforts to improve the quality of bowel preparation and improve bowel cleansing outcomes include use of overnight split-dose or same-day regimen versus the day before dosing,^6,28,39–43 tailored preparation protocols,⁴⁴ delivery of enhanced education provided by trained healthcare professionals,⁵ patient navigation programmes,⁴⁵ multimedia messaging services or educational programmes, including computer-based educational materials,^4,46–50 a smart phone application to assess bowel preparation according to the appearance of the faeces in the toilet⁵¹ and the use of bowel preparation regimens designed to improve patient adherence, tolerability and cleansing success.^{22,23,28,35,52–59}

Regarding lower-volume cleansing preparations, in addition to the aforementioned advantages, published evidence supports the use of lower-volume polyethylene glycol-based regimens in special populations such as hospitalised inpatients⁵⁸ and the elderly.^60,61 Additionally, published evidence suggests that such regimens can achieve HQC in the entire colon and/or the right colon (Table 3) and may represent one option among multiple guideline-supported regimens and implementation measures to facilitate achieving HQC. The choice of bowel preparation regimen in clinical practice should therefore be guided by patient characteristics, local organisational factors and current guideline recommendations.

Table 3.

Selected evidence on bowel preparation regimens and high-quality cleansing outcomes.

Study	Study design	No. of pts	Comparator agent	Outcomes^a
Bednarska 2022⁵⁷	Qualitative, prospective, multi-centre, comparative, single-blind, observational study	1098	1L PEG + Asc vs 2L PEG + Asc	Adequate bowel cleansing (total BBPS score ⩾6 with a partial BBPS ⩾2 in each segment): 97% vs 95%, p = 0.100 HCQ (total BBPS score = 9): 73% vs 45%, p < 0.001 HQC right colon (BBPS right colon = 3): 77% vs 51%, p < 0.001
			1L PEG + Asc vs 4L PEG	Adequate bowel cleansing (total BBPS score ⩾6 with a partial BBPS ⩾2 in each segment):97% vs 97%, p = 0.877HCQ (total BBPS score = 9):73% vs 53%, p < 0.001HQC right colon (BBPS right colon = 3):77% vs 58%, p < 0.001
Choi 2022⁶²	Prospective, randomised, non-inferiority, open-label, phase 4 clinical trial	173	CleanViewAL® vs Plenvu® (both 1L PEG + Asc regimens)	Bowel cleansing success (total BBPS ⩾ 6 with a partial BBPS ⩾ 2 in each segment):97.6% vs 98.8%, p = 0.207
Hong 2022³⁹	Multi-centre, randomised, endoscopist-blinded, non-inferiority phase 4 study	360	1L PEG + Asc vs 2L PEG + Asc	Primary endpoint:Overall bowel cleansing success (BBPS score ⩾2 for all segments of the colon):93.1% vs 91.9%, p_{non-inferiority} < 0.001Secondary endpoints:(1) segmental bowel cleansing success rate (segmental colon BBPS score ⩾2):95.4% vs 94.2%, p_{non-inferiority} < 0.001;(2) high-quality bowel cleansing (overall, BBPS score = 9, segmental colon, BBPS score = 3):49.4% vs 37.8%, p_{non-inferiority} < 0.001;(3) Overall PDR: 48.9% vs 37.8%, p_{non-inferiority} < 0.001;(4) Overall ADR: 24.7% vs 20.4%, p_{non-inferiority} < 0.001
Lopez-Jamar 2023⁶	Observational, retrospective, multi-centre study	13,169	1L PEG + Ascovernight split-dose vs same-day regimen	Main endpoints:(1) overall adequate colon cleansing (BBPS score ⩾6 with a BBPS score ⩾2 in each segment): 94.7% vs 86.7%, p < 0.0001;(2) HQC in the right colon (BBPS score = 3): 65.4% vs 41.4%, p < 0.0001;(3) HQC in the total colon (BBPS score ⩾8): 72.0% vs 43.7%, p < 0.0001Main exploratory endpoints:(1) PDRs in the total colon and right colon^b: 48.9% vs 49.4%, p = 0.60(2) ADR in the total colon and right colon^c: 42.5% vs 24.3%^d
Machlab 2025⁶⁰	Post hoc analysis of an observational, multi-centre, retrospective study	423(⩾80 years)	1L PEG + Asc	Main endpoints:(1) adequate bowel cleansing (BBPS score ⩾6 with a BBPS score ⩾2 in each segment): 88.9%(2) overall HCQ (BBPS score ⩾8 for the overall colon): 54.1%(3) HCQ in the right colon (BBPS score = 3 for the right colon): 46.1%
Maida 2023⁴¹	Meta-analysis of randomised controlled trials	–	1L PEG + Asc vs other bowel preparations	Cleansing success (BBPS score ⩾6 with a partial BBPS score ⩾2 in each segment):OR = 1.50; 95% CI 1.25, 1.81; p < 0.01Right-colon HQC (partial BBPS score = 3): OR = 1.67; 95% CI 1.21, 2.31; p < 0.01ADR (pooled estimate): OR = 1.02; 95% CI 0.87, 1.20; p = 0.79
Pérez Arellano 2024⁶³	Randomised controlled trial	876	1L PEG + Asc vs SPMC	Primary endpoints:(1) Adequate bowel cleansing in the overall colon (BBPS score ⩾6 with a BBPS score ⩾2 in each segment): 90.8% vs 77.7%, p < 0.001(2) Whole colon preparation quality:- excellent (total BBPS score 8–9): 55.2% vs 25.4%, p < 0.001- good (total BBPS score 6–7): 25.6% vs 52.2%, p < 0.001- poor (total BBPS score 1–5): 9.2% vs 22.3%, p < 0.001(3) Adequate cleansing of the right colon (BBPS score ⩾2): 92.0% vs 82.7%, p < 0.001(4) HQC of the right colon (BBPS score = 3):- excellent (total BBPS score 8–9): 58.7% vs 27.2%, p < 0.001- good (total BBPS score 6–7): 33.2% vs 55.5%, p < 0.001- poor (total BBPS score 1–5): 5.6% vs 15.9%, p < 0.001Secondary endpoint: PDR in the overall colon^e 47.2% vs 42.2%, p = 0.139
Repici 2021²²	Multicentre, single-blind, randomised controlled non-inferiority trial	388	1L PEG + Asc vs 4L PEG	Bowel preparation quality for entire colon (BBPS score ⩾6 with a BBPS score ⩾2 in each segment): 97.9% vs 93.0%, p_{non-inferiority} < 0.001Bowel cleansing quality:- excellent/HQC (total BBPS score 8–9): 78.7% vs 64.5%- good (total BBPS score 6–7 and each colon segment score ⩾2): 18.6% vs 28.0%- fair (total BBPS score 3–5 or total BBPS score 6–7, but ⩾1 colon segment score < 2): 2.7% vs 6.5%- poor (total BBPS score 0–2): 0 vs 1.1%
Vassallo 2024²⁸	Multicentre, single-blind, randomised controlled non-inferiority trial	478	1L PEG + Asc vs 4L PEG	Primary endpoint: overall cleansing success (total BBPS ⩾6, with a segmental BBPS ⩾2): 91.8% vs 83.6%, p = 0.009Secondary endpoints:(1) excellent cleansing of the right colon (total BBPS score 9): 39.1% vs 27.7%, p = 0.001(2) HQC of the right colon (total BBPS score = 3): 52.3% vs 38.5%, p = 0.004

This table is illustrative and non-exhaustive, is provided for contextual purposes, and does not imply endorsement of any specific product.

Data are reported to one decimal place where known.

PDRs in the total colon and right colon were defined as the proportion of colonoscopies, where ⩾1 polyp was found and removed.

ADR in the total colon and right colon was defined as the proportion of colonoscopies, where ⩾1 adenoma was found as determined by histological analysis.

The study reports the ADR only as overall values for the total colon and right colon, not for each dosing regimen.

PDR in the overall colon was defined as the proportion of colonoscopies, where ⩾1 polyp was found and removed.

ADR, adenoma detection rate; Asc, ascorbate; BBPS, Boston Bowel Preparation Scale; CI, confidence interval; HCQ, high-quality cleansing; No., number; OR, odds ratio; PDR, polyp detection rate; PEG, polyethylene glycol; PEG + Asc, polyethylene glycol plus ascorbate; pts, patients; RR, relative risk; SPMC, sodium picosulphate with magnesium citrate.

Limitations

Some limitations of this study should be acknowledged. First, selection bias may be present, as online surveys imply a certain degree of computer literacy and may exclude less digitally engaged respondents. Second, as an exploratory survey based on self-reported data, the findings may be affected by recall, response and social desirability bias and could not be independently verified against objective quality indicators or endoscopy reporting systems. Future studies combining survey findings with objective quality indicators (e.g. audit of endoscopy reports) would help validate and extend these results. Third, because the sampling strategy focused on experienced, high-volume, predominantly hospital-based endoscopists and excluded ‘opinion leaders’ as operationally defined above, the findings may not be fully generalisable to all endoscopists, particularly those working predominantly in private practice or those with high academic visibility. Finally, as this study was conducted in Italy, the findings may not be directly transferable to other healthcare systems where screening pathways, reimbursement models and endoscopy service organisation differ.

Conclusion

The results of this survey reinforce the central role of high-quality bowel cleansing in colonoscopy and support the transition from ‘good’ to ‘high-quality’ cleansing as the new standard in clinical practice. HQC has demonstrated multiple benefits over adequate bowel preparation, including higher adenoma and SSL detection rates, a significant improvement in ADRs across all colonic segments, as well as a reduced risk of PCCRC. Other advantages include an improved procedural efficiency and better overall clinical outcomes. Future research should focus on standardising HQC criteria, improving patient adherence through enhanced education strategies and evaluating the long-term cost-effectiveness of adopting HQC as the default standard in colonoscopy procedures. By prioritising HQC, the gastroenterology community can ensure more effective CRC prevention, improved diagnostic accuracy and optimised endoscopic efficiency, ultimately enhancing patient outcomes.

Supplemental Material

sj-docx-1-cmg-10.1177_26317745261441726 – Supplemental material for Toward high-quality bowel preparation in Italy: insights from a nationwide cross-sectional survey of endoscopists

Supplemental material, sj-docx-1-cmg-10.1177_26317745261441726 for Toward high-quality bowel preparation in Italy: insights from a nationwide cross-sectional survey of endoscopists by Cesare Hassan, Roberto Di Mitri, Lorenzo Fuccio, Marcello Maida, Gianpiero Manes, Mauro Manno, Franco Radaelli, Cristiano Spada, Roberto Vassallo and Alessandro Repici in Therapeutic Advances in Gastrointestinal Endoscopy

Supplemental Material

sj-docx-2-cmg-10.1177_26317745261441726 – Supplemental material for Toward high-quality bowel preparation in Italy: insights from a nationwide cross-sectional survey of endoscopists

Supplemental material, sj-docx-2-cmg-10.1177_26317745261441726 for Toward high-quality bowel preparation in Italy: insights from a nationwide cross-sectional survey of endoscopists by Cesare Hassan, Roberto Di Mitri, Lorenzo Fuccio, Marcello Maida, Gianpiero Manes, Mauro Manno, Franco Radaelli, Cristiano Spada, Roberto Vassallo and Alessandro Repici in Therapeutic Advances in Gastrointestinal Endoscopy

Footnotes

Acknowledgements

We would like to thank Maurizio Tarzia who assisted with the preparation of the outline of this manuscript on behalf of Springer Health+ and Iona MacDonald of Springer Health+ who assisted with the first and subsequent drafts. This medical writing assistance was funded by Norgine Italia Srl.

Declarations

ORCID iD

Cesare Hassan

Supplemental material

Supplemental material for this article is available online.

References

Bretthauer

Loberg

Wieszczy

, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022; 387: 1547–1556.

Zhang

Chen

, et al. Colonoscopic screening is associated with reduced Colorectal Cancer incidence and mortality: a systematic review and meta-analysis. J Cancer 2020; 11: 5953–5970.

Rex

DK.

Key quality indicators in colonoscopy. Gastroenterol Rep (Oxf) 2023; 11: goad009.

Guo

Wang

, et al. Reinforced education improves the quality of bowel preparation for colonoscopy: an updated meta-analysis of randomized controlled trials. PLoS One 2020; 15: e0231888.

Hassan

East

Radaelli

, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy 2019; 51: 775–794.

Lopez-Jamar

JME

Gorjao

Cotter

, et al. Bowel cleansing effectiveness and safety of 1L PEG + Asc in the real-world setting: Observational, retrospective, multicenter study of over 13000 patients. Endosc Int Open 2023; 11: E785–E793.

Keswani

Crockett

Calderwood

AH.

AGA clinical practice update on strategies to improve quality of screening and surveillance colonoscopy: expert review. Gastroenterology 2021; 161: 701–711.

Jacobson

Anderson

Burke

, et al. Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2025; 120: 738–764.

Calderwood

Jacobson

BC.

Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010; 72: 686–692.

10.

Aronchick

CA.

Bowel preparation scale. Gastrointest Endosc 2004; 60: 1037–1038.

11.

Aronchick

Lipshutz

Wright

, et al. Validation of an instrument to assess colon cleansing [Abstract 360]. Am J Gastroenterol 1999; 94: 2577–2766.

12.

Rostom

Jolicoeur

Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc 2004; 59: 482–486.

13.

Halphen

Heresbach

Gruss

, et al. Validation of the Harefield Cleansing Scale: a tool for the evaluation of bowel cleansing quality in both research and clinical practice. Gastrointest Endosc 2013; 78: 121–131.

14.

Gerard

Foster

Raiser

, et al. Validation of a new bowel preparation scale for measuring colon cleansing for colonoscopy: the Chicago Bowel Preparation Scale. Clin Transl Gastroenterol 2013; 4: e43.

15.

Kastenberg

Bertiger

Brogadir

Bowel preparation quality scales for colonoscopy. World J Gastroenterol 2018; 24: 2833–2843.

16.

Mehrotra

Morris

Gourevitch

, et al. Physician characteristics associated with higher adenoma detection rate. Gastrointest Endosc 2018; 87: 778–786.

17.

Zessner-Spitzenberg

Waldmann

Rockenbauer

, et al. Impact of bowel preparation quality on colonoscopy findings and colorectal cancer deaths in a nation-wide colorectal cancer screening program. Am J Gastroenterol 2024; 119: 2036–2044.

18.

Solitano

Siegel

Korzenik

, et al. Performance of bowel preparation quality scales in patients with Crohn’s disease. Aliment Pharmacol Ther 2024; 60: 1042–1050.

19.

Kaminski

Thomas-Gibson

Bugajski

, et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378–397.

20.

Cold

Heen

Vamadevan

, et al. Development and validation of the Open-Source Automatic Bowel Preparation Scale. Gastrointest Endosc 2025; 101: 1201–1210.

21.

Kim

Choi

Lee

, et al. Boston bowel preparation scale score 6 has more missed lesions compared with 7-9. Sci Rep 2024; 14: 1605.

22.

Repici

Spada

Cannizzaro

, et al. Novel 1-L polyethylene glycol + ascorbate versus high-volume polyethylene glycol regimen for colonoscopy cleansing: a multicenter, randomized, phase IV study. Gastrointest Endosc 2021; 94: 823–831 e829.

23.

Ahmad

Marshall

Bassett

, et al. Evaluation of bowel preparation regimens for colonoscopy including a novel low volume regimen (Plenvu): CLEANSE study. BMJ Open Gastroenterol 2023; 10: e001070.

24.

Rees

Bevan

Zimmermann-Fraedrich

, et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65: 2045–2060.

25.

Shahini

Sinagra

Vitello

, et al. Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: evidence from the literature. World J Gastroenterol 2023; 29: 1685–1707.

26.

Clark

Laine

High-quality bowel preparation is required for detection of sessile serrated polyps. Clin Gastroenterol Hepatol 2016; 14: 1155–1162.

27.

Hassan

Manning

Alvarez Gonzalez

, et al. Improved detection of colorectal adenomas by high-quality colon cleansing. Endosc Int Open 2020; 8: E928–E937.

28.

Vassallo

Maida

Zullo

, et al. Efficacy of 1 L polyethylene glycol plus ascorbate versus 4 L polyethylene glycol in split-dose for colonoscopy cleansing in out and inpatient: a multicentre, randomized trial (OVER 2019). Dig Liver Dis 2024; 56: 495–501.

29.

von Elm

Altman

Egger

, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Bmj 2007; 335: 806–808.

30.

Zagari

Frazzoni

Fuccio

, et al. Adherence to European society of gastrointestinal endoscopy quality performance measures for upper and lower gastrointestinal endoscopy: a nationwide survey from the Italian society of digestive endoscopy. Front Med (Lausanne) 2022; 9: 868449.

31.

Radaelli

Meucci

Minoli

Colonoscopy practice in Italy: a prospective survey on behalf of the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2008; 40: 897–904.

32.

Murphy

Jenks

McCool

, et al. A systematic review and cost analysis of repeat colonoscopies due to inadequate bowel cleansing in five European countries. Expert Rev Pharmacoecon Outcomes Res 2019; 19: 701–709.

33.

Bruno

Di Matteo

Valentino

, et al. Approccio, gestione e presa in carico del paziente nella fase preparatoria all’esame diagnostico di colonscopia: un’analisi economica per il sistema sanitario italiano. Clinico Economics Italian Articles on Outcomes Research 2024; 19: 71–84.

34.

Zorzi

Valiante

Germanà

, et al. Comparison between different colon cleansing products for screening colonoscopy. A noninferiority trial in population-based screening programs in Italy. Endoscopy 2016; 48: 223–231.

35.

Maida

Sinagra

Morreale

, et al. Effectiveness of very low-volume preparation for colonoscopy: a prospective, multicenter observational study. World J Gastroenterol 2020; 26: 1950–1961.

36.

Chokshi

Hovis

Hollander

, et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012; 75: 1197–1203.

37.

Rex

Cutler

Lemmel

, et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24–28.

38.

Rex

Schoenfeld

Cohen

, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31–53.

39.

Hong

Lee

, et al. Efficacy and safety of split-dose bowel preparation with 1 L polyethylene glycol and ascorbate compared with 2 L polyethylene glycol and ascorbate in a Korean population: a phase IV, multicenter, randomized, endoscopist-blinded study. Gastrointest Endosc 2022; 95: 500–511.

40.

Kang

Jeen

Lee

, et al. Comparison of a split-dose bowel preparation with 2 liters of polyethylene glycol plus ascorbic acid and 1 liter of polyethylene glycol plus ascorbic acid and bisacodyl before colonoscopy. Gastrointest Endosc 2017; 86: 343–348.

41.

Maida

Ventimiglia

Facciorusso

, et al. Effectiveness and safety of 1-L PEG-ASC versus other bowel preparations for colonoscopy: a meta-analysis of nine randomized clinical trials. Dig Liver Dis 2023; 55: 1010–1018.

42.

Magier

Jahandideh

Pourmorady

, et al. Split-dose bowel preparation is superior to straight-dose in hospitalized patients undergoing inpatient colonoscopy. Arq Gastroenterol 2023; 60: 39–47.

43.

Radaelli

Paggi

Hassan

, et al. Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme. Gut 2017; 66: 270–277.

44.

Baker

Mari

Nafrin

, et al. Predictors and colonoscopy outcomes of inadequate bowel cleansing: a 10-year experience in 28,725 patients. Ann Gastroenterol 2019; 32: 457–462.

45.

Solonowicz

Stier

Kim

, et al. Digital navigation improves no-show rates and bowel preparation quality for patients undergoing colonoscopy: a randomized controlled quality improvement study. J Clin Gastroenterol 2022; 56: 166–172.

46.

Arslanca

Aygun

Effect of nurse-performed enhanced patient education on colonoscopy bowel preparation quality. Rev Lat Am Enfermagem 2022; 30: e3626.

47.

Back

Kim

Ahn

, et al. Impact of patient audiovisual re-education via a smartphone on the quality of bowel preparation before colonoscopy: a single-blinded randomized study. Gastrointest Endosc 2018; 87: 789–799.

48.

van der Zander

QEW

Reumkens

van de Valk

, et al. Effects of a personalized smartphone app on bowel preparation quality: randomized controlled trial. JMIR Mhealth Uhealth 2021; 9: e26703.

49.

Wen

Kau

Huang

, et al. Smartphone education improves embarrassment, bowel preparation, and satisfaction with care in patients receiving colonoscopy: a randomized controlled trail. Medicine (Baltimore) 2020; 99: e23102.

50.

Veldhuijzen

Klemt-Kropp

Terhaar Sive Droste

, et al. Computer-based patient education is non-inferior to nurse counselling prior to colonoscopy: a multicenter randomized controlled trial. Endoscopy 2021; 53: 254–263.

51.

Zhu

Zhang

, et al. Improving bowel preparation for colonoscopy with a smartphone application driven by artificial intelligence. NPJ Digit Med 2023; 6: 41.

52.

Bisschops

Manning

Clayton

, et al. Colon cleansing efficacy and safety with 1 L NER1006 versus 2 L polyethylene glycol + ascorbate: a randomized phase 3 trial. Endoscopy 2019; 51: 60–72.

53.

Cash

Moncrief

MBC

Epstein

, et al. Patient experience with NER1006 as a bowel preparation for colonoscopy: a prospective, multicenter US survey. BMC Gastroenterol 2021; 21: 70.

54.

Clayton

Tayo

Halphen

, et al. Novel 1 L polyethylene glycol-based bowel preparation (NER1006): proof of concept assessment versus standard 2 L polyethylene glycol with ascorbate - a randomized, parallel group, phase 2, colonoscopist-blinded trial. BMC Gastroenterol 2019; 19: 79.

55.

Epstein

Halonen

Sharma

Bowel preparation with 1L polyethylene glycol and ascorbate NER1006 doubles the chance to detect three or more adenomas in overweight or obese males. Endosc Int Open 2021; 9: E1324–E1334.

56.

Yuan

Zhang

Xie

, et al. Comparison of 1L adjuvant auxiliary preparations with 2L solely polyethylene glycol plus ascorbic acid regime for bowel cleaning: a meta-analysis of randomized, controlled trials. Biomed Res Int 2021; 2021: 6638858.

57.

Bednarska

Nyhlin

Schmidt

, et al. The effectiveness and tolerability of a very low-volume bowel preparation for colonoscopy compared to low and high-volume polyethylene glycol-solutions in the real-life setting. Diagnostics (Basel) 2022; 12: 1155.

58.

Fuccio

Frazzoni

Spada

, et al. Factors that affect adequacy of colon cleansing for colonoscopy in hospitalized patients. Clin Gastroenterol Hepatol 2021; 19: 339–348.

59.

Neri

Scarozza

Giannarelli

, et al. Efficacy and tolerability of very low-volume bowel preparation in patients with inflammatory bowel diseases. Eur J Gastroenterol Hepatol 2021; 33: 977–982.

60.

Machlab

Lorenzo-Zuniga

Pantaleon

, et al. Real-world effectiveness and safety of 1L polyethylene glycol and ascorbic acid for bowel preparation in patients aged 80 years or older. Endosc Int Open 2025; 13: a25259938.

61.

Lim

Kim

, et al. Efficacy and safety of 1 L polyethylene glycol plus ascorbic acid for bowel preparation in elderly: comparison with oral sulfate solution. Korean J Intern Med 2023; 38: 651–660.

62.

Choi

Yoon

Kim

, et al. Comparison of two types of 1-L polyethylene glycol-ascorbic acid as colonoscopic bowel preparation: a prospective randomized study. Korean J Gastroenterol 2022; 80: 85–92.

63.

Pérez Arellano

Rodríguez García

Galera Ródenas

, et al. 1-L polyethylene glycol + ascorbic acid versus sodium picosulfate + magnesium citrate bowel preparations for colonoscopy: effectiveness and safety. Rev Esp Enferm Dig 2024; 116: 186–192.

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