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DOI: 10.1055/s-0034-1365310
Non-physician performance of lower and upper endoscopy: a systematic review and meta-analysis
Publication History
submitted 15 October 2013
accepted after revision 16 January 2014
Publication Date:
13 March 2014 (online)
![](https://www.thieme-connect.de/media/endoscopy/201405/lookinside/thumbnails/10.1055-s-0034-1365310-1.jpg)
Background and study aims: Demand for endoscopic procedures worldwide has increased while the number of physicians trained to perform endoscopy has remained relatively constant. The objective of this study was to characterize non-physician performance of lower and upper endoscopic procedures.
Patients and methods: Bibliographical searches were conducted in Medline, EMBASE, and Cochrane Library databases. Studies were included where patients underwent flexible sigmoidoscopy, colonoscopy, or upper endoscopy done by a non-physician (nurse, nurse practitioner, physician assistant) and outcome measures were reported (detection of polyps, adenomas, cancer, and/or adverse events). Pooled rates were calculated for specific outcomes and rate ratios were determined for selected comparison groups.
Results: Most studies involved nurses performing flexible sigmoidoscopies for colorectal cancer screening. Nurses and nurse-practitioners/physician assistants performing flexible sigmoidoscopies showed pooled polyp detection rates of 9.9 % and 23.7 %, adenoma detection rates of 2.9 % and 7.2 %, colorectal cancer detection rates of 1.3 % and 1.2 %, and adverse event rates of 0.3 and 0 per 1000 sigmoidoscopies, respectively. There was no significant difference between polyp and adenoma detection rates in sigmoidoscopy performance studies comparing nurses or nurse-practitioners/physician assistants with physicians. For the 3 studies of non-physician performance of colonoscopy, pooled adenoma detection rate was 26.4 %, cecal intubation rate was 93.5 %, and adverse event rate was 2.2 /1000 colonoscopies. In the few studies examining upper endoscopies, 99.4 % of upper endoscopy procedures performed by nurses were successful with no reported adverse events.
Conclusion: Available studies suggest that when non-physicians perform endoscopic procedures, especially lower endoscopies, outcomes and adverse events are in line with those of physicians.
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References
- 1 Vijan S, Inadomi J, Hayward RA et al. Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States. Aliment Pharmacol Ther 2004; 20: 507-515
- 2 Elta GH. GI training: where are we headed?. Am J Gastroenterol 2011; 106: 395-397
- 3 Kolata G. 50 and Ready for Colonoscopy? Doctors Say Wait Is Often Long. New York Times A ed New York Times New York 2003; December, 8 1
- 4 Schoenfeld P, Lipscomb S, Crook J et al. Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999; 117: 312-318
- 5 Schroy PC, Wiggins T, Winawer SJ et al. Video endoscopy by nurse practitioners: a model for colorectal cancer screening. Gastrointest Endosc 1988; 34: 390-394
- 6 Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994; 330: 183-187
- 7 DiSario JA, Sanowski RA. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc 1993; 39: 29-32
- 8 Ikenberry SO, Anderson MA, Banerjee S et al. Endoscopy by nonphysicians. Gastrointest Endosc 2009; 69: 767-770
- 9 Wells GA, Shea B, O’Connell D et al. The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. 2011 www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed August 1, 2013
- 10 Jadad AR, Moore RA, Carroll D et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996; 17: 1-12
- 11 Dobrow MJ, Cooper MA, Gayman K et al. Referring patients to nurses: outcomes and evaluation of a nurse flexible sigmoidoscopy training program for colorectal cancer screening. Can J Gastroenterol 2007; 21: 301-308
- 12 Duthie GS, Drew PJ, Hughes MA et al. A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist. Gut 1998; 43: 711-714
- 13 Goodfellow PB, Fretwell IA, Simms JM. Nurse endoscopy in a district general hospital. Ann R Coll Surg Engl 2003; 85: 181-184
- 14 Gruber M. Performance of flexible sigmoidoscopy by a clinical nurse specialist. Gastroenterol Nurs 1996; 19: 105-108
- 15 Kelly SB, Murphy J, Smith A et al. Nurse specialist led flexible sigmoidoscopy in an outpatient setting. Colorectal Dis 2008; 10: 390-393
- 16 Maruthachalam K, Stoker E, Nicholson G et al. Nurse led flexible sigmoidoscopy in primary care – the first thousand patients. Colorectal Dis 2006; 8: 557-562
- 17 Morcom J, Dunn SV, Luxford Y. Establishing an Australian nurse practitioner-led colorectal cancer screening clinic. Gastroenterol Nurs 2005; 28: 33-42
- 18 Redwood D, Joseph DA, Christensen C et al. Development of a flexible sigmoidoscopy training program for rural nurse practitioners and physician assistants to increase colorectal cancer screening among Alaska Native people. J Health Care Poor Underserved 2009; 20: 1041-1048
- 19 Rosevelt J, Frankl H. Colorectal cancer screening by nurse practitioner using 60-cm flexible fiberoptic sigmoidoscope. Dig Dis Sci 1984; 29: 161-163
- 20 Shapero TF, Hoover J, Paszat LF et al. Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian community-based program. Gastrointest Endosc 2007; 65: 640-645
- 21 Shum NF, Lui YL, Choi HK et al. A comprehensive training programme for nurse endoscopist performing flexible sigmoidoscopy in Hong Kong. J Clin Nurs 2010; 19: 1891-1896
- 22 Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum 1977; 20: 94-96
- 23 van Putten PG, Ter BorgF, Adang RP et al. Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction. Endoscopy 2012; 44: 1127-1132
- 24 Wu K, Titzer D, Soetikno R et al. Use of a colonoscope instead of a sigmoidoscope to screen asymptomatic adults for colorectal cancer. Gastrointest Endosc 2003; 58: 720-724
- 25 Arumugam PJ, Rao GN, West J et al. The impact of open access flexible sigmoidoscopy: a comparison of two services. J R Coll Surg Edinb 2000; 45: 366-368
- 26 Wallace MB, Kemp JA, Meyer F et al. Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. Am J Med 1999; 107: 214-218
- 27 Schoenfeld PS, Cash B, Kita J et al. Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointest Endosc 1999; 49: 158-162
- 28 Williams J, Russell I, Durai D et al. What are the clinical outcome and cost-effectiveness of endoscopy undertaken by nurses when compared with doctors? A Multi-Institution Nurse Endoscopy Trial (MINuET). Health Technol Assess 2006; 10 iii–iv, ix–x, 1-195
- 29 Koornstra JJ, Corporaal S, Giezen-Beintema WM et al. Colonoscopy training for nurse endoscopists: a feasibility study. Gastrointest Endosc 2009; 69 (03) 688-695
- 30 Limoges-Gonzalez M, Mann NS, Al-Juburi A et al. Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial. Gastroenterol Nurs 2011; 34: 210-216
- 31 Meaden C, Joshi M, Hollis S et al. A randomized controlled trial comparing the accuracy of general diagnostic upper gastrointestinal endoscopy performed by nurse or medical endoscopists. Endoscopy 2006; 38: 553-560
- 32 Smale S, Bjarnason I, Forgacs I et al. Upper gastrointestinal endoscopy performed by nurses: scope for the future?. Gut 2003; 52: 1090-1094
- 33 Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008; 149: 627-637
- 34 Ladabaum U, Song K. Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand. Gastroenterology 2005; 129: 1151-1162
- 35 Wendt E. Screening for colorectal cancer. N Engl J Med 2001; 345: 1851; author reply 1852
- 36 Steinwachs D, Allen JD, Barlow WE et al. National Institutes of Health state-of-the-science conference statement: Enhancing use and quality of colorectal cancer screening. Ann Intern Med 2010; 152: 663-667
- 37 Hutfless S, Kalloo AN. Screening colonoscopy: a new frontier for nurse practitioners. Clin Gastroenterol Hepatol 2013; 11: 106-108
- 38 Lieberman DA, Ghormley JM. Physician assistants in gastroenterology: should they perform endoscopy?. Am J Gastroenterol 1992; 87: 940-943
- 39 Gossman ER. Endoscopy by nonphysicians. Can J Gastroenterol 2007; 21: 17-18
- 40 Ferraro KF, Southerland T. Domains of medical practice: physicians' assessment of the role of physician extenders. J Health Soc Behav 1989; 30: 192-205
- 41 Norris B, Harris T, Stringer S. Effective use of physician extenders in an outpatient otolaryngology setting. Laryngoscope 2011; 121: 2317-2321
- 42 Burgess SE, Pruitt RH, Maybee P et al. Rural and urban physicians' perceptions regarding the role and practice of the nurse practitioner, physician assistant, and certified nurse midwife. J Rural Health 2003; 19 Suppl: 321-328
- 43 Mathur M, Rampersad A, Howard K et al. Physician assistants as physician extenders in the pediatric intensive care unit setting-A 5-year experience. Pediatr Crit Care Med 2005; 6: 14-19
- 44 Matsusaki T, Sakai T. The role of Certified Registered Nurse Anesthetists in the United States. J Anesth 2011; 25: 734-740
- 45 Rex DK, Petrini JL, Baron TH et al. Quality indicators for colonoscopy. Gastrointest Endosc 2006; 63 (04) 16-S28
- 46 Littlejohn C, Hilton S, Macfarlane GJ et al. Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer. Br J Surg 2012; 99: 1488-1500
- 47 Atkin W, Rogers P, Cardwell C et al. Wide variation in adenoma detection rates at screening flexible sigmoidoscopy. Gastroenterology 2004; 126: 1247-1256
- 48 Neale AV, Demers RY, Budev H et al. Physician accuracy in diagnosing colorectal polyps. Dis Colon Rectum 1987; 30: 247-250
- 49 Rozen P, Ron E, Fireman Z et al. The relative value of fecal occult blood tests and flexible sigmoidoscopy in screening for large bowel neoplasia. Cancer 1987; 60: 2553-2558
- 50 Verne JE, Aubrey R, Love SB et al. Population based randomized study of uptake and yield of screening by flexible sigmoidoscopy compared with screening by faecal occult blood testing. BMJ 1998; 317: 182-185
- 51 Paillot B, Czernichow P, Michel P et al. Incidence of rectosigmoid adenomatous polyps in subjects without prior colorectal adenoma or cancer: a prospective cohort study. Gut 1999; 44: 372-376
- 52 Wexner SD, Litwin D, Cohen J et al. Principles of privileging and credentialing for endoscopy and colonoscopy. Gastrointest Endosc 2002; 55: 145-148