Non-physician endoscopists: A systematic review

Table 1 Summary table of all competency research regarding medical and nurse and other non-physician endoscopists

Publication	Setting	Non-physician proce-dures	Supervision	True randomization of patients?	Procedurists	Potential biases	Outcome parameters	Modality	Outcome
Rosevelt et al[8], 1984	Metropolitan Tertiary Centre, United States	825	Yes	No	1 NE	Patient selection biasEndoscopist selection biasLevel of assistance not documented	Polyp detection rateComplications	FS	Polyp detection rate of 8.7%No complications
Schroy et al[4], 1988	Metropolitan Tertiary Centre, United States	100	Yes	No	1 NE	Patient selection biasEndoscopist selection biasLevel of assistance not documentedConcordance criteria not given	Polyp detection rateConcordance of findings with expert opinion	FS	Polyp detection rate of 36%Video review showed k = 0.72 concordance with GCNurse sensitivity = 75%, specificity = 94%
DiSario et al[15], 1993	Metropolitan Tertiary Centre, United States	80	Yes	Yes	5 NEs5 GRs	Endoscopist selection biasLevel of assistance not documented1 NE excluded due to incompetency after trainingComparison of outcome groups for missed lesions not calculated	Insertion depthIdentification of anatomyComplicationsProcedure timeMissed lesions	FS	Polyp detection rate of 24%Insertion depth, complications and procedure time similar between groupsNEs missed more lesions and missed more anatomy
Maule[7], 1994	Metropolitan Tertiary Centre, United States	1881	Yes	No	4 NEs2 GCs	Endoscopist selection biasComplicated patient referred away from NEsLevel of assistance not documented	Insertion depthComplicationsPolyp detection ratePatient satisfaction	FS	GCs had significantly deeper insertion depthsSimilar polyp detection rateSimilar patient satisfaction
Moshakis et al[16], 1996	Metropolitan Tertiary Centre, United Kingdom	50	Yes	No	1 NE1 GC	Endoscopist selection biasPatient selection biasNE was compared to GC who performed trainingLevel of assistance not documentedMethod of quality scoring not given	Insertion depth“Quality and accuracy”	FS	Insertion depth, quality and accuracy were similar between comparison groups
Duthie et al[6], 1998	Metropolitan Tertiary Centre, United Kingdom	205	Not specified	No	1 NE	Endoscopist selection biasPatient selection biasCriteria for “successful procedure” not given	Successful procedure when compared to various other imaging modalities	FS	93% of procedures considered “successful”
Schoenfeld, Cash et al[17], 1999	Metropolitan Tertiary Centre, United States	114	Yes	No	1 NE3 GFs3 Surgical Consultants	Endoscopist selection biasPatient selection biasLevel of assistance not documented	Depth of insertionProcedure timePolyp detection ratePatient satisfactionComplications	FS	Surgeons had less depth of insertion than NEs or GFsNEs had longer procedures than GFs or surgeonsPolyp detection rate similarNo complications
Schoenfeld, Lipscomb et al[10], 1999	Metropolitan Tertiary Centre, United States	151	Yes	Yes	3 NEs4 GCs	Endoscopist selection biasPatient selection biasLevel of assistance not documentedHigh threshold for detecting difference in polyp detection rate	Polyp detection rateDepth of insertionComplications	FS	Polyp detection rates similar between groups (43%-45%)GCs had much greater depth of insertionNo complications
Wallace et al[9], 1999	Metropolitan Tertiary Centre, United States	2323	Yes	No	1 NE2 PAs15 GCs	Endoscopist selection biasPatient selection biasLevel of assistance not documented	Depth of insertionPolyp detection rateComplications	FS	GCs had significantly greater depths of insertion compared with NE+PAsPolyp detection rate similar between groups (23%-27%)No complications
Schoen et al[26], 2000	Metropolitan Tertiary Centre, United States	660	Not specified	No	1 PE1 GC1 MC	Endoscopist selection biasPatient selection biasLevel of assistance not documented	Patient satisfaction	FS	Similar patient satisfaction between groups
Shapero et al[27], 2001	Metropolitan Tertiary Centre, Canada	488	No	No	2 NEs	Endoscopist selection biasPatient selection bias Level of assistance not documented	Polyp detection rateComplicationsDepth of insertionProcedure time	FS	Average depth of insertion 52.9 cm8.4 min average procedure timePolyp detection rate of 15.4%
Jain et al[28], 2002	Metropolitan Tertiary Centre, United States	5000	No	No	Not specifiedNo physicians	Unknown endoscopistsPatient selection biasLevel of assistance not documentedNo comparison	Polyp detection rateNo complications	FS	No major complications polyp detection rate of 13.3%
Meenan et al[29], 2003	Metropolitan Tertiary Centre, United Kingdom	25	Yes	No	1 NE4 GFs	Endoscopist selection biasPatient selection biasLevel of assistance not documentedViews by NE were limited to the esophagus	Adequacy of views obtain by radial ultrasound by endoscopy	EGD	NEs had consistently lower quality scores
Smale et al[30], 2003	Metropolitan Tertiary Centre, United Kingdom	1487	Yes	No	2 NEs15 mixed medical/surgical physicians	Endoscopist selection biasPatient selection biasLevel of assistance not documentedComplicated patients excludedRetrospective and prospective	Differences in sedationPatient satisfaction	EGD	No difference between groups for sedation or patient satisfactionSubjectively, nurses reporter fewer studies as normal
Wildi et al[22], 2003	Metropolitan Tertiary Centre, United States	40	Yes	No	1 NE1GC	Endoscopist selection biasPatient selection biasLevel of assistance not documentedMethod of assessment not given	Concordance of findings with GC	EGD	NE had sensitivity of 75% and specificity of 98% with GC as gold standard
Nielsen et al[12], 2005	Metropolitan Tertiary Centre, Denmark	69	Yes	No	2 NEsUnknown number of physicians	Endoscopist selection biasPatient selection biasLevel of assistance not documented	Patient satisfaction	FS	Nurses had better patient satisfaction than physicians
Meining et al[3], 2007	Metropolitan Tertiary Centre, United Kingdom	190	Yes	Yes	2 NEs1 GC2 GRs1 Physician not specified1 MC	Endoscopist selection biasPatient selection biasLevel of assistance not documentedSubjectivey, nurses tended to focus on the entire examination whilst physicians focused on the reason for referral	Adequacy of views for entire procedureDuration of procedureUse of sedation	EGD	Nurses had twice the amount of adequate views however took twice as long on average.Nurses used sedation more frequently
Williams et al[19], 2006 Williams et al[21], 2009	Nation-wide Metropolitan Tertiary Centres, United Kingdom	957	Yes	Yes	30 NEs67 physicians (not specified)	Significantly higher numbers of patients changed schedule from physician to nurse (due	Patient satisfactionAdequacy of viewsDepth of insertionEndoscopic procedures performedDuration of examinationComplications	EGD	Patient satisfaction favoured nursesNo difference for depth of insertionNurses took biopsies for histology in upper endoscopy and FS more frequently than physicians.There were more normal histology findings for nurses
Richardson et al[20], 2009							Need for assistanceNeed for subsequent follow up and investigationCost-benefit analysis		Nurses were more likely to report sedation and procedural details whilst physicians were more likely to report diagnosis and suggested treatment.Nurses took biopsies for H. pylori more frequentlyNo major differences in final diagnoses frequency between 2 groups.No serious complicationsSimilar need for assistance.Nurses had greater follow-up cost per procedure whilst physicians had greater labor costs per procedure.Physicians had greater overall costs per procedure but greater patient improvement.Physicians were 87% more likely to be cost-effective than nurse endoscopists.
Koornstra et al[11], 2009	Metropolitan Tertiary Centre, Netherlands	300	Yes	No	2 NEs1 GF1 GC	Endoscopist selection biasPatient selection biasLevel of assistance not documented	Caecal intubation rateCaecal intubation timeComplicationsPatient satisfaction	Col	Similar caecal intubation rates/times (80%-90%) between GF and NEs but much lower/longer than GC after 150 procedures.Patient satisfaction similar between GF and NEs, less than for GC.Similar complication rate.
Maslekar, Hughes et al[31], 2010	Metropolitan Tertiary Centre, United Kingdom	308	Not specified	No	1 NE1 PA/TSeveral physicians not specified	Endoscopist selection biasPatient selection biasLevel of assistance not documentedNE and PA/Ts had less colonoscopies more FS	ComplicationsPatient satisfaction	Col and FS	No difference between all 3 groups
Maslekar, Waudby et al[32], 2010	Metropolitan Tertiary Centre, United Kingdom	26	Yes	No	1 Surgical Registrar1 PA/T	Endoscopist selection biasPatient selection biasLevel of assistance not documentedPatients needing resection excluded	Accuracy of endoscopists to gauge position in colon	FS	PA/T accuracy of 70% with Registrars accuracy of 80%, not statistically significant.
Shum et al[18], 2010	Metropolitan Tertiary Centre, HK	119	Yes	No	1 NE	No comparison group	Mean procedure timeDepth of insertionComplications	FS	9.4 min average procedure time53.5 cm average depth of insertionNo major complications
Limoges-Gonzalez et al[44], 2011	Metropolitan Endoscopy Centre, United States	50	Yes	Yes	1 NE2 GCs	Endoscopist selection biasLevel of assistance not documented	Adenoma detection rateCaecal intubation rateCaecal intubation timePatient satisfactionSedation useComplications	Col	Adenoma detection rate higher in NE (42%) than GCs (17%)All other parameters similar across both groups
de Jonge et al[33], 2012	Multi-metropolitan tertiary centre, Netherlands	162	Not specified	No (retrospective)	6 NEs113 Staff not specified including GCs, GFs, surgeons, MCs	Data was retrospective review of reports	Overall caecal intubation rateAdenoma detection rate	Col	NEs and GFs and GCs found more adenomas and had greater caecal intubation rates (94%) than nongastroenterology staff, especially surgical
van Putten et al[34], 2012	Multi-metropolitan tertiary centre, Netherlands	1000	Yes	No	10 NEs	Endoscopist selection biasPatient selection bias	Unassisted caecal intubation rateWithdrawal timeAdenoma detection rateAssistance requirementsPatient satisfactionComplications	Col	Unassisted caecal intubation rate of 94%23% of colonoscopies required assistance from GCWithdrawal time of 10 minAdenoma detection rate of 23%1 perforation and 1 onset of atrial fibrillation95% of patients satisfied with procedure
Massl et al[5], 2013	Multi-metropolitan tertiary centre, Netherlands	866	Yes	No	7 NEs8 GFs	Endoscopist selection biasNEs had significantly lower ASA scores on patientsLevel of assistance not reported	Unassisted caecal intubation rateCaecal intubation timeComplicationsPolyp detection rate	Col	Unassisted caecal intubation rate was significantly lower 77% for NE than GFs (88%).Polyp detection rate (45%), complications, withdrawal and intubation times were similar between groups.Crude cost-analysis showed a saving of €7.61 per colonoscopy where 1 GC supervises 3 NEs. Did not account for higher need for repeat colonoscopies due to incomplete procedures

Col: Colonoscopy; EGD: Esophagogastroduodenoscopy; FS: Flexible sigmoidoscopy; NE: Nurse endoscopist; GF: Gastroenterology fellow; GC: Gastroenterology consultant (attending); GR: Gastroenterology registrar/resident; PA/T: Physician’s assistant or technician; MC: Medical (non-gastroenterology) consultant.