Systematic Reviews
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 28, 2015; 21(16): 5056-5071
Published online Apr 28, 2015. doi: 10.3748/wjg.v21.i16.5056
Non-physician endoscopists: A systematic review
Maximilian Stephens, Luke F Hourigan, Mark Appleyard, George Ostapowicz, Mark Schoeman, Paul V Desmond, Jane M Andrews, Michael Bourke, David Hewitt, David A Margolin, Gerald J Holtmann
Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia
Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane QLD 4072, Australia
Mark Appleyard, Department of Gastroenterology and Hepatology, RBWH, Herston QLD 4006, Australia
George Ostapowicz, Department of Gastroenterology and Hepatology, Gold Coast Hospital QLD 4215, Australia
Mark Schoeman, Jane M Andrews, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital and University of Adelaide, Adelaide SA 5000, Australia
Paul V Desmond, St Vincent’s Hospital, University of Melbourne, Melbourne VIC 3010, Australia
Michael Bourke, Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Sydney NSW 2145, Australia
David Hewitt, School of Medicine, University of Queensland, Brisbane QLD 4072, Australia
David Hewitt, Department of Gastroenterology, Queensland Elizabeth II Jubilee Hospital, Coopers Plains, Brisbane QLD 4108, Australia
David A Margolin, Department of Colon and Rectal Surgery Ochsner Clinic Foundation, Ochsner Clinical School, University of Queensland, New Orleans LA 70121, United States
Author contributions: Holtmann GJ, Stephens M designed the research; Stephens M, Hourigan LF, Appleyard M, Ostapowicz G, Schoeman M, Desmond PV, Andrews JM, Bourke M, Hewitt D, Margolin DA, Holtmann GJ performed the research; Stephens M, Hourigan LF, Appleyard M, Ostapowicz G, Schoeman M, Desmond PV, Andrews JM, Bourke M, Hewitt D, Margolin DA, Holtmann GJ analyzed the data; Stephens M, Holtmann GJ wrote the paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Gerald J Holtmann, MD, PhD, MBA, Professor, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane QLD 4102, Australia. gerald_holtmann@health.qld.gov.au
Telephone: +61-7-31767792 Fax: +61-7-31765111
Received: July 27, 2014
Peer-review started: July 27, 2014
First decision: September 15, 2014
Revised: September 18, 2014
Accepted: December 14, 2014
Article in press: December 22, 2014
Published online: April 28, 2015
Processing time: 274 Days and 10.2 Hours
Abstract

AIM: To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services.

METHODS: The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms. Studies were screened against eligibility criteria and for relevance. Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of non-physician endoscopists. These publications included a total of 28883 procedures performed by non-physician endoscopists.

RESULTS: The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter. 17/26 studies related to flexible sigmoidoscopies, 5 to upper GI endoscopy and 6 to colonoscopy. All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists. Geographic distribution of publications showed the majority of research was conducted in the United States (43%), the United Kingdom (39%) and the Netherlands (7%). Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. However, in relation to endoscopic competency, safety or patient satisfaction, all studies had major methodological limitations. Patients were often not randomized (21/26 studies) and not appropriately controlled. In relation to cost-efficiency, nurse endoscopists were less cost-effective per procedure at year 1 when compared to services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations.

CONCLUSION: Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite. Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.

Keywords: Nurse endoscopist; Cost-benefit; Service model; Patient satisfaction; Outcome parameter

Core tip: A systematic review was performed to examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal endoscopy services. Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. The empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients.