Non-physician endoscopists： A systematic review

AIM： To examine the available evidence on safety,competency and cost-effectiveness of nursing staffproviding gastrointestinal （GI） endoscopy services.METHODS： The literature was searched for publicationsreporting nurse endoscopy using several databasesand specific search terms. Studies were screenedagainst eligibility criteria and for relevance. Initialsearches yielded 74 eligible and relevant articles;26 of these studies were primary research articlesusing original datasets relating to the ability of nonphysicianendoscopists. These publications included atotal of 28883 procedures performed by non-physicianendoscopists.RESULTS： The number of publications in the field ofnon-specialist gastrointestinal endoscopy reached a peakbetween 1999 and 2001 and has decreased thereafter.17/26 studies related to flexible sigmoidoscopies,5 to upper GI endoscopy and 6 to colonoscopy. Allstudies were from metropolitan centres with nursesworking under strict supervision and guidance byspecialist gastroenterologists. Geographic distributionof publications showed the majority of research wasconducted in the United States （43%）, the UnitedKingdom （39%） and the Netherlands （7%）. Moststudies conclude that after appropriate training nurse endoscopists safely perform procedures. However, inrelation to endoscopic competency, safety or patientsatisfaction, all studies had major methodologicallimitations. Patients were often not randomized （21/26studies） and not appropriately controlled. In relationto cost-efficiency, nurse endoscopists were less costeffectiveper procedure at year 1 when compared toservices provided by physicians, due largely to theincreased need for subsequent endoscopies, specialistfollow-up and primary care consultations.CONCLUSION： Contrary to general beliefs, endoscopicservices provided by nurse endoscopists are notmore cost effective compared to standard servicemodels and evidence suggests the opposite. Overallsignificant shortcomings and biases limit the validityand generalizability of studies that have exploredsafety and quality of services delivered by non-medicalendoscopists.