Commentaries on health services research.

Researchers evaluated 26 studies of nonphysician endoscopists and the available evidence on safety, competency, and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The 26 studies represented 28,883 procedures performed by nonphysician endoscopists; 17 of the studies related to fl exible sigmoidoscopies, fi ve to upper GI endoscopy, and six to colonoscopy. All studies were 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%), United Kingdom (39%), and the Netherlands (7%). Most studies conclude that after appropriate training, a nurse is competent to provide endoscopic services safely and with patient satisfaction. All studies had major methodologic limitations. Patients often were not randomized (21 of 26 studies) and not appropriately controlled. In relation to cost-effi ciency, nurse endoscopists were less cost-effective per procedure at year 1 when compared with services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up, and primary care consultations. Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost-effective compared with standard service models. Overall signifi cant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by nonphysician endoscopists.1 Commentary by Joseph Marzucco: The most that can be concluded from this review of the literature is that the poor quality of most of the studies precludes any reliable conclusion. Most of the studies were not randomized, used inappropriate statistical analyses, and were not adequately controlled; most did not provide a direct comparison, as the nurse endoscopists were closely supervised in their activities. Only one study out of 28 looked at cost-effectiveness. The authors concluded that only a physician was a cost-effi cient option when compared with traditional service models. Most of the 28 studies that suggested that nurse endoscopists compared favorably with physicians cautioned that better-controlled studies are needed before a defi nitive assessment of nonphysician endoscopists’ cost-effectiveness can be made.