Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists.
OBJECTIVE
Screening with sigmoidoscopy reduces the risk of death from colorectal cancer. Only 30% of eligible patients have undergone sigmoidoscopy, in part because of a limited supply of endoscopists. We evaluated the performance and safety of screening sigmoidoscopic examinations by trained nonphysician endoscopists in comparison with board-certified gastroenterologists.


METHODS
Asymptomatic patients 50 years or older without evidence of fecal occult blood and no personal history or family history of a first-degree relative with colorectal cancer under age 55 years were offered sigmoidoscopy. All examinations were performed either by a gastroenterologist or a trained nonphysician endoscopist at a staff model health maintenance organization. Outcomes included the depth of examination, number and histology of polyps, and complications.


RESULTS
Nonphysicians performed 2,323 sigmoidoscopic examinations, and physicians performed 1,378 examinations. The mean (+/-SD) depth of sigmoidoscopy examinations performed by nonphysicians was 52 +/- 10 cm compared with 55 +/- 9 cm (P <0.001) in physicians. Nonphysicians detected neoplastic polyps in a greater proportion of patients (7.8%) than physicians (5.8%), but this difference was not significant after adjusting for differences in the age, sex, and family history of the patients (P = 0.35). No major complications occurred. The cost per examination, including the nonphysician training cost, was lower for nonphysicians ($186 per examination) than for physicians ($283 per examination).


CONCLUSIONS
Appropriately trained nonphysicians may be capable of performing safe and effective screening for colorectal cancer with flexible sigmoidoscopy. An increased use of nonphysicians to perform sigmoidoscopy may increase the availability and reduce the cost of the procedure.
Wallace
M B
MB
Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Kemp
J A
JA
Meyer
F
F
Horton
K
K
Reffel
A
A
Christiansen
C L
CL
Farraye
F A
FA
D000368:Aged; D001900:Boston; D002983:Clinical Competence; D015179:Colorectal Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control*; D003363:Cost Control / Q000379:methods*; D003937:Diagnosis, Differential; D005260:Female; D005762:Gastroenterology / Q000191:economics / Q000592:standards; D006784:Hospitals, Teaching / Q000191:economics; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000592:standards*; D008875:Middle Aged; D016017:Odds Ratio; D012812:Sigmoidoscopy / Q000191:economics / Q000592:standards*; D000078329:Workforce