A randomized controlled trial comparing the accuracy of general diagnostic upper gastrointestinal endoscopy performed by nurse or medical endoscopists.
OBJECTIVE
Rising demand for general diagnostic upper gastrointestinal endoscopy in the UK is outgrowing the capacity of doctors to provide this service within a reasonable time. One solution is to train nurses to carry out the procedure, but it is not known whether nurses can perform general diagnostic upper gastrointestinal endoscopy as competently as doctors.


METHODS
A randomized controlled non-inferiority trial compared the adequacy and the accuracy of diagnostic upper gastrointestinal endoscopies performed by five medical and two nurse endoscopists. The videotaped procedures were assessed by a consultant gastroenterologist blinded to the identity of the endoscopist.


RESULTS
641 patients were randomly allocated (before attendance and consent procedure) to endoscopy carried out either by a doctor or a nurse. Of these, 412 were enrolled and 367 (89 %) were included in the analysis. An adequate view was obtained throughout in 53.4 % (93/177) of doctor endoscopies and 91.6 % (174/190) of nurse endoscopies (difference 38.2 %, 95 % CL 30.5 %, 47.2 %). In adequately viewed areas, the mean agreement between doctor and expert was 81.0 % and between nurse and expert it was 78.3 % (difference between the means 2.7 %, 95 % CL - 1.0 %, 6.4 %). There was no difference between doctors and nurses in the rate of biopsy performance (90.4 % and 91.1 %, respectively, P = 0.862). Nurses took longer (8.1 minutes vs. 4.6 minutes, P < 0.001) and used intravenous sedation more often (57.6 %, P = 0.027). Adequacy of view correlated positively with endoscopy duration ( P < 0.001), but diagnostic accuracy correlated inversely with duration ( P < 0.001). Neither adequacy or accuracy correlated significantly with use of intravenous sedation.


CONCLUSIONS
In endoscopies performed by nurses, the proportion of adequate examinations was much higher than that found for doctors. In areas with an adequate view, there is no significant difference in accuracy between nurses and doctors. Nurses can provide an accurate general diagnostic upper gastrointestinal endoscopy service as competently as doctors.
Meaden
C
C
Royal Lancaster Infirmary, Lancaster, UK. chrismeaden@aol.com
Joshi
M
M
Hollis
S
S
Higham
A
A
Lynch
D
D
D002983:Clinical Competence / Q000592:standards*; D016292:Procedural Sedation; D004378:Duodenal Diseases / Q000175:diagnosis*; D016099:Endoscopy, Gastrointestinal / Q000379:methods / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000592:standards*; D015588:Observer Variation; D015203:Reproducibility of Results; D013272:Stomach Diseases / Q000175:diagnosis*