title: Non-physician performance of lower and upper endoscopy: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Demand for endoscopic procedures worldwide has increased while the number of physicians trained to perform endoscopy has remained relatively constant. The objective of this study was to characterize non-physician performance of lower and upper endoscopic procedures.
  
  
  METHODS
  Bibliographical searches were conducted in Medline, EMBASE, and Cochrane Library databases. Studies were included where patients underwent flexible sigmoidoscopy, colonoscopy, or upper endoscopy done by a non-physician (nurse, nurse practitioner, physician assistant) and outcome measures were reported (detection of polyps, adenomas, cancer, and/or adverse events). Pooled rates were calculated for specific outcomes and rate ratios were determined for selected comparison groups.
  
  
  RESULTS
  Most studies involved nurses performing flexible sigmoidoscopies for colorectal cancer screening. Nurses and nurse-practitioners/physician assistants performing flexible sigmoidoscopies showed pooled polyp detection rates of 9.9 % and 23.7 %, adenoma detection rates of 2.9 % and 7.2 %, colorectal cancer detection rates of 1.3 % and 1.2 %, and adverse event rates of 0.3 and 0 per 1000 sigmoidoscopies, respectively. There was no significant difference between polyp and adenoma detection rates in sigmoidoscopy performance studies comparing nurses or nurse-practitioners/physician assistants with physicians. For the 3 studies of non-physician performance of colonoscopy, pooled adenoma detection rate was 26.4 %, cecal intubation rate was 93.5 %, and adverse event rate was 2.2 /1000 colonoscopies. In the few studies examining upper endoscopies, 99.4 % of upper endoscopy procedures performed by nurses were successful with no reported adverse events.
  
  
  CONCLUSIONS
  Available studies suggest that when non-physicians perform endoscopic procedures, especially lower endoscopies, outcomes and adverse events are in line with those of physicians.
authors.affiliation: Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
authors.forename: Lukejohn W
authors.initials: LW
authors.lastname: Day
authors.affiliation: Gastroenterology Division, Department of Medicine, University of California, San Francisco, California, USA.
authors.forename: Derrick
authors.initials: D
authors.lastname: Siao
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, University of Washington, Seattle, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Inadomi
authors.affiliation: Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
authors.forename: Ma
authors.initials: M
authors.lastname: Somsouk
mesh_terms: D002983:Clinical Competence; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000592:standards*; D005767:Gastrointestinal Diseases / Q000175:diagnosis*; D006801:Humans; D009722:Nurse Practitioners; D009726:Nurses; D010823:Physician Assistants; D057184:Practice Patterns, Nurses'