title: Non-physician endoscopists: A systematic review.
abstract: OBJECTIVE
  To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services.
  
  
  METHODS
  The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms. Studies were screened against eligibility criteria and for relevance. Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of non-physician endoscopists. These publications included a total of 28883 procedures performed by non-physician endoscopists.
  
  
  RESULTS
  The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter. 17/26 studies related to flexible sigmoidoscopies, 5 to upper GI endoscopy and 6 to colonoscopy. All studies were from metropolitan centres 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%), the United Kingdom (39%) and the Netherlands (7%). Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. However, in relation to endoscopic competency, safety or patient satisfaction, all studies had major methodological limitations. Patients were often not randomized (21/26 studies) and not appropriately controlled. In relation to cost-efficiency, nurse endoscopists were less cost-effective per procedure at year 1 when compared to services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations.
  
  
  CONCLUSIONS
  Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite. Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Stephens
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Luke F
authors.initials: LF
authors.lastname: Hourigan
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Appleyard
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Ostapowicz
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Schoeman
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Paul V
authors.initials: PV
authors.lastname: Desmond
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Jane M
authors.initials: JM
authors.lastname: Andrews
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Bourke
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Hewitt
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: David A
authors.initials: DA
authors.lastname: Margolin
authors.affiliation: Maximilian Stephens, Luke F Hourigan, Gerald J Holtmann, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba QLD 4102, Australia.
authors.forename: Gerald J
authors.initials: GJ
authors.lastname: Holtmann
mesh_terms: D002983:Clinical Competence; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D004506:Education, Nursing; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000191:economics / Q000193:education / Q000451:nursing*; D017048:Health Care Costs; D006801:Humans; D009722:Nurse Practitioners / Q000191:economics / Q000193:education; D009740:Nursing Staff / Q000191:economics
keywords: Cost-benefit; Nurse endoscopist; Outcome parameter; Patient satisfaction; Service model