Is it Time to Transfer Flexible Sigmoidoscopy to Non- Physician Endoscopists?
Is it Time to Transfer Flexible Sigmoidoscopy to Non- Physician Endoscopists?
Abstracts & commentary
Synopsis: In this report, a large series of patients were examined by either an experienced gastroenterologist or a trained, nonphysician endoscopist. The outcomes were nearly identical, no complications occurred, and the costs of the procedure were approximately $100 less if performed by the nonphysician endoscopist.
Sources: Wallace MB, et al. Am J Med 1999;107: 214-218; Shaheen NJ, Ransohoff DF. Am J Med 1999;107:286-287.
Routine screening of individuals older than 50 years of age by flexible sigmoidoscopy has been shown to be an effective way to reduce mortality from colorectal cancer.1,2 Yet, only a small percentage of patients are screened.3 Although there are a number of reasons for this failure to screen, one is the limited supply of trained endoscopists. To meet this need, it has been proposed that trained, nonphysician endoscopists perform routine examinations. In the current report, Wallace and colleagues from the Division of Gastroenterology at Brigham and Women’s Hospital, Harvard Medical School, describe their experience with nonphysician endoscopists.
Asymptomatic patients 50 years of age or older without evidence for intestinal blood loss or symptoms and without a personal or family history of colon cancer were examined by flexible sigmoidoscopy performed either by a staff gastroenterologist or nonphysician endoscopist. There were 15 gastroenterologists and three nonphysician endoscopists (1 nurse practitioner and 2 physician assistants) that participated in the program. Outcomes included the depth of examination, number and histology of polyps, and complications.
Nonphysicians performed 2323 sigmoidoscopy examinations, and physicians performed 1378 examinations. Depth of exam was no different between the groups (52 ± 10 cm for exams by the nonphysicians and 55 ± 9 cm for exams by the gastroenterologists). Similarly, there was no difference in the number of polyps observed or biopsied. No major complications occurred in any of the exams. The cost per examination, including the nonphysician training cost, was lower for nonphysicians ($186) than for physicians ($283).
Wallace et al conclude that appropriately trained nonphysicians are capable of performing safe and effective screening for colorectal cancer by flexible sigmoidoscopy. Recruitment of such individuals may improve availability and reduce the cost of the procedure.
COMMENTARY
There are a number of reasons why the majority of individuals who might benefit from screening sigmoidoscopy don’t undertake the procedure. There is the perception that the procedure is both uncomfortable and embarrassing.4 Furthermore, there is the issue of availability. In general, primary care physicians have been slow to pick up the technique for a number of reasons including the training time involved, the cost of equipment, including maintenance, and the low rate of reimbursement from Medicare or other insurance carriers. Shaheen and Ransohoff emphasize this latter point in the commentary accompanying this report. They note that Medicare reimbursement for the procedure without biopsy is $86.76, well below the costs for either physician or nonphysician endoscopists from the Harvard group. The derivation of the costs involved is complicated, and not satisfactorily established. Yet, there is no question that the costs are lower with the nonphysician endoscopists. In the current study, the approximate $100 difference was the result of salary costs alone. However, even with this savings, the costs exceed the current reimbursement rate by a substantial margin. Physicians might well be ready to transfer the procedure to nonphysician endoscopists on this basis alone.
However, the issue of examination quality remains, and was directly addressed in this report. The three nonphysician endoscopists were well-trained and quickly developed substantial experience with the technique. Upon analysis, there was no difference in examination performance or outcome. However, Wallace et al did not comment on patient satisfaction and this may be a factor in some communities. Furthermore, although there were no complications in this series, some are bound to occur in time (with either a physician or nonphysician endoscopist) and one can envision a great potential for liability if a complication occurred during a procedure performed by a nonphysician. Yet, like a number of other clinical tasks once solely in the domain of physicians, it is likely that routine flexible sigmoidoscopy will soon be handed off to nonphysician endoscopists who, after suitable (and hopefully, standardized) training, can perform the procedure efficiently and in high volume. This will then reduce costs and make available an effective screening procedure for a large population of individuals, some of whom will be discovered to have surgically curable colorectal cancer.
References
1. Winawer SJ, et al. N Engl J Med 1993;329:1977-1981.
2. Newcomb PA, et al. J Natl Cancer Inst 1992;84: 1572-1575.
3. MMWR Morb Mortal Wkly Rep 1999;48:116-121.
4. Lewis SF, et al. J Gen Intern Med 1996;11:542-544.
Which of the following statements about colorectal cancer screening by flexible sigmoidoscopy is not true?
a. The procedure is an effective screening tool for the discovery of surgically curable cancers.
b. The procedure can be performed safely and effectively by nonphysician endoscopists.
c. The procedure can be performed safely by nonphysicians, but the outcomes are not as optimal as if the procedure were performed by a gastroenterologist.
d. The costs of the procedure can be substantially reduced if performed by a nonphysician endoscopist.
e. Flexible sigmoidoscopy performed by either physicians or nonphysicians is effective in detecting curable colon cancers.
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