Clinical Studies
Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists

https://doi.org/10.1016/S0002-9343(99)00225-9Get rights and content

Abstract

PURPOSE: 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.

SUBJECTS AND 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.

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Material and methods

The study was conducted at the outpatient colorectal cancer screening program of Harvard Vanguard Medical Associates, a staff model health maintenance organization covering approximately 300,000 lives. All data were collected prospectively on a standardized form. Patients referred by their primary care provider for screening flexible sigmoidoscopy were contacted by phone and asked about demographic characteristics and risk factors for colorectal cancer, including personal or family history of

Results

Screening flexible sigmoidoscopy was performed on 3,701 patients between 1995 and 1997. Of these, 1,378 examinations were performed by 1 of 15 gastroenterologists, and 2,323 by the 3 nonphysicians (n = 726, 791, and 806 for each endoscopist). The baseline demographic characteristics of the patients are shown in Table 1. Compared with the patients examined by nonphysicians, those examined by physicians were younger, more likely to be male, and more likely to have a minor family history of

Discussion

In comparison with gastroenterologists, trained nonphysician endoscopists perform screening flexible sigmoidoscopy with similar accuracy and safety, but at lower cost. After adjusting for baseline differences in patient age and sex, nonphysicians had a slightly shorter depth of examination, but this did not result in a reduction in the rate of detection of neoplastic polyps, the primary purpose of screening. No major complications were observed in more than 3,000 examinations.

Schroy et al (12)

Acknowledgements

We would like to thank the gastroenterology staff of Harvard Vanguard Medical Associates for their efforts in data collection, and Jean Killiam, RN, Andrew Wallace, MD, Fran Cook, PhD, and Robert Fletcher, MD, for their assistance in preparation of the manuscript.

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