Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
- John G. Williams, John Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton and Gerry Richardson (26 February 2009)
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Cost effectiveness of nurse endoscopists
- Faiyaz Mohammed (2 March 2009)
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The "opportunity" costs of endoscopy
- Richard J Aspinall (2 March 2009)
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Nurse Endoscopists
- James McK Manson (5 March 2009)
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Nurse delivered endoscopy
- Sidhartha Sinha (5 March 2009)
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Nurse delivered endoscopy and primary care.
- Julian J Moore (5 March 2009)
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Doctors and Nurses: Delivering endoscopy
- Said F Mishriki (9 March 2009)
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John G. Williams, Consultant Gastroenterologist / Professor of Health Services Research School of Medicine, Swansea University SA2 8PP, John Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton and Gerry Richardson
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Dear Editor, We would like to thank Professor Norton and her colleagues for their helpful editorial (BMJ 2009;338:a3049), but also to clarify a few points to avoid any misunderstandings. First, the subtitle of the editorial, stating that nurse endoscopy ‘is as clinically effective as that delivered by doctors, but may cost more’ is inaccurate. The reason that the economic paper found doctors to be more likely to be cost-effective than nurses was not that they cost less, but that their outcomes were better. This difference did not reach traditional levels of statistical significance, but using a Bayesian approach, we are able to conclude that the slight additional cost of doctors has a high probability of being worthwhile at current threshold values of a QALY. The authors are right to comment that economic analysis of diagnostic tests is inherently difficult, and that a much larger sample size would have been required to have sufficient power to find any difference in rates of diagnoses detected. In the papers we reported the main outcome measures of the trial (symptom severity and quality of life), but any interested readers may wish to explore the full trial report (available as an HTA monograph at http://www.hta.ac.uk/execsumm/summ1040.htm) where we report a number of other measures including, for example, polyp detection rates. None of these revealed any statistically significant difference between the two groups. Professor Norton criticises the time taken for procedures, noting that this was considerably longer than the 15 minutes allowed in her unit, but perhaps misunderstands that this was the total time for each examination (from procedure room entry to next patient procedure room entry) thus accounting for all operator activities during a list. The editorial’s discussion of the threshold chosen for the cost per QALY is, we believe, open to misinterpretation. The threshold mentioned in the editorial (£5000) does reveal a 60 per cent probability of doctors being cost-effective. But as this threshold increases (and, as the authors mention, NICE is unlikely to reject a technology with a cost-per- QALY of up to £15,000), the probability of doctors being cost-effective increases. So, at a threshold of £15,000, the probability of doctors being cost-effective is over 80 per cent. Nevertheless, we reiterate the considerable uncertainty in these findings, and still advocate caution in interpreting the results. Finally, we did not state that ‘shortages of doctors are no longer relevant’, just that over the course of the trial, policy concern shifted from doctor shortages to potential surpluses of junior doctors. We agree however that screening for bowel cancer will necessitate an increase in the endoscopy workforce, and we hope that this trial informs the policy debate. John Williams, Gerry Richardson and Karen Bloor Competing interests: None declared |
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Faiyaz Mohammed, Consultant Physician Chorley Hospital, Preston Road, Chorley, PR7 1PP
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At our trust we have found that the key to maintaining cost effectiveness of nurse endoscopists is to extend their remit beyond just providing endoscopy services. One of our nurse endoscopists also runs the inflammatory bowel disease nurse led clinic and in a third role he is also competent in interpretation of video capsule endoscopy images. Expanding the roles of such talented individuals will improve the delivery of patient care and guarantee cost effectiveness. Competing interests: None declared |
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Richard J Aspinall, Consultant Physician Department of Gastroenterology & Hepatology, University Hospital of Wales, Heath Park, Cardiff CF14
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Norton and colleagues refer to the "opportunity costs" of endoscopic procedures performed by doctors and consider if the physicians' time could be more effectively spent elsewhere. Of course, one might ask the same question as to whether valuable clinical nurses are best used as endoscopists. Acquiring the manual skills to perform these procedures is quite straightforward. Indeed, the recent pilot study by the UK Department of Health "Changing Workforce" programme confirmed that administrators, healthcare assistants, phlebotomists and clinical physiologists can all be successfully trained to become endoscopy "practitioners" [1]. The opportunity costs of these workers may be even lower than nurses. For a well-defined, large volume screening test such as flexible sigmoidoscopy in asymptomatic patients this may be a reasonable approach, perhaps even a cost-effective one. However, evaluating patients with gastrointestinal disorders requires more than practical dexterity. It relies on a physician's ability to interpret symptoms and signs and understand the natural history of disease. As Sir Christopher Booth warned more than 20 years ago, once gastroenterologists stop seeing the patient as a whole, we too risk becoming "technicians" [2]. REFERENCES: 1. Gardiner AB. Results of the United Kingdoms first pilot study for nonmedical endoscopy practitioners. Colorectal Dis. 2009;11(2):208-214 2. Booth CC. What has technology done to gastroenterology? Gut. 1985;26(10):1088-1094 Competing interests: RJA performs endoscopies. |
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James McK Manson, Consultant Surgeon Singleton Hospital, Sketty Lane, Swansea SA2 8QA
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In what is described as an “editorial” but which, in reality, is a commentary on a publication in the same issue of the BMJ (ref 1), Norton and colleagues give us their views on nurse delivered endoscopy. The article loses itself in consideration of “cost per quality adjusted life year” and such like but the lack of balance and objectivity evident throughout is clearly exposed by a remarkable statement in the penultimate sentence – “could doctors doing endoscopy be better used elsewhere?”. The infinitely more appropriate and relevant question is whether nurses doing endoscopy could be better used elsewhere? There is a widespread view that the nursing profession has to a great extent lost its way, a reality recently all but conceded by the RCN. The traditional vocational training provided in schools located in all the major teaching hospitals in the UK has been replaced by degree courses largely based outside hospital. It is difficult to find an experienced nurse who approves of this change. Although it would not be admitted, there is a strong suspicion that a major reason behind the move to make nurses graduates was to allow them to ‘compete’ with doctors. In reality nurses never needed to indulge in such competition. When I qualified 30 years ago the nurse’s position as the ‘angel’ of healthcare was untouchable - nurses cared for patients. If any reader, or their elderly relative, has recently been in hospital were they satisfied with the standard of nursing care on the ward? In addition there are hopeless problems with understaffing in other areas including ITU, HDU, A+E, theatres (especially anaesthetic and recovery nurses) and, ironically, endoscopy. What we need in our unit is not nurse endoscopists but endoscopy nurses. The problem is that today too many nurses do not want to “nurse” they want to become mini-doctors – nurse endoscopists, surgical care practitioners or, even worse, become involved in shameful wastes of money like NHS Direct, an innovation never shown to be of benefit to anyone. The real tragedy is that many of the most talented and able nurses follow this path, those who have much to offer their real profession. Of course nurses “can do” endoscopy, certainly flexible sigmoidoscopy and diagnostic upper GI endoscopy. If you took somebody off the street with average manual dexterity and slightly above average intelligence it would be possible to teach them to perform these tasks adequately. However, it takes more time and more money to train a nurse than a doctor, as has been repeatedly shown in relation to such skills (ref 2) (an issue conveniently ignored by these authors) and there are major concerns about how long a trained nurse may spend in such activity. The real question is why would you want to train a nurse endoscopist, an approach essentially unique to the UK among countries with advanced health care systems? The answer, as everybody knows, has nothing to do with cost, still less with quality of care, and everything to do with politics. Yours sincerely JAMES MANSON ChM FRCS
References: 1. Williams J, Russell I, Durai D et al Effectiveness of nurse delivered endoscopy: findings from multi- institution nurse endoscopy trial. BMJ 2009; 338: b231 2. Kingsnorth AN Training SCPs to perform inguinal hernia surgery. Bulletin R Coll Surg Eng 2005; 87: 242-243 Competing interests: None declared |
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Sidhartha Sinha, SpR North Middlesex Hospital
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As a GI surgical trainee who has grown increasingly disillusioned with the loss of training opportunities (including in, but not limited to, endoscopy), I read this editorial with interest. Of particular note was the sentence "could doctors doing endoscopy be better used elsewhere?". I note a failure of the authors to elaborate on this suggestion. Perhaps they meant - 1) Clerking acute admissions in A/E departments
Given the intent of politicians to change the nature of the NHS workforce, doctors could additionally take over - 4) Ward paperwork, administration and filing
Perhaps then nurse endoscopists and other non-medical "specialists" would be free to assume other roles to which doctors are less suited - such as endoscopy and surgery. I should state that, despite my prejudiced view, I did not consider Richardson et al's paper to show convincing evidence of superiority in doctor performed endoscopy. Nonetheless, I do subscribe to the (now seemingly obsolete) school of thought that if one wishes to perform medical procedures, one should go to medical school. Competing interests: I am a GI surgical trainee who has grown increasingly disillusioned with the loss of training opportunities in endoscopy. |
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Julian J Moore, GP Principal Seal Medical Group, Selsey, PO20 0QG
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The BMJ of 28th February provided some puzzling juxtapositions. The front cover paraphrased the title of an editorial suggesting doctors are more cost-effective endoscopists than nurses, yet the content of this hinted otherwise [1]. One research article suggested no significant outcome differences between doctor and nurse endoscopists (except satisfaction at one day favouring nurses) [2], yet the linked study of cost-effectiveness found sufficient difference in QALYs that doctors were 80-90% more likely to be cost effective despite their higher cost [3]. The professional grouping is tantalizingly omitted for Indrajit Tiwari, whose endoscopy skills were improved by advice from a plumber, but we know that both the transnasal technique and the extra training came too late for inclusion in the research [4]. Does this render it obsolete? Endoscopy is a diagnostic procedure, but one which depends in large part upon visual recognition of a relatively narrow range of pathologies, often confirmed by biopsy. Success demands technical ability, which is amenable to training and unlikely to be dependent on professional grouping. Aspinall’s rapid response highlights the predictable finding that even non-clinical staff can successfully be trained [5]. The research provides no reason to oppose this, and it would have been interesting to compare the degree of inter-operator variability within and between groups. Early satisfaction was strongly determined by information-giving, which may be influenced by gender. This was not explored as a potential confounder. By contrast, primary care is a non-technical speciality and a much more complex area for study, so perhaps it is inevitable that the editorial was misleading. “No appreciable differences” is a curious phrase and not defined, but only one of the sixteen studies in the review was powered to assess equivalence of care [6]. This related to use of nurses as first contact for urgent out-of-hours care. It was in this role that higher patient satisfaction with nurses was seen. However, significantly longer consultations and a higher likelihood of patients being recalled contributed to lower productivity with no benefit in outcomes. Studies of nurses providing first contact and ongoing care for all presenting patients found no evidence of higher satisfaction with nurses and the only measure which reached significance favoured doctors. Across all studies, follow-up was generally 12 months or less, providing no reassurance that major diagnoses were not delayed. 1. Norton C, Grieve A, Vance M. Nurse delivered endoscopy. BMJ 2009; 338: a3049 2. Williams J, Russell I, Durai D, Cheung W, Farrin A, Karen Bloor K, Simon Coulton S, Richardson G. Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2009; 338: b231 3. Richardson G, Bloor K, Williams J, Russell I, Durai D, Cheung W, Farrin A, Coulton S. Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2009; 338: b270 4. Tiwari I. Transnasal gastroscopy – lesson from a plumber. BMJ 2009; 338: b336 5. Gardiner A. Results of the United Kingdoms first pilot study for nonmedical endoscopy practitioners. Colorectal Dis. 2009;11(2):208-214 6. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2004;(4):CD001271. Competing interests: JM is a doctor who would prefer not to be replaced. |
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Said F Mishriki, Consultant Urological Surgeon Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB15 6JE
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Nurses can do it just as good as doctors, but doctors do it cheaper [1, 2]. The same exercise took place with nurse led flexible cystoscopy (FC) [3]. Adequately trained urology nurse practitioners undertake FC as precisely as consultant urologists [4]. Again, urology nurses were found to be more expensive than doctors between £30, 000 to 48, 000 in 4 months [3]. This was related to more patients having to have general anaesthetic procedures. What has not been audited and should have been is the patient's preference when the diagnosis of cancer is made. Would the patient favour a more experienced doctor? I know under these circumstances whom I would prefer. 1. Williams J, Russell I, Durai D, Cheung WY, Farrin A, Bloor K, et al. Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2009;338:b231. 2. Richardson G, Bloor K, Williams J, Russell I, Durai D, Cheung WY, et al. Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2008;337:b270. 3. Nurse-led flexible cystoscopy: experience from one UK centre. Radhakrishnan S, Dorkin TJ, Johnson P, Menezes P, Greene D. BJU Int 2006 98:256-8 4. Gidlow AB, Laniado ME, Ellis BW. The nurse cystoscopist: a feasible option? BJU Int 2000; 85: 651–4 Competing interests: None declared |
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