Letters Nurse delivered endoscopy

Study authors respond to editorial

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1082 (Published 17 March 2009) Cite this as: BMJ 2009;338:b1082
  1. John Williams, professor of health services research1,
  2. Gerry Richardson, senior research fellow2,
  3. Karen Bloor, senior research fellow3
  1. 1Centre for Health Information, Research and Evaluation, School of Medicine, Swansea University, Swansea SA2 8PP
  2. 2Centre for Health Economics and Hull York Medical School (HYMS), University of York, York
  3. 3Department of Health Sciences, University of York
  1. j.g.williams{at}swansea.ac.uk

    We wish to clarify some points raised by Norton and colleagues in their editorial accompanying our papers.1 2 3

    The subtitle, stating that nurse endoscopy “is as clinically effective as that delivered by doctors, but may cost more,” is inaccurate. We found doctors more cost effective because their outcomes were slightly better, even though they cost slightly more than nurses.

    In the papers we summarised the main outcome measures of the trial, but more detail is given in the full report, where we describe other measures including polyp detection rates.4 The procedure duration seems long because it was timed from one extubation to the next, to reflect any activities undertaken by endoscopists between patients.

    The editorial’s discussion of the threshold chosen for cost per QALY is open to misinterpretation. A threshold of £5000 does reveal a 60% probability of doctors being cost-effective, but as this threshold increases so the probability of doctors being cost effective increases. At a threshold of £15 000 (at which the National Institute for Health and Clinical Excellence (NICE) is unlikely to reject a technology), the probability of doctors being cost effective is over 80%. Nevertheless, we reiterate the 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,” but noted that policy concerns have shifted from doctor shortages to potential surpluses. We agree that bowel cancer screening will necessitate an increase in the endoscopy workforce, and we hope that this trial informs the policy debate.


    Cite this as: BMJ 2009;338:b1082


    • Competing interests: None declared.


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