Intended for healthcare professionals


Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)

BMJ 2009; 338 doi: (Published 10 February 2009) Cite this as: BMJ 2009;338:b270

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  1. Gerry Richardson, senior research fellow1,
  2. Karen Bloor, senior research fellow2,
  3. John Williams, professor3,
  4. Ian Russell, director4,
  5. Dharmaraj Durai, consultant gastroenterologist5,
  6. Wai Yee Cheung, senior lecturer3,
  7. Amanda Farrin, director and principal statistician (health sciences division)6,
  8. Simon Coulton, reader in health services research7
  1. 1Centre for Health Economics and Hull York Medical School (HYMS), University of York, York YO10 5DD
  2. 2Department of Health Sciences, University of York, York
  3. 3Centre for Health Information, Research and Evaluation, School of Medicine, Swansea University, Swansea
  4. 4North Wales Organisation for Randomised Trials in Health, Institute for Medical and Social Care Research, Bangor University, Gwynedd
  5. 5Wishaw General Hospital, Wishaw, Lanarkshire
  6. 6Clinical Trials Research Unit, University of Leeds, Leeds
  7. 7Centre for Health Services Studies, University of Kent, Canterbury, Kent
  1. Correspondence to: G Richardson gar2{at}
  • Accepted 15 October 2008


Objective To compare the cost effectiveness of nurses and doctors in performing upper gastrointestinal endoscopy and flexible sigmoidoscopy.

Design As part of a pragmatic randomised trial, the economic analysis calculated incremental cost effectiveness ratios, and generated cost effectiveness acceptability curves to address uncertainty.

Setting 23 hospitals in the United Kingdom.

Participants 67 doctors and 30 nurses, with a total of 1888 patients, from July 2002 to June 2003.

Intervention Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy carried out by doctors or nurses.

Main outcome measure Estimated health gains in QALYs measured with EQ-5D. Probability of cost effectiveness over a range of decision makers’ willingness to pay for an additional quality adjusted life year (QALY).

Results Although differences did not reach traditional levels of significance, patients in the doctor group gained 0.015 QALYs more than those in the nurse group, at an increased cost of about £56 (€59, $78) per patient. This yields an incremental cost effectiveness ratio of £3660 (€3876, $5097) per QALY. Though there is uncertainty around these results, doctors are probably more cost effective than nurses for plausible values of a QALY.

Conclusions Though upper gastrointestinal endoscopies and flexible sigmoidoscopies carried out by doctors cost slightly more than those by nurses and improved health outcomes only slightly, our analysis favours endoscopies by doctors. For plausible values of decision makers’ willingness to pay for an extra QALY, endoscopy delivered by nurses is unlikely to be cost effective compared with endoscopy delivered by doctors.

Trial registration International standard RCT 82765705


  • Contributors: GR was responsible for the design, conduct, and interpretation of the analysis, drafted the paper, and is guarantor. KB contributed to analysis, interpretation, and drafting the paper. JW led the trial team and was principal author of the final report. IR contributed to the design and implementation of the trial and drafting of the paper. DD developed, validated, and applied the method of assessing the upper GI endoscopy video recordings, validated the gastrointestinal symptom rating questionnaire, collected and analysed clinical data, notably from hospital records. WYC validated the gastrointestinal symptom rating and gastrointestinal endoscopy satisfaction questionnaires. AF contributed to the overall design and implementation of the trial and drafting of the paper. SC developed, validated, and managed the main database. All authors reviewed successive drafts of both papers.

  • Funding: The study was funded by the NIHR Evaluation Trials and Studies Coordinating Centre. All researchers are independent from this source of funding.

  • Competing interests: None declared.

  • Ethical approval: The study was approved by the Welsh multicentre research ethics committee and informed consent was given by all patients.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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