Screening Colonoscopy: A New Frontier for Nurse Practitioners
Authors: Susan Hutfless, Anthony N. Kalloo
Journal: Clinical Gastroenterology and Hepatology (2012)

This month and next month’s Practice Management columns concern colorectal cancer (CRC) prevention (since March is Colon Cancer Awareness Month), and both articles may generate significant controversy. This month, Dr Kalloo and his colleague Susan Hutfless, PhD, from Johns Hopkins University, write about their process for training Nurse Practitioners to perform screening colonoscopy. Increased demand and reduced reimbursement for colonoscopy both may force us to re-examine our current practices. The concept of a gastroenterologist supervising several nurse practitioners as they perform procedures has been considered previously. If we move to such a model, we will need to carefully define the training requirements and understand the broad ramifications of such a departure from current norms. In reading this article, we should keep an open mind and focus on what new models may best reduce the burden of CRC and perhaps better serve people who now cannot access our procedural services.John I. Allen, MD, MBA, AGAFSpecial Section Editor“But I'm a rock ‘n’ roll singer; that's my livelihood, my occupation.”Little RichardColorectal cancer is the third leading cause of death in both men and women in the United States. If detected at an early stage, it is preventable and curable. In 2002, the United States Preventive Services Task Force recommended colonoscopy as one of the screening methods to prevent colorectal cancer mortality. Despite the strong evidence and numerous medical and professional society guidelines, much of the population remains unscreened, resulting in 150,000 new cases and 50,000 deaths annually. In 2010, 58.6% of U.S. adults 50–75 years old were up-to-date with recommended colorectal cancer screening according to the 2010 Behavioral Risk Factor Surveillance System. States in the Northeast, Minnesota, and Washington were in the top quartile of individuals up-to-date with screening (69%–75%). Southern and rural states, such as Alaska and North Dakota, were more likely to be in the bottom quartile for up-to-date colorectal cancer screening (54%–59%). The states with lower screening rates tended to be states that lacked gastroenterology training programs. A Healthy People 2020 objective is to increase the colorectal cancer screening rate to 70.5%.There Is a Shortage of Gastroenterologists to Perform Screening ColonoscopiesAn Agency for Healthcare Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the-Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity will need to be substantially increased to continue to perform screening colonoscopies at the current rate even after screening the 40% of the eligible population that has not yet been screened.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to nonphysicians such as nurse practitioners (NPs) may be warranted.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50–74 years old who needed screening as compared with 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand because the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1000 colonoscopists are needed by 2020 to meet the rising demand for colorectal cancer screening and surveillance.2The Lewin Group IncThe impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists, 2009.http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdfGoogle Scholar These estimates do not account for the growing number of gastroenterologists working fewer hours because of changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.3Elta G.H. GI training: where are we headed?.Am J Gastroenterol. 2011; 106: 395-397Crossref PubMed Scopus (17) Google Scholar Finally, lack of insurance has been cited as a barrier to colorectal cancer screening. It is estimated that the Patient Protection and Affordable Care Act will increase the number of insured individuals by 30 million.Gastroenterologists Can Increase the Colorectal Cancer Screening Rate by Training a Specialized Nurse Practitioner WorkforceHistorically, the role of NPs as advanced health care providers began in the mid-20th century in the United States, driven by a shortage of physicians. Certified Registered Nurse Anesthetists (CRNAs) are the most organized group of advanced practice providers working as surrogates for physicians. Today, CRNAs practice in all 50 states and administer approximately 32 million anesthetics per year. Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the anesthesia care team. NPs have been a recognized component of gastroenterology practices since the 1960s when the American Society for Gastrointestinal Endoscopy (ASGE) leadership helped to create a forum for formal membership for NPs (http://www.sgna.org/AboutUs.aspx). We believe that the traditional cognitive role of NPs within gastroenterology might be expanded successfully to include their performing screening colonoscopy.Nurse Practitioners Perform Screening Colonoscopies With Equivalent Effectiveness and Safety as PhysiciansFive centers have reported the outcomes of NP colonoscopy training.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar, 7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar, 8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar A Dutch center trained 2 endoscopy nurses to perform colonoscopies and compared their efficacy, safety, and patient satisfaction scores with those of a gastroenterology fellow and an experienced gastroenterologist. After 150 colonoscopies, the cecal intubation rate, time to the cecum, and complications were similar in the groups.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Patients also reported similar levels of pain, discomfort, satisfaction, and willingness to undergo a later procedure. NPs and colonoscopists who had no medical training performed similarly to physicians in the United Kingdom.5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar A randomized trial at the University of California Davis also reported an equivalent efficacy and safety profile for a gastroenterology-trained NP and 2 experienced gastroenterologists.6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar The NP and each gastroenterologist performed 50 procedures. The efficacy measures included the adenoma detection rate, cecal intubation rate, procedure duration, sedative and analgesic use, complications, and patient-reported procedural pain scores and overall satisfaction.7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar The Portland Department of Veterans Affairs Medical Center first trained a physician assistant to perform endoscopy, including colonoscopy, in 1989.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar Benefits to the Portland Veterans Affairs hospital included their ability to increase the volume of procedures, increase staff efficiency, and improve house-staff education.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google ScholarNurse Practitioner Colonoscopy Training ProgramSince 2009, we have trained 3 NPs to perform colorectal cancer screening colonoscopies. Our training program is based on the ASGE Endoscopy curriculum for physician gastroenterology fellows. We understand the need to train NPs to be more than technicians with the ability to manipulate an endoscope. Therefore, this training program has been designed to train the NPs with knowledge and core competencies to manage digestive diseases and to recognize the variations in colonoscopic abnormalities. NPs attend the same didactic core competency courses as first-year gastroenterology fellows. They attend outpatient clinics and perform inpatient services under the mentorship of a board-certified full-time faculty gastroenterologist, which is identical to the schedule of the first-year fellow.The NPs are trained to perform colonoscopy in an identical fashion to their contemporary gastroenterology fellows. Competency was achieved by using national standards in accordance with ASGE guidelines. Table 1 shows the performance of our index NP. Her performance exceeded all benchmarks expected of fully trained gastroenterologists. The NPs also produce cost savings because they are reimbursed at 85% of the physician fee schedule. All 3 NPs are board-certified in Maryland to perform colonoscopies and achieved this certification after 1 year of training.Table 1Evaluation of the First NP Trained in Our Program According to Quality Indicator BenchmarksQuality indicator benchmarkStandard for benchmarkNP trained by using 2009 curriculum (n = 119 procedures)Patient factors Age100% between 50–74 yMean age, 54 y Severe comorbidityIdeally 0%; no standard exists0% Prescreening discussion and informed consentIdeally 100%; no standard exists100% Appropriate surveillance interval, if previously screenedIdeally 100%; no standard exists99% Attendance at endoscopy appointmentIdeally 90%; no standard existsNE Adequate bowel preparationNo standard existsNE Appropriate follow-upIdeally 100%; no standard existsNE Patient satisfactionNo standard existsNEProcedure factors Photo documentation of intestinal landmarks100%100% Cecal intubation rate>95%96% Adenoma detection rate for adenomas ≥10 mm>25% men; >15% women29% Number/rate of polypectomies for colonic lesions <5 mm100% Mean colonoscopy withdrawal time (min)>615 Incidence of perforationNo greater than 1 in 500 patients0 Management of postpolypectomy bleeding>90% should be managed endoscopically0 events occurred Other complicationsNo standard exists0NE, not evaluated. Open table in a new tab Physician AcceptancePhysicians may find the training of nonphysician colonoscopists threatening for professional and personal reasons. Gastroenterologists and surgeons invest at least 3 years in their specialty training. They will rightfully question the quality and safety of the procedures performed by NPs who participate in a 1-year gastroenterology training program with a focus on colonoscopy. Colonoscopy is also a major revenue generator for gastroenterologists because of the demand for screening colonoscopies with the aging population and its relatively high reimbursement. NPs performing screening colonoscopies may be seen as competition for patients and as a threat to physicians' revenue and livelihood.Whether screening colonoscopy will continue to be the “bread and butter” procedure for the practicing gastroenterologist remains uncertain. Fecal genetic biomarkers, capsule endoscopy, and computed tomography colonography may evolve to be safer and more cost-effective alternatives, challenging the longevity of screening colonoscopy. Unlike Little Richard, for whom “rock ‘n’ roll” is the main source of his livelihood, gastroenterologists should be prepared that screening colonoscopy may not be a self-sustaining source of income in the long-term.ConclusionsOn the basis of our experience and the previously published studies, well-trained NPs performing screening colonoscopy are equivalent to physicians in quality, safety, and patient satisfaction. NPs and physician assistants can increase the colorectal cancer screening rate in the United States at a reduced cost to taxpayers and other payers with equal safety and effectiveness. This month and next month’s Practice Management columns concern colorectal cancer (CRC) prevention (since March is Colon Cancer Awareness Month), and both articles may generate significant controversy. This month, Dr Kalloo and his colleague Susan Hutfless, PhD, from Johns Hopkins University, write about their process for training Nurse Practitioners to perform screening colonoscopy. Increased demand and reduced reimbursement for colonoscopy both may force us to re-examine our current practices. The concept of a gastroenterologist supervising several nurse practitioners as they perform procedures has been considered previously. If we move to such a model, we will need to carefully define the training requirements and understand the broad ramifications of such a departure from current norms. In reading this article, we should keep an open mind and focus on what new models may best reduce the burden of CRC and perhaps better serve people who now cannot access our procedural services.John I. Allen, MD, MBA, AGAFSpecial Section Editor“But I'm a rock ‘n’ roll singer; that's my livelihood, my occupation.”Little Richard Colorectal cancer is the third leading cause of death in both men and women in the United States. If detected at an early stage, it is preventable and curable. In 2002, the United States Preventive Services Task Force recommended colonoscopy as one of the screening methods to prevent colorectal cancer mortality. Despite the strong evidence and numerous medical and professional society guidelines, much of the population remains unscreened, resulting in 150,000 new cases and 50,000 deaths annually. In 2010, 58.6% of U.S. adults 50–75 years old were up-to-date with recommended colorectal cancer screening according to the 2010 Behavioral Risk Factor Surveillance System. States in the Northeast, Minnesota, and Washington were in the top quartile of individuals up-to-date with screening (69%–75%). Southern and rural states, such as Alaska and North Dakota, were more likely to be in the bottom quartile for up-to-date colorectal cancer screening (54%–59%). The states with lower screening rates tended to be states that lacked gastroenterology training programs. A Healthy People 2020 objective is to increase the colorectal cancer screening rate to 70.5%. There Is a Shortage of Gastroenterologists to Perform Screening ColonoscopiesAn Agency for Healthcare Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the-Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity will need to be substantially increased to continue to perform screening colonoscopies at the current rate even after screening the 40% of the eligible population that has not yet been screened.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to nonphysicians such as nurse practitioners (NPs) may be warranted.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50–74 years old who needed screening as compared with 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand because the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1000 colonoscopists are needed by 2020 to meet the rising demand for colorectal cancer screening and surveillance.2The Lewin Group IncThe impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists, 2009.http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdfGoogle Scholar These estimates do not account for the growing number of gastroenterologists working fewer hours because of changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.3Elta G.H. GI training: where are we headed?.Am J Gastroenterol. 2011; 106: 395-397Crossref PubMed Scopus (17) Google Scholar Finally, lack of insurance has been cited as a barrier to colorectal cancer screening. It is estimated that the Patient Protection and Affordable Care Act will increase the number of insured individuals by 30 million. An Agency for Healthcare Research and Quality report commissioned for the 2010 National Institutes of Health State-of-the-Science Conference on Colorectal Cancer Screening found that the colonoscopy capacity will need to be substantially increased to continue to perform screening colonoscopies at the current rate even after screening the 40% of the eligible population that has not yet been screened.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar The State-of-the-Science Conference recommended that an increase in the endoscopic screening capacity is needed and recommended that expanding high-quality endoscopy training to nonphysicians such as nurse practitioners (NPs) may be warranted.1Allen J.D. Barlow W.E. Duncan R.P. et al.NIH state-of-the-science conference statement: enhancing use and quality of colorectal cancer screening.NIH Consens State Sci Statements. 2010; 27: 15-17Google Scholar Several studies have estimated the number of additional colonoscopists needed to meet the demand for screening colonoscopy. A 2004 study estimated that 1000 additional colonoscopists were needed if 70% of the 2004 population was screened. At that time there were only 59 million Americans ages 50–74 years old who needed screening as compared with 80.5 million in 2010. Gastroenterologists are unlikely to meet the demand because the number of gastroenterology fellowship positions increased by only 50 between 2004 and 2009. Similarly, a report prepared on behalf of the colonoscope industry estimated an additional 1000 colonoscopists are needed by 2020 to meet the rising demand for colorectal cancer screening and surveillance.2The Lewin Group IncThe impact of improved colorectal cancer screening on adequacy of future supply of gastroenterologists, 2009.http://www.crcawareness.com/files/Lewin-Gastroenterologist-Report.pdfGoogle Scholar These estimates do not account for the growing number of gastroenterologists working fewer hours because of changes in lifestyle and the increasing number of female gastroenterologists who tend to work fewer hours than their male counterparts.3Elta G.H. GI training: where are we headed?.Am J Gastroenterol. 2011; 106: 395-397Crossref PubMed Scopus (17) Google Scholar Finally, lack of insurance has been cited as a barrier to colorectal cancer screening. It is estimated that the Patient Protection and Affordable Care Act will increase the number of insured individuals by 30 million. Gastroenterologists Can Increase the Colorectal Cancer Screening Rate by Training a Specialized Nurse Practitioner WorkforceHistorically, the role of NPs as advanced health care providers began in the mid-20th century in the United States, driven by a shortage of physicians. Certified Registered Nurse Anesthetists (CRNAs) are the most organized group of advanced practice providers working as surrogates for physicians. Today, CRNAs practice in all 50 states and administer approximately 32 million anesthetics per year. Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the anesthesia care team. NPs have been a recognized component of gastroenterology practices since the 1960s when the American Society for Gastrointestinal Endoscopy (ASGE) leadership helped to create a forum for formal membership for NPs (http://www.sgna.org/AboutUs.aspx). We believe that the traditional cognitive role of NPs within gastroenterology might be expanded successfully to include their performing screening colonoscopy. Historically, the role of NPs as advanced health care providers began in the mid-20th century in the United States, driven by a shortage of physicians. Certified Registered Nurse Anesthetists (CRNAs) are the most organized group of advanced practice providers working as surrogates for physicians. Today, CRNAs practice in all 50 states and administer approximately 32 million anesthetics per year. Approximately 65% of CRNAs practice in collaboration with anesthesiologists, in what is termed the anesthesia care team. NPs have been a recognized component of gastroenterology practices since the 1960s when the American Society for Gastrointestinal Endoscopy (ASGE) leadership helped to create a forum for formal membership for NPs (http://www.sgna.org/AboutUs.aspx). We believe that the traditional cognitive role of NPs within gastroenterology might be expanded successfully to include their performing screening colonoscopy. Nurse Practitioners Perform Screening Colonoscopies With Equivalent Effectiveness and Safety as PhysiciansFive centers have reported the outcomes of NP colonoscopy training.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar, 7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar, 8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar A Dutch center trained 2 endoscopy nurses to perform colonoscopies and compared their efficacy, safety, and patient satisfaction scores with those of a gastroenterology fellow and an experienced gastroenterologist. After 150 colonoscopies, the cecal intubation rate, time to the cecum, and complications were similar in the groups.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Patients also reported similar levels of pain, discomfort, satisfaction, and willingness to undergo a later procedure. NPs and colonoscopists who had no medical training performed similarly to physicians in the United Kingdom.5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar A randomized trial at the University of California Davis also reported an equivalent efficacy and safety profile for a gastroenterology-trained NP and 2 experienced gastroenterologists.6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar The NP and each gastroenterologist performed 50 procedures. The efficacy measures included the adenoma detection rate, cecal intubation rate, procedure duration, sedative and analgesic use, complications, and patient-reported procedural pain scores and overall satisfaction.7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar The Portland Department of Veterans Affairs Medical Center first trained a physician assistant to perform endoscopy, including colonoscopy, in 1989.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar Benefits to the Portland Veterans Affairs hospital included their ability to increase the volume of procedures, increase staff efficiency, and improve house-staff education.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar Five centers have reported the outcomes of NP colonoscopy training.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar, 7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar, 8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar A Dutch center trained 2 endoscopy nurses to perform colonoscopies and compared their efficacy, safety, and patient satisfaction scores with those of a gastroenterology fellow and an experienced gastroenterologist. After 150 colonoscopies, the cecal intubation rate, time to the cecum, and complications were similar in the groups.4Koornstra J.J. Corporaal S. Giezen-Beintema W.M. et al.Colonoscopy training for nurse endoscopists: a feasibility study.Gastrointest Endosc. 2009; 69: 688-695Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Patients also reported similar levels of pain, discomfort, satisfaction, and willingness to undergo a later procedure. NPs and colonoscopists who had no medical training performed similarly to physicians in the United Kingdom.5Vance M. The nurse colonoscopist: training and quality assurance.Gastrointest Endosc Clin N Am. 2005; 15: 829-837Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar A randomized trial at the University of California Davis also reported an equivalent efficacy and safety profile for a gastroenterology-trained NP and 2 experienced gastroenterologists.6Maslekar S. Hughes M. Gardiner A. et al.Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.Colorectal Dis. 2010; 12: 1033-1038Crossref PubMed Scopus (28) Google Scholar The NP and each gastroenterologist performed 50 procedures. The efficacy measures included the adenoma detection rate, cecal intubation rate, procedure duration, sedative and analgesic use, complications, and patient-reported procedural pain scores and overall satisfaction.7Limoges-Gonzalez M. Mann N.S. Al-Juburi A. et al.Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: a single-center randomized controlled trial.Gastroenterol Nurs. 2011; 34: 210-216Crossref PubMed Scopus (37) Google Scholar The Portland Department of Veterans Affairs Medical Center first trained a physician assistant to perform endoscopy, including colonoscopy, in 1989.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar Benefits to the Portland Veterans Affairs hospital included their ability to increase the volume of procedures, increase staff efficiency, and improve house-staff education.8Lieberman D.A. Ghormley J.M. Physician assistants in gastroenterology: should they perform endoscopy?.Am J Gastroenterol. 1992; 87: 940-943PubMed Google Scholar Nurse Practitioner Colonoscopy Training ProgramSince 2009, we have trained 3 NPs to perform colorectal cancer screening colonoscopies. Our training program is based on the ASGE Endoscopy curriculum for physician gastroenterology fellows. We understand the need to train NPs to be more than technicians with the ability to manipulate an endoscope. Therefore, this training program has been designed to train the NPs with knowledge and core competencies to manage digestive diseases and to recognize the variations in colonoscopic abnormalities. NPs attend the same didactic core competency courses as first-year gastroenterology fellows. They attend outpatient clinics and perform inpatient services under the mentorship of a board-certified full-time faculty gastroenterologist, which is identical to the schedule of the first-year fellow.The NPs are trained to perform colonoscopy in an identical fashion to their contemporary gastroenterology fellows. Competency was achieved by using national standards in accordance with ASGE guidelines. Table 1 shows the performance of our index NP. Her performance exceeded all benchmarks expected of fully trained gastroenterologists. The NPs also produce cost savings because they are reimbursed at 85% of the physician fee schedule. All 3 NPs are board-certified in Maryland to perform colonoscopies and achieved this certification after 1 year of training.Table 1Evaluation of the First NP Trained in Our Program According to Quality Indicator BenchmarksQuality indicator benchmarkStandard for benchmarkNP trained by using 2009 curriculum (n = 119 procedures)Patient factors Age100% between 50–74 yMean age, 54 y Severe comorbidityIdeally 0%; no standard exists0% Prescreening discussion and informed consentIdeally 100%; no standard exists100% Appropriate surveillance interval, if previously screenedIdeally 100%; no standard exists99% Attendance at endoscopy appointmentIdeally 90%; no standard existsNE Adequate bowel preparationNo standard existsNE Appropriate follow-upIdeally 100%; no standard existsNE Patient satisfactionNo standard existsNEProcedure factors Photo documentation of intestinal landmarks100%100% Cecal intubation rate>95%96% Adenoma detection rate for adenomas ≥10 mm>25% men; >15% women29% Number/rate of polypectomies for colonic lesions <5 mm100% Mean colonoscopy withdrawal time (min)>615 Incidence of perforationNo greater than 1 in 500 patients0 Management of postpolypectomy bleeding>90% should be managed endoscopically0 events occurred Other complicationsNo standard exists0NE, not evaluated. Open table in a new tab Since 2009, we have trained 3 NPs to perform colorectal cancer screening colonoscopies. Our training program is based on the ASGE Endoscopy curriculum for physician gastroenterology fellows. We understand the need to train NPs to be more than technicians with the ability to manipulate an endoscope. Therefore, this training program has been designed to train the NPs with knowledge and core competencies to manage digestive diseases and to recognize the variations in colonoscopic abnormalities. NPs attend the same didactic core competency courses as first-year gastroenterology fellows. They attend outpatient clinics and perform inpatient services under the mentorship of a board-certified full-time faculty gastroenterologist, which is identical to the schedule of the first-year fellow. The NPs are trained to perform colonoscopy in an identical fashion to their contemporary gastroenterology fellows. Competency was achieved by using national standards in accordance with ASGE guidelines. Table 1 shows the performance of our index NP. Her performance exceeded all benchmarks expected of fully trained gastroenterologists. The NPs also produce cost savings because they are reimbursed at 85% of the physician fee schedule. All 3 NPs are board-certified in Maryland to perform colonoscopies and achieved this certification after 1 year of training. NE, not evaluated. Physician AcceptancePhysicians may find the training of nonphysician colonoscopists threatening for professional and personal reasons. Gastroenterologists and surgeons invest at least 3 years in their specialty training. They will rightfully question the quality and safety of the procedures performed by NPs who participate in a 1-year gastroenterology training program with a focus on colonoscopy. Colonoscopy is also a major revenue generator for gastroenterologists because of the demand for screening colonoscopies with the aging population and its relatively high reimbursement. NPs performing screening colonoscopies may be seen as competition for patients and as a threat to physicians' revenue and livelihood.Whether screening colonoscopy will continue to be the “bread and butter” procedure for the practicing gastroenterologist remains uncertain. Fecal genetic biomarkers, capsule endoscopy, and computed tomography colonography may evolve to be safer and more cost-effective alternatives, challenging the longevity of screening colonoscopy. Unlike Little Richard, for whom “rock ‘n’ roll” is the main source of his livelihood, gastroenterologists should be prepared that screening colonoscopy may not be a self-sustaining source of income in the long-term. Physicians may find the training of nonphysician colonoscopists threatening for professional and personal reasons. Gastroenterologists and surgeons invest at least 3 years in their specialty training. They will rightfully question the quality and safety of the procedures performed by NPs who participate in a 1-year gastroenterology training program with a focus on colonoscopy. Colonoscopy is also a major revenue generator for gastroenterologists because of the demand for screening colonoscopies with the aging population and its relatively high reimbursement. NPs performing screening colonoscopies may be seen as competition for patients and as a threat to physicians' revenue and livelihood. Whether screening colonoscopy will continue to be the “bread and butter” procedure for the practicing gastroenterologist remains uncertain. Fecal genetic biomarkers, capsule endoscopy, and computed tomography colonography may evolve to be safer and more cost-effective alternatives, challenging the longevity of screening colonoscopy. Unlike Little Richard, for whom “rock ‘n’ roll” is the main source of his livelihood, gastroenterologists should be prepared that screening colonoscopy may not be a self-sustaining source of income in the long-term. ConclusionsOn the basis of our experience and the previously published studies, well-trained NPs performing screening colonoscopy are equivalent to physicians in quality, safety, and patient satisfaction. NPs and physician assistants can increase the colorectal cancer screening rate in the United States at a reduced cost to taxpayers and other payers with equal safety and effectiveness. On the basis of our experience and the previously published studies, well-trained NPs performing screening colonoscopy are equivalent to physicians in quality, safety, and patient satisfaction. NPs and physician assistants can increase the colorectal cancer screening rate in the United States at a reduced cost to taxpayers and other payers with equal safety and effectiveness.