An uncommon practice
The American Gastroenterological Association (AGA) referred questions from this news organization to the American Society for Gastrointestinal Endoscopy (ASGE).
It is very uncommon to have NPs do coloscopies, commented Douglas K. Rex, MD, director of endoscopy at Indiana University, Indianapolis, and incoming ASGE president.
“There was more of a movement the United Kingdom, but not in the United States,” he said. “I can’t tell you the reason. It’s a combination of minimal data and also the fact that there are plenty of gastroenterologists.”
The ASGE guidelines for endoscopy by nonphysicians concludes: “There are insufficient data to support nonphysician endoscopists to perform colonoscopy.”
Asked about concerns that the demand for colonoscopies will increase now that the recommendation is to start colorectal cancer screening at 45 years old, Dr. Rex said he thinks the system has enough capacity.
But will it continue to be sufficient? In a 2020 white paper on colorectal cancer screening, the AGA noted that lowering the starting age to 45 years will add 21 million people to the current pool of 94 million eligible for screening, an increase of 22%.
Lukejohn Day, MD, a gastroenterologist at the University of California, San Francisco, has reviewed the data collected on nonphysicians performing colorectal cancer screening. He led a meta-analysis of 24 studies conducted from 1997 to 2011, and the team concluded that “nonphysicians can safely perform endoscopic procedures with similar quality, especially with respect to screening flexible sigmoidoscopy. Far fewer data was reported for nonphysicians performing colonoscopy and upper endoscopy, but among this data nonphysicians perform both procedures within accepted national benchmarks for quality measures used in endoscopy.”
Dr. Day told this news organization that he had trained two NPs to do colonoscopies and did the study to get a better sense of the practice. Even still, he said the NPs required extensive training before they could perform the procedure.
“It’s not like someone could finish school and become an endoscopist. It requires a very rigorous training program – a lot of education and mentoring,” he said. “Their program is very similar to what our GI fellows go through.”
Dr. Day said they faced opposition from the gastroenterologists, but they “had enough guardrails” in place to convince skeptics.
One of those guardrails was the requirement that an attending physician be in the building. But when San Francisco General Hospital moved to a new facility, they were unable to guarantee that coverage and the program ended, Dr. Day said.
Quality and depth of training hard to replicate
One place where both NPs and PAs do colonoscopies is at the VA. However, the administration doesn’t keep track of how many work there, according to a VA spokesperson. Regulations on physician providers also vary from state to state, and that is reflected in its workforce.
At the St. Louis VA Medical Center, PAs have been performing diagnostic and colorectal cancer screening colonoscopies for nearly 20 years, according to a 2020 article on the quality of care delivered by PAs. The researchers looked at data from more than 700 patients treated over a year. They had colonoscopies performed by one of seven gastroenterologists, five PAs, or 32 GI fellows from two academic affiliates. The PAs performed better than the fellows and just as well as the gastroenterologists, they concluded.
Samir Gupta, MD, chief of gastroenterology at the VA San Diego Healthcare System, California, said in an email that he thinks a range of clinically licensed health care providers can be trained to do high-quality colonoscopy.
“The challenge has been ensuring training structure and volume of cases sufficient to consistently enable high-quality colonoscopy practice, including achieving adequate rates of polyp detection and removal and complete exams,” he wrote.
This is a challenge for gastroenterologists, but they receive ongoing medical education, and, in many settings, quality is closely monitored and managed, he wrote. He added that in a 3-year training program, most fellows do hundreds of colonoscopies.
“It is really hard to replicate this quality and depth of training outside of a GI fellowship,” Dr. Gupta said.
A version of this article first appeared on Medscape.com.