Comparison of Flexible Sigmoidoscopy Screening in Average Risk Patients Performed by Nurses Versus Gastroenterologists

Comparison of Flexible Sigmoidoscopy Screening in Average Risk Patients Performed by Nurses... Background: Screening sigmoidoscopy is effective in reducing mortality from colorectal cancer. In 2009, Cancer Care Ontario (CCO) launched a nurse-performed screening flexible sigmoidoscopy program at Hotel Dieu Hospital, Kingston, Ontario. Prior to this program, there was a pilot sigmoidos- copy screening program by gastroenterologists in a similar average risk cohort. Aim: To compare neoplasia detection rates and associated costs of screening sigmoidoscopy per- formed by nurses and gastroenterologists. Method: A retrospective chart review was conducted on flexible sigmoidoscopies performed as part of two average risk screening programs performed by gastroenterologists and nurse-endoscopists. Detected polyps were categorized as hyperplastic, low-risk adenomas or high-risk adenomas. Average cost per procedure was estimated based on physician fee for service charges, nurse wage and benefits, physician supervisory fees, pathology costs and administrative expenses. Results: There were 538 procedures performed by nurses and 174 by physicians. Adenomas were detected in 18% of nurse-performed procedures versus 9% in physician-performed procedures (p=0.003), with the higher adenoma detection rate restricted to low risk adenomas. One cancer was found in the physician group. Seven physicians performed the 174 sigmoidoscopies, with one physi- cian performing the majority. This physician’s adenoma detection rate was 4.5%, whereas detection rate for the remaining physicians combined was 16.5%. Nurses biopsied more polyps per case (0.96 versus 0.18). Average estimated cost per case was greater for nurses ($387.54 versus $309.37). Conclusion: Well-trained nurse-endoscopists can provide an effective service for colorectal cancer screening, but as currently structured in Ontario, the associated cost is higher for nurse-performed procedures. Keywords: Colon cancer screening , sigmoidoscopy, nurse-endoscopist, adenoma Flexible sigmoidoscopy is an acceptable method to diagnose INTRODUCTION CRC and pre-malignant neoplasms. Indeed, results from a large Colorectal cancer (CRC) is one of the most common cancers prospective trial indicated that population screening using flex - in Canada, with estimates that one in 13 men and one in 15 ible sigmoidoscopy reduces incidence of and mortality from women will be diagnosed with CRC in their lifetime (1, 2). This CRC (4). Due to an aging population and increased demand translates into approximately 23,900 new cases of CRC per year on endoscopy procedures, Ontario faces serious capacity issues in Canada (3). Accordingly, provincial health authorities have to deliver endoscopic services both for screening and follow-up. begun implementing population  based screening programs As a result, the Ministry of Health and Long Term Care, as well across the country. © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 82 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 83 as Cancer Care Ontario, have sponsored several pilot programs For entry into the physician program, subjects were required to across Ontario where nurses trained in performing sigmoidos- have undergone fecal occult blood testing with negative results. copy are working under physician supervision. The first Canadian Although recommended, this was not a requirement for en- nurse-performed flexible sigmoidoscopy screening program was rollment into the nursing screening program. Ethics approval established in 1999 (5). In 2006, a pilot project to train nurses was obtained for this study from the Queen’s Human Ethics on performing screening sigmoidoscopy was completed in review Board. Data pertaining to nurse and gastroenterologist Ontario (6). This, and a technology report from the Canadian performed sigmoidoscopies was extracted from the Hotel Dieu Coordinating Office for Health Technology Assessment (7 ) Hospital patient care electronic database, as well as individual indicating that nurse-performed flexible sigmoidoscopies were patient paper charts and procedure notes. safe and cost-effective, provided the incentive for establishing Spreadsheets were developed, and data related to adenoma nurse-performed flexible sigmoidoscopy screening programs at detection rates, depth of insertion, number of polyps and his- multiple centres across the province. The structured nurse train- tological findings were included. The primary outcome of the ing was extensive, involving a one-week course with didactic study was adenoma detection rates. Detected polyps were cat- sessions and simulator use followed by the nurse observing an egorized as either hyperplastic, low-risk adenomas (< 1 cm, no experienced endoscopist perform 100 flexible sigmoidoscopies, villous component or high-grade dysplasia) or high-risk adeno- then100 sigmoidoscopies where the instructor inserted the scope mas (≥ 1 cm, villous or serrated component and/or high-grade and the nurse withdrew, and finally 100 full procedures under di - dysplasia). When more than one neoplastic polyp was found rect observation. Before starting independent practice, the nurses during the same procedure, the parameters of the highest-grade were then observed and approved by external examiners using pathology polyp were used in the analysis. For polyps that were pre-set criteria. not biopsied at the initial sigmoidoscopy (because neoplasia To date, several studies from outside Canada have reported was assumed based on gross appearance and a decision was that the outcome of flexible sigmoidoscopies performed by made to proceed to colonoscopy), the histology result included appropriately trained nurses is comparable to physician-per- in the analysis was that of the tissue subsequently obtained at formed procedures with respect to diagnostic yield and patient colonoscopy. satisfaction (8–13). In addition, one study reported that these The average cost per procedure in Canadian dollars (CAD), results could be achieved at lower cost (10). Up until now, com- including pathology and administrative costs, was calculated for parable data has not been available in Canada. both nurse- and physician-performed procedures, using Ontario Two trained nurses began performing screening sigmoidos- Health Insurance Plan fee for physician service charges and copy procedures in our academic centre at Hotel Dieu Hospital nursing salary charges prorated to number of cases performed in 2009, with several hundred procedures now available for per half-day session. For the physicians, this included fees analysis. In addition, gastroenterologists previously engaged in charged for a consultation ($118 CAD assuming a 50:50 mix a pilot flexible sigmoidoscopy screening program in average risk of full versus limited consult fees), the flexible sigmoidoscopy subjects at the same centre, and the outcome data from this pro- ($58 CAD) and biopsies ($27 CAD). This likely overestimates gram was prospectively collected and available for comparison. the actual cost of physician-performed procedures, because the Given the availability of this data, the current study sought to majority of physicians participating in this study were funded compare the results of our nurse-based CRC screening sigmoid- via an alternative funding plan in which the average half-day re- oscopy program with the results of a previous pilot screening imbursement was significantly less than what would have been program performed by gastroenterologists in a similar average earned through fee for service billings. For the nurses, the cost risk population. Patients in both groups who were found to have of each procedure was estimated to be one-sixth of 10% of their adenomatous polyps at flexible sigmoidoscopy were contacted annual salary, plus benefits (i.e. on average six procedures on and recommended to undergo full colonoscopy. one half day per week were booked during the study period), as well as the physician supervisory fee. Pathology costs (pro- cessing and interpretation) were estimated at $65 CAD per METHODS biopsy, plus $9 CAD charge for disposable biopsy forceps. A retrospective chart review of average risk screening sigmoid- Administrative costs for physicians were based on $20,000 oscopy procedures performed by nurses from 2011 to 2014 and CAD grant to fund a nurse coordinator who was responsible for physicians between 2004 and 2006 was performed. To be el- data collection and recruiting of patients by liaising with family igible for these two screening programs, subjects had to be > physicians. Other administrative costs were handled through 50 years of age, have no active lower gastrointestinal symptoms the physician’s offices using professional income. Nursing ad - and no family history of CRC in first degree relatives. Patients ministrative costs related to CCO funding of a 0.8 FTE nurse who had undergone a previous colonoscopy were not included. administrator, who was responsible for patient recruitment and Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 84 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 education, data collection for CCO, and follow-up of pathology Adenoma Detection Rate results with booking of colonoscopy where appropriate. The The adenoma detection rate was significantly higher in the nurs - cost of equipment depreciation, medical records and other fa- ing group (18.0% vs 9.2%; p = 0.003; Figure 1). Of note, adenoma cility costs were not included in the calculation, as these were detection rate varied substantially between individual physicians essentially the same for both physician- and nurse-performed with the physician performing the majority of the procedures procedures. The nurse administrator also served as an endos - having an adenoma detection rate of 4.5%, whereas the other copy assistant for the nursing flexible sigmoidoscopy, so her physicians combined had a detection rate of 16.5%. The higher cost was discounted by one half day per week (i.e., from 0.8 FTE adenoma detection rate in the nursing group was restricted to low to 0.7 FTE). risk adenomas (14% vs 4.5%), with the high-risk adenoma de- Data was imported into IBM SPSS (version 22.0 for tection rate being comparable (4.5% in physician group; 4.1% in Windows) for statistical analysis. It was initially analyzed de- nurses group). A partially obstructing cancer was detected in the scriptively, including means and standard deviations for con- physician group, despite the patient being asymptomatic at the tinuous data, such as depth of insertion, number of polyps time of the sigmoidoscopy. The higher adenoma detection rate detected and location of polyps detected. Frequencies and was associated with a much higher polyp biopsy rate per case in percentages for categorical data, such as adenoma detection nurse-performed versus physician-performed procedures (0.96 rates and pathology findings, were used. Comparisons be- versus 0.18; CI -0.997, -0.571; p=0.001), with the majority of tween the nurse and GI groups were then made using inde- polyps (65%) being hyperplastic in the nursing cohort. pendent samples t-tests. Categorical data was compared using Chi-square tests. P-value less than 0.05 was considered statis- Depth of Insertion tically significant. The reported depth of insertion was slightly larger in the physi - cian arm (61.02 ± 12.8 cm versus 57.89 ± 10.5 cm for Nurses; p=0.001;Table 1). RESULTS There were a total of 712 procedures performed by nurses Cost and gastroenterologists during the study periods analyzed. The average costs per procedure in the two groups are summa - Nurses performed 538 (76%) of the procedures, and phy- rized in Table  2. Although the charges for the actual procedure sicians performed 174 procedures (24%) (Table  1). Two were much less for the nurse-performed sigmoidoscopy, this was nurses participated in the program. Nurse 1 completed 472 offset by the higher administrative and pathology costs, such that (87.7%) procedures, and Nurse 2 completed 66 (12.3%) the average total cost per physician-performed procedure was sub- procedures. Seven gastroenterologists performed the screen- stantially less than that of nurse-performed procedure ($309.37 ing sigmoidoscopies, with the majority (61%) done by one CAD versus $387.54 CAD). The cost to detect one patient with physician. There were 34 procedures in the nursing arm, an adenoma was $3,830 in the gastroenterology program versus and 19 procedures in the physician arm where the flexible $2,149 in the nursing program. On the other hand, the cost to sigmoidoscopy had to be aborted due to poor bowel prep detect one patient with a high-risk adenoma was $6,729 for gas- (even after repeating the enema) that significantly affected troenterologists and $9,447 for nurse-endoscopists. the ability to perform a satisfactory screening, or due to a patient experiencing severe discomfort. DISCUSSION The mean age of participants was slightly younger in the nursing program (60.7+/-6.9 versus 62.4+/-7.7; p=0.038), and This study confirms the ability of an adequately trained there was a higher proportion of female participants in the nurs- nurse-endoscopist to provide a high-quality screening pro- ing group (61.0% versus 47.1%; p=0.0012) (Table 1). gram with excellent adenoma detection rates. Contrary to Table 1. Comparison of Nurse and Physician-Performed Screening Flexible Sigmoidoscopies Physician Nurse p-value # of endoscopists 7 2 Total # of patients 174 538 Patient sex (F/M) 82/92 329/210 0.0012 Mean patient age (range) 62.1 (50–88) 60.7 (50–75) 0.038 Mean depth of scope insertion (+/-SD) (cm) 61.02 ± 12.8 57.89 ± 10.5 0.001 Mean # of polyps biopsied/procedure 0.18 0.96 0.001 Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 85 than that in the physician program (9%), as well as that re- ported previously in other average risk flexible sigmoidoscopy screening programs performed by nurses or physicians, which has ranged from 5.8 to 9% (5,10,11,12,14). Adenoma detection rates ranging from 9 to 16% were previously reported in a large flexible sigmoidoscopy screening program in the UK, but the population studied included subjects with a family history of CRC (15). This clearly demonstrates that a high-quality flexible sigmoidoscopy screening program can be conducted by well- trained nurses, thereby freeing up physician time. The reason for the higher adenoma detection rate in the nursing arm of the study is unclear. This did not appear to relate to the re- ported depth of insertion, as this was slightly greater in the phy- sician group. It could partly relate to the population under study. Figure 1. Comparison of adenoma detection rate (ADR) of sigmoidoscopy performed by nurses The physician pilot project was performed in average risk individ - or physicians. Solid bars represent overall ADR, whereas diagonal cross-hatched bars represent uals over 50 years of age who also had negative fecal occult blood high risk ADRs. Overall, adenomas were detected in a significantly higher proportion of subjects testing. Although it was strongly recommended in the nursing in nurse-performed (18%) than physician-performed procedures (9%) (p=0.003), however the detection rates for high risk adenomas were the same (4.1% versus 4.5%). There was significant program that all participants have a FOBT as part of the program, variation in the ADR between physicians; the physician who did the majority of the procedures this was not required before having a flexible sigmoidoscopy. It had an ADR of 4.5%, whereas the ADR for all other physicians combined was 16.5%. is therefore possible that the nurse program was seeing a slightly higher risk population (that is, a portion of patients in the nurs- expectations, however, it appears that the cost of the nursing ing group may have been FOBT positive). This is unlikely to be a flexible sigmoidoscopy program, as structured in Ontario, is significant number, however, based on the rate of positivity in an higher than a comparable program provided by physicians. average risk population. Furthermore, the increased risk conferred In the current study, the overall polyp detection rate was 18% by including a small proportion of patients who may have tested in the nursing screening program. This was significantly higher positive for FOB would likely be offset by the fact that the nursing Table  2. Comparison of Procedural Costs Between Nurse- and group included a slightly younger population and a significantly Physician-Performed Screening Flexible Sigmoidoscopy: ($CAD) higher proportion of female patients, who are known to be at lower risk for colonic neoplasia than male subjects of comparable A) Cost per flexible sigmoidoscopy performed by age. The more likely explanation is the care and thoroughness with Gastroenterologist which the procedure was performed, as well as the lower threshold Procedure + Consult (limited/full) $176 for the nurses to sample very small polyps that physicians might Biopsy fee $4.05 ignore or consider likely to be hyperplastic. Certainly, the mark- Biopsy forceps $1.34 edly increased biopsy rate in the nursing arm would be consistent Pathology charges $13.04 with this explanation and likely contributed to the higher ade- Administrative $114.94 noma detection rate. This is also supported by an analysis of the TOTAL $309.37 adenoma detection rate between the seven physicians performing the procedure. The one physician who performed the majority of B) Cost per flexible sigmoidoscopy performed by Nurse the procedures had a fairly low adenoma detection rate (4.5%), endoscopist whereas the adenoma detection rate for the remaining physicians Procedure $34 combined (16.5%) was comparable to that of the nurses. Physician Supervision $66.67 A surprising finding related to relative cost. One would assume Biopsy forceps $4.68 that a program in which the flexible sigmoidoscopy procedures Pathology $65.19 were carried out by a nurse, rather than physician, would be Administration $217 less costly, but this proved not to be the case. Although charges TOTAL $387.54 incurred by actually doing the procedure were much higher with C) Comparison of cost to detect a patient with an adenoma physicians versus nurses, a number of factors resulted in the esti- mated per case cost being higher than the nursing program. The Endoscopist Any Adenoma High-risk increased biopsies resulted in an increased pathology lab cost, Adenoma but the major difference related to administrative costs. As cur - Nurse $2,149 $9,477 rently structured, the nursing flexible sigmoidoscopy program in Gastroenterologist $3,830 $6,729 Ontario employs a 0.8 FTE nursing administrative and patient Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 86 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 education position. This person promotes the program by liais - analysis and Lola Joyce and Dr. David Hurlbut for providing cost- ing data. ing with the local primary care physicians and is responsible for Author Competing Interests: None data collection, patient education and follow-up of pathology with booking of colonoscopy where appropriate. In addition, fees are paid to gastroenterologists who supervise the nursing References program. Although these administrative costs were undoubtedly 1. Canadian Cancer Society’s Advisory Committee on Cancer of importance in getting the program established, it appears the Statistics. Canadian Cancer Statistics 2013. Toronto, ON: expense may not be necessary on an ongoing basis. Indeed, since Canadian Cancer Society, 2013. this study was conducted, Cancer Care Ontario has reduced 2. Cancer Care Ontario: Insight on Cancer. News and Information administrative costs slightly by reducing the physician supervi- on ColorectalCancer. Toronto: Canadian Cancer Society (Ontario sion fee, but even if this were eliminated, the costs per procedure Division), 2004. would still be substantially higher for nurse-performed pro- 3. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2013. Toronto, ON: cedures. Nevertheless, the overall adenoma detection rate was Canadian Cancer Society, 2013. higher in the nurse-endoscopist program, such that the cost per 4. Schoen RE, Pinsky PF, Weissfeld JL, et  al. Colorectal-cancer in- patient found to have an adenoma was lower in the nursing pro- cidence and mortality with screening flexible sigmoidoscopy. N gram. However, the reverse was true with respect to detecting Engl J Med 2012;366(25):2345–57. patients with high-risk adenomas, which arguably are more rele- 5. Shapero TF, Alexander PE, Hoover J. Colorectal cancer screening: vant with respect to reducing CRC risk. Video-reviewed flexible sigmoidoscopy by nurse endoscopists: The retrospective nature of the current study is an obvious limita - A  Canadian community-based perspective. Can J Gastroenterol tion, and clearly, a prospective randomized controlled trial compar- 2001;15:441–5. ing outcomes would have provided more robust results. Although 6. Dobrow M, Cooper M, Rabeneck L. Referring patients to nurses: both population cohorts studied were average risk patients > Outcomes and evaluation of a nurse flexible sigmoidoscopy train- 50  years old referred for screening flexible sigmoidoscopy, there ing program for colorectal cancer screening. Canadian Journal of were some differences in patient demographics between the two Gastroenterology 2007;21:301–208. 7. Costa E, Coyte P, Laporte A, et  al. The use of registered nurses groups, a problem that would not likely to have occurred in a pro- to perform flexible sigmoidoscopy procedures in Ontario: A cost spective randomized trial. However, a prospective randomized minimization analysis. Health Policy 2012;7:e119–30. study might actually have been less reflective of ‘real world’ prac - 8. DiSario JA, Sanowski RA. Sigmoidoscopy training for nurses and tice in that participant endoscopists, knowing that the quality resident physicians. Gastrointest Endosc 1993:39;29–32 of their procedure is being compared to others, might alter their 9. Palitz AM, Selby JV, Grossman S, et al. The colon cancer preven- practice accordingly. Another limitation is that the two cohorts tion program (CoCaP): rationale, implementation, and prelimi- were studied approximately seven years apart, and during that in- nary results. HMO Pract 1997:11;5–12. terval, there has been an increased focus on improving endoscopic 10. Wallace MB, Kemp JA, Meyer F, et  al. Screening for colorectal quality, which may be reflected in the improved performance of cancer with flexible sigmoidoscopy by nonphysician endoscopists. the nurse-endoscopists. Also, at the time of the physician program, Am J Med 1999;107:214–218. ‘cold snaring’ of small polyps at sigmoidoscopy was not performed. 11. Schoenfeld P, Lipscomb S, Crook J, et  al. Accuracy of Polyp This intervention would increase the cost of physician-performed Detection by Gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: A  randomized trial. Gastroenterology flexible sigmoidoscopies, although this would be offset by lower 1999;117:312–318. costs incurred at a subsequent colonoscopy. 12. Schoenfeld PS, Cash B, Kita J, et al. Effectiveness and patient satis - In conclusion, this study confirms that appropriately trained faction with screening flexible sigmoidoscopy performed by regis - nurse-endoscopists can perform high-quality screening flexible tered nurses. Gastrointest Endosc 1999;49;158–62. sigmoidoscopies, but it appears that further reductions in asso- 13. Williams J, Russell I, Durai D, et al. Effectiveness of nurse delivered ciated administrative costs are required to optimize the cost-ef- endoscopy: findings from randomized multi-institution nurse en- fectiveness of this program in Ontario. doscopy trial (MINuET). BMJ 2009;338:b231. 14. Shapero TF, Hoover J, Paszat LF, et al. Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian ACKNOWLEDGEMENTS community-based program. Gastrointest Endosc 2007;65:640–5. Funded in part by a grant from the Jeanne Mance Foundation, 15. Atkin W, Rogers P, Cardwell C, et  al. Wide variation in ad- Hotel Dieu Hospital, Kingston, Ontario. The authors would like enoma detection rates at screening flexible sigmoidoscopy. to thank Wilma Hopman for her expert assistance with statistical Gastroenterology 2004;126(5):1247–56. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Canadian Association of Gastroenterology Oxford University Press

Comparison of Flexible Sigmoidoscopy Screening in Average Risk Patients Performed by Nurses Versus Gastroenterologists

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Abstract

Background: Screening sigmoidoscopy is effective in reducing mortality from colorectal cancer. In 2009, Cancer Care Ontario (CCO) launched a nurse-performed screening flexible sigmoidoscopy program at Hotel Dieu Hospital, Kingston, Ontario. Prior to this program, there was a pilot sigmoidos- copy screening program by gastroenterologists in a similar average risk cohort. Aim: To compare neoplasia detection rates and associated costs of screening sigmoidoscopy per- formed by nurses and gastroenterologists. Method: A retrospective chart review was conducted on flexible sigmoidoscopies performed as part of two average risk screening programs performed by gastroenterologists and nurse-endoscopists. Detected polyps were categorized as hyperplastic, low-risk adenomas or high-risk adenomas. Average cost per procedure was estimated based on physician fee for service charges, nurse wage and benefits, physician supervisory fees, pathology costs and administrative expenses. Results: There were 538 procedures performed by nurses and 174 by physicians. Adenomas were detected in 18% of nurse-performed procedures versus 9% in physician-performed procedures (p=0.003), with the higher adenoma detection rate restricted to low risk adenomas. One cancer was found in the physician group. Seven physicians performed the 174 sigmoidoscopies, with one physi- cian performing the majority. This physician’s adenoma detection rate was 4.5%, whereas detection rate for the remaining physicians combined was 16.5%. Nurses biopsied more polyps per case (0.96 versus 0.18). Average estimated cost per case was greater for nurses ($387.54 versus $309.37). Conclusion: Well-trained nurse-endoscopists can provide an effective service for colorectal cancer screening, but as currently structured in Ontario, the associated cost is higher for nurse-performed procedures. Keywords: Colon cancer screening , sigmoidoscopy, nurse-endoscopist, adenoma Flexible sigmoidoscopy is an acceptable method to diagnose INTRODUCTION CRC and pre-malignant neoplasms. Indeed, results from a large Colorectal cancer (CRC) is one of the most common cancers prospective trial indicated that population screening using flex - in Canada, with estimates that one in 13 men and one in 15 ible sigmoidoscopy reduces incidence of and mortality from women will be diagnosed with CRC in their lifetime (1, 2). This CRC (4). Due to an aging population and increased demand translates into approximately 23,900 new cases of CRC per year on endoscopy procedures, Ontario faces serious capacity issues in Canada (3). Accordingly, provincial health authorities have to deliver endoscopic services both for screening and follow-up. begun implementing population  based screening programs As a result, the Ministry of Health and Long Term Care, as well across the country. © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 82 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 83 as Cancer Care Ontario, have sponsored several pilot programs For entry into the physician program, subjects were required to across Ontario where nurses trained in performing sigmoidos- have undergone fecal occult blood testing with negative results. copy are working under physician supervision. The first Canadian Although recommended, this was not a requirement for en- nurse-performed flexible sigmoidoscopy screening program was rollment into the nursing screening program. Ethics approval established in 1999 (5). In 2006, a pilot project to train nurses was obtained for this study from the Queen’s Human Ethics on performing screening sigmoidoscopy was completed in review Board. Data pertaining to nurse and gastroenterologist Ontario (6). This, and a technology report from the Canadian performed sigmoidoscopies was extracted from the Hotel Dieu Coordinating Office for Health Technology Assessment (7 ) Hospital patient care electronic database, as well as individual indicating that nurse-performed flexible sigmoidoscopies were patient paper charts and procedure notes. safe and cost-effective, provided the incentive for establishing Spreadsheets were developed, and data related to adenoma nurse-performed flexible sigmoidoscopy screening programs at detection rates, depth of insertion, number of polyps and his- multiple centres across the province. The structured nurse train- tological findings were included. The primary outcome of the ing was extensive, involving a one-week course with didactic study was adenoma detection rates. Detected polyps were cat- sessions and simulator use followed by the nurse observing an egorized as either hyperplastic, low-risk adenomas (< 1 cm, no experienced endoscopist perform 100 flexible sigmoidoscopies, villous component or high-grade dysplasia) or high-risk adeno- then100 sigmoidoscopies where the instructor inserted the scope mas (≥ 1 cm, villous or serrated component and/or high-grade and the nurse withdrew, and finally 100 full procedures under di - dysplasia). When more than one neoplastic polyp was found rect observation. Before starting independent practice, the nurses during the same procedure, the parameters of the highest-grade were then observed and approved by external examiners using pathology polyp were used in the analysis. For polyps that were pre-set criteria. not biopsied at the initial sigmoidoscopy (because neoplasia To date, several studies from outside Canada have reported was assumed based on gross appearance and a decision was that the outcome of flexible sigmoidoscopies performed by made to proceed to colonoscopy), the histology result included appropriately trained nurses is comparable to physician-per- in the analysis was that of the tissue subsequently obtained at formed procedures with respect to diagnostic yield and patient colonoscopy. satisfaction (8–13). In addition, one study reported that these The average cost per procedure in Canadian dollars (CAD), results could be achieved at lower cost (10). Up until now, com- including pathology and administrative costs, was calculated for parable data has not been available in Canada. both nurse- and physician-performed procedures, using Ontario Two trained nurses began performing screening sigmoidos- Health Insurance Plan fee for physician service charges and copy procedures in our academic centre at Hotel Dieu Hospital nursing salary charges prorated to number of cases performed in 2009, with several hundred procedures now available for per half-day session. For the physicians, this included fees analysis. In addition, gastroenterologists previously engaged in charged for a consultation ($118 CAD assuming a 50:50 mix a pilot flexible sigmoidoscopy screening program in average risk of full versus limited consult fees), the flexible sigmoidoscopy subjects at the same centre, and the outcome data from this pro- ($58 CAD) and biopsies ($27 CAD). This likely overestimates gram was prospectively collected and available for comparison. the actual cost of physician-performed procedures, because the Given the availability of this data, the current study sought to majority of physicians participating in this study were funded compare the results of our nurse-based CRC screening sigmoid- via an alternative funding plan in which the average half-day re- oscopy program with the results of a previous pilot screening imbursement was significantly less than what would have been program performed by gastroenterologists in a similar average earned through fee for service billings. For the nurses, the cost risk population. Patients in both groups who were found to have of each procedure was estimated to be one-sixth of 10% of their adenomatous polyps at flexible sigmoidoscopy were contacted annual salary, plus benefits (i.e. on average six procedures on and recommended to undergo full colonoscopy. one half day per week were booked during the study period), as well as the physician supervisory fee. Pathology costs (pro- cessing and interpretation) were estimated at $65 CAD per METHODS biopsy, plus $9 CAD charge for disposable biopsy forceps. A retrospective chart review of average risk screening sigmoid- Administrative costs for physicians were based on $20,000 oscopy procedures performed by nurses from 2011 to 2014 and CAD grant to fund a nurse coordinator who was responsible for physicians between 2004 and 2006 was performed. To be el- data collection and recruiting of patients by liaising with family igible for these two screening programs, subjects had to be > physicians. Other administrative costs were handled through 50 years of age, have no active lower gastrointestinal symptoms the physician’s offices using professional income. Nursing ad - and no family history of CRC in first degree relatives. Patients ministrative costs related to CCO funding of a 0.8 FTE nurse who had undergone a previous colonoscopy were not included. administrator, who was responsible for patient recruitment and Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 84 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 education, data collection for CCO, and follow-up of pathology Adenoma Detection Rate results with booking of colonoscopy where appropriate. The The adenoma detection rate was significantly higher in the nurs - cost of equipment depreciation, medical records and other fa- ing group (18.0% vs 9.2%; p = 0.003; Figure 1). Of note, adenoma cility costs were not included in the calculation, as these were detection rate varied substantially between individual physicians essentially the same for both physician- and nurse-performed with the physician performing the majority of the procedures procedures. The nurse administrator also served as an endos - having an adenoma detection rate of 4.5%, whereas the other copy assistant for the nursing flexible sigmoidoscopy, so her physicians combined had a detection rate of 16.5%. The higher cost was discounted by one half day per week (i.e., from 0.8 FTE adenoma detection rate in the nursing group was restricted to low to 0.7 FTE). risk adenomas (14% vs 4.5%), with the high-risk adenoma de- Data was imported into IBM SPSS (version 22.0 for tection rate being comparable (4.5% in physician group; 4.1% in Windows) for statistical analysis. It was initially analyzed de- nurses group). A partially obstructing cancer was detected in the scriptively, including means and standard deviations for con- physician group, despite the patient being asymptomatic at the tinuous data, such as depth of insertion, number of polyps time of the sigmoidoscopy. The higher adenoma detection rate detected and location of polyps detected. Frequencies and was associated with a much higher polyp biopsy rate per case in percentages for categorical data, such as adenoma detection nurse-performed versus physician-performed procedures (0.96 rates and pathology findings, were used. Comparisons be- versus 0.18; CI -0.997, -0.571; p=0.001), with the majority of tween the nurse and GI groups were then made using inde- polyps (65%) being hyperplastic in the nursing cohort. pendent samples t-tests. Categorical data was compared using Chi-square tests. P-value less than 0.05 was considered statis- Depth of Insertion tically significant. The reported depth of insertion was slightly larger in the physi - cian arm (61.02 ± 12.8 cm versus 57.89 ± 10.5 cm for Nurses; p=0.001;Table 1). RESULTS There were a total of 712 procedures performed by nurses Cost and gastroenterologists during the study periods analyzed. The average costs per procedure in the two groups are summa - Nurses performed 538 (76%) of the procedures, and phy- rized in Table  2. Although the charges for the actual procedure sicians performed 174 procedures (24%) (Table  1). Two were much less for the nurse-performed sigmoidoscopy, this was nurses participated in the program. Nurse 1 completed 472 offset by the higher administrative and pathology costs, such that (87.7%) procedures, and Nurse 2 completed 66 (12.3%) the average total cost per physician-performed procedure was sub- procedures. Seven gastroenterologists performed the screen- stantially less than that of nurse-performed procedure ($309.37 ing sigmoidoscopies, with the majority (61%) done by one CAD versus $387.54 CAD). The cost to detect one patient with physician. There were 34 procedures in the nursing arm, an adenoma was $3,830 in the gastroenterology program versus and 19 procedures in the physician arm where the flexible $2,149 in the nursing program. On the other hand, the cost to sigmoidoscopy had to be aborted due to poor bowel prep detect one patient with a high-risk adenoma was $6,729 for gas- (even after repeating the enema) that significantly affected troenterologists and $9,447 for nurse-endoscopists. the ability to perform a satisfactory screening, or due to a patient experiencing severe discomfort. DISCUSSION The mean age of participants was slightly younger in the nursing program (60.7+/-6.9 versus 62.4+/-7.7; p=0.038), and This study confirms the ability of an adequately trained there was a higher proportion of female participants in the nurs- nurse-endoscopist to provide a high-quality screening pro- ing group (61.0% versus 47.1%; p=0.0012) (Table 1). gram with excellent adenoma detection rates. Contrary to Table 1. Comparison of Nurse and Physician-Performed Screening Flexible Sigmoidoscopies Physician Nurse p-value # of endoscopists 7 2 Total # of patients 174 538 Patient sex (F/M) 82/92 329/210 0.0012 Mean patient age (range) 62.1 (50–88) 60.7 (50–75) 0.038 Mean depth of scope insertion (+/-SD) (cm) 61.02 ± 12.8 57.89 ± 10.5 0.001 Mean # of polyps biopsied/procedure 0.18 0.96 0.001 Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 85 than that in the physician program (9%), as well as that re- ported previously in other average risk flexible sigmoidoscopy screening programs performed by nurses or physicians, which has ranged from 5.8 to 9% (5,10,11,12,14). Adenoma detection rates ranging from 9 to 16% were previously reported in a large flexible sigmoidoscopy screening program in the UK, but the population studied included subjects with a family history of CRC (15). This clearly demonstrates that a high-quality flexible sigmoidoscopy screening program can be conducted by well- trained nurses, thereby freeing up physician time. The reason for the higher adenoma detection rate in the nursing arm of the study is unclear. This did not appear to relate to the re- ported depth of insertion, as this was slightly greater in the phy- sician group. It could partly relate to the population under study. Figure 1. Comparison of adenoma detection rate (ADR) of sigmoidoscopy performed by nurses The physician pilot project was performed in average risk individ - or physicians. Solid bars represent overall ADR, whereas diagonal cross-hatched bars represent uals over 50 years of age who also had negative fecal occult blood high risk ADRs. Overall, adenomas were detected in a significantly higher proportion of subjects testing. Although it was strongly recommended in the nursing in nurse-performed (18%) than physician-performed procedures (9%) (p=0.003), however the detection rates for high risk adenomas were the same (4.1% versus 4.5%). There was significant program that all participants have a FOBT as part of the program, variation in the ADR between physicians; the physician who did the majority of the procedures this was not required before having a flexible sigmoidoscopy. It had an ADR of 4.5%, whereas the ADR for all other physicians combined was 16.5%. is therefore possible that the nurse program was seeing a slightly higher risk population (that is, a portion of patients in the nurs- expectations, however, it appears that the cost of the nursing ing group may have been FOBT positive). This is unlikely to be a flexible sigmoidoscopy program, as structured in Ontario, is significant number, however, based on the rate of positivity in an higher than a comparable program provided by physicians. average risk population. Furthermore, the increased risk conferred In the current study, the overall polyp detection rate was 18% by including a small proportion of patients who may have tested in the nursing screening program. This was significantly higher positive for FOB would likely be offset by the fact that the nursing Table  2. Comparison of Procedural Costs Between Nurse- and group included a slightly younger population and a significantly Physician-Performed Screening Flexible Sigmoidoscopy: ($CAD) higher proportion of female patients, who are known to be at lower risk for colonic neoplasia than male subjects of comparable A) Cost per flexible sigmoidoscopy performed by age. The more likely explanation is the care and thoroughness with Gastroenterologist which the procedure was performed, as well as the lower threshold Procedure + Consult (limited/full) $176 for the nurses to sample very small polyps that physicians might Biopsy fee $4.05 ignore or consider likely to be hyperplastic. Certainly, the mark- Biopsy forceps $1.34 edly increased biopsy rate in the nursing arm would be consistent Pathology charges $13.04 with this explanation and likely contributed to the higher ade- Administrative $114.94 noma detection rate. This is also supported by an analysis of the TOTAL $309.37 adenoma detection rate between the seven physicians performing the procedure. The one physician who performed the majority of B) Cost per flexible sigmoidoscopy performed by Nurse the procedures had a fairly low adenoma detection rate (4.5%), endoscopist whereas the adenoma detection rate for the remaining physicians Procedure $34 combined (16.5%) was comparable to that of the nurses. Physician Supervision $66.67 A surprising finding related to relative cost. One would assume Biopsy forceps $4.68 that a program in which the flexible sigmoidoscopy procedures Pathology $65.19 were carried out by a nurse, rather than physician, would be Administration $217 less costly, but this proved not to be the case. Although charges TOTAL $387.54 incurred by actually doing the procedure were much higher with C) Comparison of cost to detect a patient with an adenoma physicians versus nurses, a number of factors resulted in the esti- mated per case cost being higher than the nursing program. The Endoscopist Any Adenoma High-risk increased biopsies resulted in an increased pathology lab cost, Adenoma but the major difference related to administrative costs. As cur - Nurse $2,149 $9,477 rently structured, the nursing flexible sigmoidoscopy program in Gastroenterologist $3,830 $6,729 Ontario employs a 0.8 FTE nursing administrative and patient Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018 86 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 education position. This person promotes the program by liais - analysis and Lola Joyce and Dr. David Hurlbut for providing cost- ing data. ing with the local primary care physicians and is responsible for Author Competing Interests: None data collection, patient education and follow-up of pathology with booking of colonoscopy where appropriate. In addition, fees are paid to gastroenterologists who supervise the nursing References program. Although these administrative costs were undoubtedly 1. Canadian Cancer Society’s Advisory Committee on Cancer of importance in getting the program established, it appears the Statistics. Canadian Cancer Statistics 2013. Toronto, ON: expense may not be necessary on an ongoing basis. Indeed, since Canadian Cancer Society, 2013. this study was conducted, Cancer Care Ontario has reduced 2. Cancer Care Ontario: Insight on Cancer. News and Information administrative costs slightly by reducing the physician supervi- on ColorectalCancer. Toronto: Canadian Cancer Society (Ontario sion fee, but even if this were eliminated, the costs per procedure Division), 2004. would still be substantially higher for nurse-performed pro- 3. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2013. Toronto, ON: cedures. Nevertheless, the overall adenoma detection rate was Canadian Cancer Society, 2013. higher in the nurse-endoscopist program, such that the cost per 4. Schoen RE, Pinsky PF, Weissfeld JL, et  al. Colorectal-cancer in- patient found to have an adenoma was lower in the nursing pro- cidence and mortality with screening flexible sigmoidoscopy. N gram. However, the reverse was true with respect to detecting Engl J Med 2012;366(25):2345–57. patients with high-risk adenomas, which arguably are more rele- 5. Shapero TF, Alexander PE, Hoover J. Colorectal cancer screening: vant with respect to reducing CRC risk. Video-reviewed flexible sigmoidoscopy by nurse endoscopists: The retrospective nature of the current study is an obvious limita - A  Canadian community-based perspective. Can J Gastroenterol tion, and clearly, a prospective randomized controlled trial compar- 2001;15:441–5. ing outcomes would have provided more robust results. Although 6. Dobrow M, Cooper M, Rabeneck L. Referring patients to nurses: both population cohorts studied were average risk patients > Outcomes and evaluation of a nurse flexible sigmoidoscopy train- 50  years old referred for screening flexible sigmoidoscopy, there ing program for colorectal cancer screening. Canadian Journal of were some differences in patient demographics between the two Gastroenterology 2007;21:301–208. 7. Costa E, Coyte P, Laporte A, et  al. The use of registered nurses groups, a problem that would not likely to have occurred in a pro- to perform flexible sigmoidoscopy procedures in Ontario: A cost spective randomized trial. However, a prospective randomized minimization analysis. Health Policy 2012;7:e119–30. study might actually have been less reflective of ‘real world’ prac - 8. DiSario JA, Sanowski RA. Sigmoidoscopy training for nurses and tice in that participant endoscopists, knowing that the quality resident physicians. Gastrointest Endosc 1993:39;29–32 of their procedure is being compared to others, might alter their 9. Palitz AM, Selby JV, Grossman S, et al. The colon cancer preven- practice accordingly. Another limitation is that the two cohorts tion program (CoCaP): rationale, implementation, and prelimi- were studied approximately seven years apart, and during that in- nary results. HMO Pract 1997:11;5–12. terval, there has been an increased focus on improving endoscopic 10. Wallace MB, Kemp JA, Meyer F, et  al. Screening for colorectal quality, which may be reflected in the improved performance of cancer with flexible sigmoidoscopy by nonphysician endoscopists. the nurse-endoscopists. Also, at the time of the physician program, Am J Med 1999;107:214–218. ‘cold snaring’ of small polyps at sigmoidoscopy was not performed. 11. Schoenfeld P, Lipscomb S, Crook J, et  al. Accuracy of Polyp This intervention would increase the cost of physician-performed Detection by Gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: A  randomized trial. Gastroenterology flexible sigmoidoscopies, although this would be offset by lower 1999;117:312–318. costs incurred at a subsequent colonoscopy. 12. Schoenfeld PS, Cash B, Kita J, et al. Effectiveness and patient satis - In conclusion, this study confirms that appropriately trained faction with screening flexible sigmoidoscopy performed by regis - nurse-endoscopists can perform high-quality screening flexible tered nurses. Gastrointest Endosc 1999;49;158–62. sigmoidoscopies, but it appears that further reductions in asso- 13. Williams J, Russell I, Durai D, et al. Effectiveness of nurse delivered ciated administrative costs are required to optimize the cost-ef- endoscopy: findings from randomized multi-institution nurse en- fectiveness of this program in Ontario. doscopy trial (MINuET). BMJ 2009;338:b231. 14. Shapero TF, Hoover J, Paszat LF, et al. Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian ACKNOWLEDGEMENTS community-based program. Gastrointest Endosc 2007;65:640–5. Funded in part by a grant from the Jeanne Mance Foundation, 15. Atkin W, Rogers P, Cardwell C, et  al. Wide variation in ad- Hotel Dieu Hospital, Kingston, Ontario. The authors would like enoma detection rates at screening flexible sigmoidoscopy. to thank Wilma Hopman for her expert assistance with statistical Gastroenterology 2004;126(5):1247–56. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/82/4846196 by Ed 'DeepDyve' Gillespie user on 20 June 2018

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Journal of the Canadian Association of GastroenterologyOxford University Press

Published: Feb 8, 2018

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