Background-Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation. Methods and Results-In

Background and study aims Demand for endoscopic procedures worldwide has increased while the number of physicians trained to perform endoscopy has remained relatively constant. The objective of this study was to characterize lower and upper endoscopic procedures performed by non-physicians. Patients and methods Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. Studies were included if patients underwent flexible sigmoidoscopy, colonoscopy or upper endoscopy by a non-physician (nurse, nurse practitioner, physician assistant) and had outcome measures reported (polyps, adenomas and/or cancer detected, adverse events). Pooled rates were calculated for specific outcomes and rate ratios were determined for selected comparison groups. Results The majority of studies included nurses who performed flexible sigmoidoscopies for colorectal cancer screening. Nurses and nurse practitioners/physician assistants who performed flexible sigmoidoscopies had a pooled polyp detection rate of 9.9% and 23.7%, adenoma detection rate of 2.9% and 7.2%, colorectal cancer detection rate of 1.3% and 1.2% and an adverse event rate of 0.3 and 0 per 1,000 sigmoidoscopies, respectively. There was no significant difference between polyp and adenoma detection rates in studies comparing nurses or nurse practitioners/physician assistants with physicians performing sigmoidoscopy. Among studies of non-physicians performing colonoscopies (n=3), the pooled adenoma detection rate was 26.4%, cecal intubation rate of 93.5% and an adverse event rate of 2.2/1,000 colonoscopies. Of the few studies examining upper endoscopies 99.4% of upper endoscopy procedures performed by nurses were successful with no reported adverse events. Conclusion Available studies in the literature suggest that non-physicians perform endoscopic procedures, especially lower endoscopies, with outcomes and adverse events in line with physicians.

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