The use of registered nurses to perform flexible sigmoidoscopy procedures in ontario: a cost minimization analysis.

Ontario has one of the highest rates of colorectal cancer (CRC) in the world (MOHLTC 2010a). According to the Canadian Cancer Society, one in 13 men and one in 16 women will develop CRC during their lifetime, with CRC being the fourth most common cancer behind breast, prostate and lung cancers (Canadian Cancer Society 2011a,b). Increasing age can lead to greater prevalence of and mortality from CRC; considering the rise in Canada's aging population, the number of individuals eligible for screening for this disease will only increase over time (Canadian Cancer Society et al. 2008). CRC has a long pre-malignant phase, which is both easily identified and treated, making it an ideal candidate for screening (Schultz et al. 2004). The chances of survival and cure for colorectal cancer greatly increase the earlier the cancer is detected – for instance, the chances of survival rise to nearly 90% when caught in earlier stages compared to just 10% in later stages of disease progression (Cancer Care Ontario 2008). Therefore, it is important that access to CRC screening is made available for average-risk individuals in Ontario, that is, persons aged 50 years or older with no family history of the disease (Kielar and El-Maraghi 2008; Schoenfeld 1999; Schoenfeld et al. 1999a,b,c; Wong 1999). Healthcare interventions targeted at prevention and early detection have the potential to yield positive benefits for the healthcare system by mitigating future treatment costs, enhancing population health and assisting in health system sustainability. Flexible sigmoidoscopy offers a practical approach to increasing screening capacity for CRC. In Ontario, four procedures are available for screening, three of which are invasive: flexible sigmoidoscopy (FS), colonoscopy and double-barium contrast enema (Madlensky et al. 2003). The fourth is the non-invasive faecal occult blood test (FOBT) (Clemen and Lacke 2001). Flexible sigmoidoscopy is endorsed by the Canadian Task Force on Preventive Health Care as an initial screening test for CRC in men and women at average risk, as well as supported in consensus guidelines by the American Cancer Society, the US Multisociety Task Force on Colorectal Cancer and the American College of Radiology (Levin et al. 2008). Although colonoscopy as a screening strategy is often considered the “gold standard,” it has not yet been demonstrated to be more effective than FS in reducing mortality through detection of CRC (Neugut and Lebwohl 2010). A recent large, randomized trial in the United Kingdom found that the cumulative reduction in distal colon cancer incidence and mortality was 50% after one-time FS screening, with some case-control studies reporting this reduction to be as high as 70% (Atkin et al. 2010). The most serious complication during FS is perforation of the colon, which would usually require surgical repair (Horton et al. 2001); however, the rates of these complications are very low, at about one perforation per 10,000 procedures (Johnson 1999). The procedure requires less time to prepare for and perform than a colonoscopy, is safer owing to decreased risk of perforation as compared to colonoscopy, is less costly and can be undertaken without anaesthesia (NC Cancer Partnership 2007). According to the Canadian Credentialing Guidelines for Flexible Sigmoidoscopy, developed by the Canadian Association of Gastroenterology (CAG), colonoscopy is recommended if one or more adenomas are found, regardless of their size, or if a polyp is found that is greater than 1 centimetre in size (Enns et al. 2008). The removal of polyps smaller than 1 centimetre discovered during the FS procedure requires that the sigmoidoscopist be trained to biopsy the polyp. This requirement was addressed for the nurse FS project, a pilot project initiated in 2006 with the MOHLTC and Cancer Care Ontario, the first initiative of its kind in Canada. The project was launched in various cancer centres around the province to assess the impact and acceptability of this procedure as a method of CRC screening as performed by registered nurses (Green et al. 2010). At the time, the Ontario Task Force on Large Bowel Endoscopic Services determined that the Ontario Regulated Health Professions Act and the Nursing Act allowed biopsied polyps “by RNs (general class), for the purpose of assessment, to be within their scope of practice” (Dobrow 2007). According to the Canadian Partnership Against Cancer's (2010) watching brief on flexible sigmoidoscopy, criteria are still needed for referral to colonoscopy of persons in whom one or more polyps are found. Considerations – including physician supervision and availability, and malpractice issues – have not yet been completely resolved by regulatory bodies (Dobrow et al. 2007; CPAC 2010; OMA 2007). There is evidence to suggest that other healthcare practitioners, including registered nurses, may be trained to perform FS safely and competently (Lal et al. 2004; Rabeneck and Paszat 2003). The effectiveness of RNs in performing FS has also been shown in the United States with the Colon Cancer Prevention Program at the Kaiser Permanente Center for Health Research, in the United Kingdom with the National Health Service National Endoscopy Project and in Canada (Dobrow et al. 2007; Shapero et al. 2007). Schoenfeld and colleagues (1999b) found that there was no difference in detection of adenamatous polyps between nurse endoscopists and gastroenterologists. Complication rates for both endoscopists and RNs that have been appropriately trained have been found to be similar (Goodfellow 2006; Schoenfeld et al. 1999b). Experienced nurse endoscopists may perform screening FS as safely and as effectively as gastroenterologists (Schoenfeld et al. 1999b). Internationally, flexible sigmoidoscopy, along with FOBT and colonoscopy, is seen as an appropriate screening modality for CRC because it is a safe and well-endured procedure and can be performed by non-physician endoscopists (O'Brien et al. 2003; Terhaar Sive Droste et al. 2006; Winawer et al. 1990). Members of the nursing profession have successfully assumed this role in various jurisdictions, and have been supported by professional guidelines from both nursing bodies (Society of Gastroenterology Nurses and Associates Practice Committee in the United States) and medical societies (British Society of Gastroenterology Endoscopy Section Working Party) (O'Brien et al. 2003; Terhaar Sive Droste et al. 2006; Winawer et al. 1990; Arumugam et al. 2000; Basnyat et al. 2000; Goodfellow 2006). The issue of RN-performed FS is a timely one for Ontario for multiple reasons. First, recent investments by the provincial government, such as the ColonCancerCheck program (a mutual partnership between the Ministry of Health and Long-Term Care and Cancer Care Ontario), are aimed at increasing access to CRC screening; however, there is a risk that there are insufficient hospital-based resources to meet present needs (OMA 2007). Second, Health Force Ontario announced its commitment to the establishment of a new healthcare professional role – the registered nurse–performed flexible sigmoidoscopy (RNFS) – as a part of its health human resources strategy intended to help meet the province's screening objectives (OMA 2007). Pilot projects are underway in various cancer centres throughout Ontario, where nursing professionals, after receiving specialized education and participating in training procedures, perform flexible sigmoidoscopy procedures on eligible patients under physician supervision. Physician-related issues such as malpractice coverage, physician reimbursement for training and back-up and medical directives that allow RNs to perform the procedures still need to be addressed beyond the current pilot study setting (CPAC 2010). An on-call physician fee was incorporated into the model for this analysis to address these as of yet unresolved issues. Notwithstanding human resource constraints throughout the healthcare system, including the supply of nurses, we examine whether RN-performed flexible sigmoidoscopy is a viable option to increase the screening capacity in the province. Our study compares the cost of FS conducted by RNs relative to physicians (i.e., gastroenterologists, general surgeons, internists and family physicians) in Ontario.