Setting minimum standards for training in EUS and ERCP: Results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees (AETS).
Wani SB, Han S, Simon VC, Hall M, Early D, Aagaard E, Carlin L, Ellert S, Abidi WM, Baron TH, Brauer BC, Chatrath H, Cote GA, Das KK, DiMaio CJ, Edmundowicz SA, El Hajj II, Hammad HT, Jalaj S, Kochman ML, Komanduri S, Lee LS, Mullady D, Raman Muthusamy V, Nett AS, Olyaee MS, Pakseresht K, Perera P, Pfau P, Piraka C, Rastogi A, Shah RJ, Sharma R, Scheiman JM, Tabibian JH, Uppal D, Urayama S, Wang AY, Zuchelli T, Bowman E, Lang G, Loren DE, El Chafic AH, Yachimski P, Gamboa A, Poneros JM, Wassef W, Sohail M, Stevens T, Confer B, Guda NM, Ian Gan S, Razzak A, Gordon SR, Ferriera J, Banerjee S, Choudhary A, Dries AM, Buscaglia JM, Tzimas D, Zepeda-Gomez S, Kenshil S, Lukens F, Bartel M, Jowell P, Spaete JP, Riff B, Harris C, Saligram S, Gannavarapu B, Chak A, Singh A, and Keswani RN. Setting minimum standards for training in EUS and ERCP: Results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees (AETS). Gastrointest Endosc 2018; 87(6):AB109.
Background: Despite the dramatic increase in advanced endoscopy training programs (AETPs), there is no fixed mandatory curriculum and minimal standards as to what constitutes a “high quality” AETP has not been defined. Understanding the mean number of procedures required to achieve competence in all aspects of EUS and ERCP would help structure AETPs. Aims: To define the mean number of procedures required by an “average” AET to achieve competence in technical and cognitive EUS and ERCP tasks. Methods: ASGE recognized AETPs were invited and AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCP exams using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves (LCs) using cumulative sum (CUSUM) analysis for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable failures rates were set a priori. In order to generate aggregate CUSUM LCs across AETs, we used generalized linear mixed effects models with a random intercept for each AET and an AR1 covariance structure. This allowed us to use data from all AETs to estimate the average learning experience for trainees with 95% CIs. We then fit a spline to the modeled estimates with knots at 40 and 80 evaluations to smooth the results and estimate the mean number of procedures needed to achieve competence. Results: Of the 62 AETPs invited, 37 AETs from 32 AETPs participated in this study; 24 AETs were included in the final analysis. Prior to AETP, 52% reported hands-on EUS (median 20 cases) and 68% hands-on ERCP (median 50 cases) experience prior to AETP. At the end of training, median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP-biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (69.9%) and ERCP exams for ASGE biliary grade of difficulty 1 (72.1%). Table 1 highlights the substantial variability in EUS and ERCP learning curves. The majority of trainees achieved overall technical (EUS: 91.7%; ERCP: 73.9%) and cognitive (EUS: 91.7%, ERCP: 95.7%) competence at the end of training. Table 1 and Figure highlight the number of procedures required by an average AET to achieve competence in all aspects of EUS and ERCP. Conclusions: The results of this study confirm the substantial variability in achieving competence in EUS and ERCP. The thresholds provided for an average AET to achieve competence in EUS (w225 cases) and ERCP (w250) may be used by ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training.