An analysis of the learning curve to achieve competency at colonoscopy using the JETS database

Stephen Thomas Ward, Mohammed A Mohammed, Robert Walt, Roland Valori, Tariq Ismail, Paul Dunckley, Stephen Thomas Ward, Mohammed A Mohammed, Robert Walt, Roland Valori, Tariq Ismail, Paul Dunckley

Abstract

Objective: The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion.

Design: The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects.

Results: 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion.

Conclusions: This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

Keywords: Colonoscopy.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Figure 1
Figure 1
Study protocol. JETS, Joint Advisory Group endoscopy training system.
Figure 2
Figure 2
Mean moving average caecal intubation rate (CIR) against colonoscopy number (black line), plotted with 1 and 2 SDs of the mean. The mean CIR reached 90% at 233 colonoscopies.
Figure 3
Figure 3
Median number of colonoscopies required to achieve competency for those trainees defined as competent by the learning curve cumulative summation (LC-Cusum) method.
Figure 4
Figure 4
Scatterplot of the proportion of colonoscopies successfully completed against number of procedures performed, unadjusted intensity, adjusted intensity, number of different trainers and patient age.

References

    1. NHS Cancer Screening Programmes, Great Britain, National Health Service. Quality assurance guidelines for colonoscopy. Sheffield: NHS Cancer Screening Programmes, 2011.
    1. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97:1296–308.
    1. JAG Joint Advisory Group on GI Endoscopy. BSG Quality and Safety Indicators for Endoscopy. (accessed 7 Jan 2013).
    1. Brahmania M, Park J, Svarta S, et al. Incomplete colonoscopy: maximizing completion rates of gastroenterologists. Can J Gastroenterol 2012;26:589–92.
    1. Johna S, Klaristenfeld D. Surgery resident training in endoscopy: the saga continues. Arch Surg 2011;146:899–900.
    1. JAG—Certification Criteria. (accessed 16 Oct 2012).
    1. Lee S-H, Chung I-K, Kim S-J, et al. An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve. Gastrointest Endosc 2008;67:683–9.
    1. Selvasekar CR, Holubar SD, Pendlimari R, et al. Assessment of screening colonoscopy competency in colon and rectal surgery fellows: a single institution experience. J Surg Res 2012;174:e17–23.
    1. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319–24.
    1. Parry BR, Williams SM. Competency and the colonoscopist: a learning curve. Aust NZ J Surg 1991;61:419–22.
    1. Tassios PS, Ladas SD, Grammenos I, et al. Acquisition of competence in colonoscopy: the learning curve of trainees. Endoscopy 1999;31:702–6.
    1. Chung JI, Kim N, Um MS, et al. Learning curves for colonoscopy: a prospective evaluation of gastroenterology fellows at a single center. Gut Liver 2010;4:31–5.
    1. Marshall JB. Technical proficiency of trainees performing colonoscopy: a learning curve. Gastrointest Endosc 1995;42:287–91.
    1. Koch AD, Haringsma J, Schoon EJ, et al. Competence measurement during colonoscopy training: the use of self-assessment of performance measures. Am J Gastroenterol 2012;107:971–5.
    1. Sedlack RE. Training to competency in colonoscopy: assessing and defining competency standards. Gastrointest Endosc 2011;74:355–366.e2.
    1. Mehta T, Dowler K, McKaig BC, et al. Development and roll out of the JETS e-portfolio: a web based electronic portfolio for endoscopists. Frontline Gastroenterol 2011;2:35–42.
    1. Diggle P. Time series: a biostatistical introduction. Oxford University Press on Demand, 1990.
    1. Biau DJ, Williams SM, Schlup MM, et al. Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg 2008;95:925–9.
    1. Sibanda T, Sibanda N. The CUSUM chart method as a tool for continuous monitoring of clinical outcomes using routinely collected data. BMC Med Res Methodol 2007;7:46.
    1. Gombay E, Hussein AA, Steiner SH. Monitoring binary outcomes using risk-adjusted charts: a comparative study. Stat Med 2011;30:2815–26.
    1. Yap C-H, Colson ME, Watters DA. Cumulative sum techniques for surgeons: a brief review. ANZ J Surg 2007;77:583–6.
    1. Bolsin S, Colson M. The use of the Cusum technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 2000;12:433–8.
    1. Williams SM, Parry BR, Schlup MM. Quality control: an application of the cusum. BMJ 1992;304:1359–61.
    1. Noyez L. Control charts, Cusum techniques and funnel plots. A review of methods for monitoring performance in healthcare. Interact CardioVasc Thorac Surg 2009;9:494–9.
    1. Walker E, Nowacki AS. Understanding equivalence and noninferiority testing. J Gen Intern Med 2011;26:192–6.
    1. Thomas-Gibson S, Bassett P, Suzuki N, et al. Intensive training over 5 days improves colonoscopy skills long-term. Endoscopy 2007;39:818–24.
    1. Jorgensen JE, Elta GH, Stalburg CM, et al. Do breaks in gastroenterology fellow endoscopy training result in a decrement in competency in colonoscopy? Gastrointest Endosc 2013;78:503–9.
    1. Bowles CJA, Leicester R, Romaya C, et al. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004;53:277–83.
    1. Dafnis G, Granath F, Påhlman L, et al. Patient factors influencing the completion rate in colonoscopy. Dig Liver Dis 2005;37:113–8.
    1. Bates D, Maechler M, Bolker B. lme4: Linear mixed-effects models using S4 classes. 2012.
    1. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10.
    1. ABS Statement on GI Endoscopy/American Board of Surgery. (accessed 7 Aug 2013).
    1. Dunckley P, Elta G. Quality assurance of training. Best Pract Res Clin Gastroenterol 2011;25:397–407.
    1. Gavin DR, Valori RM, Anderson JT, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013;62:242–9.
    1. Parry BR, Goh H-S. Quality control in colonoscopy: a Singapore perspective. Int J Colorectal Dis 1993;8:139–41.
    1. Parry BR. Cusum: timely and trendy. ANZ J Surg 2007;77:523.
    1. Tsai M-S, Su Y-H, Liang J-T, et al. Patient factors predicting the completion of sedation-free colonoscopy. Hepatogastroenterology 2008;55:1606–8.
    1. Shah HA, Paszat LF, Saskin R, et al. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007;132:2297–303.
    1. Gupta M, Holub JL, Eisen G. Do indication and demographics for colonoscopy affect completion? A large national database evaluation. Eur J Gastroenterol Hepatol 2010;22:620–7.
    1. Shah SG, Brooker JC, Williams CB, et al. Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial. Lancet 2000;356:1718–22.
    1. Barton JR, Corbett S, van der Vleuten CP, et al. The validity and reliability of a Direct Observation of Procedural Skills assessment tool: assessing colonoscopic skills of senior endoscopists. Gastrointest Endosc 2012;75:591–7.
    1. Naeem N. Validity, reliability, feasibility, acceptability and educational impact of direct observation of procedural skills (DOPS). J Coll Physicians Surg Pak 2013;23:77–82.
    1. Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. JAMA 2009;302:1316–26.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj