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Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

ABSTRACT: BACKGROUND & AIMS:It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS:We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS:By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS:In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

SUBMITTER: Wani S

PROVIDER: S-EPMC6504935 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

Wani Sachin S Keswani Rajesh N RN Han Samuel S Aagaard Eva M EM Hall Matthew M Simon Violette V Abidi Wasif M WM Banerjee Subhas S Baron Todd H TH Bartel Michael M Bowman Erik E Brauer Brian C BC Buscaglia Jonathan M JM Carlin Linda L Chak Amitabh A Chatrath Hemant H Choudhary Abhishek A Confer Bradley B Coté Gregory A GA Das Koushik K KK DiMaio Christopher J CJ Dries Andrew M AM Edmundowicz Steven A SA El Chafic Abdul Hamid AH El Hajj Ihab I Ellert Swan S Ferreira Jason J Gamboa Anthony A Gan Ian S IS Gangarosa Lisa M LM Gannavarapu Bhargava B Gordon Stuart R SR Guda Nalini M NM Hammad Hazem T HT Harris Cynthia C Jalaj Sujai S Jowell Paul S PS Kenshil Sana S Klapman Jason J Kochman Michael L ML Komanduri Srinadh S Lang Gabriel G Lee Linda S LS Loren David E DE Lukens Frank J FJ Mullady Daniel D Muthusamy V Raman VR Nett Andrew S AS Olyaee Mojtaba S MS Pakseresht Kavous K Perera Pranith P Pfau Patrick P Piraka Cyrus C Poneros John M JM Rastogi Amit A Razzak Anthony A Riff Brian B Saligram Shreyas S Scheiman James M JM Schuster Isaiah I Shah Raj J RJ Sharma Rishi R Spaete Joshua P JP Singh Ajaypal A Sohail Muhammad M Sreenarasimhaiah Jayaprakash J Stevens Tyler T Tabibian James H JH Tzimas Demetrios D Uppal Dushant S DS Urayama Shiro S Vitterbo Domenico D Wang Andrew Y AY Wassef Wahid W Yachimski Patrick P Zepeda-Gomez Sergio S Zuchelli Tobias T Early Dayna D

Gastroenterology 20180726 5

<h4>Background & aims</h4>It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.<h4>Methods</h4>We performed a prospective multicenter cohort study o ...[more]

PMID: 30056094

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Project description:Background & aimsCholecystectomy (CCY) after an episode of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction reduces recurrent biliary events compared to expectant management. We studied practice patterns for performance of CCY after ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.MethodsWe conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days after discharge from index admission.ResultsOf the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P < .001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P < .001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P < .001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.ConclusionsIn a retrospective analysis of >4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed after ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow-up, particularly among patients who are ethnic minorities or have little or no health insurance.

Dataset Information

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

Publications

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

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