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.

Keywords: Advanced Endoscopy Training; Learning Curves; Quality Indicators; The EUS and ERCP Skills Assessment Tool (TEESAT).

Figure 1.

Learning curves of individual trainees achieving and those not achieving competence for the end point of overall ERCP and EUS technical competence. Learning curves were made with CUSUM analysis using median scores for overall technical and cognitive aspects of biliary ERCP and EUS (a positive deflection indicates an incompetent result [score of 3 or 4] and a negative deflection represents a competent result [score of 1 or 2]).

Figure 2.

Learning curves of individual trainees achieving competence for individual end points in ERCP. Graphical representation shows learning curves for cannulation overall, cannulation of NP cases, stone clearance, and sphincterotomy. Learning curves were made with CUSUM analysis using scores for individual end points (a positive deflection indicates an incompetent result [score of 3 or 4] and a negative deflection represents a competent result [score of 1 or 2]). NP, native papilla.