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. 2023 Mar 1;8(3):248-256.
doi: 10.1001/jamacardio.2022.5016.

Effectiveness of Simulation-Based Training on Transesophageal Echocardiography Learning: The SIMULATOR Randomized Clinical Trial

Théo Pezel  1   2   3 , Julien Dreyfus  4 , Basile Mouhat  5 , Clémence Thébaut  6 , Etienne Audureau  7 , Anne Bernard  8   9   10 , Yoan Lavie Badie  11 , Yohann Bohbot  12   13   14 , Damien Fard  15 , Lee S Nguyen  16 , Cécile Monteil  2 , Loïc Bière  17 , Florent Le Ven  18   19 , Marjorie Canu  20 , Sophie Ribeyrolles  21 , Baptiste Mion  22 , Baptiste Bazire  23 , Charles Fauvel  24   25 , Jennifer Cautela  26 , Théo Cambet  27 , Thierry Le Tourneau  28 , Erwan Donal  29 , Stéphane Lafitte  30 , Julien Magne  31 , Nicolas Mansencal  32   33 , Augustin Coisne  34   35   36 ; SIMULATOR investigators
Collaborators, Affiliations

Effectiveness of Simulation-Based Training on Transesophageal Echocardiography Learning: The SIMULATOR Randomized Clinical Trial

Théo Pezel et al. JAMA Cardiol. .

Abstract

Importance: Evidence is scarce on the effectiveness of simulation-based training in transesophageal echocardiography (TEE).

Objective: To assess the effectiveness of simulation-based teaching vs traditional teaching of TEE knowledge and skills of cardiology fellows.

Design, setting, and participants: Between November 2020 and November 2021, all consecutive cardiology fellows inexperienced in TEE from 42 French university centers were randomized (1:1; n = 324) into 2 groups with or without simulation support.

Main outcomes and measures: The co-primary outcomes were the scores in the final theoretical and practical tests 3 months after the training. TEE duration and the fellows' self-assessment of their proficiency were also assessed.

Results: While the theoretical and practical test scores were similar between the 2 groups (324 participants; 62.6% male; mean age, 26.4 years) before the training (33.0 [SD, 16.3] points vs 32.5 [SD, 18.5] points; P = .80 and 44.2 [SD, 25.5] points vs 46.1 [SD, 26.1] points; P = .51, respectively), the fellows in the simulation group (n = 162; 50%) displayed higher theoretical test and practical test scores after the training than those in the traditional group (n = 162; 50%) (47.2% [SD, 15.6%] vs 38.3% [SD, 19.8%]; P < .001 and 74.5% [SD, 17.7%] vs 59.0% [SD, 25.1%]; P < .001, respectively). Subgroup analyses showed that the effectiveness of the simulation training was even greater when performed at the beginning of the fellowship (ie, 2 years or less of training) (theoretical test: an increase of 11.9 points; 95% CI, 7.2-16.7 vs an increase of 4.25 points; 95% CI, -1.05 to 9.5; P = .03; practical test: an increase of 24.9 points; 95% CI, 18.5-31.0 vs an increase of 10.1 points; 95% CI, 3.9-16.0; P < .001). After the training, the duration to perform a complete TEE was significantly lower in the simulation group than in the traditional group ( 8.3 [SD, 1.4] minutes vs 9.4 [SD, 1.2] minutes; P < .001, respectively). Additionally, fellows in the simulation group felt more ready and more confident about performing a TEE alone after the training (mean score, 3.0; 95% CI, 2.9-3.2 vs mean score, 1.7; 95% CI, 1.4-1.9; P < .001 and mean score, 3.3; 95% CI, 3.1-3.5 vs mean score, 2.4; 95% CI, 2.1-2.6; P < .001, respectively).

Conclusions and relevance: Simulation-based teaching of TEE showed a significant improvement in the knowledge, skills, and self-assessment of proficiency of cardiology fellows, as well as a reduction in the amount of time needed to complete the examination. These results should encourage further investigation of clinical performance and patient benefits of TEE simulation training.

Trial registration: ClinicalTrials.gov NCT05564507.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bernard reported personal fees from Abbott Medical, General Electric Healthcare, Bristol Myers Squibb/Pfizer, and Novartis outside the submitted work. Dr Lavie Badie reported personal fees from General Electric outside the submitted work. Dr Le Ven reported consultant fees from General Electric outside the submitted work. Dr Fauvel reported personal fees from Janssen and grants from Pfizer outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of the Study
Among the 385 cardiology fellows planned for recruitment, 369 fellows were assessed for eligibility in 42 French centers. Forty-five fellows were excluded from the study: 40 had already performed a transesophageal echocardiography (TEE) alone and 5 declined to participate. A total of 324 fellows were randomized with a stratification by center. Among the 162 fellows assigned to the simulation group, 11 had protocol violation, 7 had only 1 simulation session, and 4 did not have simulation session.
Figure 2.
Figure 2.. Final Tests Score 3 Months After the Training in the Transesophageal Echocardiography (TEE) Simulation Group and in the Traditional Group
The fellows in the simulation group displayed higher final theoretical test (47.2 [SD,15.6] points vs 38.3 [SD, 19.8] points; P < .001) (A) practical test (74.5 [SD, 17.7] points vs 59.0 [SD, 25.1] points; P < .001) (B) and global test score (121.6 [SD, 25.3] points vs 97.3 [SD, 38.8] points; P < .001) (C) P value by t test. The median value was used as a cutoff for age (median, 26 years). Number of TTEs previously performed was divided in 3 groups (less than 50, 50 to 100 and more than 100), as well as the number of TEEs previously observed (less than 5, 5 to 20, more than 20). The pretraining test score was divided in terciles.
Figure 3.
Figure 3.. Subgroup Analysis
TEE indicates transesophageal echocardiography.
Figure 4.
Figure 4.. Change in Self-assessment of Proficiency of Fellows
Each question was graded from 1 (lower grade) to 5 (higher grade). P values by χ2 for trend or paired t test. TEE indicates transesophageal echocardiography.
See this image and copyright information in PMC

Comment in

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