how should we establish the clinical case numbers required to achieve proficiency in flexible...
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How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy?
Melina C. Vassiliou, MD, M.Ed, FRCSCBenjamin K Poulose MD, Pepa A Kaneva MSc, Brian J Dunkin MD, Jeffrey M Marks MD, Riadh Sadik MD, Gideon Sroka MD, Stephen D Pooler MD, Klaus Thaler MD, Gina L Adrales MD, Jeffrey W Hazey MD, Jenifer R Lightdale MD, Vic Velanovich MD ,Lee L. Swanstrom MD, John D Mellinger MD, Gerald M Fried MD
Flexible endoscopy is a necessary part of the general surgery curriculum
• Flexible endoscopy: important skill for GI & community surgeons
• Retrospective review of 5 surgeons: 54% of procedures were flex endo
• Survey of PD in 2000: 60% of programs have formal endoscopy rotations, only 33.3% by fellowship trained instructors
• Increased requirements for surgical trainees (35 EGDs and 50 colos)
1- Nimeri AA, Hussein SA, Panzeter E, et al. The economic impact of incorporating flexible endoscopy into a community general surgery practice. Surg Endosc 2005; 19(5):702-4.2- Marks JM, Nussbaum MS, Pritts TA, et al. Evaluation of endoscopic and laparoscopic training practices in surgical residency programs. Surg Endosc 2001; 15(9):1011-5
How many cases are needed to achieve proficiency?
• Case #’s as a surrogate for proficiency• ASGE - 130 EGDs & 140 colos (90% esophageal &
pyloric/splenic flex &cecum)• Surgical study: no correlation between #’s and
completion/complications• Another study – only 50 colonoscopies needed for
90% completion rate1. Cass OW, Freeman ML, Cohen J, et al. Acquisition of competency in endoscopic skills (ACES) during training: a multicenter study
[abstract]. Gastrointest Endosc 1995;41:3172. Reed WP, Kilkenny JW, Dias CE, Wexner SD. A prospective analysis of 3525 esophagogastroduodenoscopies performed by surgeons.
Surg Endosc 2004;18:11-21.3. Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc
2001;15:251-61.
GAGESGlobal Assessment of Gastrointestinal
Endoscopic Skills• Created by expert
endoscopists• Multicenter study
demonstrated interrater reliability, internal consistency and construct validity
1- Intubation of the esophagus
2- Scope Navigation
3- Ability to keep a clear endoscopic field
4-Instrumentation
5- Quality of the Examination
1- Intubation of the esophagus
2- Scope Navigation
3- Ability to keep a clear endoscopic field
4-Instrumentation
5- Quality of the Examination
GAGES- Upper endoscopy
consists of 5 items scored on a
Likert scale
Interrater Reliability: 0.96 (0.90-0.99)
Internal Consistency: 0.89 (n=82)
1- Scope Navigation
2- Use of Strategies
3- Ability to keep a clear endoscopic field
4-Instrumentation
5- Quality of the Examination
1- Scope Navigation
2- Use of Strategies
3- Ability to keep a clear endoscopic field
4-Instrumentation
5- Quality of the Examination
GAGES- Colonoscopy consists of 5
items scored on Likert scale
Interrater Reliability: 0.97 (0.92-0.99)
Internal Consistency: 0.95 (n=57)
The purpose of this study was to:
• Challenge the current case number recommendations and methods by which proficiency in flexible endoscopy is determined
• Use GAGES to help define proficiency in flexible endoscopy
Methods
• IRB approved 11 institutions in Europe and NA• Demographic information• Participants from surgery and
gastroenterology• Scored by attending during routine upper
endoscopy and/or colonoscopy
Data Analysis
• For Upper endoscopy: 3 groups compared using ANOVA (Tukey post-hoc analysis) <35, >35<130, >130
• GAGES –C scores compared for different case cut-offs (T-test): >50 versus >140
• Scores plotted against case numbers to identify plateau
Results: The participants
139 evaluations, 11 centers
Demographic Percentage of total cohort
Dominant Hand 96% RightDiscipline 62 % surgeons; 38% GISex 79% male
GAGES upper endoscopy
GAGES Upper group Mean score ±SD
<35 n=35 14.4 ±3.7 NS
>35 & <130 n=22 17.8 ±1.8 P<0.05
>130 n=29 19.1 ±1.1 P<0.05
There is no difference between groups 2 and 3Both groups 2 and 3 are significantly different compared to group 1
1
2
3
Both groupings show statistically significant differences between novice and experienced
colonoscopists
GAGES -C Novice (95%CI) Experienced (95%CI) p-value
Novice <50 n=29 11.8 (10.3-13.2)
n=28 18.8 (18.3-19.3) p<0.001
Novice <140 n=32 12.4(10.9-14.0)
n=25 18.8 (18.8-19.3) p<0.001
NS NS
Scores plateau at ~ 50 cases for upper endoscopy
Upper Endoscopy Case numbers
Tota
l GAG
ES-U
pper
Sco
re
Scores seem to plateau at ~ 100 cases for colonoscopy
Colonoscopy Case numbers
Tota
l GAG
ES C
olon
osco
py S
core
Summary- Upper endoscopy
• For upper endoscopy, participants with 35-130 previous cases perform similarly to those with >130 cases
• Both of these groups perform better than those with less than 35 cases
• Performance as measured by GAGES seems to plateau at the 50 case level for upper endoscopy
Summary- Colonoscopy
• There was no difference in performance when the cut-off was set a 50 cases or at 140 cases
• We do not have enough data for the “intermediate” group
• Performance measured by GAGES plateaus at ~ 100 cases
Discussion & Limitations
• Still not enough data in the intermediate group
• We have not yet determined what the “passing score” for GAGES should be
• ROC – sensitivity and specificity• Ceiling effect
In Conclusion
• Current case recommendations may not represent what is needed for proficiency
• GAGES scores may help to define proficiency in basic flexible endoscopy
• Clinical numbers needed to achieve proficiency may vary from one learner to another
• GAGES may be a valuable tool to measure outcomes of training strategies and to provide feedback to learners
Acknowledgements:Members of the FES committeeLisa Jukelevics, Carla Bryant & Sarah ColonParticipants and contributors from all of the institutions