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

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

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

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

Overview on practices in thalassemia intermedia management aiming for lowering complication rates across a region of endemicity : the OPTIMAL CARE study

Despite recent advances in understanding the pathophysiologic mechanisms behind the thalassemia intermedia (TI) phenotype, data on the effects of treatment are deficient. To provide such data, we evaluated 584 TI patients for the associations between patient and disease characteristics, treatment received, and the rate of complications. The most common disease-related complications were osteoporosis, extramedullary hematopoeisis (EMH), hypogonadism, and cholelithiasis, followed by thrombosis, pulmonary hypertension (PHT), abnormal liver function, and leg ulcers. Hypothyroidism, heart failure, and diabetes mellitus were less frequently observed. On multivariate analysis, older age and splenectomy were independently associated with an increased risk of most disease-related complications. Transfusion therapy was protective for thrombosis, EMH, PHT, heart failure, cholelithiasis, and leg ulcers. However, transfusion therapy was associated with an increased risk of endocrinopathy. Iron chelation therapy was in turn protective for endocrinopathy and PHT. Hydroxyurea treatment was associated with an increased risk of hypogonadism yet was protective for EMH, PHT, leg ulcers, hypothyroidism, and osteoporosis. Attention should be paid to the impact of age on complications in TI, and the beneficial role of splenectomy deserves revisiting. This study provides evidence that calls for prospective evaluation of the roles of transfusion, iron chelation, and hydroxyurea therapy in TI patients

A prospective multicenter study evaluating EUS and ERCP competence during advanced endoscopy training and subsequent independent practice: The rapid assessment of trainee endoscopy skills (rates2) study.

Background: We have shown that AETs achieve EUS and ERCP competence at varying rates, validating the shift from defining competence based on an absolute number of procedures to well-defined metrics. However, there are no data to confirm that advanced endoscopy trainees (AETs) who achieve competence during training subsequently perform high quality EUS and ERCP in their 1st year of independent practice. Aims: To report the outcomes of AETs during their 1st year of independent practice using ASGE established quality indicator (QI) thresholds To measure the relationship between achieving competence benchmarks during training and reported outcomes during independent practice. Methods: ASGE recognized advanced endoscopy training programs (AETPs) were invited to participate. In Phase I, AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCPs using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves using cumulative sum (CUSUM) analysis. Learning curves were created using CUSUM for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable (Table presented) failures rates were set a priori and AETs with \u3c20 evaluations were excluded. During Phase II, AETs provided QI performance data on all EUS and ERCP procedures during the 1st year of independent practice. Results: Of the 62 programs invited, 37 AETs from 32 AETPs participated in this study and 24 AETs were included in the final analysis (Phase I). At the end of training, median number of EUS and ERCPs performed/ AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP-biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (70%) and ERCPs for ASGE biliary grade of difficulty 1 (72.1%). Majority of trainees achieved overall technical (EUS: 91.6%; ERCP: 73.9%) and cognitive (EUS: 91.6%, ERCP: 95.6%) competence at conclusion of training (Table 1). 22 of 24 AETs participated in (Phase II) and median EUS and ERCP procedures completed in independent practice/AET were 136 (IQR 102-204) and 116 (48-169), respectively. Table 2 highlights QI performance in EUS and ERCP during Phase II. Majority of AETs crossed the QI threshold for obtaining adequate samples (overall rate: 94.4%), diagnostic yield of malignancy (83.8%), and cannulation rates overall (94.9%) and native papilla cases (93.1%). Conclusions: Majority of AETs achieved EUS and ERCP competence by the end of training. Moreover, these AETs achieved QI thresholds for routine EUS and ERCP during their 1st year of independent practice, affirming the effectiveness of AETPs

Setting minimum standards for training in EUS and ERCP: Results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees (AETS).

Background: Despite the dramatic increase in advanced endoscopy training programs (AETPs), there is no fixed mandatory curriculum and minimal standards as to what constitutes a “high quality” AETP has not been defined. Understanding the mean number of procedures required to achieve competence in all aspects of EUS and ERCP would help structure AETPs. Aims: To define the mean number of procedures required by an “average” AET to achieve competence in technical and cognitive EUS and ERCP tasks. Methods: ASGE recognized AETPs were invited and AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCP exams using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves (LCs) using cumulative sum (CUSUM) analysis for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable failures rates were set a priori. In order to generate aggregate CUSUM LCs across AETs, we used generalized linear mixed effects models with a random intercept for each AET and an AR1 covariance structure. This allowed us to use data from all AETs to estimate the average learning experience for trainees with 95% CIs. We then fit a spline to the modeled estimates with knots at 40 and 80 evaluations to smooth the results and estimate the mean number of procedures needed to achieve competence. Results: Of the 62 AETPs invited, 37 AETs from 32 AETPs participated in this study; 24 AETs were included in the final analysis. Prior to AETP, 52% reported hands-on EUS (median 20 cases) and 68% hands-on ERCP (median 50 cases) experience prior to AETP. At the end of training, median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP-biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (69.9%) and ERCP exams for ASGE biliary grade of difficulty 1 (72.1%). Table 1 highlights the substantial variability in EUS and ERCP learning curves. The majority of trainees achieved overall technical (EUS: 91.7%; ERCP: 73.9%) and cognitive (EUS: 91.7%, ERCP: 95.7%) competence at the end of training. Table 1 and Figure highlight the number of procedures required by an average AET to achieve competence in all aspects of EUS and ERCP. Conclusions: The results of this study confirm the substantial variability in achieving competence in EUS and ERCP. The thresholds provided for an average AET to achieve competence in EUS (w225 cases) and ERCP (w250) may be used by ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training

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

Background & aimsIt 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.MethodsWe 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.ResultsBy 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).ConclusionsIn 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

Sisymbrium altissimum Asso (BR0000010459645)

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