Competence and quality assessment: the future of training in GI endoscopy

__Abstract__ __Introduction__: Training procedural skills in gastrointestinal endoscopy once focused on threshold numbers. However, as threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training program. __Aims__: The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Secondly, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Thirdly, we aimed to propose a structured training curriculum based on the presented evidence. __Method__s: A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round. __Results__: The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programs for gastrointestinal endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 RCT’s. Increased performance on a virtual reality simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Simulator-based performance did not reflect competence in patientbased endoscopy. Eight out of fourteen studies on colonoscopy, ERCP and EUS reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for gastrointestinal endoscopy provided insight in performance of endoscopists. Five out of seven studies proved that intense training programs result in good performance. __Conclusions__: The use of validated virtual reality simulators in the early training setting accelerates learning of practical skills. Learning curves are valuable for continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in gastrointestinal endoscopy. A complete curriculum with assessment of competence throughout training needs to be developed for all gastrointestinal endoscopy procedures

Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data? A retrospective cohort study

OBJECTIVE: To develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation.STUDY DESIGN: Retrospective analysis of collected data from hospital information systems combined with clinical indicator definitions to define and compare short-term outcomes for three gastrointestinal pathways using the concept of Textbook Outcome.SETTING: 62 Dutch hospitals.PARTICIPANTS: 45 848 unique gastrointestinal patients discharged in 2015.MAIN OUTCOME MEASURE: A broad range of clinical outcomes including length of stay, reintervention, readmission and doctor-patient counselling.RESULTS: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease (n=4369), colonoscopy for inflammatory bowel disease (IBD; n=19 330) and colonoscopy for colorectal cancer screening (n=22 149) were submitted to five suitable clinical indicators per treatment. The percentage of all patients who met all five criteria was 54%±9% (SD) for ERCP treatment. For IBD this was 47%±7% of the patients, and for colon cancer screening this number was 85%±14%.CONCLUSION: This study shows that reusing data obtained from hospital information systems combined with clinical indicator definitions can be used to express short-term outcomes using the concept of Textbook Outcome without any excess registration. This information can provide meaningful insight into the clinical care trajectory on the level of individual patient care. Furthermore, this concept can be applied to many clinical trajectories within gastroenterology and beyond for monitoring and improving the clinical pathway and outcome for patients