Knowledge of quality performance measures associated with endoscopy among gastroenterology trainees and the impact of a web-based intervention

E-learning for health professionals

BACKGROUND

The use of e-learning, defined as any educational intervention mediated electronically via the Internet, has steadily increased among health professionals worldwide. Several studies have attempted to measure the effects of e-learning in medical practice, which has often been associated with large positive effects when compared to no intervention and with small positive effects when compared with traditional learning (without access to e-learning). However, results are not conclusive.

OBJECTIVES

To assess the effects of e-learning programmes versus traditional learning in licensed health professionals for improving patient outcomes or health professionals' behaviours, skills and knowledge.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and three trial registers up to July 2016, without any restrictions based on language or status of publication. We examined the reference lists of the included studies and other relevant reviews. If necessary, we contacted the study authors to collect additional information on studies.

SELECTION CRITERIA

Randomised trials assessing the effectiveness of e-learning versus traditional learning for health professionals. We excluded non-randomised trials and trials involving undergraduate health professionals.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias. We graded the certainty of evidence for each outcome using the GRADE approach and standardised the outcome effects using relative risks (risk ratio (RR) or odds ratio (OR)) or standardised mean difference (SMD) when possible.

MAIN RESULTS

We included 16 randomised trials involving 5679 licensed health professionals (4759 mixed health professionals, 587 nurses, 300 doctors and 33 childcare health consultants).When compared with traditional learning at 12-month follow-up, low-certainty evidence suggests that e-learning may make little or no difference for the following patient outcomes: the proportion of patients with low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL (adjusted difference 4.0%, 95% confidence interval (CI) -0.3 to 7.9, N = 6399 patients, 1 study) and the proportion with glycated haemoglobin level of less than 8% (adjusted difference 4.6%, 95% CI -1.5 to 9.8, 3114 patients, 1 study). At 3- to 12-month follow-up, low-certainty evidence indicates that e-learning may make little or no difference on the following behaviours in health professionals: screening for dyslipidaemia (OR 0.90, 95% CI 0.77 to 1.06, 6027 patients, 2 studies) and treatment for dyslipidaemia (OR 1.15, 95% CI 0.89 to 1.48, 5491 patients, 2 studies). It is uncertain whether e-learning improves or reduces health professionals' skills (2912 health professionals; 6 studies; very low-certainty evidence), and it may make little or no difference in health professionals' knowledge (3236 participants; 11 studies; low-certainty evidence).Due to the paucity of studies and data, we were unable to explore differences in effects across different subgroups. Owing to poor reporting, we were unable to collect sufficient information to complete a meaningful 'Risk of bias' assessment for most of the quality criteria. We evaluated the risk of bias as unclear for most studies, but we classified the largest trial as being at low risk of bias. Missing data represented a potential source of bias in several studies.

AUTHORS' CONCLUSIONS

When compared to traditional learning, e-learning may make little or no difference in patient outcomes or health professionals' behaviours, skills or knowledge. Even if e-learning could be more successful than traditional learning in particular medical education settings, general claims of it as inherently more effective than traditional learning may be misleading.

Colonoscopy procedural volume increases adenoma and polyp detection rates in gastroenterologytrainees

AIM

To investigate changes in polyp detection throughout fellowship training, and estimate colonoscopy volume required to achieve the adenoma detection rate (ADRs) and polyp detection rate (PDRs) of attending gastroenterologists.

METHODS

We reviewed colonoscopies from July 1, 2009 to June 30, 2014. Fellows’ procedural logs were used to retrieve colonoscopy procedural volumes, and these were treated as the time variable. Findings from screening colonoscopies were used to calculate colonoscopy outcomes for each fellow for the prior 50 colonoscopies at each time point. ADR and PDR were plotted against colonoscopy procedural volumes to produce individual longitudinal graphs. Repeated measures linear mixed effects models were used to study the change of ADR and PDR with increasing procedural volume.

RESULTS

During the study period, 12 fellows completed full three years of training and were included in the analysis. The average ADR and PDR were, respectively, 31.5% and 41.9% for all fellows, and 28.9% and 38.2% for attendings alone. There was a statistically significant increase in ADR with increasing procedural volume (1.8%/100 colonoscopies, P = 0.002). Similarly, PDR increased 2.8%/100 colonoscopies (P = 0.0001), while there was no significant change in advanced ADR (0.04%/100 colonoscopies, P = 0.92). The ADR increase was limited to the right side of the colon, while the PDR increased in both the right and left colon. The adenoma per colon and polyp per colon also increased throughout training. Fellows reached the attendings’ ADR and PDR after 265 and 292 colonoscopies, respectively.

CONCLUSION

We found that the ADR and PDR increase with increasing colonoscopy volume throughout fellowship. Our findings support recent recommendations of ≥ 275 colonoscopies for colonoscopy credentialing.

Learning curve for endoscopy training: Is it all about numbers?

Endoscopy training is an important component of postgraduate gastroenterology and general surgery programs. Proficiency in endoscopy requires the development of several tangible and intangible skills. Much attention has traditionally been paid to establishing a threshold, or minimum procedural volume during the training period, which is necessary for a trainee to achieve competence in endoscopy by the conclusion of his or her program. However, despite several attempts to characterize this target, it has become clear in recent years that training programs need to consider other factors rather than relying on this measure as the sole marker of trainee competency. Here, we present a review of general concepts in endoscopy skills acquisition that affect the learning curve, the evolving definition of competency as it relates to procedural volume, the role of simulation in endoscopy training, and the concept of massed versus spaced delivery of endoscopy training.

A Review on the Quality of Colonoscopy Reporting

Colonoscopy reports are important communication tools for providers and patients with potential to serve as information sources for research, quality, performance, and resource management. Despite decades of work, studies continue to indicate that colonoscopy reports are often incomplete. Although electronic medical records (EMRs) and databases can address this problem, costs, workflow, and interoperability (difficulty exchanging information between systems) continue to limit adoption and implementation of endoscopy EMRs in Canada and elsewhere. Quality and reporting guidelines alone have proven to be insufficient. In this review we have derived and applied five key themes to challenges in the current state of colonoscopy reporting and propose strategies to address them.

Achieving competence in colonoscopy: Milestones and the need for a new endoscopic curriculum in gastroenterology training

Colonoscopy is considered to be the most effective tool for reducing colorectal cancer (CRC) morbidity and mortality. As a result, certifying trainee competence in the performance of colonoscopy is critical to maximizing CRC screening and prevention efforts. Guidelines on training and accreditation around the world have been revised to emphasize the attainment of milestones in the technical and cognitive skills necessary to perform the procedure. To meet this challenge, new evaluation systems have been developed to measure trainee competence through all aspects of colonoscopy training. These changes stem from increased recognition that procedural numbers alone do not necessarily guarantee trainees’ proficiency in the performance of colonoscopy. Variability in endoscopic practice and in CRC screening outcomes also point to deficiencies in the current approach towards colonoscopy instruction. However, technological innovations hold great promise in training endoscopists to perform high quality colonoscopy. Furthermore, potential advances in the use of feedback as a training tool provide new avenues for research. This review summarizes the latest evidence on the effort to define, evaluate and promote the achievement of competence in colonoscopy among trainees.

Influence of colonoscopy quality measures on patients' colonoscopist selection

OBJECTIVES

The Affordable Care Act emphasizes the use of quality metrics and greater patient understanding of health-care options and access to physician performance data. The objectives of this study were to determine patients' familiarity with colonoscopy quality measures (CQMs) and their influence on patient selection of a colonoscopist.

METHODS

A prospective survey of patients before screening or surveillance colonoscopy at university hospital, community hospital, and ambulatory procedure center endoscopy units was performed from 2011 to 2012.

RESULTS

Among the 417 participants, 20% (85/417) researched their physician's rating. The rates of familiarity with CQM were 88 % (353/402) for adequate bowel preparation, 30% (118/398) for adenoma detection rate (ADR), 26% (102/397) for cecal intubation rate, and 21% (82/394) for greater-than-6-min withdrawal time. Ninety-six percent (366/386) believed that colonoscopists' reporting of ADR to other physicians was important or very important. In selecting a colonoscopist, primary care provider referral was ranked as the first or second-most important of four factors in 87% (339/391). Even among patients who responded "it is very important" to report CQM to other doctors and patients, none ranked CQM as the most important factor in selecting a colonoscopist.

CONCLUSIONS

Patient awareness of CQM, other than adequate bowel preparation, was low. Quality measure reporting is important to patients, but primary care provider referral was the most important factor in colonoscopist selection. This suggests that primary care providers, as well as patients, are important to include in educational strategies regarding quality metrics.

Validity of a Web-based educational program to disseminate a standardized bowel preparation rating scale

GOALS

Our goal was to assess the validity of a Web-based educational program on the Boston Bowel Preparation Scale (BBPS).

BACKGROUND

Data on Web-based education for improving the practice and quality of colonoscopy are limited.

STUDY

Endoscopists worldwide participated in the BBPS Educational Program. We assessed program completion rates, satisfaction, short-term (0 to 90 d) and long-term (91 to 180 d) uptake of the BBPS, and the validity of the program by measuring the reliability of the BBPS among participants.

RESULTS

A total of 207 endoscopists completed the program. Overall, 93% found the content relevant, 89% felt confident in using the BBPS, and 97% thought the quality was good or excellent. Uptake of the BBPS into clinical practice was robust with 91% and 98% of colonoscopy reports containing the BBPS at short-term and long-term follow-up, respectively. The interobserver and test-retest reliability of BBPS segment and total scores were both substantial.

CONCLUSIONS

A BBPS Web-based educational program facilitates adoption into clinical practice and teaches the BBPS to be used reliably by a diverse group of endoscopists worldwide.