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Kaltenbach T, Patel SG, Nguyen-Vu T, Malvar C, Keswani RN, Hall M, Aagaard E, Asokkumar R, Chin YK, Hammad H, Rastogi A, Shergill A, Simon V, Soetikno A, Soetikno R, Wani S. Varied Trainee Competence in Cold Snare Polypectomy: Results of the COMPLETE Randomized Controlled Trial. Am J Gastroenterol 2023; 118:1880-1887. [PMID: 37307537 DOI: 10.14309/ajg.0000000000002368] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/27/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Cold snare polypectomy (CSP) is strongly recommended as the optimal technique for the complete removal of small polyps. Though significant variability in polypectomy technique and quality has been established, the learning curve and impact of targeted training on CSP are unknown. Video feedback has shown promise as an effective pedagogy to improve performance among surgical trainees. We aimed to compare CSP performance between trainees who received video-based feedback and those who received conventional apprentice-based concurrent feedback. We hypothesized that video-based feedback would accelerate competence. METHODS We conducted a single-blinded, randomized controlled trial on competence for CSP of polyps <1 cm, comparing video-based feedback with conventional feedback. We randomly assigned deidentified consecutively recorded CSP videos to blinded raters to assess using the CSP Assessment Tool. We shared cumulative sum learning curves every 25 CSP with each trainee. The video feedback trainees also received biweekly individualized terminal feedback. Control trainees received conventional feedback during colonoscopy. The primary outcome was CSP competence. We also assessed competence across domains and change over polypectomy volume. RESULTS We enrolled and randomized 22 trainees, 12 to video-based feedback and 10 to conventional feedback, and evaluated 2,339 CSP. The learning curve was long; 2 trainees (16.7%) in the video feedback achieved competence, after a mean of 135 polyps, and no one in the control ( P = 0.481) achieved competence. Overall and in all steps of CSP, a higher percentage of the video feedback group met competence, increasing 3% every 20 CSP ( P = 0.0004). DISCUSSION Video feedback aided trainees to competence in CSP. However, the learning curve was long. Our findings strongly suggest that current training methods are not sufficient to support trainees to competency by the completion of their fellowship programs. The impact of new training methods, such as simulation-based mastery learning, should be assessed to determine whether such methods can result in achievement of competence at a faster rate; ClinicalTrials.gov : NCT03115008.
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Affiliation(s)
- Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Swati G Patel
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Gastroenterology, Rocky Mountain Regional Veterans Affairs Hospital, Aurora, Colorado, USA
| | - Tiffany Nguyen-Vu
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Carmel Malvar
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Rajesh N Keswani
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Matt Hall
- Biostatistics, Children's Hospital Association, Kansas City, Kansas, USA
| | - Eva Aagaard
- Department of Medicine, Division of General Internal Medicine, Washington University School of Medicine at St. Louis, St. Louis, Missouri, USA
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Yung Ka Chin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Hazem Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA; and
| | - Amandeep Shergill
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Violette Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Alan Soetikno
- Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Roy Soetikno
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Kerdsirichairat T, Shin EJ. Important Quality Metrics and Standardization in Endoscopy. Gastrointest Endosc Clin N Am 2021; 31:727-742. [PMID: 34538412 DOI: 10.1016/j.giec.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Quality metrics and standardization has become critical as the Affordable Care Act mandates that the Center for Medicare and Medicaid Services change reimbursement from volume to a value-based system. While the most commonly used quality indicators are related to that of colonoscopy, quality metrics for other procedures and endoscopy units have been developed mainly by the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. Data to show that these quality metrics, especially in the field of advanced endoscopy as well as in the era of COVID-19 pandemic, can improve patient outcomes, are anticipated.
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Affiliation(s)
- Tossapol Kerdsirichairat
- Digestive Disease Center, Bumrungrad International Hospital, Bangkok, Thailand 33 Soi Sukhumvit 3, Wattana, Bangkok 10110 Thailand
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Suite 7125H, Baltimore, MD 21287, USA.
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Yang D, Perbtani YB, Wang Y, Rumman A, Wang AY, Kumta NA, DiMaio CJ, Antony A, Trindade AJ, Rolston VS, D'Souza LS, Corral Hurtado JE, Gomez V, Pohl H, Draganov PV, Beyth RJ, Lee JH, Cheesman A, Uppal DS, Sejpal DV, Bucobo JC, Wallace MB, Ngamruengphong S, Ajayeoba O, Khara HS, Diehl DL, Jawaid S, Forsmark CE. Evaluating learning curves and competence in colorectal EMR among advanced endoscopy fellows: a pilot multicenter prospective trial using cumulative sum analysis. Gastrointest Endosc 2021; 93:682-690.e4. [PMID: 32961243 DOI: 10.1016/j.gie.2020.09.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Data on colorectal EMR (C-EMR) training are lacking. We aimed to evaluate C-EMR training among advanced endoscopy fellows (AEFs) by using a standardized assessment tool (STAT). METHODS This multicenter prospective study used a STAT to grade AEF training in C-EMR during their 12-month fellowship. Cumulative sum analysis was used to establish learning curves and competence for cognitive and technical components of C-EMR and overall performance. Sensitivity analysis was performed by varying failure rates. AEFs completed a self-assessment questionnaire to assess their comfort level with performing C-EMR at the completion of their fellowship. RESULTS Six AEFs (189 C-EMRs; mean per AEF, 31.5 ± 18.5) were included. Mean polyp size was 24.3 ± 12.6 mm, and mean procedure time was 22.6 ± 16.1 minutes. Learning curve analyses revealed that less than 50% of AEFs achieved competence for key cognitive and technical C-EMR endpoints. All 6 AEFs reported feeling comfortable performing C-EMR independently at the end of their training, although only 2 of them achieved competence in their overall performance. The minimum threshold to achieve competence in these 2 AEFs was 25 C-EMRs. CONCLUSIONS A relatively low proportion of AEFs achieved competence on key cognitive and technical aspects of C-EMR during their 12-month fellowship. The relatively low number of C-EMRs performed by AEFs may be insufficient to achieve competence, in spite of their self-reported readiness for independent practice. These pilot data serve as an initial framework for competence threshold, and suggest the need for validated tools for formal C-EMR training assessment.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Yu Wang
- Division of Quantitative Sciences, University of Florida Cancer Center, University of Florida, Gainesville, Florida, USA
| | - Amir Rumman
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Nikhil A Kumta
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher J DiMaio
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew Antony
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Vineet S Rolston
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Lionel S D'Souza
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | | | - Victoria Gomez
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Heiko Pohl
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Department of Gastroenterology, Veterans Administration Medical Center, White River Junction, Vermont, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Rebecca J Beyth
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ji-Hyun Lee
- Division of Quantitative Sciences, University of Florida Cancer Center, University of Florida, Gainesville, Florida, USA; Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Antonio Cheesman
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dushant S Uppal
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Juan C Bucobo
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Olumide Ajayeoba
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Harshit S Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Salmaan Jawaid
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Christopher E Forsmark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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