449 Variation in Learning Curves and Competence for Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees (AETs) Using Cumlative Sum Analysis (CUSUM)- Implication for American Scoiety for Gastrointestinal Endoscopy Society for Gastrointestinal Endoscopy Recommendations for Training

Abstract

449 Variation in Learning Curves and Competence for Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees (AETs) Using Cumlative Sum Analysis (CUSUM)Implication for American Scoiety for Gastrointestinal Endoscopy Society for Gastrointestinal Endoscopy Recommendations for Training Sachin Wani*, Andrew Y. Wang, Christopher J. Dimaio, V. Raman Muthusamy, Rajesh N. Keswani, Brian C. Brauer, Jeffrey J. Easler, Roy D. Yen, Ihab El Hajj, Norio Fukami, Kourosh F. Ghassemi, Susana Gonzalez, Lindsay Hosford, Thomas G. Hollander, Vladimir M. Kushnir, Jawad Ahmad, Faris Murad, Anoop Prabhu, Rabindra R. Watson, Daniel S. Strand, Stuart K. Amateau, Raj J. Shah, Steven A. Edmundowicz, Daniel Mullady University of Colorado, Centennial, CO; University of Virginia Health System, Charlottesville, VA; Icahn School of Medicine at Mount Sinai, New York, NY; Feinberg School of Medicine Northwestern University, Chicago, IL; Washington University School of Medicine, St. Louis, MO; University of California, Los Angeles, Los Angeles, CA Background: There are limited data on learning curves and competence in ERCP and the guidelines set forth by the ASGE are largely based on expert opinions and biliary cannulation rates (180 total procedures). These guidelines have not been validated, do not account for different rates of learning, and other relevant quality indicators in ERCP.AimTo prospectively define learning curves and measure competency among AETs at multiple training centers using a standardized data collection tool. Methods: AETs were supervised and graded at 5 training programs and introduced to all aspects of ERCP at the onset of training. Starting with 25 hands-on exam, each AET was graded on every ERCP exam during the 1-yr training period. A standardized ERCP competency assessment tool was used. Case number, indication and grade of difficulty were recorded. Technical and cognitive aspects assessed are shown in Table. A 4-point scoring system was used: 1-no assistance, 2-achieves with minimal verbal cues, 3-multiple verbal cues or hands on assistance, 4-unable to complete. CUSUM analysis was applied to produce learning curves for individual components of ERCP performance (success defined as score of 1). Acceptable and unacceptable failure rates of 10% (p0) and 20% (p1) respectively were used. Sensitivity analyses varying p1 between 0.2-0.35 and assessing competence using a less stringent definition of success (score of 1 or 2) were performed. Results: Five AETs were included with a total of 1047 graded ERCPs [mean 209.8 (SD 91.6)/AET]. Distribution of cases based on indication was: biliary 833 (80%), pancreatic (13%) and biliary and pancreatic 73 (7%). With regards to ASGE degree of difficult grade, the majority were biliary grade 1 (nZ591, 56.4%). There were overall 379 (38.9%) procedures in cases with a native papilla and sphincterotomy was performed in 474 (56.9%) cases. Overall mean time allowed for cannulation for AETs was 3.1 minutes (SD 3.6). Overall learning curves demonstrated substantial variability (Table). Nearly all AETs achieved competence in basic techniques, stent removal, overall cannulation, wire placement, balloon sweeps and cognitive aspects. However, none achieved competence in native papilla cannulation and sphincterotomy. Similarly, only 1-2 AETs achieved competence in stone clearance, dilation and insertion (Figure). Sensitivity analyses described above increased the proportion of AETs that achieved competency (Table). Conclusions: Results from this multicenter prospective study demonstrate substantial variability in achieving competency and there is a consistent need for more supervision especially for biliary cannulation and sphincterotomy than currently recommended in ASGE guidelines. Large multicenter study focusing on an assessment tool to accurately define trainee progression providing structured and objective feedback is currently underway. Table: Advanced endoscopy trainees achieving competence based on case number and sensitivity analyses* AB150 GASTROINTESTI Number of AETs achieving competence NAL ENDOSCOPY Procedure number at which competency was achieved Volume 81, Maximum number of AETs achieving competence based on sensitivity analyses* Basic technique Intubation 5 19, 21, 21, 21, 55 5 Achieving short position 5 19, 19, 26, 35,