How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy?

Melina C. Vassiliou, MD, M.Ed, FRCSCBenjamin K Poulose MD, Pepa A Kaneva MSc, Brian J Dunkin MD, Jeffrey M Marks MD, Riadh Sadik MD, Gideon Sroka MD, Stephen D Pooler MD, Klaus Thaler MD, Gina L Adrales MD, Jeffrey W Hazey MD, Jenifer R Lightdale MD, Vic Velanovich MD ,Lee L. Swanstrom MD, John D Mellinger MD, Gerald M Fried MD

Flexible endoscopy is a necessary part of the general surgery curriculum

• Flexible endoscopy: important skill for GI & community surgeons

• Retrospective review of 5 surgeons: 54% of procedures were flex endo

• Survey of PD in 2000: 60% of programs have formal endoscopy rotations, only 33.3% by fellowship trained instructors

• Increased requirements for surgical trainees (35 EGDs and 50 colos)

1- Nimeri AA, Hussein SA, Panzeter E, et al. The economic impact of incorporating flexible endoscopy into a community general surgery practice. Surg Endosc 2005; 19(5):702-4.2- Marks JM, Nussbaum MS, Pritts TA, et al. Evaluation of endoscopic and laparoscopic training practices in surgical residency programs. Surg Endosc 2001; 15(9):1011-5

How many cases are needed to achieve proficiency?

• Case #’s as a surrogate for proficiency• ASGE - 130 EGDs & 140 colos (90% esophageal &

pyloric/splenic flex &cecum)• Surgical study: no correlation between #’s and

completion/complications• Another study – only 50 colonoscopies needed for

90% completion rate1. Cass OW, Freeman ML, Cohen J, et al. Acquisition of competency in endoscopic skills (ACES) during training: a multicenter study

[abstract]. Gastrointest Endosc 1995;41:3172. Reed WP, Kilkenny JW, Dias CE, Wexner SD. A prospective analysis of 3525 esophagogastroduodenoscopies performed by surgeons.

Surg Endosc 2004;18:11-21.3. Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc

2001;15:251-61.

GAGESGlobal Assessment of Gastrointestinal

Endoscopic Skills• Created by expert

endoscopists• Multicenter study

demonstrated interrater reliability, internal consistency and construct validity

1- Intubation of the esophagus

2- Scope Navigation

3- Ability to keep a clear endoscopic field

4-Instrumentation

5- Quality of the Examination

1- Intubation of the esophagus

2- Scope Navigation

3- Ability to keep a clear endoscopic field

4-Instrumentation

5- Quality of the Examination

GAGES- Upper endoscopy

consists of 5 items scored on a

Likert scale

Interrater Reliability: 0.96 (0.90-0.99)

Internal Consistency: 0.89 (n=82)

1- Scope Navigation

2- Use of Strategies

3- Ability to keep a clear endoscopic field

4-Instrumentation

5- Quality of the Examination

1- Scope Navigation

2- Use of Strategies

3- Ability to keep a clear endoscopic field

4-Instrumentation

5- Quality of the Examination

GAGES- Colonoscopy consists of 5

items scored on Likert scale

Interrater Reliability: 0.97 (0.92-0.99)

Internal Consistency: 0.95 (n=57)

The purpose of this study was to:

• Challenge the current case number recommendations and methods by which proficiency in flexible endoscopy is determined

• Use GAGES to help define proficiency in flexible endoscopy

Methods

• IRB approved 11 institutions in Europe and NA• Demographic information• Participants from surgery and

gastroenterology• Scored by attending during routine upper

endoscopy and/or colonoscopy

Data Analysis

• For Upper endoscopy: 3 groups compared using ANOVA (Tukey post-hoc analysis) <35, >35<130, >130

• GAGES –C scores compared for different case cut-offs (T-test): >50 versus >140

• Scores plotted against case numbers to identify plateau

Results: The participants

139 evaluations, 11 centers

Demographic Percentage of total cohort

Dominant Hand 96% RightDiscipline 62 % surgeons; 38% GISex 79% male

GAGES upper endoscopy

GAGES Upper group Mean score ±SD

<35 n=35 14.4 ±3.7 NS

>35 & <130 n=22 17.8 ±1.8 P<0.05

>130 n=29 19.1 ±1.1 P<0.05

There is no difference between groups 2 and 3Both groups 2 and 3 are significantly different compared to group 1

1

2

3

Both groupings show statistically significant differences between novice and experienced

colonoscopists

GAGES -C Novice (95%CI) Experienced (95%CI) p-value

Novice <50 n=29 11.8 (10.3-13.2)

n=28 18.8 (18.3-19.3) p<0.001

Novice <140 n=32 12.4(10.9-14.0)

n=25 18.8 (18.8-19.3) p<0.001

NS NS

Scores plateau at ~ 50 cases for upper endoscopy

Upper Endoscopy Case numbers

Tota

l GAG

ES-U

pper

Sco

re

Scores seem to plateau at ~ 100 cases for colonoscopy

Colonoscopy Case numbers

Tota

l GAG

ES C

olon

osco

py S

core

Summary- Upper endoscopy

• For upper endoscopy, participants with 35-130 previous cases perform similarly to those with >130 cases

• Both of these groups perform better than those with less than 35 cases

• Performance as measured by GAGES seems to plateau at the 50 case level for upper endoscopy

Summary- Colonoscopy

• There was no difference in performance when the cut-off was set a 50 cases or at 140 cases

• We do not have enough data for the “intermediate” group

• Performance measured by GAGES plateaus at ~ 100 cases

Discussion & Limitations

• Still not enough data in the intermediate group

• We have not yet determined what the “passing score” for GAGES should be

• ROC – sensitivity and specificity• Ceiling effect

In Conclusion

• Current case recommendations may not represent what is needed for proficiency

• GAGES scores may help to define proficiency in basic flexible endoscopy

• Clinical numbers needed to achieve proficiency may vary from one learner to another

• GAGES may be a valuable tool to measure outcomes of training strategies and to provide feedback to learners

Acknowledgements:Members of the FES committeeLisa Jukelevics, Carla Bryant & Sarah ColonParticipants and contributors from all of the institutions