Download PDF
CC BY-NC-ND 4.0 · Endosc Int Open 2022; 10(04): E549-E557
DOI: 10.1055/a-1766-5259
Original article

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions

Hannah M. Schutz‡
 1   Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
,
Rutger Quispel‡
 1   Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
,
Bart J. Veldt
 1   Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
,
Frank M.M. Smedts
 2   Department of Cyto- and Histopathology, Reinier de Graaf Gasthuis, Delft, the Netherlands
,
Marie-Paule G.F. Anten
 3   Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
,
Klaas J. Hoogduin
 4   Department of Cyto- and Histopathology, Pathan B.V., Rotterdam, the Netherlands
,
Pieter Honkoop
 5   Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
,
Francien H. van Nederveen
 6   Department of Cyto- and Histopathology, PAL Dordrecht, Dordrecht, the Netherlands
,
Lieke Hol
 7   Department of Gastroenterology and Hepatology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
,
Mike Kliffen
 8   Department of Cyto- and Histopathology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
,
Claire E. Fitzpatrick
 9   Department of Gastroenterology and Hepatology, IJsselland Ziekenhuis, Capelle aan den Ijssel, the Netherlands
,
Nicole S. Erler
10   Department of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands
,
Marco J. Bruno
11   Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
,
Lydi M.J.W. van Driel
11   Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
,
on behalf of QUEST › Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background and study aims In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool.

Patients and methods All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and  2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period.

Results A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance.

Conclusions CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

Supplementary material



Publication History

Received: 03 September 2021

Accepted after revision: 03 December 2021

Article published online:
14 April 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Wani S, Wallace MB, Cohen J. et al. Quality indicators for EUS. Am J Gastroenterol 2015; 110: 102-113
    CrossrefPubMedSearch in Google Scholar
  • 2 Kitano M, Yoshida T, Itonaga M. et al. Impact of endoscopic ultrasonography on diagnosis of pancreatic cancer. J Gastroenterol 2019; 54: 19-32
    CrossrefPubMedSearch in Google Scholar
  • 3 Tempero MA, Malafa MP, Al-Hawary M. et al. Pancreatic Adenocarcinoma, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15: 1028-1061
    CrossrefPubMedSearch in Google Scholar
  • 4 Kaye AD, Okanlawon OJ, Urman RD. Clinical performance feedback and quality improvement opportunities for perioperative physicians. Adv Med Educ Pract 2014; 5: 115-123
    PubMedSearch in Google Scholar
  • 5 Wani S, Wallace MB, Cohen J. et al. Quality indicators for EUS. Gastrointest Endosc 2015; 81: 67-80
    CrossrefPubMedSearch in Google Scholar
  • 6 Eloubeidi MA. Developing an academic EUS program: the University of Alabama at Birmingham experience. Gastrointest Endosc 2007; 65: 1039-1041 ; discussion 1039
    CrossrefPubMedSearch in Google Scholar
  • 7 Gordon HM, Lloyd DAJ, Higginson A. et al. A regional EUS service using a collaborative network. Frontline Gastroenterol 2017; 8: 26-28
    CrossrefPubMedSearch in Google Scholar
  • 8 Oppong KW, Richardson DL, Charnley RM. et al. The development and evolution of a tertiary pancreaticobiliary endoscopic ultrasound service: lessons learned. Frontline Gastroenterol 2011; 2: 66-70
    CrossrefPubMedSearch in Google Scholar
  • 9 Wani S, Keswani RN, Han S. et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018; 155: 1483-1494 e1487
    CrossrefPubMedSearch in Google Scholar
  • 10 Wani S, Cote GA, Keswani R. et al. Learning curves for EUS by using cumulative sum analysis: implications for American Society for Gastrointestinal Endoscopy recommendations for training. Gastrointest Endosc 2013; 77: 558-565
    CrossrefPubMedSearch in Google Scholar
  • 11 Lee LS, Andersen DK, Ashida R. et al. EUS and related technologies for the diagnosis and treatment of pancreatic disease: research gaps and opportunities-Summary of a National Institute of Diabetes and Digestive and Kidney Diseases workshop. Gastrointest Endosc 2017; 86: 768-778
    CrossrefPubMedSearch in Google Scholar
  • 12 Wani S, Hall M, Keswani RN. et al. Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis. Clin Gastroenterol Hepatol 2015; 13: 1318-1325 e1312
    CrossrefPubMedSearch in Google Scholar
  • 13 Wani S, Hall M, Wang AY. et al. Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis. Gastrointest Endosc 2016; 83: 711-719 e711
    CrossrefPubMedSearch in Google Scholar
  • 14 Quispel R, van Driel L, Honkoop P. et al. Collaboration of community hospital endosonographers improves diagnostic yield of endoscopic ultrasonography guided tissue acquisition of solid pancreatic lesions. Endosc Int Open 2019; 7: E800-E807
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Dumonceau JM, Deprez PH, Jenssen C. et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated January 2017. Endoscopy 2017; 49: 695-714
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Eltoum IA, Chhieng DC, Jhala D. et al. Cumulative sum procedure in evaluation of EUS-guided FNA cytology: the learning curve and diagnostic performance beyond sensitivity and specificity. Cytopathology 2007; 18: 143-150
    CrossrefPubMedSearch in Google Scholar
  • 17 Williams SM, Parry BR, Schlup MM. Quality control: an application of the cusum. BMJ 1992; 304: 1359-1361
    CrossrefPubMedSearch in Google Scholar
  • 18 Davies OL. Design and analysis of industrial experiments: Statistica Neerlandica. Malden, USA: Wiley-Blackwell Publishing; 1955
    Search in Google Scholar
  • 19 [Anonymous]. JAGS 4.3.0. In: Source Forge.
    PubMed
  • 20 Erler NS, Rizopoulos D, Lesaffre EMEH. JointAI: Joint Analysis and imputation of incomplete data in R. In: Center EUM ed. ArXiv.org arXiv:1907.10867. California, USA: Foundation for Open Access Statistics; 2020
    Search in Google Scholar
  • 21 Hewitt MJ, McPhail MJ, Possamai L. et al. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc 2012; 75: 319-331
    CrossrefPubMedSearch in Google Scholar
  • 22 Vanbiervliet G, Napoleon B, Saint Paul MC. et al. Core needle versus standard needle for endoscopic ultrasound-guided biopsy of solid pancreatic masses: a randomized crossover study. Endoscopy 2014; 46: 1063-1070
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Tarantino I, Di Mitri R, Fabbri C. et al. Is diagnostic accuracy of fine needle aspiration on solid pancreatic lesions aspiration-related? A multicentre randomised trial. . Dig Liver Dis 2014; 46: 523-526
    CrossrefPubMedSearch in Google Scholar
  • 24 Laquiere A, Lefort C, Maire F. et al. 19 G nitinol needle versus 22 G needle for transduodenal endoscopic ultrasound-guided sampling of pancreatic solid masses: a randomized study. Endoscopy 2019; 51: 436-443
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Lee JK, Lee KT, Choi ER. et al. A prospective, randomized trial comparing 25-gauge and 22-gauge needles for endoscopic ultrasound-guided fine needle aspiration of pancreatic masses. Scand J Gastroenterol 2013; 48: 752-757
    CrossrefPubMedSearch in Google Scholar
  • 26 Noh DH, Choi K, Gu S. et al. Comparison of 22-gauge standard fine needle versus core biopsy needle for endoscopic ultrasound-guided sampling of suspected pancreatic cancer: a randomized crossover trial. Scand J Gastroenterol 2018; 53: 94-99
    CrossrefPubMedSearch in Google Scholar
  • 27 Bang JY, Hebert-Magee S, Trevino J. et al. Randomized trial comparing the 22-gauge aspiration and 22-gauge biopsy needles for EUS-guided sampling of solid pancreatic mass lesions. Gastrointest Endosc 2012; 76: 321-327
    CrossrefPubMedSearch in Google Scholar
  • 28 Woo YS, Lee KH, Noh DH. et al. 22G versus 25G biopsy needles for EUS-guided tissue sampling of solid pancreatic masses: a randomized controlled study. Scand J Gastroenterol 2017; 52: 1435-1441
    CrossrefPubMedSearch in Google Scholar
  • 29 Crino SF, Le Grazie M, Manfrin E. et al. Randomized trial comparing fork-tip and side-fenestrated needles for EUS-guided fine-needle biopsy of solid pancreatic lesions. Gastrointest Endosc 2020; 92: 648-658 e642
    CrossrefPubMedSearch in Google Scholar
  • 30 Capurso G, Archibugi L, Petrone MC. et al. Slow-pull compared to suction technique for EUS-guided sampling of pancreatic solid lesions: a meta-analysis of randomized controlled trials. Endosc Int Open 2020; 8: E636-E643
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Kudo T, Kawakami H, Hayashi T. et al. High and low negative pressure suction techniques in EUS-guided fine-needle tissue acquisition by using 25-gauge needles: a multicenter, prospective, randomized, controlled trial. Gastrointest Endosc 2014; 80: 1030-1037 e1031
    CrossrefPubMedSearch in Google Scholar
  • 32 Wani S, Early D, Kunkel J. et al. Diagnostic yield of malignancy during EUS-guided FNA of solid lesions with and without a stylet: a prospective, single blind, randomized, controlled trial. Gastrointest Endosc 2012; 76: 328-335
    CrossrefPubMedSearch in Google Scholar
  • 33 Wang Y, Wang RH, Ding Z. et al. Wet- versus dry-suction techniques for endoscopic ultrasound-guided fine-needle aspiration of solid lesions: a multicenter randomized controlled trial. Endoscopy 2020; 52: 995-1003
    Thieme ConnectPubMedSearch in Google Scholar
  • 34 Abe Y, Kawakami H, Oba K. et al. Effect of a stylet on a histological specimen in EUS-guided fine-needle tissue acquisition by using 22-gauge needles: a multicenter, prospective, randomized, controlled trial. Gastrointest Endosc 2015; 82: 837-844 e831
    CrossrefPubMedSearch in Google Scholar
  • 35 Noyez L. Control charts, Cusum techniques and funnel plots. A review of methods for monitoring performance in healthcare. Interact Cardiovasc Thorac Surg 2009; 9: 494-499
    CrossrefPubMedSearch in Google Scholar
  • 36 Kovacevic B, Vilmann P. EUS tissue acquisition: From A to B. Endosc Ultrasound 2020; 9: 225-231
    CrossrefPubMedSearch in Google Scholar
  • 37 Hut-Mossel L, Ahaus K, Welker G. et al. Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PLoS One 2021; 16: e0248677
    CrossrefPubMedSearch in Google Scholar