ERCP competence assessment: Miles to go before standardization

Introduction

Over the past decade, increasing emphasis has been placed on quality metrics and competency assessment in health care. The goals of high-quality endoscopy – appropriate patient selection (indicated procedure), accurate diagnosis, and appropriate implementation – should be achieved with minimal patient risk and performed by properly trained and competent endoscopists [1]. The ultimate goals should be improvement in patient outcome and satisfaction [2] [3]. Competency, an important element of quality endoscopy, should be defined as the consistent ability to meet technical goals of the intended procedure and to correctly perform cognitive aspects of the procedure. In a constantly changing environment and with the introduction of new techniques and technologies, competency is crucial to endoscopic practice.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically demanding and high-risk procedures performed by gastrointestinal endoscopists, requiring significant focused training and experience to maximize success and patient outcome. It has a steep learning curve in both physical skills and judgment/interpretation, and increasingly more sophisticated diagnostic and therapeutic techniques are employed. Goals of an endoscopy training program include ensuring that core motor and cognitive skills necessary to successfully and competently perform ERCP are acquired. Ensuring competence in ERCP has recently emerged as an area of intense scrutiny as training programs and hospital credentialing committees attempt to produce and approve, respectively, adequately trained endoscopists. Despite this, universally accepted standards for competence in ERCP have not been established. It is commonly assumed that competence is achieved when a minimum number of ERCP procedures have been performed. For most training programs this may only be in the range of 100 to 200 cases [4]. With the appreciation that individual trainees develop endoscopic skills at different rates, [5] there has been a shift towards competency-based training and certification. An assessment of individual performance is probably more robust than the use of minimum numbers for defining competence. Accurate and validated ERCP performance measures are necessary in order to effectively train practitioners using a competency-based curriculum. The endoscopic trainee must be able to achieve a standard rate of technical success, but must also be able to recognize abnormal pathology, identify it correctly, and decide upon the appropriate course of action.

Recognizing the limitations of the current models of training and assessment of competence, the Accreditation Council for Graduate Medical Education (ACGME) replaced the reporting system with the Next Accreditation System focusing on competency-based medical education (CBME). Ideally, ERCP training programs will move toward the adoption of CBME and demonstrate that trainees have achieved competence and attained the technical and cognitive skills required for safe and effective unsupervised practice in advanced endoscopy [6] [7] [8].

• References

• 1 Faigel DO, Pike IM, Baron TH. et al. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Gastrointest Endosc 2006; 63: S3-S9
• 2 Donabedian A. The quality of care. How can it be assessed?. JAMA 1988; 260: 1743-1748
• 3 Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med 2000; 51: 1611-1625
• 4 Ekkelenkamp VE, Koch AD, Rauws EA. et al. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: 949-955
• 5 Lim BS, Leung JW, Lee J. et al. Effect of ERCP mechanical simulator (EMS) practice on trainees' ERCP performance in the early learning period: US multicenter randomized controlled trial. Am J Gastroenterol 2011; 106: 300-306
• 6 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
• 7 Iobst WF, Caverzagie KJ. Milestones and competency-based medical education. Gastroenterology 2013; 145: 921-924
• 8 Nasca TJ, Philibert I, Brigham T. et al. The next GME accreditation system–rationale and benefits. N Engl J Med 2012; 366: 1051-1056
• 9 Baron TH, Petersen BT, Mergener K. et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Am J Gastroenterol 2006; 101: 892-897
• 10 Adler DG, Lieb 2nd JG, Cohen J. et al. Quality indicators for ERCP. Gastrointest Endosc 2015; 81: 54-66
• 11 Adler DG, Bakis G, Coyle WJ. ASGE Training Committee. et al. Principles of training in GI endoscopy. Gastrointest Endosc 2012; 75: 231-235
• 12 Rochester JS, Jaffe DL. Minimizing complications in endoscopic retrograde cholangiopancreatography and sphincterotomy. Gastrointest Endosc Clin N Am 2007; 17: 105-127
• 13 Ekkelenkamp VE, Dowler K, Valori RM. et al. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19: 2355-2361
• 14 Srivastava S, Sharma BC, Puri AS. et al. Impact of completion of primary biliary procedure on outcome of endoscopic retrograde cholangiopancreatographic related perforation. Endoscop Int Open 2017; 05: 706-709
• 15 Navaneethan U, Lourdusamy D, Gutierrez NG. et al. New approach to decrease post-ERCP adverse events in patients with primary sclerosing cholangitis. Endoscop Int Open 2017; 05: 710-717
• 16 Ekkelenkamp VE, Koch AD, Haringsma J. et al. Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance. Frontline Gastroenterol 2014; 5: 10-16
• 17 Shahidi N, Ou G, Telford J. et al. Establishing the learning curve for achieving competency in performing colonoscopy: a systematic review. Gastrointest Endosc 2014; 80: 410-416
• 18 Gastroenterology. BSo. ERCP - The way forward, a standards framework (June 2014). Available at: http://www.bsg.org.uk/clinical-guidance/endoscopy/ercp-%E2%80%93-the-way-forward-a-standards-framework.html Accessed October 14, 2016.
• 19 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: 711-9.e11
• 20 Sedlack RE. Validation process for new endoscopy teaching tools. Tech Gastrointest Endosc 2011; 13: 151-154
• 21 Sedlack RE, Coyle WJ, Obstein KL. ASGE Training Committee. et al. ASGE's assessment of competency in endoscopy evaluation tools for colonoscopy and EGD. Gastrointest Endosc 2014; 79: 1-7
• 22 Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998; 280: 1000-1005