Lower gastrointestinal polypectomy competencies in the United Kingdom: a retrospective analysis of Directly Observed Polypectomy Skills (DOPyS).

BACKGROUND: Polypectomy is often the most hazardous part of colonoscopy. There is significant variability in polypectomy training and assessment internationally. DOPyS (Directly Observed Polypectomy Skills) is a validated assessment tool and is used to demonstrate polypectomy competency in the UK. This study aimed to describe the learning curve for polypectomy competency in UK trainees. METHODS: Retrospective DOPyS data (January 2009 to September 2015) were obtained from the UK Joint Advisory Group (JAG) for intestinal endoscopy training system (JETS) national database. The number of lower gastrointestinal (LGI) procedures, overall cecal intubation rate (CIR), procedure intensity, and time in days to the first DOPyS assessment were recorded, and time to JAG certification was calculated. RESULTS: 4965 DOPyS assessments from 336 trainees were analyzed. Within the study period, 124 and 53 trainees achieved provisional and full colonoscopy certification, respectively. Trainees started formative assessment of polypectomy after > 130 LGI procedures and with a CIR of > 70 %. Within 3 years from the first DOPyS assessment, 94 % of trainees achieved provisional certification, and 50 % full certification. Higher procedure intensity at baseline DOPyS assessment was associated with a higher likelihood of obtaining certification sooner. CONCLUSION: There is a significant variation in time to competency, and this potentially reflects the time necessary to acquire polypectomy skills. There is a need to start polypectomy training earlier, once sufficient skills, such as tip control, have been achieved to shorten the time to competency. Overall, the CIR could be used as a guide for such technical skills. Increasing exposure to training lists also potentially reduces the time to polypectomy competency.

Colonoscopy Direct Observation of Procedural Skills Assessment Tool for Evaluating Competency Development During Training.

INTRODUCTION: Formative colonoscopy direct observation of procedural skills (DOPS) assessments were updated in 2016 and incorporated into UK training but lack validity evidence. We aimed to appraise the validity of DOPS assessments, benchmark performance, and evaluate competency development during training in diagnostic colonoscopy. METHODS: This prospective national study identified colonoscopy DOPS submitted over an 18-month period to the UK training e-portfolio. Generalizability analyses were conducted to evaluate internal structure validity and reliability. Benchmarking was performed using receiver operator characteristic analyses. Learning curves for DOPS items and domains were studied, and multivariable analyses were performed to identify predictors of DOPS competency. RESULTS: Across 279 training units, 10,749 DOPS submitted for 1,199 trainees were analyzed. The acceptable reliability threshold (G > 0.70) was achieved with 3 assessors performing 2 DOPS each. DOPS competency rates correlated with the unassisted caecal intubation rate (rho 0.404, P < 0.001). Demonstrating competency in 90% of assessed items provided optimal sensitivity (90.2%) and specificity (87.2%) for benchmarking overall DOPS competence. This threshold was attained in the following order: "preprocedure" (50-99 procedures), "endoscopic nontechnical skills" and "postprocedure" (150-199), "management" (200-249), and "procedure" (250-299) domain. At item level, competency in "proactive problem solving" (rho 0.787) and "loop management" (rho 0.780) correlated strongest with the overall DOPS rating (P < 0.001) and was the last to develop. Lifetime procedure count, DOPS count, trainer specialty, easier case difficulty, and higher cecal intubation rate were significant multivariable predictors of DOPS competence. DISCUSSION: This study establishes milestones for competency acquisition during colonoscopy training and provides novel validity and reliability evidence to support colonoscopy DOPS as a competency assessment tool.

Learning Curve Analyses for Achieving Satisfactory Procedural Completion Rates in Paediatric Oesophagogastroduodenoscopy.

BACKGROUND: The learning curve in paediatric oesophagogastroduodenoscopy (OGD) is unknown. Using ≥95% D2 (second part of the duodenum) intubation rates as a marker of technical competency, we conducted learning curve analyses to identify when trainees achieve competency in paediatric OGD. Factors associated with competency were also evaluated. METHODS: This nationwide study analysed data from paediatric OGD procedures prospectively entered into the UK endoscopy training e-portfolio between 2014 and 2018. Moving average and learning curve cumulative summation analyses were performed to determine procedural numbers required to achieve ≥95% D2 intubation rates. Factors associated with D2 intubation were assessed using a multivariable binary logistic regression approach. RESULTS: A total of 8929 procedures performed by 61 trainees were identified. These 61 trainees had recorded a mean of 124.6 procedures (range 22-571, interquartile range 165). By moving average analysis, 95% D2 intubation was achieved after 79 procedures. By learning curve cumulative summation analysis, 81.6% of trainees were competent after 100 procedures. Multivariable factors associated with unassisted procedural completion included: lifetime procedure count (P < 0.001), higher trainee seniority (P < 0.001), patient age (P = 0.002), outpatient status (P < 0.001), and attendance at a national Basic Skills OGD course (P = 0.011). CONCLUSIONS: This study demonstrates that, on average, 79 procedures in paediatric OGD are required to attain the competency outcome of ≥95% D2 intubation rates. By 100 procedures, 81.6% of our sample had achieved ≥95% D2 intubation. The minimum procedural count of 100 set by the UK and international training programmes can be used alongside existing objective assessment measures to safeguard competency within a training cohort.

Correction to: Direct observation of procedural skills (DOPS) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training.

The citation for Reference 22 should be replaced with: Kumar NL, Kugener G, Perencevich ML, et al (2018) The SAFE-T assessment tool: derivation and validation of a web-based application for point-of-care evaluation of gastroenterology fellow performance in colonoscopy. Gastrointest Endosc 87(1):262-269.

Direct observation of procedural skills (DOPS) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training.

BACKGROUND: Validated competency assessment tools and the data supporting milestone development during gastroscopy training are lacking. We aimed to assess the validity of the formative direct observation of procedural skills (DOPS) assessment tool in diagnostic gastroscopy and study competency development using DOPS. METHODS: This was a prospective multicentre (N = 275) analysis of formative gastroscopy DOPS assessments. Internal structure validity was tested using exploratory factor analysis and reliability estimated using generalisability theory. Item and global DOPS scores were stratified by lifetime procedure count to define learning curves, using a threshold determined from receiver operator characteristics (ROC) analysis. Multivariable binary logistic regression analysis was performed to identify independent predictors of DOPS competence. RESULTS: In total, 10086 DOPS were submitted for 987 trainees. Exploratory factor analysis identified three distinct item groupings, representing 'pre-procedure', 'technical', and 'post-procedure non-technical' skills. From generalisability analyses, sources of variance in overall DOPS scores included trainee ability (31%), assessor stringency (8%), assessor subjectivity (18%), and trainee case-to-case variation (43%). The combination of three assessments from three assessors was sufficient to achieve the reliability threshold of 0.70. On ROC analysis, a mean score of 3.9 provided optimal sensitivity and specificity for determining competency. This threshold was attained in the order of 'pre-procedure' (100-124 procedures), 'technical' (150-174 procedures), 'post-procedure non-technical' skills (200-224 procedures), and global competency (225-249 procedures). Higher lifetime procedure count, DOPS count, surgical trainees and assessors, higher trainee seniority, and lower case difficulty were significant multivariable predictors of DOPS competence. CONCLUSION: This study establishes milestones for competency acquisition during gastroscopy training and provides validity and reliability evidence to support gastroscopy DOPS as a competency assessment tool.

Performance indicators in colonoscopy after certification for independent practice: outcomes and predictors of competence.

BACKGROUND: Robust real-world performance data of newly independent colonoscopists are lacking. In the United Kingdom, provisional colonoscopy certification (PCC) marks the transition from training to newly independent practice. We aimed to assess changes in key performance indicators (KPIs) such as cecal intubation rate (CIR) in the periods pre- and post-PCC, particularly regarding rates and predictors of trainees exhibiting a drop in performance (DIP), defined as CIR <90% in the first 50 procedures post-PCC. METHODS: A prospective United Kingdom-wide observational study of Joint Advisory Group on Gastrointestinal Endoscopy Electronic Training System (JETS) e-portfolio colonoscopy entries (257,800) from trainees awarded PCC between July 2011 and 2016 was undertaken. Moving average analyses were used to study KPI trends relative to PCC. Pre-PCC trainee, trainer, and training environment factors were compared between DIP and non-DIP cohorts to identify predictors of DIP. RESULTS: Seven hundred thirty-three trainees from 180 centers were awarded PCC after a median of 265 procedures and 3.1 years. Throughout the early post-PCC period, average CIRs surpassed the national 90% standard. Despite this, not all trainees achieved this standard post-PCC, with DIP observed in 18.4%. DIP was not influenced by trainer presence and diminished after 100 additional procedures. On multivariable analysis, pre-PCC CIRs and trainer specialty were predictive of DIP. Trainees with DIP incurred higher post-PCC rates of moderate to severe discomfort despite requiring higher analgesic dosages and were more likely to require trainer assistance in failed procedures. CONCLUSIONS: The current PCC requirements are appropriate for diagnostic colonoscopy. It is possible to identify predictors of underperformance in trainees, which may be of value to training leads and could improve the patient experience.

Variability in cecal intubation rate by calculation method: a call for standardization of key performance indicators in endoscopy.

BACKGROUND AND AIMS: The cecal intubation rate (CIR) is a widely accepted key performance indicator (KPI) in colonoscopy but lacks a universal calculation method. We aimed to assess whether differences in CIR calculation methods could have an impact on perceived trainee outcomes. METHODS: A systematic review of CIR calculation methods was conducted on major societal guidelines (United Kingdom, European Society of Gastrointestinal Endoscopy [ESGE] and American Society for Gastrointestinal Endoscopy [ASGE]) and trainee-inclusive studies. Trainees awarded colonoscopy certification between June 2011 and 2016 were identified from the United Kingdom e-portfolio and selected as a validation cohort. For each trainee, both the crude and unassisted CIR were calculated for 50 post-certification procedures using definitions from the 3 international guidelines. The resulting CIRs, and the proportions of endoscopists failing to meet the minimum standard of CIR ≥90%, were then compared across these definitions. RESULTS: Across the 3 guidelines and 37 eligible studies identified, differences in CIR calculation methodology were demonstrated. These related to adjustment criteria (18 studies) and whether unassisted CIR was stipulated (18 studies). In the validation cohort of 733 trainees (36,650 procedures), the median crude CIR ranged from 96% (ESGE) to 98% (ASGE) (P < .001) and whether unassisted CIR was specified (ESGE, 94%; ASGE, 96%; P < .001). The proportion of trainees failing to achieve CIR ≥90% varied significantly across the different definitions, from 4.9% for the crude ASGE definition to 18.6% for the unassisted ESGE definition (P < .001). CONCLUSIONS: CIR calculation methods vary among guidelines and research studies; this has an impact on trainee performance measures. With CIR used as an example, this study highlights the need for standardized definitions and calculations of KPIs in endoscopy.

ERCP assessment tool: evidence of validity and competency development during training.

BACKGROUND: The endoscopic retrograde cholangiopancreatography (ERCP) direct observation of procedural skills (DOPS) is a 27-item competency assessment tool that was developed to support UK ERCP training. We evaluated validity of ERCP DOPS and competency development during training. METHODS: This prospective study analyzed ERCP DOPS performed in the UK between July 2016 and October 2018. Reliability was measured using Cronbach's alpha, and DOPS scores were benchmarked using the contrasting groups method. The percentage of competent scores was averaged for each item, domain, and overall rating, and stratified by lifetime procedure count to evaluate learning curves. Multivariable analyses were performed to identify predictors of DOPS competence. RESULTS: 818 DOPS (109 trainees, 80 UK centers) were analyzed. Overall Cronbach's alpha was 0.961. Attaining competency in 87 % of assessed DOPS items provided the optimal competency benchmark. This was achieved in the domain sequence of: pre-procedure, post-procedure management, endoscopic non-technical skills, cannulation & imaging, and execution of selected therapy, and across all items after 200 - 249 procedures (89 %). After 300 procedures, the benchmark was reached for selective cannulation (89 %), but not for stenting (plastic 73 %; metal 70 %), sphincterotomy (80 %), and sphincteroplasty (56 %). On multivariable analysis, lifetime procedure count (P = 0.002), easier case difficulty (P < 0.001), trainee grade (P = 0.03), and higher lifetime DOPS count (P = 0.01) were predictors of DOPS competence. CONCLUSION: This study provides novel validity, reliability, and learning curve data for ERCP DOPS. Trainees should have a minimum of 300 hands-on ERCP procedures before undertaking summative assessment for independent practice.

Changes in scoring of Direct Observation of Procedural Skills (DOPS) forms and the impact on competence assessment.

BACKGROUND: Direct Observation of Procedural Skills (DOPS) is an established competence assessment tool in endoscopy. In July 2016, the DOPS scoring format changed from a performance-based scale to a supervision-based scale. We aimed to evaluate the impact of changes to the DOPS scale format on the distribution of scores in novice trainees and on competence assessment. METHODS: We performed a prospective, multicenter (n = 276), observational study of formative DOPS assessments in endoscopy trainees with ≤ 100 lifetime procedures. DOPS were submitted in the 6-months before July 2016 (old scale) and after (new scale) for gastroscopy (n = 2998), sigmoidoscopy (n = 1310), colonoscopy (n = 3280), and polypectomy (n = 631). Scores for old and new DOPS were aligned to a 4-point scale and compared. RESULTS: 8219 DOPS (43 % new and 57 % old) submitted for 1300 trainees were analyzed. Compared with old DOPS, the use of the new DOPS was associated with greater utilization of the lowest score (2.4 % vs. 0.9 %; P < 0.001), broader range of scores, and a reduction in competent scores (60.8 % vs. 86.9 %; P < 0.001). The reduction in competent scores was evident on subgroup analysis across all procedure types (P < 0.001) and for each quartile of endoscopy experience. The new DOPS was superior in characterizing the endoscopy learning curve by demonstrating progression of competent scores across quartiles of procedural experience. CONCLUSIONS: Endoscopy assessors applied a greater range of scores using the new DOPS scale based on degree of supervision in two cohorts of trainees matched for experience. Our study provides construct validity evidence in support of the new scale format.

An analysis of the learning curve to achieve competency at colonoscopy using the JETS database.

OBJECTIVE: The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion. DESIGN: The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects. RESULTS: 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion. CONCLUSIONS: This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

JAG consensus statements for training and certification in colonoscopy.

Introduction: In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification. Methods: Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway. Results: In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS. Conclusion: The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.

JAG consensus statements for training and certification in flexible sigmoidoscopy.

Introduction: Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS). Methods: A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway. Results: In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS. Conclusion: The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.

Early use of magnetic endoscopic imaging by novice colonoscopists: improved performance without increase in workload.

BACKGROUND: Magnetic endoscopic imaging represents a recent advance in colonoscopy training. This technique provides adjunct information to the endoscopist, specifically with regard to colonoscope loop formation. OBJECTIVE: To examine the effect of a magnetic endoscopic imager on novice performance and workload in colonoscopy. METHODS: Twenty complete novices received an introductory teaching session followed by the completion of two procedures on a colonoscopy model. One-half of the participants performed their first procedure with the imager, and the second procedure without, while the other one-half were trained with the inverse sequence. Two main outcome measures were recorded: distance achieved and total workload as measured by the National Aeronautics and Space Administration task load index tool. RESULTS: A significant improvement was noted between the first and second colonoscopies, with the best performance recorded for participants who performed their first procedure with the imager, and their second without. The imager did not significantly change the total workload.  DISCUSSION: The study participants paid attention to the magnetic endoscopic imager; however, this did not translate into a measurable increase in novice workload. A delayed learning benefit was conferred to the group exposed to the imager on their first colonoscopy, suggesting that, even at an early training stage, the additional imager information entered working memory and was processed in a useful fashion. The introductory teaching strategy used in the present study was successful as judged by the overall distance achieved and performance improvement seen in all study participants.

Training in endotherapy for acute upper gastrointestinal bleeding: a UK-wide gastroenterology trainee survey.

INTRODUCTION: Competence in endoscopic haemostasis for acute upper gastrointestinal bleeding (AUGIB) is typically expected upon completion of gastroenterology training. However, training in haemostasis is currently variable without a structured training pathway. We conducted a national gastroenterology trainee survey on haemostasis exposure and on attitudes and barriers to training. METHODS: A 24-item electronic survey was distributed to UK gastroenterology trainees covering the following domains: demographics, training setup, attitudes and barriers, confidence in managing AUGIB independently and exposure to individual haemostatic modalities (supervised and independent). Responses were analysed by region and training grade to assess potential variation in training. RESULTS: A total of 181 trainees completed the questionnaire (response rate 33.5%). There was significant variation in AUGIB training setup across the UK (p<0.001), with 22.7% of trainees declaring no access to structured or ad hoc training. 31.5% expressed confidence in managing AUGIB independently; this varied by trainee grade (0% of first-year specialty trainees (ST3s) to 60.7% of final-years (ST7s)) and by training setup (p=0.001). ST7 trainees reported lack of experience with independently applying glue (86%), Hemospray (54%), heater probe (36%) and variceal banding (36%). Overall, 88% of trainees desired additional haemostasis training and 89% indicated support for a national certification process to ensure competence in AUGIB. CONCLUSION: AUGIB training in the UK is variable. The majority of gastroenterology trainees lacked confidence in haemostasis management and desired additional training. Training provision should be urgently reviewed to ensure that trainees receive adequate haemostasis exposure and are competent by completion of training.

Variation in exposure to endoscopic haemostasis for acute upper gastrointestinal bleeding during UK gastroenterology training.

INTRODUCTION: Gastroenterologists are typically expected to be competent in endoscopic haemostasis for acute upper gastrointestinal bleeding (AUGIB), with the Certificate of Completion of Training (CCT) often heralding the onset of participation in on-call AUGIB rotas. We analysed the volume of haemostasis experience recorded by gastroenterology CCT holders on the Joint Advisory Group on Gastrointestinal Endoscopy Training System (JETS) e-portfolio, the UK electronic portfolio for endoscopy, and assessed for variations in exposure to haemostasis. METHODS: UK gastroenterologists awarded CCT between April 2014 and April 2017 were retrospectively identified from the specialist register. Credentials were cross-referenced with JETS to retrieve AUGIB haemostasis procedures prior to CCT. Procedures were collated according to variceal versus non-variceal therapies and compared across training deaneries. RESULTS: Over the 3-year study period, 241 gastroenterologists were awarded CCT. 232 JETS e-portfolio users were included for analysis. In total, 12 932 haemostasis procedures were recorded, corresponding to a median of 42 (IQR 21-71) per gastroenterologist. Exposure to non-variceal modalities (median 28, IQR 15-52) was more frequent than variceal therapies (median 11, IQR 5-22; p<0.001). By procedure, adrenaline injection (median 12, IQR 6-23) and variceal band ligation (median 10, IQR 5-20) were most commonly recorded, whereas sclerotherapy experience was rare (median 0, IQR 0-1). Exposure to haemostasis did not differ by year of CCT (p=0.130) but varied significantly by deanery (p<0.001), with median procedures ranging from 20-126. CONCLUSION: Exposure to AUGIB haemostasis during UK gastroenterology training varied across deaneries and procedural modalities which should prompt urgent locoregional review of access and delivery of training. Endoscopy departments should ensure the availability of supportive provisions in haemostasis (i.e. training/upskilling, supervision, mentorship) during the early post-CCT period.

Impact of a national basic skills in colonoscopy course on trainee performance: An interrupted time series analysis.

BACKGROUND: The Joint Advisory Group on Gastrointestinal Endoscopy basic skills in colonoscopy (BSC) course was introduced in 2009 to improve colonoscopy training within the United Kingdom, but its impact on trainee performance is unknown. AIM: To assess whether attendance of the BSC could improve colonoscopy performance. METHODS: Trainees awarded colonoscopy certification between 2011-2016 were stratified into 3 groups according to pre-course procedure count (< 70, 70-140 and > 140). Study outcomes, comprising the unassisted caecal intubation rate (CIR) and the performance indicator of colonic intubation (PICI), were studied over the 50 procedures pre and post- course. Interrupted time series analyses were performed to detect step-change changes attributable to the course. RESULTS: A total of 369 trainees with pre-course procedure counts of < 70 (n = 118), 70-140 (n = 121) and > 140 (n = 130) were included. Over the 50 pre-course procedures, significant linear improvements in CIR were found, with average increases of 4.2, 3.6 and 1.7 percentage points (pp) per 10 procedures performed in the < 70, 70-140 and > 140 groups respectively (all P < 0.001). The < 70 procedures group saw a significant step-change improvement in CIR, increasing from 46% in the last pre-course procedure, to 51% in the first procedure post-course (P = 0.005). The CIR step-change was not significant in the 70-140 (68% to 71%; P = 0.239) or > 140 (86% to 87%; P = 0.354) groups. For PICI, significant step-change improvements were seen in all three groups, with average increases of 5.6 pp (P < 0.001), 5.4 pp (P = 0.003) and 3.9 pp (P = 0.014) respectively. CONCLUSION: Attendance of the BSC was associated with a significant step-change improvement in PICI, regardless of prior procedural experience. However, CIR data suggest that the optimal timing of course attendance appears to be at earlier stages of training (< 70 procedures).