A Prospective Multicenter Study Evaluating Endoscopy Competence Among Gastroenterology Trainees in the Era of the Next Accreditation System.

PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.

Time Given to Trainees to Attempt Cannulation During Endoscopic Retrograde Cholangiopancreatography Varies by Training Program and Is Not Associated With Competence.

Advanced endoscopy training programs (AETPs) were developed as a result of the lack of comprehensive endoscopic retrograde cholangiopancreatography (ERCP) training during gastroenterology fellowships. There is no standardized curriculum for AETPs and the influence of program- and trainer-associated factors on trainee competence in ERCP has not been investigated adequately. In prior work, we showed that advanced endoscopy trainees (AETs) achieve ERCP competence at varying rates.1,2 The aims of this study were to measure the variability in time given to AETs to attempt cannulation between AETPs and throughout the 1-year training period, and to determine the association between AET cannulation time and AET competence at the end of training.

Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial.

BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).

Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

BACKGROUND AND AIMS: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. METHODS: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees. RESULTS: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases. CONCLUSION: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

BACKGROUND & AIMS: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills Study.

BACKGROUND & AIMS: On the basis of the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) by using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. METHODS: ASGE recognized training programs were invited to participate, and AETs were graded on ERCP and EUS exams by using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done by using a 4-point scoring system, and a comprehensive data collection and reporting system was built to create learning curves by using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. RESULTS: Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range, 155-650) and 350 (125-500), respectively. Overall, 3786 exams were graded (EUS, 1137; ERCP-biliary, 2280; ERCP-pancreatic, 369). Learning curves for individual end points and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS, 82%; ERCP, 60%) and cognitive (EUS, 76%; ERCP, 100%) competence at conclusion of training. CONCLUSIONS: These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP. ClinicalTrials.gov: NCT02509416.

Lifestyle risk factors for chronic disease in a multiethnic population: an analysis of two prospective studies over a 20-year period.

OBJECTIVE: This study investigated changes in risk factors in Hawaii over 20 years and compared health behaviors among ethnic groups with well-documented differences in disease risk. DESIGN: Comparison of scores of a Chronic Disease Risk Index (CDRI) in the population of two large population-based cohorts. PARTICIPANTS: The respective sample sizes for the two cohorts were 19,319 and 97,746 persons ages > or = 40 years of White, Chinese, Filipino, Japanese, and Native Hawaiian ancestry. MAIN OUTCOME MEASURES: The CDRI included smoking status, alcohol use, meat intake, fruit and vegetable consumption, and body mass index. Mean total and component scores were compared over time and by ethnic group after adjustment for age and education. RESULTS: We found a reduction in overall CDRI scores, ie, improved health profiles, for both men and women over time. Men, Native Hawaiians, and Whites had higher CDRI scores than women and Japanese, Chinese, and Filipinos due to their higher scores for smoking, alcohol use, and overweight, whereas nutritional intakes were similar in all ethnic categories. Smoking, alcohol use, and overweight increased over time in both men and women, whereas dietary composition appeared to improve. CONCLUSIONS: This analysis suggests an overall reduction in modifiable dietary and lifestyle risk factors in Hawaii over time. Persistent differences by sex and ethnic category indicate that interventions to modify lifestyle factors need to tailor messages to the groups at highest risk.

Cervical cancer screening and management practices among providers in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

BACKGROUND: This study was conducted to describe clinicians serving women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with regard to demographic and practice characteristics and their usual practices in cervical cancer screening and abnormal cytology management, as well as human papillomavirus (HPV) test use. METHODS: The authors analyzed data from a nationally representative survey conducted in 2004 of providers practicing 7 specialties that commonly offer cervical cancer screening. The program providers were compared with nonprogram providers. RESULTS: Program providers were found to be significantly more likely than nonprogram providers to be midlevel providers and to serve low-income, racial/ethnic minorities who are insured by Medicaid. In addition, they had significantly more patients with abnormal Papanicolaou tests and were more likely to offer onsite colposcopy (57% vs 40%). Program providers were less likely to use liquid-based cytology (LBC) as their sole method for cytology. Approximately 20% of program and nonprogram providers used HPV DNA testing as an adjunct to screening cytology and two-thirds used HPV tests to manage patients with abnormal cytology results. However, many also used HPV testing for reasons not approved by the U.S. Food and Drug Administration (FDA), such as for screening women age <30 years. CONCLUSIONS: As of mid-2004, program providers served racially and ethnically diverse, low-income patients who are at high risk for cervical cancer compared with nonprogram providers, as intended by this program. Because many providers offered on-site colposcopy, used LBC, and used HPV tests for patients with abnormal cytology results, they are well equipped to reduce the risk of cervical cancer. Many program providers used the HPV test for reasons that were not approved of by the FDA or reimbursed by the NBCCEDP. The results of this survey have informed training materials for program providers, reimbursement policies for LBC and HPV tests, and interventions to discourage inappropriate HPV testing.

Use of DNA tests for human Papillomavirus infection by US clinicians, 2004.

Since 1999, human papillomavirus (HPV) DNA tests have been approved only for abnormal cervical cytology management and as an adjunct to cervical cytology screening. To assess HPV DNA testing practices, we mailed surveys to 6906 randomly selected clinicians in mid-2004. Awareness (87%) and ever use (67%) of HPV DNA tests was high. Test users were more likely than nonusers to be obstetricians/gynecologists or midwives, to be female, and to serve mainly privately insured patients. Respondents reported ever using HPV DNA tests for both approved and nonapproved indications, which included testing for HPV infection in women with anogenital warts or other sexually transmitted diseases, in their sex partners, and in men. Interventions are needed to discourage HPV DNA test use for nonapproved indications.

Anogenital warts knowledge and counseling practices of US clinicians: results from a national survey.

OBJECTIVES: To examine messages US clinicians use when counseling patients diagnosed with anogenital warts. STUDY DESIGN: In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts. RESULTS: After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement. CONCLUSIONS: Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Cervical cancer screening, abnormal cytology management, and counseling practices in the United States.

OBJECTIVE: We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results. METHODS: In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices. RESULTS: The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences. CONCLUSION: New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.

Family physicians' knowledge of genital human papillomavirus (HPV) infection and HPV-related conditions, United States, 2004.

BACKGROUND AND OBJECTIVES: Information about human papillomavirus (HPV) has evolved rapidly and HPV DNA tests are now available. Little is known about family physicians' knowledge about HPV and how it relates to HPV test use and counseling practices. METHODS: In mid-2004, confidential surveys were mailed to a nationally representative sample of 760 family physicians. We assessed and analyzed relationships between knowledge about HPV, HPV test use, and counseling messages provided when collecting cervical cytology and managing anogenital warts. RESULTS: The adjusted response rate was 68% (n=368). Ninety-one percent provided cervical cancer screening, and 90% had managed genital warts. Responses indicated that more than 90% had up-to-date knowledge about several issues: HPV infection is common, persistent infection increases risk of cervical neoplasia, and treatment does not eliminate the causative infection. However, fewer than 50% were aware that HPV infections may clear spontaneously and that the HPV types associated with warts and cervical neoplasia differ. Only 57% had ever used HPV tests. Some HPV knowledge varied by clinician characteristics, and knowledge was associated with HPV test use but not counseling messages. CONCLUSIONS: Most physicians were aware of new information about HPV infection, but some were unaware of important information relevant for patient counseling. These topics have been highlighted in new clinical training and patient education materials.

Trends and dietary determinants of overweight and obesity in a multiethnic population.

OBJECTIVES: To describe trends in BMI among different ethnic groups in Hawaii and to explore the relation of nutrient and food intake with excess weight. RESEARCH METHODS AND PROCEDURES: We pooled demographic, anthropometric, and nutritional data derived from a detailed diet history for 159,683 participants of 18 population-based epidemiological studies conducted in Hawaii over a 25-year period. The age-adjusted prevalence of excess weight (BMI > or = 25 kg/m(2)) was estimated for 5-year intervals. To explore dietary determinants of excess weight, we computed odds ratios using logistic regression. RESULTS: During the study period, the prevalence of excess weight increased considerably among all ethnic groups. Native Hawaiians had the highest and Asian Americans had the lowest prevalence of excess weight at all times. Although the percentage of calories consumed from carbohydrates increased, the percentage of calories from fat decreased over time. On an individual level, fat and protein consumption predicted a higher BMI, and dietary fiber intake predicted a lower BMI. Similarly, a higher consumption of meat, poultry, and fish was related to excess weight, whereas fruit and vegetable intake were inversely associated with excess weight. After stratification by ethnicity, the associations were not materially altered among women, but carbohydrates seemed to have a stronger association with excess weight among Native Hawaiian and Japanese men than among white men. DISCUSSION: In this large ethnically diverse population, plant-based foods and dietary fiber emerged as a potential protective factor against excess weight regardless of ethnicity.

Ethnicity, sense of coherence, and tobacco use among adolescents.

BACKGROUND: Prevention of youth smoking has great potential to improve the health of Americans. There is limited information about correlates of tobacco use among adolescents from ethnic minority groups, especially Asians, Pacific Islanders, and Native Hawaiians. PURPOSE: This article examines the relationships among ethnicity, sense of coherence (SOC), and tobacco use. METHODS: We conducted a baseline survey of a cluster randomized tobacco prevention trial in public middle schools in Hawaii with a multiethnic sample of 3,438 seventh-grade students. RESULTS: Ethnic differences in smoking prevalence were very large, with high smoking rates among Native Hawaiian/Pacific Islander, White, and Filipino students and with low rates among Japanese and Chinese students. Higher SOC scores predicted significantly lower risk of having ever smoked and of smoking in the past 30 days. SOC was most strongly related to ever smoking among Filipino, Hawaiian/Pacific Islander, and White students; Japanese students experienced the strongest protective effect from SOC for past-month smoking. CONCLUSIONS: The results suggest that SOC is strongly associated with tobacco use among this age group. It will be important to examine whether SOC can be improved by an intervention program and whether increases in SOC are associated with reduced smoking.

Ethnic differences in trends and determinants of cigarette smoking in Hawaii.

BACKGROUND: The prevalence of smoking continues to be higher in some ethnic groups than in others, despite the overall decrease of smoking during the last 30 years. The goal of this project was to investigate the trends and predictors of cigarette smoking among a population of Caucasians, Japanese, Chinese, Filipino, and Native Hawaiians. METHODS: We combined data from 19 earlier studies conducted in Hawaii between 1975 and 2001. After excluding 1,885 individuals without smoking data, 158,629 subjects (40.0% Japanese, 30.3% Caucasian, 14.3% Hawaiian, 8.1% Filipino, 3.0% Chinese) were included in the analysis. The prevalence of current smoking and past smoking was estimated for 5-year periods by sex and ethnicity and age-adjusted to the state's population. We calculated odds ratios and 95% confidence intervals by using polytomous logistic regression to explore determinants of smoking, while controlling for clustering by study. RESULTS: Men were more likely to smoke than women throughout the study period, but they experienced a greater decline in smoking until 1994. We observed a small increase in smoking prevalence thereafter. Native Hawaiians reported the highest smoking prevalence, Japanese the lowest, and Caucasians intermediate levels. Graduate level education had the strongest inverse association with current and past smoking. Older age at interview, being married, and a higher body weight were related to lower smoking prevalence. CONCLUSIONS: Our data suggest a modest reversal in the declining smoking prevalence during the late 1990s. The persistent ethnic differences require new approaches that reach those groups who remain at high risk for adverse health effects from smoking.