HOT TOPICS TRAINING AND COMPETENCY DDW 2018

MOST ADVANCED ENDOSCOPY TRAINEES (AETS) MEET QUALITY INDICATOR (QI) THRESHOLDS IN THE FIRST YEAR OF INDEPENDENT PRACTICE: THE RAPID ASSESSMENT OF TRAINEE ENDOSCOPY SKILLS (RATES2) STUDY Presentation Number:

AuthorBlock: Sachin B. Wani1, Rajesh N. Keswani2, Dayna Early4, Samuel Han1, Eva Aagaard4, Violette Carolyn Simon1, Linda Carlin1, Swan Ellert1, Michael Bartel22, Erik Bowman15, Hemant Chatrath6, Abhishek Choudhary20, Bradley Confer18, Gregory A. Cote5, Koushik Kumar Das4, Christopher J. DiMaio9, Abdul Hamid El Chafic16, Steven A. Edmundowicz1, Jason Ferriera19, Bhargava Gannavarapu2, Hazem T. Hammad1, Sujai Jalaj13, Sri Komanduri2, Gabriel Lang4, Daniel Mullady4, V. Raman Muthusamy6, Kavous Pakseresht12, Amit Rastogi7, Brian Riff9, Shreyas Saligram23, Raj J. Shah1, Rishi Sharma11, Isaiah Paul Schuster21, Ajaypal Singh24, Muhammad Sohail17, James H. Tabibian14, Demetrios Tzimas21, Dushant Uppal8, Andrew Y. Wang8, Tobias Zuchelli10, Matt Hall3 1University of Colorado, Aurora, Colorado, United States; 2Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States; 3Children's Hospital Association, Aurora, Colorado, United States;4Washington University in St. Louis, St. Louis, Missouri, United States; 5Medical University of South Carolina, Charleston, South Carolina, United States; 6University of California, Los Angeles, Los Angeles, California, United States; 7 University of Kansas School of Medicine and Kansas City VA Medical Center, Kansas City, Kansas, United States; 8University of Virginia School of Medicine, Charlottesville, Virginia, United States;9Icahn School of Medicine at Mount Sinai, New York City, New York, United States; 10Henry Ford Hospital, Detroit, Michigan, United States; 11University of California, Davis, Davis, California, United States; 12Kansas University Medical Center, Kansas City, Kansas, United States; 13University of North Carolina, Chapel Hill, North Carolina, United States; 14University of Pennsylvania, Philadelphia, Pennsylvania, United States;15University of Wisconsin, Madison, Wisconsin, United States; 16Thomas Jefferson University, Philadelphia, Pennsylvania, United States; 17University of Massachusetts Memorial Medical Center, Boston, Massachusetts, United States; 18Cleveland Clinic Foundation, Cleveland, Ohio, United States; 19Dartmouth-Hitchcock Medical Center , Lebanon, New Hampshire, United States; 20Stanford University, Stanford, California, United States; 21Stony Brook University School of Medicine, Stony Brook, New York, United States; 22Mayo School of Graduate Medical Education, Jacksonville, Jacksonville, Florida, United States; 23Moffitt Cancer Center, Tampa, Florida, United States; 24Case Western Reserve University, Cleveland, Ohio, United States;

Background: There are no prospective data on the perceptions, performance and progression of learning curves (LCs) among AETs in the 1st yr of independent practice following an advanced endoscopy training

program (AETP). It is unclear whether AETs who complete an AETP with structured feedback achieve established QI benchmarks in the 1st yr of independent practice. Aims: To measure outcomes during 1st year of practice using established QIs in EUS and ERCP for AETP graduates who received continuous structured feedback. To examine the perceptions and practice patterns among AETs in independent practice Methods: In Phase I, ASGE-recognized AETPs were invited to participate. AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCP exams using the validated EUS and ERCP Skills Assessment Tool (TEESAT). A comprehensive data collection and reporting system was used to create LCs using cumulative sum (CUSUM) analysis for technical and cognitive components of EUS and ERCP. AETs completed a post-Phase I study questionnaire assessing comfort level in EUS and ERCP using a 5-point Likert scale. During Phase II, AETs entered ASGE QI performance data on all advanced procedures during 1styr of independent practice and the defined QIs with performance targets served as benchmarks for performance. Results: 37 AETs from 32 AETPs participated and 24 AETs were included in the final analysis (Phase I). Majority of AETs achieved overall technical (EUS: 91.6%; ERCP: 73.9%) and cognitive (EUS: 91.6%, ERCP: 95.6%) competence at end of training. 22 of 24 AETs participated in (Phase II). Majority of AETs expressed comfort in independently performing EUS (94.4%) and ERCP (94.5%) at end of training (Table 1). Most AETs started in an academic environment (61%) and expressed difficulty finding a position (67%). Credentialing was determined by completion of training alone (31%), no. of procedures performed (52%), or proctoring of cases at outset (17%). Median EUS procedures completed in independent practice/AET was 136 (IQR 102-204); 65% performed for pancreatobiliary indications and EUS-FNA was performed in 41.4% of all cases. The median ERCPs/AET was 116 (IQR 48-169); majority performed for biliary indications and in normal anatomy cases (95.7%). Table 2 highlights that most AETs meet the performance thresholds for QIs in EUS and ERCP during 1st year of independent practice. Conclusions: These results demonstrate that most AET graduates meet the ASGE QI thresholds in EUS and ERCP at the end of 1st yr of independent practice. Our results further highlight the variability in the case volume in independent practice and that the majority of AETs perform “routine” EUS and ERCP in their 1st year. Finally, our results provide construct validity for the assessment tool and our data collection and reporting system. Supported by the ASGE Endoscopic Research Award

Table 1: Results of post-Phase I study questionnaire assessing comfort level in performing EUS and ERCP (overall and independent tasks) in independent practice

Strongly

Agree (%)

Tend to Agree (%)

Neutral (%)

Tend to Disagree

Strongly Disagree

(%)

EUS

1. I feel comfortable with independently performing EUS 61% 33% 6% 0 0

2. I feel comfortable performing EUS-FNA 61% 33% 6% 0 0

3. I feel comfortable performing celiac plexus

block/neurolysis 22% 55% 11% 6% 6%

4. I feel comfortable placing fiducials 11% 28% 44% 6% 11%

5. I feel comfortable performing pancreatic fluid

collection drainage 28% 61% 11% 0 0

6. I feel comfortable performing biliary/pancreatic

EUS-guided rendezvous procedures

6% 28% 28% 32% 6%

7. I feel comfortable interpreting EUS images (e.g. finding a mass, tracing the bile

duct and pancreatic duct)

50% 39% 11% 0 0

8. I feel comfortable in appropriate cancer staging

using the AJCC criteria 33% 44% 17% 6% 0

ERCP

1. I feel comfortable with independently performing

ERCP 67% 27% 6% 0 0

2. I feel comfortable with deep cannulation of duct of interest 61% 33% 6% 0 0

3. I feel comfortable performing sphincterotomy 72% 22% 6% 0 0

4. I feel comfortable with stone clearance (<1 cm) 78% 16% 6% 0 0

5. I feel comfortable with placement of biliary stents 94% 6% 0 0 0

6. I feel comfortable with placement of pancreatic stents 61% 33% 6% 0 0

7. I feel comfortable interpreting cholangiograms

and pancreatograms 72% 22% 6% 0 0

Table 2: Performance of advanced endoscopy trainees in 1st year of independent practice based on ASGE/ACG established Quality Indicators in EUS and ERCP (Phase II)

Quality Indicator* (measure type and

performance target)

No. of procedures

Overall AET performance (n,%) Range

No. of AETs reaching

performance target n (%)

EUS

Diagnostic rate of adequate sample in all solid lesions

undergoing EUS-FNA (outcome, ≥85%)

1255 1185 (94.4) Range: 77.1-100% 19 (90.5%)

Diagnostic rates for malignancy in patients undergoing EUS-FNA of pancreatic masses

(Outcome, ≥ 70% ) (Priority Indicator)

519 435 (83.8) Range: 45-100% 17 (81%)

Incidence of Adverse Events after EUS-FNA

Acute Pancreatitis (Outcome, <2%) 3258 13 (0.4) NA

Perforation (Outcome, <0.5%) 3258 2 (0.06) NA

Clinically significant bleeding (Outcome, <1%) 3258 8 (0.25) NA

ERCP

Frequency with which deep cannulation of the ducts of 2668 2532 (94.9)

Range: 84-100%

interest is achieved (Process, NA)

Frequency with which deep cannulation of ducts of interest in patients with native papillae

is achieved (Process, >90%) (Priority

Indicator)

1552 1445 (93.1) Range: 76.5-100% 17 (77.3%)

Frequency with which common bile duct stones <1cm are

extracted successfully (Outcome, ≥90%)

1141 1068 (93.6) Range: 62.1-100% 18 (81.8%)

Frequency with which stent placement for biliary obstruction

is successfully achieved (Outcome, ≥90%)

1325 1244 (93.9) Range: 80-100% 15 (68.2%)

Adverse Events

Rate of post-ERCP Pancreatitis (Outcome, NA)

(Priority Indicator) 2673 67 (2.51)

Rate of Perforation (Outcome, ≤0.2%) 2673 9 (0.34)

Rate of clinically significant hemorrhage

(Outcome, ≤1%) 2673 22 (0.82)

* Based on the ASGE/ACG Quality Indicators in EUS and ERCP

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SETTING MINIMUM STANDARDS FOR TRAINING IN EUS AND ERCP: RESULTS FROM A PROSPECTIVE MULTICENTER STUDY EVALUATING LEARNING CURVES AND COMPETENCE AMONG ADVANCED ENDOSCOPY TRAINEES (AETS) Presentation Number: 762

AuthorBlock: Sachin B. Wani1, Samuel Han1, Violette Carolyn Simon1, Matt Hall3, Dayna Early4, Eva Aagaard4, Linda Carlin1, Swan Ellert1, Wasif M. Abidi5, Todd H. Baron6, Brian C. Brauer1, Hemant Chatrath7, Gregory A. Cote8, Koushik Kumar Das9, Christopher J. DiMaio10, Steven A. Edmundowicz1, Ihab I. El Hajj11, Hazem T. Hammad1, Sujai Jalaj6, Michael L. Kochman9, Sri Komanduri2, Linda S. Lee5, Daniel Mullady4, V. Raman Muthusamy7, Andrew Scot Nett12, Mojtaba Seyed Olyaee13, Kavous Pakseresht13, Pranith Perera12, Patrick Pfau14, Cyrus Piraka15, Amit Rastogi16, Raj J. Shah1, Rishi Sharma17, James M. Scheiman12, James H. Tabibian9, Dushant Uppal18, Shiro Urayama19, Andrew Y. Wang18, Tobias Zuchelli15, Erik Bowman20, Gabriel Lang4, David E. Loren21, Abdul Hamid El Chafic21, Patrick Yachimski22, Anthony Gamboa22, John Mark Poneros23, Wahid Wassef24, Muhammad Sohail24, Tyler Stevens25, Bradley Confer25, Nalini M. Guda26, S. Ian Gan27, Anthony Razzak27, Stuart R. Gordon28, Jason Ferriera28, Subhas Banerjee29, Abhishek Choudhary29, Andrew M. Dries30, Jonathan M. Buscaglia31, Demetrios Tzimas31, Sergio Zepeda-Gomez32, Sana Kenshil32, Frank Lukens33, Michael Bartel33, Paul Jowell34, Joshua Paul Spaete34, Brian Riff10, Cynthia Harris35, Shreyas Saligram35, Bhargava Gannavarapu2, Amitabh Chak36, Ajaypal Singh36, Rajesh N. Keswani2 1University of Colorado, Aurora, Colorado, United States; 2Feinberg School of Medicine - Northwestern University, Chicago, Illinois, United States; 3Children's Hospital Association, Aurora, Colorado, United States;4Washington University in St. Louis, St. Louis, Missouri, United States; 5Brigham and Women's Hospital, Boston, Massachusetts, United States; 6University of North Carolina, Chapel Hill, North Carolina, United States;7University of California, Los Angeles, Los Angeles, California, United States; 8Medical University of South Carolina, Charleston, South Carolina, United States; 9University of Pennsylvania, Philadelphia, Pennsylvania, United States; 10Icahn School of Medicine at Mount Sinai, New York City, New York, United States; 11Indiana University, Indianapolis, Indiana, United States; 12University of Michigan, Ann Arbor, Michigan, United States; 13Kansas University Medical Center, Kansas City, Kansas, United States; 14University of Wisconsin, Madison, Wisconsin, United States; 15Henry Ford Hospital, Detroit, Michigan, United States; 16University of Kansas School of Medicine and Kansas City VA Medical Center, Kansas City, Kansas, United States; 17University of California, Davis, Davis, California, United States; 18University of Virginia School of Medicine, Charlottesville, Virginia, United States; 19University of California, Davis, Davis, California, United States; 20University of Wisconsin School of Medicine, Madison, Wisconsin, United States; 21Thomas Jefferson University, Philadelphia, Pennsylvania, United States; 22Vanderbilt University, Nashville, Tennessee, United States; 23Columbia University, New York City, New York, United States; 24University of Massachusetts Memorial Medical Center, Boston, Massachusetts, United States; 25Cleveland Clinic Foundation, Cleveland, Ohio, United States; 26Aurora Health Care, Milwaukee, Wisconsin, United States; 27Virginia Mason Medical Center, Seattle, Washington, United States; 28Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States; 29Stanford University, Stanford, California, United States; 30Carolinas Medical Center, Charlotte, North Carolina, United States; 31Stony Brook University, Stony Brook, New York, United States; 32University of Alberta, Edmonton, Edmonton,

Alberta, Canada; 33Mayo Clinic School of Gradual Medical Education, Jacksonville, Jacksonville, Florida, United States; 34Duke University, Durham, North Carolina, United States; 35Moffitt Cancer Center, Tampa, Florida, United States; 36University Hospitals Case Medical Center, Cleveland, Ohio, United States;

Background: Despite the dramatic increase in advanced endoscopy training programs (AETPs), there is no fixed mandatory curriculum and minimal standards as to what constitutes a “high quality” AETP has not been defined. Understanding the mean number of procedures required to achieve competence in all aspects of EUS and ERCP would help structure AETPs. Aims: To define the mean number of procedures required by an “average” AET to achieve competence in technical and cognitive EUS and ERCP tasks. Methods: ASGE recognized AETPs were invited and AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCP exams using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves (LCs) using cumulative sum (CUSUM) analysis for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable failures rates were set a priori. In order to generate aggregate CUSUM LCs across AETs, we used generalized linear mixed effects models with a random intercept for each AET and an AR1 covariance structure. This allowed us to use data from all AETs to estimate the average learning experience for trainees with 95% CIs. We then fit a spline to the modeled estimates with knots at 40 and 80 evaluations to smooth the results and estimate the mean number of procedures needed to achieve competence. Results: Of the 62 AETPs invited, 37 AETs from 32 AETPs participated in this study; 24 AETs were included in the final analysis. Prior to AETP, 52% reported hands-on EUS (median 20 cases) and 68% hands-on ERCP (median 50 cases) experience prior to AETP. At the end of training, median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP – biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (69.9%) and ERCP exams for ASGE biliary grade of difficulty 1 (72.1%). Table 1 highlights the substantial variability in EUS and ERCP learning curves. The majority of trainees achieved overall technical (EUS: 91.7%; ERCP: 73.9%) and cognitive (EUS: 91.7%, ERCP: 95.7%) competence at the end of training. Table 1 and Figure highlight the number of procedures required by an average AET to achieve competence in all aspects of EUS and ERCP. Conclusions: The results of this study confirm the substantial variability in achieving competence in EUS and ERCP. The thresholds provided for an average AET to achieve competence in EUS (~225 cases) and ERCP (~250) may be used by ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. Supported by the ASGE Endoscopic Research Award

Table: Competence rates in EUS and ERCP using TEESAT and global rating scale with the mean number of procedures required for competence for an average advanced endoscopy trainee

No. of AETs

meeting

No. of evaluations

No. of AETs achieving

Mean number of procedures performing

Mean number of

overall

inclusion criteria

competence n (%)*

this skill required for competence

for an average AET (95%

CI)

ERCPs performed at competence thresholds

EUS

EUS-FNA 11 320 7 (63.6%) 110 (90, 140) 226

Overall Technical 24 1151 22 (91.7%) 125 (100, 155)

Overall Cognitive 24 1113 22 (91.7%) 135 (110, 160)

Global rating scale 24 1123 17 (70.8%) 165 (135, 185)

ERCP

Overall cannulation 19 774 15 (78.9%) 105 (80, 130) 230

Cannulation in native papilla 11 295 6 (54.5%) 110 (85, 135) 226

Sphincterotomy 11 318 8 (72.7%) 120 (100, 145) 254

Stone clearance 7 170 6 (85.7%) 70 (60, 85) 157

Overall technical 23 972 17 (73.9%) 140 (115, 175)

Overall cognitive 23 985 22 (95.7%) 90 (60, 115)

Global rating scale 20 914 15 (75%) 165 (130, N/A)

* Primary analysis: TEESAT: success defined as score of 1 or 2 (no assistance/minimum verbal cues), Global rating scale: success defined as score of 3 or 4 (competent to perform procedure independently/able to perform independently with limited coaching and/or requires additional time to complete). Acceptable failure rate p0=0.1 and unacceptable failure rate p1=0.3

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ASSESSING COMPETENCE IN COLD SNARE POLYPECTOMY: EVALUATION OF A MODIFIED VERSION OF THE DIRECT OBSERVATION OF POLYPECTOMY SKILLS (DOPYS) TOOL Presentation Number: Mo1660

AuthorBlock: Swati Patel1,2, Anna Duloy3, Tonya R. Kaltenbach4, Roy M. Soetikno10, Matt Hall5, Arun Rajendran6, Siwan Thomas-Gibson6, Charles J. Kahi7, Heiko Pohl8, Dennis Ahnen1, Amit Rastogi9, Hazem T. Hammad1,2, Amandeep K. Shergill4, Ajay Bansal9, Violette Carolyn Simon1, Eze Ezekwe1, Tara Ahi4, Rajesh N. Keswani3, Sachin B. Wani1 1University of Colorado Anschutz Medical Center, Denver, Colorado, United States; 2Veterans Affairs Medical Center, Denver, Colorado, United States; 3Northwestern University, Chicago, Illinois, United States;4Veterans Affairs Medical Center, San Francisco, California, United States; 5Children's Hospital, Kansas City, Kansas, United States; 6St. Mark's Hospital, London, United Kingdom; 7Indiana University, Indianapolis, Indiana, United States; 8Veterans Affairs Medical Center, White River Junction, Vermont, United States; 9University of Kansas, Kansas City, Kansas, United States; 10Singapore General Hospital, Singapore, Singapore;

BACKGROUND: Small polyps (<1cm) are commonly found during routine colonoscopy and are frequently removed piecemeal raising risk of incomplete resection. Formal training methods and a validated tool to measure competence in cold snare polypectomy are urgently needed since en bloc resection is recommended. Unfortunately, the validated Direct Observation of Polypectomy Skills (DOPyS) tool is not specific to cold snare polypectomy. AIMS: (1) Phase I: adapt and validate the DOPyS tool for evaluation of competence in cold snare polypectomy and (2) Phase II: evaluate reliability of the modified tool using video-based assessments. METHODS: Phase I: We extracted the elements applicable to cold snare polypectomy from DOPyS and developed additional metrics specific to cold snare polypectomy. We added these metrics, a global assessment and determination of polyp size/morphology and excluded elements that could not be evaluated by video. We subsequently invited 20 international experts in colonoscopic polypectomy, endoscopy quality and training to rate the importance of each proposed metric. We selected metrics with ≥80% agreement in being ‘important’ or ‘very important.’ Phase II: We measured rater agreements of each item in the modified tool by inviting 17 experts to review a specifically collected library of cold snare polypectomy videos (embedded in a RedCap survey). We used Kappa statistic to determine inter-observer agreement. We needed 5 reviewers rating 55 videos in order to power for a kappa value of 0.90, with precision of 95% CI of 0.10. Based on convention, we considered a kappa value of 0.41-0.60 moderate and 0.61-0.80 substantial. RESULTS: Phase I: Based on feedback from 18 experts, we included a total of 12 metrics; 9 were from the original DOPyS and 3 are new (see Figure). Phase II: We developed a library of 55 cold snare polypectomy videos and thirteen experts rated the videos using the new tool. We found a moderate degree of agreement in ten metrics (kappa 0.52-0.59) and a substantial degree of agreement (kappa 0.61 and 0.63) in the other two (see Table). There was a strong correlation between the average of

metrics 1-12 compared to the global competence assessment (0.882, p<0.001). Reviewers agreed over 70% of the time for nine out of twelve metrics. 75% of reviewers agreed in global assessment of polypectomy competence. 50% of reviewers agreed on “ensures appropriate amount of tissue is captured within the snare” and “identifies and appropriately treats residual polyp.” CONCLUSIONS: We have developed and validated a modified DOPyS metric to assess competence in cold snare polypectomy. We found a moderate to substantial inter-observer reliability across all metrics. We are currently conducting a prospective study to examine the competence of cold snare polypectomy among trainees. Supported by the ASGE Quality in Endoscopic Research Award

Interobserver Agreement in Cold Snare Polypectomy Metrics

Assessment Metrics1

Weighted Kappa

(standard error)

Mean Reviewers who agree on competence vs incompetence2(%,

standard deviation)

1. Achieves optimal polyp position 0.5242 (0.0741) 77.6 (12.5)

2. Optimizes view by aspiration/insufflation/wash 0.5907 (0.0632) 81.0 (14.4)

3. Adjusts/stabilizes scope position 0.6273 (0.06) 78.8 (16.2)

4. Directs snare accurately over the lesion 0.6099 (0.0606) 72.2 (15.5)

5. Anchors sheath of snare several mm distal to polyp 0.5940 (0.0615) 77.3 (15.2)

6. Keeps tools close to scope 0.5804 (0.0615) 78.8 (15.5)

7. Appropriate positioning of snare over lesion as snare closed 0.5864 (0.061) 76.2 (16.6)

8. Ensures appropriate amount of tissue is trapped within snare 0.5963 (0.0598) 48.8 (10.1)

9. Ensures rim of normal tissue is resected around polyp 0.5932 (0.0596) 76.5 (15.4)

10. Examines post-polypectomy site 0.5878 (0.0593) 69.1 (13.7)

11. Identifies and appropriately treats residual polyp 0.5835 (0.0572) 47.8 (14.8)

12. Retrieves, or attempts, retrieval of polyp 0.583 (0.0559) 85.5 (11.8)

13. RATE THE OVERALL POLYPECTOMY 0.5752 (0.0563) 75.0 (15.8)

14. Polyp Morphology 0.5602 (0.0559) 90.9 (5.5) 1Each metric was assessed as: 4-Highly skilled; 3-Competent & Safe, no uncorrected errors; 2-Some standards not yet met, aspects to be improved, some errors uncorrected; 1-accepted standards not met, frequent uncorrected errors. 2Competence is a score of 3 or 4, incompetence is a score of 1 or 2

A COLON POLYPECTOMY REPORT CARD IMPROVES POLYPECTOMY COMPETENCY: RESULTS OF A PROSPECTIVE QUALITY IMPROVEMENT STUDY

Presentation Number: Mo1709

AuthorBlock: Anna Duloy1, Tonya R. Kaltenbach2, Mariah Wood1, Rajesh N. Keswani1 1Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, United States; 2Gastroenterology, University of California, San Francisco, San Francisco, California, United States;

Introduction: Poor polypectomy technique may lead to interval colorectal cancer and/or adverse events. In prior work, we showed that polypectomy competency varies significantly between providers. Our aim was to determine the effect of a colon polypectomy skills report card upon polypectomy performance. Methods: We conducted a prospective single-blinded study of endoscopists at an academic medical center. The study had 3 phases [Figure]. Phase 1 (“baseline”): we recorded >20 colonoscopies/endoscopist. Ten polypectomies/endoscopist were randomly selected and polypectomy technique was graded (Direct Observation of Polypectomy Skills; DOPyS) by 2 reviewers. A score of 1-4 was given; mean scores >3 are competent. Phase 2 (“pre-report card”): >20 colonoscopies/endoscopist were recorded. Following this, endoscopists received a personalized report card based on their baseline data, which included: polypectomy performance (overall and individual skills) and 9 instructional videos demonstrating poor and optimal polypectomy technique. Phase 3 (“post-report card”): endoscopists were again recorded. The 2 reviewers, blinded to study phase (2 vs. 3), graded 10 pre- and 10 post-report card polypectomies/endoscopist. We compared rate of competent polypectomy and mean DOPyS scores in the pre-and post-report card phases. Results: We assessed 220 polypectomies (110 pre- and 110 post-report card) performed by 11 endoscopists (annual median colonoscopy volume of 877 [IQR: 762-981]). All endoscopists reviewed their report cards and 7/11 (64%) watched the instructional videos. All polyps were <17 mm. Mean polyp size and number of diminutive (<6 mm) polyps did not significantly differ between pre- and post-report card phases [Figure]. Most polyps were removed by cold snare in both phases, though cold snare use increased from pre- to post-report card phase (58% vs. 76%, p=0.001; Table). Rate of piecemeal polypectomy significantly decreased from pre- to post-report card phase (40% vs. 21%, p=0.001). Rate of competent polypectomy was 63% and mean DOPyS score was 2.7±0.4 in the baseline phase. Rate of competent polypectomy significantly improved from pre- to post-report card phase (56% vs. 69%, p=0.04); this improvement was seen for diminutive polyps (57% vs. 81%, p=0.001) but not small-large polyps (55% vs. 36%, p=0.2). Mean DOPyS score increased significantly between the pre- and post-report card phases (2.7±0.9 vs. 3.0±0.8; p=0.01); this improvement was seen for diminutive but not small-large polyps. Three endoscopists significantly improved their mean DOPyS scores; none significantly worsened.

Discussion: Report cards improved polypectomy technique due to improvements in resecting diminutive polyps, which are the majority of polyps encountered in practice. As polypectomy competency is integral to high quality colonoscopy, this intervention should be broadly adopted.

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