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Endoscopic asessment

ASGE publishes initiative for endoscopic simulators

Article assesses what data are required to support a wider adoption of endoscopy training
What are the thresholds for incorporation of a simulator into training?

The American Society for Gastrointestinal Endoscopy (ASGE) has published an article addressing the use of endoscopy simulators for training.

ASGE claims the “Preservation and Incorporation of Valuable Endoscopic Innovations” (PIVI) initiative addresses the use of endoscopy simulators for training and assessing. This latest PIVI is one in a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice.

The article is featured in the September 2012 issue of GIE: Gastrointestinal Endoscopy.

“Although the use of simulators has become much more widespread, particularly via the use of ex vivo–based hands-on training courses, there is no consensus to date on just how much of a role they should play in standard training,” said PIVI Committee Chair, Dr Jonathan Cohen. “Ultimately, the decision about whether to incorporate these technologies into a training programme must rely on data regarding the magnitude of training benefits, any cost savings resulting from accelerated learning, the initial and on-going expenses associated with the simulator work, and the local needs of the institution.”

The PIVI reviews the current literature on simulator use in endoscopy and assesses what data are required to support a wider adoption of their use for endoscopy training and skills assessment.

Specifically, the article addresses two questions:

  • How much benefit must be demonstrated from the use of simulators to justify widespread adoption into standard endoscopy training?
  • How reliable do simulator-based assessments need to be as a predictor of patient-based skills to justify their use in credentialing and re-credentialing for endoscopy?

The article also reports on the threshold for incorporation of a simulator into training. For an endoscopy simulator to be integrated into the standard instruction for a procedure, it must demonstrate a 25% or greater reduction in the median number of clinical cases required for the trainees to achieve the minimal competence parameters for that procedure. The threshold for using a simulator to assess skill, a simulator-based assessment tools must be procedure specific and predictive of independently defined minimal competence parameters from real procedures with a к value (i.e. correlation coefficient with value of 0 meaning that skills on a simulator had no correlation with real procedures and value of 1.0 had perfect correlation of simulator skills with real procedures) of at least 0.70 for high-stakes assessment.

A summary of PIVI methodology and literature review includes:

  • A comprehensive review of published trials using ex vivo and computer simulators was performed and circulated to the members of the PIVI committee.
  • Training: Despite their varied capabilities and promising potential, use of the current endoscopic simulators appears to help primarily with early learning curves for endoscopic procedures. However, to date, simulator use has not yet led to an accelerated achievement of competency benchmarks or improved outcomes for patients.
  • Assessing skill: There are only limited data examining the ability of endoscopy simulators to be used as tools to assess endoscopic skill. The limited literature available in this respect has shown these models to lack performance metrics of adequate sensitivity or reliability for use as meaningful assessment tools.

The article also looks at the study designs needed to address the questions raised by this PIVI:

  • Training: The benefit of using simulators for training can only be validated in an adequately powered, controlled trial that demonstrates that the incorporation of simulators in a training programme leads to acquisition of technical and cognitive competency with fewer clinical endoscopic procedures than required by traditional supervised endoscopic instruction without access to the simulator.
  • Assessment: A simulator that is able to assess the actual clinical skills (technical and cognitive) of a clinician performing endoscopy may be a useful tool for credentialing (or re-credentialing). A prerequisite for any validation of such a tool would be a previous consensus on how to measure competency for a particular procedure in real patients.

The PIVI also states that reaching the target for simulator-based skills assessments will require both improvement in the way in which actual clinical procedure performance is assessed and advances in the simulators themselves.

Specifically, this will require the following:

  • Development of accurate, reliable and validated clinical patient-based assessment tools for all endoscopic procedures to establish learning curves and benchmark clinical performance abilities.
  • Development of simulated cases of increased difficulty to allow discrimination of differing grades of ability (not just novice/expert).
  • Development of clinically relevant, accurate, and reliable simulator assessment metrics that effectively distinguish the different grades of ability and correlate with clinical performance benchmarks in prospective validation studies.

As professional societies work to better define the constituents and benchmarks for competency in various procedures, investigators and providers of simulators will need to focus their efforts on addressing current unmet needs, determining which trainees get the most benefit from which tools, and reducing the cost of simulation to improve access and use.

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