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The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection

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Title: The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection
Authors: Markar, S
Mackenzie, H
Ni, Z
Huddy, J
Askari, A
Faiz, O
Griffin, M
Lovat, L
Hanna, GB
Item Type: Journal Article
Abstract: Objective Endoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper gastrointestinal disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality. Design Patients undergoing upper gastrointestinal EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer reintervention. Risk-adjusted Cumulative Sum (RA-CUSUM) analysis was used to assess patient mortality-risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in RA-CUSUM curve. Results 11,051 patients underwent upper gastrointestinal EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight percent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30- and 90-day mortality rate for cancer patients, 6.1% vs. 0.4%; P<0.001 and 12% vs. 2.1%; P<0.001 respectively. The requirement for emergency intervention after EMR for cancer was also greater with low-volume endoscopists (1.8%vs. 0.1%; P=0.002). In cancer patients, the RA-CUSUM curve change-point for 30-day mortality and elective re-intervention was 4 and 43 cases respectively. Conclusion EMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
Issue Date: 18-Oct-2017
Date of Acceptance: 28-Aug-2016
URI: http://hdl.handle.net/10044/1/39555
DOI: https://dx.doi.org/10.1136/gutjnl-2015-311237
ISSN: 1468-3288
Publisher: BMJ Publishing Group
Start Page: 79
End Page: 85
Journal / Book Title: Gut
Volume: 67
Copyright Statement: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Keywords: GASTRIC CANCER
OESOPHAGEAL CANCER
THERAPEUTIC ENDOSCOPY
1103 Clinical Sciences
1114 Paediatrics And Reproductive Medicine
Gastroenterology & Hepatology
Publication Status: Published
Appears in Collections:Department of Surgery and Cancer