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.