Variation in exposure to endoscopic haemostasis for acute upper gastrointestinal bleeding during UK gastroenterology training

Abstract

Introduction

Gastroenterologists are typically expected to be competent in endoscopic haemostasis for acute upper gastrointestinal bleeding (AUGIB), with the Certificate of Completion of Training (CCT) often heralding the onset of participation in on-call AUGIB rotas. We analysed the volume of haemostasis experience recorded by gastroenterology CCT holders on the Joint Advisory Group on Gastrointestinal Endoscopy Training System (JETS) e-portfolio, the UK electronic portfolio for endoscopy, and assessed for variations in exposure to haemostasis.

Methods

UK gastroenterologists awarded CCT between April 2014 and April 2017 were retrospectively identified from the specialist register. Credentials were cross-referenced with JETS to retrieve AUGIB haemostasis procedures prior to CCT. Procedures were collated according to variceal versus non-variceal therapies and compared across training deaneries.

Results

Over the 3-year study period, 241 gastroenterologists were awarded CCT. 232 JETS e-portfolio users were included for analysis. In total, 12 932 haemostasis procedures were recorded, corresponding to a median of 42 (IQR 21–71) per gastroenterologist. Exposure to non-variceal modalities (median 28, IQR 15–52) was more frequent than variceal therapies (median 11, IQR 5–22; p<0.001). By procedure, adrenaline injection (median 12, IQR 6–23) and variceal band ligation (median 10, IQR 5–20) were most commonly recorded, whereas sclerotherapy experience was rare (median 0, IQR 0–1). Exposure to haemostasis did not differ by year of CCT (p=0.130) but varied significantly by deanery (p<0.001), with median procedures ranging from 20–126.

Conclusion

Exposure to AUGIB haemostasis during UK gastroenterology training varied across deaneries and procedural modalities which should prompt urgent locoregional review of access and delivery of training. Endoscopy departments should ensure the availability of supportive provisions in haemostasis (i.e. training/upskilling, supervision, mentorship) during the early post-CCT period.

Introduction

Definitive management of acute upper gastrointestinal bleeding (AUGIB) is reliant on timely and competent endoscopy.¹ Given the frequency of the condition,¹ endoscopy units face increasing expectations to provide a 24-hour, on-call, gastroenterologist-led AUGIB service.^{2 3} As such, gastroenterologists are expected to be competent in the delivery of endoscopic therapy for AUGIB (haemostasis) on completion of training, with attainment of the Certificate of Completion of Training (CCT) often heralding participation in on-call AUGIB rotas. Currently, UK gastroenterology training is facing imminent reforms. From 2021, higher specialist training will be shortened from 5 to 4 years under ‘Shape of Training’ proposals.⁴ This has raised concerns regarding competency acquisition in endoscopy, particularly when shortfalls have been reported during the existing 5-year training period.^5–7

Over the last decade, training in endoscopy has largely shifted away from local ‘apprenticeship’ models towards competency-based curricula, with emphasis on structured training, objective competency assessment, milestone acquisition, certification and ongoing performance monitoring.⁸ These transformations, driven by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG), have underpinned the transformation in the quality of diagnostic endoscopy in the UK.⁹ In contrast, attention to haemostasis training has been relatively underwhelming, despite the potential complexity and life-threatening nature of AUGIB. JAG certification in oesophagogastroduodenoscopy (OGD) is a requirement for independent practice and leads to high-quality service delivery,⁷ but this alone does not ensure competence in haemostasis.¹⁰ In the absence of a standardised training pathway or certification system, haemostasis training remains enshrined within a traditional apprenticeship model where training remains at the discretion of individual trainees/units, not subjected to national quality assurance and with the assumption of competency on completion of gastroenterology training.

To our knowledge, the volume of haemostasis experience amassed at the point of completion of UK gastroenterology training has not previously been studied. These data may guide training provision in haemostasis and workforce planning of AUGIB services. We therefore aimed to estimate the volume of haemostasis experience reported by UK gastroenterologists up to their CCT date and assess for regional variations in training.

Methods

Study design

In the UK, it is incumbent on endoscopy trainees to enter training and independent procedures onto the JAG Endoscopy Training System (JETS) e-portfolio, a UK-wide electronic logbook of endoscopy procedures. In this retrospective UK-wide study, gastroenterologists awarded CCT between April 2014 and April 2017 were identified from the General Medical Council specialist register. Credentials were cross-referenced with JETS to retrieve AUGIB endotherapy experience prior to CCT. Subjects without JETS involvement or those not identified on cross-referencing were excluded. Sensitivity analyses were undertaken using the lifetime OGD count to evaluate validity of JETS data.

Study outcomes

Haemostasis experience was measured for JETS-supported modalities and collated according to variceal (band ligation and sclerotherapy) and non-variceal therapies (epinephrine injection therapy, heater probe, clip placement and argon plasma coagulation). The outcome measured was the number of recorded procedures requiring haemostasis; for example, a procedure in which three clips were applied was considered as one procedure. Deaneries were collated according to each trainee’s JETS-registered deanery.

Statistical analyses

All continuous variables were subjected to normality assessment; comparisons of non-parametric continuous data were made using Mann-Whitney and Kruskal-Wallis tests as appropriate. Statistical analyses were performed in SPSS V.25 (IBM), with p<0.05 indicative of significance.

Results

Baseline characteristics

Over the 3-year study period, 241 gastroenterologists who were awarded CCT were identified. After exclusion of those who had not participated on JETS (n=9; 3.7%), 232 gastroenterologists from 19 UK training deaneries were included for analysis. Sensitivity analysis revealed a median lifetime OGD count of 854 (IQR 601–1214), without significant variation over the 3 years (p=0.817), attesting to data integrity.

AUGIB procedures

In total, the 232 gastroenterologists recorded 12 932 endotherapy procedures (median 42, IQR 21–71). Haemostasis procedures constituted 5.8% of all OGD procedures performed. Exposure to non-variceal modalities (median 28, IQR 15–52) was more frequent than variceal therapies (median 11, IQR 5–22; p<0.001). By modality (figure 1), epinephrine injection (median 12, IQR 6–23) and variceal band ligation (median 10, IQR 5–20) were most commonly recorded, while sclerotherapy experience was rare (median 0, IQR 0–1). In total, 150 (64.7%) had recorded in excess of 30 haemostasis procedures.

Figure 1.

Volume of modality-specific haemostasis procedures reported by gastroenterologists prior to completion of training. AUGIB, acute upper gastrointestinal bleeding.

Subgroup analyses

Exposure to AUGIB haemostasis procedures did not vary significantly by year of CCT (p=0.130). Deanery registration data were available for 228/232 CCT holders (98.3%). By deanery (figure 2), there was significant variation in overall AUGIB numbers found (p<0.001), with medians of pre-CCT endotherapy procedures ranging from 20 to 126. On subgroup analysis, the variation by deanery was found for both non-variceal (p=0.003) and variceal (p<0.001) modalities.

Figure 2.

Haemostasis procedures according to registered deanery. CCT, Certificate of Completion of Training;. N/A, data unavailable.

Discussion

High-quality endoscopy is reliant on high-quality training. This retrospective UK-wide analysis of the JETS e-portfolio provides objective data on the volume of haemostasis experience recorded by gastroenterologists prior to CCT. Although gastroenterologists performed a median of 854 diagnostic OGD procedures during specialist training, exposure to haemostasis was relatively low (median 42), particularly with regard to sclerotherapy, but also with heater probe, clip placement and argon plasma coagulation. The regional variation in JETS-recorded haemostasis procedures demonstrated within our study highlights discrepancies in access to training. These findings should prompt urgent locoregional review on the access and delivery of existing haemostasis training by regional training programme directors (TPDs).

Training in AUGIB within the UK has been a persistently contentious issue.¹¹ Previous data point to a reduction in trainee exposure to AUGIB cases over time,⁶ particularly with high-risk cases, and lack of confidence in final-year trainees with managing the condition.⁵ At present, there is no UK AUGIB curriculum or minimum procedural numbers recommended by JAG or the British Society of Gastroenterology (BSG) to benchmark competence in AUGIB haemostasis. The European Section and Board of Gastroenterology and Hepatology (ESBGH) has arbitrarily recommended a minimum of 30 haemostatic procedures.¹² Based on our analysis, only 65% had met this ESBGH threshold.

With the looming reforms in gastroenterology training, it is necessary to ensure that the quality of haemostasis training does not become compromised. Within the JAG Global Rating Scale accreditation framework,⁹ responsibility for addressing training requirements largely lies within individual endoscopy units. However, it is recognised that competing commitments determined at Trust level will have a knock-on effect on haemostasis training, for example, general medical on-calls. Given the shortfall in procedural numbers at CCT, the focus on haemostasis competency development should not be merely confined to trainees. It would be prudent for endoscopy departments to ensure the availability and accessibility of post-CCT support, that is, training/upskilling, supervision and/or mentorship, to gastroenterologists within the early stages of their consultant careers.

Several limitations should be discussed. First, JETS e-portfolio data are based on self-reported entries. Not all CCT holders were enrolled, as some (3.7%) remained on paper portfolios. Self-reporting carries the risk of underestimation and selection bias, although the data is arguably more accurate than survey data which is susceptible to recall bias. Second, it was not possible to stratify analyses by subspecialty or length of training. Trainees often take time out of programme (OOP)¹³ (eg, for higher degrees/endoscopy fellowships) and may accrue more haemostasis procedures by CCT. Access to OOP opportunities may vary across deaneries which can contribute to the interdeanery differences observed. Third, our study was centred on pre-CCT procedures. A minority will have embarked on post-CCT fellowships and ‘topped up’ their haemostasis experienced prior to joining an on-call AUGIB rota. Fourth, the e-portfolio was not all-inclusive in AUGIB modalities (eg, haemostatic powder sprays) and does not record the appropriateness and quality of haemostasis. Last, it is unclear which factors account for differences in exposure to haemostasis training, for example, trainee involvement on AUGIB on-call rotas or service lists involving AUGIB, which merits evaluation within a national survey.

National efforts led by JAG and BSG are underway to improve training in AUGIB.⁹ A practical, industry-sponsored haemostasis course covering theory and hands-on simulator models for a range of therapeutic modalities has recently been JAG-approved and shown to improve trainee confidence.¹⁴ A national Train-the-Bleed-Trainers course is being designed to improve the delivery of haemostasis training. A UK-wide haemostasis curriculum with defined competency endpoints and modality-specific minimum procedural requirements is currently under consultation which will culminate in a JAG certification pathway in AUGIB haemostasis.¹¹ Invariably, this will place additional scrutiny on locoregional training, introduce the possibility of post-CCT certification and emphasise the role of post-CCT support. In parallel, a multisociety care bundle for AUGIB has recently been developed to improve quality of care.¹⁵ Finally, with the roll-out of the National Endoscopy Database,¹⁶ training leads will be able to monitor haemostasis training, akin to our study, using unbiased and real-time data uploaded from individual training units. Through a combination of prioritising training and facilitating quality assurance, these initiatives aim to modernise haemostasis training and quality, with the objective of supporting trainees, TPDs, endoscopy services and ultimately, to safeguard patients and improve outcomes in AUGIB.

Conclusion

Exposure to AUGIB haemostasis during UK gastroenterology training varied across deaneries and procedural modalities which should prompt urgent locoregional review of access and delivery of training. Endoscopy departments should ensure the availability of supportive provisions in haemostasis (ie, training/upskilling, supervision, mentorship) during the early post-CCT period.