Variation in learning curves and competence for ERCP among advanced endoscopy trainees using cumulative sum analysis.

There are limited data on learning curves and competence in ERCP. Using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) using cumulative sum (CUSUM) analysis.AETs were evaluated by attending endoscopists starting with the 26(th) hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and using a less-stringent definition of success were performed.Five AETs were included with a total of 1049 graded ERCPs (mean 209.8 [SD 91.6]/AET). The majority of cases were performed for biliary indication (80%). The overall and native papilla allowed cannulation times was 3.1 (SD 3.6) and 5.7 (SD 4), respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses described above increased the proportion of AETs that achieved competence.This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence especially for native papilla cannulation.