Learning Curves for Electromagnetic Navigation Bronchoscopy Using CUSUM Analysis

Abstract

Background: Electromagnetic navigation bronchoscopy (ENB) is a relatively new and technically demanding procedure for the guidance of bronchoscopic biopsy to help locate small lung lesions. The results in experienced hands are well described. However, we do not know the results in unexperienced hands-in other words, we have no knowledge about how fast you can learn the procedure.Aim: The aim of this study was to draw learning curves for beginners in ENB using Cumulated Sum (CUSUM) analysis, a method for quantitative evaluation of the learning curves for clinical procedures.Methods: Four operators from 3 centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or nondiagnostic based on sample adequacy. Learning curves were drawn based on diagnostic yield.Results: A total of 215 procedures were assessed. For 2 of the operators (operators 1 and 4), at least 25 to 30 procedures were necessary to obtain competency whereas operators 2 and 3 showed more horizontal learning curves indicating an overweight of diagnostic procedures from the beginning.Conclusion: Operators achieve competences in ENB at different paces. This must be taken in account when beginners start to learn the procedure. There is a huge need for a structured educational program and a validated test to determine competences.

When Pulmonologists Are Novice to Navigational Bronchoscopy, What Predicts Diagnostic Yield?

“…To support this, a randomized trial found that simulation-based training was more efficient than traditional apprenticeship training in the beginning of novice EBUS operators’ learning curves [ 16 ]. Furthermore, earlier studies evaluating EBUS and ENB have shown that the learning curves of individual trainees vary considerably [ 14 , 17 ] and international guidelines now recommend the use of structured assessment of performance, instead of relying on an arbitrary number of performed procedures to ensure competency [ 18 ]. Furthermore, earlier studies evaluating EBUS and ENB have shown that learning curves of individual trainees vary considerably [ 14 , 17 ] and international guidelines now recommend the use of structured assessment of performance instead of relying on an arbitrary number of performed procedures to ensure competency [ 18 ].…”

“…Furthermore, earlier studies evaluating EBUS and ENB have shown that the learning curves of individual trainees vary considerably [ 14 , 17 ] and international guidelines now recommend the use of structured assessment of performance, instead of relying on an arbitrary number of performed procedures to ensure competency [ 18 ]. Furthermore, earlier studies evaluating EBUS and ENB have shown that learning curves of individual trainees vary considerably [ 14 , 17 ] and international guidelines now recommend the use of structured assessment of performance instead of relying on an arbitrary number of performed procedures to ensure competency [ 18 ]. It is also important to note that other factors also contribute to the complexity of the ENB procedure, with one major important problem being the challenge of image-to-patient divergence due to (1) the patient usually not being positioned in the exact same position during CT-imaging and on the operation table and (2) the lungs, especially the lower parts, potentially moving during breathing, and thereby, the real-time location of a given target will often not perfectly match the position known from the preoperative CT-scan [ 2 ].…”

“…In an observational prospective design, four operators were enrolled from three hospitals in Denmark where the ENB equipment was purchased recently. We have previously published the study design as well as data of operators’ learning curves [ 14 ]. In short, we included all consecutive ENB procedures in consenting adult patients who were candidates for ENB.…”

Carefully Navigating to the Periphery of the Lung

“…In this issue of Journal of Bronchology & Interventional Pulmonology , Toennesen et al4 used CUSUM to calculate the learning curves for 4 experienced bronchoscopists, albeit novice operators in ENB from 3 different hospitals in Denmark. The outcome of each ENB was categorized as either success or failure based on sample adequacy defined as malignant cells at cytopathologic evaluation or nonmalignant diagnosis at cytopathologic and/or microbiological evaluation with verification of the diagnosis at follow-up after at least 6 months.…”

Learning Curves in Electromagnetic Navigational Bronchoscopy: What Do They Tell Us?

“…Different approaches can lead to different conclusions about the typical number of procedures needed to achieve competence. For example, Lee and colleagues found 15 ENB procedures were required for all fellows to achieve a competency standard based on checklist scores, whereas Toennesen and colleagues found an average of 40–50 ENB procedures were required for experienced bronchoscopists to achieve a competency standard based on diagnostic accuracy ( 12 ). The difference between the learning curves in these studies can be explained by differences in how performance was assessed (checklist vs. clinical outcome).…”