title: Effects of the Learning Curve on Efficacy of Radiofrequency Ablation for Barrett's Esophagus.
abstract: OBJECTIVE
  Complete eradication of Barrett's esophagus (BE) often requires multiple sessions of radiofrequency ablation (RFA). Little is known about the effects of case volume on the safety and efficacy of RFA or about the presence or contour of learning curves for this procedure.
  
  
  METHODS
  We collected data from the US RFA Patient Registry (from 148 institutions) for patients who underwent RFA for BE from July 2007 to July 2011. We analyzed the effects of the number of patients treated by individual endoscopists and individual centers on safety and efficacy outcomes of RFA. Outcomes, including stricture, bleeding, hospitalization, and complete eradication of intestinal metaplasia (CEIM), were assessed using logistic regression. The effects of center and investigator experience on numbers of treatment sessions to achieve CEIM were examined using linear regression.
  
  
  RESULTS
  After we controlled for potential confounders, we found that as the experience of endoscopists and centers increased with cases, the numbers of treatment sessions required to achieve CEIM decreased. This relationship persisted after adjusting for patient age, sex, race, length of BE, and presence of pretreatment dysplasia (P < .01). Center experience was not significantly associated with overall rates of CEIM or complete eradication of dysplasia. We did not observe any learning curve with regard to risks of stricture, gastrointestinal bleeding, perforation, or hospitalization (P > .05).
  
  
  CONCLUSIONS
  Based on analysis of a large multicenter registry, efficiency of the treatment, as measured by number of sessions needed to achieve CEIM, increased with case volume, indicating a learning curve effect. This trend began to disappear after treatment of approximately 30 patients by the center or individual endoscopist. However, there was no significant association between safety or efficacy outcomes and previous case volume.
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Sarina
authors.initials: S
authors.lastname: Pasricha
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Cary
authors.initials: C
authors.lastname: Cotton
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Kelly E
authors.initials: KE
authors.lastname: Hathorn
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Nan
authors.initials: N
authors.lastname: Li
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: William J
authors.initials: WJ
authors.lastname: Bulsiewicz
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: W Asher
authors.initials: WA
authors.lastname: Wolf
authors.affiliation: Division of Gastroenterology, Department of Medicine, UCLA School of Medicine, Los Angeles, California.
authors.forename: V Raman
authors.initials: VR
authors.lastname: Muthusamy
authors.affiliation: Division of Gastroenterology, Department of Medicine, Northwestern University School of Medicine, Chicago, Illinois.
authors.forename: Srinadh
authors.initials: S
authors.lastname: Komanduri
authors.affiliation: Division of Gastroenterology, Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida.
authors.forename: Herbert C
authors.initials: HC
authors.lastname: Wolfsen
authors.affiliation: Nashville Gastrointestinal Specialists, Nashville, Tennessee.
authors.forename: Ron E
authors.initials: RE
authors.lastname: Pruitt
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Texas School of Medicine, Houston, Texas.
authors.forename: Atilla
authors.initials: A
authors.lastname: Ertan
authors.affiliation: Division of Thoracic and Cardiac Surgery, Department of Surgery, Rush Medical College, Chicago, Illinois.
authors.forename: Gary W
authors.initials: GW
authors.lastname: Chmielewski
authors.affiliation: Department of Medicine, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Electronic address: nshaheen@med.unc.edu.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Shaheen
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000601:surgery*; D000368:Aged; D001471:Barrett Esophagus / Q000175:diagnosis / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects; D002983:Clinical Competence; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D004945:Esophagoscopy / Q000009:adverse effects; D005260:Female; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D059032:Learning Curve; D016018:Least-Squares Analysis; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D011446:Prospective Studies; D012042:Registries; D012074:Remission Induction; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
keywords: Cancer Prevention; Database Analysis; Endoscopy; Training