title: The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection.
abstract: Endoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper GI disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality.
  
  
  
  Patients undergoing upper GI EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer re-intervention. Risk-adjusted cumulative sum (RA-CUSUM) analysis was used to assess patient mortality risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in the RA-CUSUM curve.
  
  
  
  11 051 patients underwent upper GI EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight per cent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30-day and 90-day mortality rate for patients with cancer, 6.1% vs 0.4% (p<0.001) and 12% vs 2.1% (p<0.001), respectively. The requirement for emergency intervention after EMR for cancer was also greater with low volume endoscopists (1.8% vs 0.1%, p=0.002). In patients with cancer, the RA-CUSUM curve change points for 30-day mortality and elective re-intervention were 4 cases and 43 cases, respectively.
  
  
  
  EMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
authors: Department of Surgery & Cancer, Imperial College London, London, UK.
authors: Sheraz R
authors: SR
authors: Markar
authors: Department of Surgery & Cancer, Imperial College London, London, UK.
authors: Hugh
authors: H
authors: Mackenzie
authors: Department of Surgery & Cancer, Imperial College London, London, UK.
authors: Melody
authors: M
authors: Ni
authors: Department of Surgery & Cancer, Imperial College London, London, UK.
authors: Jeremy R
authors: JR
authors: Huddy
authors: St Mark's Hospital and Academic Institute, Harrow, UK.
authors: Alan
authors: A
authors: Askari
authors: Department of Surgery & Cancer, Imperial College London, London, UK.|St Mark's Hospital and Academic Institute, Harrow, UK.
authors: Omar
authors: O
authors: Faiz
authors: Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
authors: S Michael
authors: SM
authors: Griffin
authors: Division of Surgery & Interventional Science, University College London, London, UK.
authors: Laurence
authors: L
authors: Lovat
authors: Department of Surgery & Cancer, Imperial College London, London, UK.
authors: George B
authors: GB
authors: Hanna
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D015897:Comorbidity; D016208:Databases, Factual; D004502:Education, Medical, Continuing; D004630:Emergencies; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000193:education / Q000401:mortality* / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D005767:Gastrointestinal Diseases / Q000601:surgery*; D005770:Gastrointestinal Neoplasms / Q000601:surgery; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume / Q000592:standards; D061846:Hospitals, Low-Volume / Q000592:standards; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013222:State Medicine / Q000592:standards / Q000706:statistics & numerical data; D055815:Young Adult
keywords: GASTRIC CANCER; OESOPHAGEAL CANCER; THERAPEUTIC ENDOSCOPY