ASSESSMENT OF THE LEARNING CURVE IN HEALTH TECHNOLOGIES A Systematic Review

Ramsay, Craig; Grant, Adrian; Wallace, S; Garthwaite, Paul H.; Monk, Andrew; Russell, Ian

doi:10.1017/s0266462300103149

Cited by 188 publications

(146 citation statements)

References 51 publications

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“…The surgeons in that study [25] accumulated experience with PAO by scrubbing as first assistant during residency and by visiting with the originator of the technique. However, we did find an inverse relationship between experience (number of PAO procedures performed) and operative time, a possible surrogate measure of surgical performance and learning curve [22]. This is consistent with the study by Davey and Santore [8] that reported a statistically significant reduction in surgical time from 3 hours 48 minutes to 3 hours 24 minutes.…”

Section: Discussionsupporting

confidence: 92%

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Novais

Carry

Kestel

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Bernese periacetabular osteotomy (PAO) is a technically challenging procedure with potential risk for major complications and a previously reported steep learning curve. However, the impact of contemporary hip preservation fellowships on the learning curve of PAO has not been established. Questions/purposes (1) What was the frequency of major complications during the PAO learning curve of two surgeons who recently graduated from hip preservation fellowships? (2) Is increasing level of experience associated with the risk of a complication and with operative time, a possible surrogate measure of surgical performance? Methods We retrospectively studied 81 PAOs performed by one of two surgeons who recently graduated from a hip preservation fellowship during their first 4 years of practice in two institutions. One of the surgeons participated as a fellow in 78 PAOs with an increasing level of responsibility during the course of 1 full year. The other surgeon performed 41 PAOs as a fellow during 6 months, also with an increasing level of responsibility during that time. There were 68 (84%) female and 13 (16%) male patients (mean age, 18 years; range, 10-36 years). The frequency of complications was recorded early and at 1 year after surgery and graded according to a validated classification system describing five grades of complications. Complications that required surgical intervention (Grade III) and life-threatening complications (Grade IV) were considered major complications. Persistent pain after surgery, although considered a failure of PAO, was not considered a surgical complication as a result of the multifactorial etiology of pain after hip-preserving surgery. However, early reoperation and revision surgery were counted as complications. To evaluate the association between increasing level of experience and the occurrence of complications, we divided each surgeon's experience into his first 20 procedures (initial interval) and his second 20 (experienced interval) to test whether the incidence of complications or operative time was different between the two intervals. Because the association between experience and the likelihood of a complication was estimated to be consistent between the two surgeons, the analysis was performed with data pooled from the two surgeons. To test whether there was a difference in the likelihood of a complication in the Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical princ...

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Section: Discussionsupporting

confidence: 92%

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Novais

Carry

Kestel

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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“…Ramsay et al 16 conducted a study in which they searched the medical literature to ascertain how learning curves are evaluated. In searching multiple databases, they found 4571 abstracts that contained the phrase "learning curve."…”

Section: Discussionmentioning

confidence: 99%

Resident learning curve for minimal-access transforaminal lumbar interbody fusion in a military training program

Neal

Rosner

2010

FOC

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Object Minimal-access transforaminal lumbar interbody fusion (TLIF) has gained popularity as a method of achieving interbody fusion via a posterior-only approach with the aim of minimizing injury to adjacent tissue. While many studies have reported successful outcomes, questions remain regarding the potential learning curve for successfully completing this procedure. The goal of this study, based on a single resident's experience at the only Accreditation Council for Graduate Medical Education–approved neurosurgical training center in the US military, was to determine if there is in fact a significant learning curve in performing a minimal-access TLIF. Methods The authors retrospectively reviewed all minimal-access TLIFs performed by a single neurosurgical resident between July 2006 and January 2008. Minimal-access TLIFs were performed using a tubular retractor inserted via a muscle-dilating exposure to limit approach-related morbidity. The accuracy of screw placement and operative times were assessed. Results A single resident/attending team performed 28 minimal-access TLIF procedures. In total, 65 screws were placed at L-2 (1 screw), L-3 (2 screws), L-4 (18 screws), L-5 (27 screws), and S-1 (17 screws) from the resident's perspective. Postoperative CTs were reviewed to determine the accuracy of screw placement. An accuracy of 95.4% (62 of 65) properly placed screws was noted on postoperative imaging. Two screws (at L-5 in the patient in Case 17 and at S-1 in the patient in Case 9) were lateral, and no revision was needed. One screw (at L-4 in Case 24) was 1 mm medial without symptoms or the need for revision. In evaluating the operative times, 2 deformity cases (Grade III spondylolisthesis) were excluded. The average operating time per level in the remaining 26 cases was 113.25 minutes. The average time per level for the first 13 cases was 121.2 minutes; the amount of time decreased to 105.3 minutes for the second group of 13 cases (p = 0.25). Conclusions In summary, minimal-access TLIF can be safely performed in a training environment without a significant complication rate due to the expected learning curve.

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“…15 Commonly data are split into arbitrary groups and the means compared by chi-squared test or ANOVA. Some studies had data displayed graphically with no statistical analysis.…”

Section: Statistical Evaluation Of Learning Curvesmentioning

confidence: 99%

The Impact of the Learning Curve in Laparoscopic Surgery

Raja¹

2008

WJOLS

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TP Wright originally introduced the concept of a learning curve in aircraft manufacturing in 1936.1 He described a basic theory for costing the repetitive production of airplane assemblies. The term was introduced to medicine in the 1980s after the advent of minimal access surgery. It also caught the attention of the public and the legal profession when a surgeon told a public enquiry in Britain that a high death rate was inevitable while surgeons were on a learning curve. 2Recently it has been labeled as a dangerous curve 3 with a morbidity, mortality and unproven outcomes. Yet there is no standardization of what the term means. In an endeavor to help laparoscopic surgeons towards evidence based practices this commentary will define and describe the learning curve, its drawing followed by a discussion of the factors affecting it, statistical evaluation, effect on randomized controlled trials and clinical implications for both practice and training, the limitations and pitfalls, ethical dilemmas and some thoughts to pave the way ahead. DEFINITION AND DESCRIPTIONFor the Wright learning curve, the underlying hypothesis is that the direct man-hours necessary to complete a unit of production will decrease by a constant percentage each time the production quantity is doubled. In manufacturing, the learning curve applies to the time and cost of production. Can a surgeons learning curve be described on similar lines? A simple definition would be : the time taken and/or the number of procedures an average surgeon needs to be able to perform a procedure independently with a reasonable outcome.1 But then who is an average surgeon ? Another definition may be that a learning curve is a graphic representation of the relationship between experience with a new procedure or technique and an outcome variable such as operation time, complication rate, hospital stay or mortality. 4 A learning curve may also be operationally defined as an improvement in performance over time. Although learning theorists often disagree about what learning is, they agree that whatever the process is, its effects are clearly cumulative and may therefore be plotted as a curve. By cumulative it is meant that somehow the effects of experience carry over to aid later performance. This property is fundamental to the construction of learning curves. The improvement tends to be most rapid at first and then tails off. Hence there are three main features of a learning curve. First, the initial or starting point defines where the performance of an individual surgeon begins. Secondly, the rate of learning measures how quickly the surgeon will reach a certain level of performance and thirdly the asymptote or expert level measures where the surgeons performance stabilizes.5 This has implications for the laparoscopic surgeon-it suggests that practice always help improve performance but the most dramatic improvement happens first. Also with sufficient practice surgeons can achieve comparable levels of performance. THE DRAWING OF LEARNING CURVESThere are a ...

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ASSESSMENT OF THE LEARNING CURVE IN HEALTH TECHNOLOGIES A Systematic Review

Cited by 188 publications

References 51 publications

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Does Surgeon Experience Impact the Risk of Complications After Bernese Periacetabular Osteotomy?

Resident learning curve for minimal-access transforaminal lumbar interbody fusion in a military training program

The Impact of the Learning Curve in Laparoscopic Surgery

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