Collaboration of community hospital endosonographers improves diagnostic yield of endoscopic ultrasonography guided tissue acquisition of solid pancreatic lesions

Abstract

Background and study aims Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is the method of choice for establishing a pathological diagnosis of solid pancreatic lesions. Data on quality and yield of EUS-guided TA performed in community hospitals are lacking. A study was performed to determine and improve the diagnostic yield of EUS-guided TA in a group of community hospitals. Methods Following analysis of the last 20 EUS-guided TA procedures of solid pancreatic lesions performed in each of four community hospitals, a collaborative EUS interest group was formed and a prospective registry was started. During meetings of the interest group, feedback on results per center were provided and strategies for improvement were discussed. Results In the BEFORE team formation cohort, 80 procedures were performed in 66 patients. In the AFTER team formation cohort, 133 procedures were performed in 125 patients. After team formation, the rate of adequate sample increased from 80 % (95 %CI [0.7 – 0.9]) to 95 % (95 %CI [0.9 – 1.0]) , diagnostic yield of malignancy improved from 28 % (95 %CI [0.2 – 0.4]) to 64 % (95 % CI [0.6 – 0.7]), and sensitivity of malignancy improved from 63 % (95 %CI [0.4 – 0.8]) to 84 % (95 %CI [0.8 – 0.9]). Multivariate regression analysis revealed team formation to be the only variable significantly associated with an increased rate of adequate sample. Conclusions Formation of a regional EUS interest group with regular feedback on results per center, and discussions on methods and techniques used, significantly improved the outcome of EUS-guided TA procedures in patients with solid pancreatic lesions in community hospitals.

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions

“…In contrast to these studies, we used CUSUM curves to evaluate the entire process defining quality and yield of these procedures, including the work of both endosonographers and cytopathologists. Some of the data presented in this study (133 procedures, performed from January 2015 to September 2016) were previously described in the initial publication about this community hospital quality initiative 14 . The current study shows ongoing and persistent improvement in performance and introduces learning curves as a feedback and monitoring tool.…”

“…Collected data on EUS-guided TA procedures included: patient demographics, localization of the pancreatic mass, hospital, endosonographer, pathologist, needle diameter ( < 22-gauge or 22-gauge), type of needle (fine-needle aspiration [FNA]/fine-needle biopsy [FNB]), number of passes, use of suction (slow withdrawal of stylet or vacuum suction), availability of rapid on-site specimen evaluation (ROSE), and the result of the cytopathological and/or histopathological evaluation of the EUS-guided TA specimen. Based on current practice guidelines and previous experience of our group, endosonographers were advised to perform at least three passes with FNA needles or at least two passes with FNB needles (unless ROSE detected sufficient material for diagnosis earlier), and to use vacuum suction 14 15 . All other techniques and materials used were at the discretion of the local clinicians and according to local availability of equipment and hospital standards.…”

“…At a subsequent meeting, the results of these analyses were presented and discussed, with emphasis on potential learning opportunities for all participants. All gastroenterologists and pathologists involved had completed their training at least 3 years before the start of this study 14 .…”

“…QUEST aims to improve performance of EUS-guided TA by providing feedback on KPIs of individual centers based on a prospective registration of consecutive EUS-guided TA procedures of solid pancreatic lesions. This has led to improvements in RAS (80 % to 95 %), DYM (28 % to 64 %), and SFM (63 % to 84 %) comparing the results of an initial retrospective analysis of yield of EUS-guided TA to the first 21 months of prospective registration 14 .…”

Optimizing cytological specimens of EUS‐FNA of solid pancreatic lesions: A pilot study to the effect of a smear preparation training for endoscopy personnel on sample quality and accuracy

“…This group decided to organize structured meetings to provide centers with feedback on their results and discuss the methods and techniques that were used. Surprisingly, this small intervention (forming a working group and discussing each other's outcomes and techniques) significantly decreased the inter‐center variation between the centers 15 . A major finding was the suboptimal FNA smear quality, which motivated the group to focus on its improvement.…”