NEWS & VIEWS INTERVENTIONAL CARDIOLOGY
to determine inflection points or volume thresholds where the improvement in practice seems to enter a flat slope as a func tion of volume. Although these inflection points do not define full competency, they indicate a skill-set milestone that results in a distinctly different and marginal improve ment in performance metrics, such as con trast use and fluoroscopy time. Owing to the ambiguity inherent in low denomina tor data, procedural information from the lowest volume operators (200 cases per year were removed by the investi gators to perform a robust statistical analy sis.1 The removal of this data is, therefore, a potential source of uncertainty beyond that inherent in any retrospective analysis of a large database. Multiple attempts at defining transradial learning curves with smaller data collec tions than the NCDR® have already been published.2–4 In general, these studies have shown learning curves similar in magni tude to that found by Hess and colleagues, although these earlier estimates have tended to suggest a marginally higher number of procedures needed to reach proficiency beyond the estimated 30–50 range. 2–4 Radial procedures have been performed in the USA since the mid‑1990s,5 but volume was initially low as skills were fostered by only a small, but dedicated, group of opera tors. The NCDR®data used in this analysis was collected from July 2009 to December 2012,1 a period that encompassed a rapid adoption of transradial techniques in the USA.6 Individuals motivated to learn, and those deliberately seeking new skills, might be more readily trainable and potentially
Transformation to transradial —safe and effective Ian C. Gilchrist
Analysis of cardiovascular registry data suggests that cardiologists who practice femoral cardiac catheterization can convert to safer transradial approaches with a learning experience of 30–50 procedures. This conversion is associated with no loss of procedural success and no increase in serious adverse outcomes.
A conundrum of medical education has always been the balance between learn ing or teaching new techniques and the dictum ‘primum non nocere’—do no harm. Although a perfect solution to this enigma might never be found, recognition and minimization of harm involved in medical advances is an ethical priority. The concept of learning curves, which were first devel oped for industrial processes, has been applied to medicine to help quantitate this delicate balance. A new publication has now provided an interesting analysis of the learning curve that defines the introduction of transradial cardiac catheterization tech niques by practicing femoral operators using data from the US National Cardiovascular Data Registry®(NCDR®, American College of Cardiology Foundation, USA).1
‘‘
…transradial ... adoption within the USA has remained surprising slow
’’
Although transradial approaches have rapidly become prominent throughout the world, adoption within the USA has remained surprising slow. One argument has been that the learning curve for trans radial catheterization is too long and poten tially dangerous for those operators more used to femoral procedures to safely sur mount. However, the results presented by Hess et al. suggest otherwise. The authors report a reasonably short learning experi ence of 30–50 transradial interventional cases to reach proficiency, with no apparent effect on overall procedural success during
the training period.1 When transradial tech niques are adopted, an immediate reduc tion in the number of complications is observed compared with transfemoral vas cular interventions.2 These results strongly support the further dissemination of trans radial techniques within the interventional cardiology community. The potential complications, on an operator-based level, during the learning phase of transradial procedures were also investigated.1 To retrospectively identify transradial practice initiation, operators who performed at least one transfemoral procedure in the 6 months before their initial transradial procedure were defined as beginners, and their results followed through different levels of subsequent cumulative transradial experience. Overall procedural success and a series of metrics were then evaluated over the spectrum of physician experience. Across this spectrum, from the most novice transradial operators (1–10 cases) to the more experienced (101– 200 cases), improvements in mean fluoro scopy time from 16.0 mins to 12.6 mins (interquartile range 10.8–23.6 mins and 8.4– 19.3 mins respectively; P
to determine inflection points or volume thresholds where the improvement in practice seems to enter a flat slope as a func tion of volume. Although these inflection points do not define full competency, they indicate a skill-set milestone that results in a distinctly different and marginal improve ment in performance metrics, such as con trast use and fluoroscopy time. Owing to the ambiguity inherent in low denomina tor data, procedural information from the lowest volume operators (200 cases per year were removed by the investi gators to perform a robust statistical analy sis.1 The removal of this data is, therefore, a potential source of uncertainty beyond that inherent in any retrospective analysis of a large database. Multiple attempts at defining transradial learning curves with smaller data collec tions than the NCDR® have already been published.2–4 In general, these studies have shown learning curves similar in magni tude to that found by Hess and colleagues, although these earlier estimates have tended to suggest a marginally higher number of procedures needed to reach proficiency beyond the estimated 30–50 range. 2–4 Radial procedures have been performed in the USA since the mid‑1990s,5 but volume was initially low as skills were fostered by only a small, but dedicated, group of opera tors. The NCDR®data used in this analysis was collected from July 2009 to December 2012,1 a period that encompassed a rapid adoption of transradial techniques in the USA.6 Individuals motivated to learn, and those deliberately seeking new skills, might be more readily trainable and potentially
Transformation to transradial —safe and effective Ian C. Gilchrist
Analysis of cardiovascular registry data suggests that cardiologists who practice femoral cardiac catheterization can convert to safer transradial approaches with a learning experience of 30–50 procedures. This conversion is associated with no loss of procedural success and no increase in serious adverse outcomes.
A conundrum of medical education has always been the balance between learn ing or teaching new techniques and the dictum ‘primum non nocere’—do no harm. Although a perfect solution to this enigma might never be found, recognition and minimization of harm involved in medical advances is an ethical priority. The concept of learning curves, which were first devel oped for industrial processes, has been applied to medicine to help quantitate this delicate balance. A new publication has now provided an interesting analysis of the learning curve that defines the introduction of transradial cardiac catheterization tech niques by practicing femoral operators using data from the US National Cardiovascular Data Registry®(NCDR®, American College of Cardiology Foundation, USA).1
‘‘
…transradial ... adoption within the USA has remained surprising slow
’’
Although transradial approaches have rapidly become prominent throughout the world, adoption within the USA has remained surprising slow. One argument has been that the learning curve for trans radial catheterization is too long and poten tially dangerous for those operators more used to femoral procedures to safely sur mount. However, the results presented by Hess et al. suggest otherwise. The authors report a reasonably short learning experi ence of 30–50 transradial interventional cases to reach proficiency, with no apparent effect on overall procedural success during
the training period.1 When transradial tech niques are adopted, an immediate reduc tion in the number of complications is observed compared with transfemoral vas cular interventions.2 These results strongly support the further dissemination of trans radial techniques within the interventional cardiology community. The potential complications, on an operator-based level, during the learning phase of transradial procedures were also investigated.1 To retrospectively identify transradial practice initiation, operators who performed at least one transfemoral procedure in the 6 months before their initial transradial procedure were defined as beginners, and their results followed through different levels of subsequent cumulative transradial experience. Overall procedural success and a series of metrics were then evaluated over the spectrum of physician experience. Across this spectrum, from the most novice transradial operators (1–10 cases) to the more experienced (101– 200 cases), improvements in mean fluoro scopy time from 16.0 mins to 12.6 mins (interquartile range 10.8–23.6 mins and 8.4– 19.3 mins respectively; P
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