QS215 - Learning on the Job: Colonoscopic Perforation in the First 10 years of Practice

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Purpose/Background: Although there are benchmarks for procedure numbers required for trainees to achieve competence in colonoscopy, endoscopist performance may improve with further experience in practice. This has not been well studied particularly in relation to the rate of serious complications such as perforation.

Methods/Interventions: Using population-based healthcare administrative data capturing all procedural records, we identified all endoscopists in the province of Ontario who began performing colonoscopy after 1992. For colonoscopy performed from 2005-2022 (the observation period), we identified perforations using a validated algorithm. We compared the rate of perforation per 1000 colonoscopies for endoscopists in their 1st year through their 10th year of practice. We compared rates for the time periods (eras) 2005-2010, 2011-2016, and 2017-2022, and between gastroenterologists and surgeons. We performed a longitudinal Poisson generalized estimating equations regression at the endoscopist level to evaluate the association between colonoscopic perforation and years of experience, adjusting for endoscopist specialty and era. We included interactions between experience/specialty and experience/era.

Results/Outcomes: We identified 1,069 endoscopists (662 surgeons and 407 gastroenterologists) within their first 10 years of practice who performed 2,676,759 colonoscopies with 1,178 perforations (0.44 perforations/1000 colonoscopies) in the province during the observation period. Rates of perforation declined from 0.57 in 2005-2010 to 0.30 in 2017-2022. Over the first 5 years of practice, the perforation rate was higher for surgeons (0.57 [95% CI .51-.64]) than for gastroenterologists (0.46 [95% CI .40-.52]) but declined more quickly such that in years 6-10 both specialties had similar rate (surgeons 0.41 [95% CI .36-.45] and gastroenterologists 0.36 [95% CI .32-.41]; see figure). In our multivariable model, perforation rates improved with years of practice for both gastroenterologists and surgeons in most eras – this relationship was most marked in 2005-2010 (relative rate [RR] of perforation per year practiced in this era for surgeons = 0.94 [95% CI .92-.97, p< 0.0001] and for gastroenterologists = 0.95 [95% CI .93-.98, p=0.0004]). While perforation rates were higher for surgeons than gastroenterologists in the first year of practice (RR=1.25, 95% CI 1.02-1.52, p=0.03) by the 10th year of practice the difference was not statistically significant (RR=1.13, 95% CI 0.98-1.23, p=0.09).

Conclusion/Discussion: The rate of perforation after colonoscopy is associated with years in practice for both gastroenterologists and surgeons. While surgeons initially have higher rates of perforation, by the 10th year of practice rates are similar between specialties. Although colonoscopic perforation rates have declined over time, there is a potential to reduce complication rates early in practice further, particularly for surgeons.