Division of Fetal Medicine, Department of Obstetrics, K6-35, Leiden University Medical Center, Leiden, The Netherlands. i.t.m.lindenburg @ lumc.nl
Fetal Diagn Ther. 2011;29(4):307-14. doi: 10.1159/000322919. Epub 2011 Feb 8.
Intravascular intrauterine transfusion (IUT) is an effective and relatively safe method for the treatment of fetal anemia. Although implemented in centers all over the world in the 1980s, the length and strength of the learning curve for this procedure has never been studied. Cumulative sum (CUSUM) analysis has been increasingly used as a graphical and statistical tool for quality control and learning curve assessment in clinical medicine. We aimed to test the feasibility of CUSUM analysis for quality control in fetal therapy by using this method to monitor individual performance of IUT in the learning phase and over the long term.
IUTs performed in the Dutch referral center for fetal therapy from 1987 to 2009 were retrospectively classified as successful or failed. Failed was defined as no net transfusion or the occurrence of life-threatening procedure-related complications. The CUSUM statistical method was used to estimate individual learning curves and to monitor long-term performance. Four operators who each performed at least 200 procedures were included.
Individual CUSUM graphs were easily assessed. Both operators pioneering IUT in the late 1980s had long learning phases. The 2 operators learning IUT in later years in an experienced team performed acceptably from the start and reached a level of competence after 34 and 49 procedures.
CUSUM analysis is a feasible method for quality control in fetal therapy. In an experienced setting, individual competence may be reached after 30 to 50 IUTs. Our data suggest that operators need at least 10 procedures per year to keep a level of competence.
血管内宫内输血（IUT）是治疗胎儿贫血的一种有效且相对安全的方法。尽管该方法于 20 世纪 80 年代在世界各地的中心实施，但该手术的学习曲线的长度和强度从未被研究过。累积和（CUSUM）分析已越来越多地被用作临床医学中质量控制和学习曲线评估的图形和统计工具。我们旨在通过使用该方法监测 IUT 在学习阶段和长期的个体表现，来测试 CUSUM 分析在胎儿治疗中的质量控制的可行性。
对 1987 年至 2009 年荷兰胎儿治疗转诊中心进行的 IUT 进行回顾性分类，成功或失败。失败定义为无净输血或发生危及生命的与手术相关的并发症。使用 CUSUM 统计方法来估计个体学习曲线并监测长期表现。纳入至少进行了 200 次操作的 4 名操作人员。
个体 CUSUM 图很容易评估。1980 年代后期率先开展 IUT 的两位操作人员都有很长的学习阶段。后来在经验丰富的团队中学习 IUT 的 2 位操作人员从一开始就表现得可以接受，并在进行了 34 次和 49 次手术后达到了胜任水平。
CUSUM 分析是胎儿治疗质量控制的一种可行方法。在经验丰富的环境中，个体能力可能在进行 30 到 50 次 IUT 后达到。我们的数据表明，操作人员每年至少需要进行 10 次手术才能保持胜任水平。
