{ "abstract": "Background: Despite the increasing use of liver contrast-enhanced ultrasound (CEUS), no standardized, organ-specific tool exists for assessing trainees’ cognitive competency. Existing instruments lack multidimensional evaluation and external validation, which limit training quality and patient safety.\n\nObjective: This study aims to develop and validate the CEUS Competency Assessment for the Liver (CCAL), a tool to standardize the evaluation of theoretical and cognitive skills in liver CEUS.\n\nMethods: This retrospective cohort study had four stages: (1) item generation from literature and guidelines, (2) 3 Delphi rounds (12/21, 57.1% female experts; mean age 51.0, SD 7.2 y) and cognitive testing (10 trainees) for content validity (>85% agreement) and clarity, (3) internal validation involving 100 sonography trainees (n=66, 66% assistant professors; n=27, 27% associate professors; n=7, 7% professors; n=70, 70% CEUS-naive) with 1 month or more of training at 4 hospitals (2018‐2020), and (4) external validation on 579 sonography trainees (n=299, 51.6% assistant professors; n=183, 31.6% associate professors; n=97, 16.8% professors; n=439, 75.8% CEUS-naive) with 1 or more months of training at 25 multicenter sites (2018‐2020). Primary outcomes were reliability (Cronbach α and Guttman split-half) and validity (exploratory factor analysis and item discrimination), while secondary outcomes included item difficulty distribution, pass rates, and between-group differences.\n\nResults: The final CCAL comprised 74 items across 3 domains (demographics: 8, self-evaluation: 13, and objective questions: 53). Internal consistency was excellent (Cronbach α=0.916 and Guttman split-half=0.908). Factor analysis confirmed a 3-factor structure explaining 74.6% of the cumulative variance. Item analysis showed a balanced difficulty distribution (35/53, 66.0% easy; 17/53, 32.1% moderate; 1/53, 1.9% difficult items). Scores varied significantly by CEUS training duration (P<.001); trainees with 4 to 6 months or more than 6 months of training achieved higher self-evaluation (F2,576=34.751, partial η²=0.108, 95% CI 0.069-0.147) and objective question (F2,576=34.374, partial η²=0.107, 95% CI 0.068-0.146) scores than those with less than 3 months of training. Prior independent CEUS experience was also associated with higher scores on the self-evaluation (t577=6.736, Cohen d=0.561, 95% CI 0.393-0.728; P<.001) and objective question sections (t577=3.494, Cohen d=0.291, 95% CI 0.127-0.454; P=.001). Competency gaps were identified across specific competency domains: the pass rate ranged from 32.5% (188/579; image-guided intervention) to 81.3% (471/579; indications and contraindications).\n\nConclusions: The CCAL is the first liver-specific CEUS competency tool integrating objective knowledge testing with structured self-evaluation. Unlike generic or simulation-based tests, it is organ-specific and validated across a large multicenter cohort, providing a multidimensional framework that identifies specific competency gaps, most notably in advanced image-guided procedures, beyond global pass/fail outcomes. The tool supports competency-based medical education through rigorous data-driven assessment, targeted curricular improvements, cross-institutional benchmarking, and informed training standards. It evaluates cognitive competence exclusively and should not replace procedural assessment in high-stakes decisions. International validation and the establishment of criterion-related and predictive validity are essential next steps.", "abstract_shown": true, "affiliations": [ "Department of Medical Ultrasonics, Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, 510630, China, 86 13925155583", "Beijing Tiantan Hospital, Capital Medical University, Beijing, China", "Department of Health Statistics, School of Preventive Medicine, Air Force Medical University, Xi'an, China", "Department of Ultrasound, China-Japan Union Hospital of Jilin University, Jilin, China", "Shanxi Provincial Cancer Hospital, Taiyuan, China", "Lanzhou University Second Hospital, Lanzhou, China", "The First Hospital Affiliated to AMU, Chongqing, China", "Chinese PLA General Hospital, Beijing, China", "Tianjin Third Central Hospital, Tianjin, China", "First Affiliated Hospital of Zhengzhou University, Zhengzhou, China", "Henan Provincial People's Hospital, Zhengzhou, China", "Shanghai First People's Hospital, Shanghai, China", "Yunnan Cancer Hospital, Kunming, China", "First Affiliated Hospital of Soochow University, Soochow, China", "West China Hospital of Sichuan University, Sihchuan, China", "Xiangya Hospital Central South University, Changsha, China", "Second Affiliated Hospital of Zhejiang University, Hangzhou, China", "Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China", "Peking University People's Hospital, Beijing, China", "The Affiliated First Hospital of Ningbo University, Ningbo, China", "The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China" ], "article_type": "research article", "arxiv": null, "author_total": 26, "authors": [ { "affs": [ 0 ], "name": "Yanping Ma", "orcid": "0000-0002-6925-9710" }, { "affs": [ 0 ], "name": "Bowen Zheng", "orcid": "0000-0001-9205-4441" }, { "affs": [ 0 ], "name": "Jie Ren", "orcid": "0000-0003-2599-9001" }, { "affs": [ 1 ], "name": "Wen He", "orcid": "0009-0009-9524-449X" }, { "affs": [ 2 ], "name": "Lei Shang", "orcid": "0000-0003-0470-0066" }, { "affs": [ 3 ], "name": "Hui Wang", "orcid": "0000-0001-6729-8292" }, { "affs": [ 4 ], "name": "Gaiqin Xue", "orcid": "0000-0003-3734-6147" }, { "affs": [ 5 ], "name": "Fang Nie", "orcid": "0009-0005-7540-7758" }, { "affs": [ 6 ], "name": "Yanli Guo", "orcid": "0000-0003-1685-4441" }, { "affs": [ 7 ], "name": "Yukun Luo", "orcid": "0000-0002-5944-8198" }, { "affs": [ 1 ], "name": "Hongxia Zhang", "orcid": "0009-0000-9403-935X" }, { "affs": [ 1 ], "name": "Xuan Wang", "orcid": "0009-0008-2850-6165" }, { "affs": [ 8 ], "name": "Xiang Jing", "orcid": "0000-0001-9088-365X" }, { "affs": [ 9 ], "name": "Ruifang Zhang", "orcid": "0009-0001-0189-1883" }, { "affs": [ 10 ], "name": "Jianjun Yuan", "orcid": "0000-0003-1823-8239" }, { "affs": [ 11 ], "name": "Rong Wu", "orcid": "0000-0003-3528-5360" }, { "affs": [ 12 ], "name": "Xiaomao Luo", "orcid": "0009-0004-4127-2632" }, { "affs": [ 13 ], "name": "Fenglin Dong", "orcid": "0000-0003-2457-663X" }, { "affs": [ 14 ], "name": "Yan Luo", "orcid": "0009-0006-5703-422X" }, { "affs": [ 14 ], "name": "Qiang Lu", "orcid": "0000-0002-4057-1997" }, { "affs": [ 15 ], "name": "Jintang Liao", "orcid": "0000-0001-8642-8291" }, { "affs": [ 16 ], "name": "Pintong Huang", "orcid": "0000-0003-0747-5765" }, { "affs": [ 17 ], "name": "Qin Chen", "orcid": "0000-0002-6802-504X" }, { "affs": [ 18 ], "name": "Jia’an Zhu", "orcid": "0009-0005-8568-1814" }, { "affs": [ 19 ], "name": "Youfeng Xu", "orcid": "0009-0002-2734-1983" }, { "affs": [ 20 ], "name": "Xiaoyan Xie", "orcid": "0009-0002-9761-9525" } ], "bibtex": "https://research.draconitic.com/paper/2ftk3pm9zcd6t.bib", "cited_by": 0, "doi": "10.2196/86730", "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13747318/", "id": "2ftk3pm9zcd6t", "issns": [ "2369-3762" ], "landing_url": "https://doi.org/10.2196/86730", "language": "en", "licence": "CC-BY-4.0", "licence_label": "CC BY 4.0", "licence_source": "article", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "heading", "Continuing Medical Education (CME) for Doctors" ], [ "heading", "Decision Support for Health Professionals" ], [ "heading", "Design and Usability of Medical Devices" ], [ "heading", "Original Paper" ], [ "heading", "Research Instruments, Questionnaires, and Tools" ], [ "heading", "e-Learning and Digital Medical Education" ], [ "heading", "mHealth for Screening" ], [ "openalex", "3304|Innovations in Medical Education" ] ], "openalex": "W7166869060", "pdf_url": null, "pmcid": "PMC13747318", "pmid": "43002749", "published": "2026-11-09", "publisher": "JMIR Publications Inc.", "ris": "https://research.draconitic.com/paper/2ftk3pm9zcd6t.ris", "sources": [ { "first_seen": "2026-11-12T12:23:23Z", "native_id": "PMC13747318", "source": "pmc", "url": "https://doi.org/10.2196/86730" } ], "subjects": [ { "field": "medicine", "origin": "journal-openalex:F27", "subfield": "general" } ], "title": "A Competency Assessment Tool for Liver Contrast-Enhanced Ultrasound Among Sonography Trainees: Development and Multicenter Validation Study", "title_text": "A Competency Assessment Tool for Liver Contrast-Enhanced Ultrasound Among Sonography Trainees: Development and Multicenter Validation Study", "type": "peer-reviewed", "updated_at": "2026-11-13T12:24:13Z", "url": "https://research.draconitic.com/paper/2ftk3pm9zcd6t", "venue": "JMIR Medical Education", "versions": [] }