This year we celebrate 60 years of ESGE. However, the ESGE quality initiative is significantly younger and only a teenager. As we entered the 21st century, it became apparent that GI endoscopy was not only about new technical achievements and innovations. Credit must be given to the United Kingdom, who for the first time analysed data from their national registry, and concluded that despite technical progress in endoscopy, many endoscopists were lacking in quality. Indeed, in 1999, a caecal intubation rate of only 56 % was reported [1]. In addition, the Polish registry revealed significant differences between endoscopists in adenoma detection rates, directly impacting the risk of interval colorectal cancers (CRC) [2]. With the introduction of CRC screening programmes throughout Europe, it became obvious that quality in GI endoscopy needed to be addressed to assure good outcomes for our patients and for society.
With this in mind, from 2011 to 2016, ESGE conducted a series of quality in endoscopy symposiums addressing best “standards of care” in all fields of GI endoscopy. In parallel, in 2013, the ESGE Quality Improvement Committee (QIC) was launched under the chairmanship of Professor Matt Rutter [3]. From the beginning, the focus was not only on colonoscopy for which the evidence for high quality was accumulating. Indeed, it could be anticipated that for all fields of endoscopy, the risk of underperformance and associated underdiagnosis for patients was imminent. Therefore, ESGE developed for the first time, in collaboration with UEG, a set of key performance measures (KPMs) for each subbranch of endoscopic procedures with a focus on measurable, auditable, and achievable KPMs with direct impact on patient outcomes. From the start of the quality initiative, dissemination of the KPMs to achieve wide implementation was the main goal, resulting in a series of thematic ESGE meetings on quality in endoscopy and educational sessions at UEG Week. Moreover, several ESGE member societies picked up the theme for dedicated quality sessions at their national meetings. According to an ESGE survey conducted in 2021, 75 % of the ESGE member societies explicitly promoted the KPMs and took a leading role by endorsing, adapting, and translating the KPMs to facilitate local health authorities in the implementation process [4] ([Fig. 1]).
Fig. 1 ESGE QIC publications 2014–2022.
However, 10 years after the initiation of the ESGE QIC, there is still a long way to go. Barriers for implementation of KPMs remain. Besides resistance to change and practicalities in auditing performance, one of the main barriers is the lack of regulation. Most national health care authorities are not consciously aware of the importance of quality in GI endoscopy. On the other hand, in countries where quality requirements were implemented by national bodies like JAG in the UK, quality has improved significantly. ESGE addressed this matter during a high-level summit meeting at the European Parliament in 2023, and we hope that more effort will be undertaken to further the implementation of KPMs in the European Union.
In order to overcome the resistance to change and further stimulate KPM measurement, ESGE and QIC, under the leadership of Professor Raf Bisschops, developed a Quality Check App that allows ESGE individual members to audit their endoscopy practice more efficiently. The main hurdle for KPM assessment is the inclusion and exclusion criteria for endoscopic procedures that define the denominator. The ESGE Quality Check App will guide the assessor through the relevant procedure related questions and take indications and exclusion criteria automatically into consideration. Despite all the effort, the App is not widely used and therefore ESGE, under the guidance of the ESGE QIC, now led by Professor Monika Ferlitsch, issued an "ESGE Certification of Quality” to those centres that deliver proof of measuring KPMs in their endoscopy units ([Fig. 2]).
Fig. 2 ESGE Certification of Quality.
While the ESGE QIC is analysing newly available evidence to update the KPMs in 2024, we must continue to further implement and disseminate the current KPMs. Quality reporting in GI endoscopy should become mandatory, like the endoscopy report itself. With regards to the latter, it is in fact still quite frustrating that in 2024, where instantaneously every flower, dessert or sunset can be shared with the entire world through social media, it remains in many cases not feasible to provide a report with high quality endoscopic photo documentation. To those who claim that additional remuneration should be in place for this, we would argue that perhaps an endoscopic procedure that does not meet certain quality standards should not be financially reimbursed.
In the future, artificial intelligence has the potential to play an important role in automated quality control and we believe that the providers of endoscopic equipment should include such systems that automatically provide photo-documentation, quality metrics (e. g. bowel preparation scale, inspection time, caecal intubation, …) to provide real time feedback to the endoscopist. In the end, as physicians, we owe it to our patients and society to provide the best possible care, and this includes high quality GI endoscopy.
