The Pediatric Endoscopy Quality Improvement Network Joint NASPGHAN/ESPGHAN Guidelines

Five years ago, a group of us stepped down from a podium panel discussion at the Fifth World Congress of Pediatric Gastroenterology, Hepatology and Nutrition in Montreal, inspired to develop a global consensus statement outlining best practices for pediatric endoscopy. Gastrointestinal endoscopy has become integral to the diagnosis and management of many digestive disorders in children and is routinely performed worldwide. Although numerous medical societies and international organizations have put forward guidelines for endoscopy in adults, these have largely been guided by colorectal cancer screening programs and focused on quality metrics such as withdrawal time, adenoma detection, and compliance with recommended surveillance intervals that are not relevant to pediatrics. The multinational group that began to form in 2016 shared a like-minded stance that pediatric endoscopists must be open to defining high-quality endoscopy in children and engaging in continuous quality improvement activities. We all noted the risk of not engaging in the quality movement was that others (including regulatory boards, administrative agencies, or third-party payers) would define these measures for us. Over the next year, we applied to the North American and European Societies of Pediatric, Gastroenterology, Hepatology and Nutrition (NASPGHAN and ESPGHAN) to support the development of our affectionately logoed Pediatric Endoscopy Quality Improvement Network (PEnQuIN). Although it was not logistically possible to have direct representation in the consensus process from all societies in the Federation of International Societies of Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN), there was tremendous support for the development of pediatric-specific endoscopy clinical practice guidelines (CPGs). The United States National Academy of Medicine defines CPGs as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence (1).” Even when a healthcare practice is largely conventional and based on limited evidence, the process of developing a CPG should still begin with a comprehensive review and evaluation of existing literature. NASPGHAN and ESPGHAN vetted a proposed working-group of experts in pediatric endoscopy and research methodology that represented both societies, as well as various regions and practice types, to interpret the evidence and formulate recommendations. With the full knowledge that CPGs are only as good as the methodology that is used to develop them, the PEnQuIN working group committed to using the framework for guideline development set out in the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument (2), and grading the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (3). The 5 guidelines in this supplement represent the results of the PEnQuIN working group's mission to develop standards and indicators for high-quality pediatric endoscopy, and to delineate the reporting elements that should be used for pediatric endoscopy documentation. As part of the AGREE II framework, final stages of the guideline development process have involved posting the statements for external review by all members of NASPGHAN and ESPGHAN. Additionally, we are particularly grateful to the patient representatives as key stakeholders who thoughtfully reviewed the guidelines, as well as to the American Society for Gastrointestinal Endoscopy (ASGE) and the Canadian Association of Gastroenterology (CAG) for formally endorsing PEnQuIN. We would like to continue to welcome all professional organizations, government agencies and other stakeholders to also endorse the PEnQuIN standards and indicators. Taken together, the PEnQuIN guidelines call for all who perform endoscopic procedures in children to recognize that high-quality pediatric endoscopy begins with procedural scheduling and ends when all procedural outcomes are communicated to the patient and their caregivers. Additionally, they establish 4 domains of pediatric endoscopy quality—facilities, procedures, endoscopists and reporting elements—and stipulate that patient- and family-centered perspectives are paramount. The PEnQuIN guidelines also drive home the reality that endoscopy in children is rarely performed for cancer screening; rather, pediatric endoscopy is largely performed for diagnostic and disease monitoring purposes and is dependent upon completeness of the examination. As with all healthcare, pediatric endoscopy must be performed in a timely, expeditious, skillful, successful, safe, and comfortable manner, and be of high value, providing the best quality for the least cost. Going forward, it will be important to move from identification of key standards and indicators to their widespread adoption and integration across pediatric endoscopy services. Additionally, research will be essential to expand the evidence base and to prospectively validate the PEnQuIN standards and indicators as predictors of excellent care and patient outcomes. Thank you for joining us in ensuring that all children undergoing gastrointestinal endoscopy receive the highest quality of care, and for considering how you can engage with PEnQuIN in your practice as pediatric endoscopists.

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