Abstract
Background:
China has made significant progress in medical accessibility and quality over the past decades, and quality improvements in gastroenterology and digestive endoscopy have been consistent. The study aimed to describe the status quo of gastroenterology and digestive endoscopy in the Chinese mainland based on the data from the National Clinical Improvement System (NCIS) and the Hospital Quality Monitoring System (HQMS).
Methods:
Data were extracted from the NCIS and the HQMS. Data analysis included general information from the Department of Gastroenterology and Endoscopy centers, management of inpatients and outpatients, and annual volume and quality indicators of digestive endoscopy. Acute pancreatitis, gastrointestinal bleeding, inflammatory bowel disease, and cirrhosis were identified as priority diseases and were subjected to detailed analysis.
Results:
Data from 4620 and 7074 hospitals were extracted from the NCIS and HQMS, respectively. In 2023, 9.6 gastroenterologists, 6.7 endoscopists, and 37.3 gastroenterology beds per hospital nationwide were observed, achieving 19,252.4 outpatient visits, 1615.2 hospitalizations (97.0 for acute pancreatitis, 146.1 for gastrointestinal bleeding, 40.2 for inflammatory bowel disease, and 111.4 for cirrhosis), and 9432.7 digestive endoscopic procedures per hospital. Overall, the quality of practice improved significantly. The proportion of early cancer among gastrointestinal cancers increased from 11.1% in 2015 to 23.4% in 2023, and the adenoma detection rate during colonoscopy increased from 19.3% in 2019 to 26.9% in 2023. Regarding priority diseases, hospitalizations increased, and 31-day unplanned readmission rates decreased between 2019 and 2023. The median hospitalization costs and median proportion of medication costs decreased for acute pancreatitis, gastrointestinal bleeding, and cirrhosis. However, it increased for inflammatory bowel disease.
Conclusion:
This report evaluates the status quo and development of gastroenterology and digestive endoscopy in the Chinese mainland, providing guidance for future quality improvements.
Keywords: Gastroenterology, Digestive diseases, Digestive endoscopy, Quality improvement, Quality indicator, Health care surveys
Introduction
Digestive diseases are a major public health concern worldwide, with a broad range of conditions affecting billions of individuals and imposing a substantial burden on the healthcare system.[1] In China, the high incidence and disease burden of these conditions have made digestive diseases a critical area of focus for improving healthcare quality.
Over the past decade, the National Gastroenterology Quality Improvement System (NGQIS) of China has focused its efforts on enhancing the quality of gastroenterology and digestive endoscopy and has published several reports establishing standardized quality indicators.[2–5] With the significant advancements in gastroenterology and digestive endoscopy in China, an updated report is needed.[6,7] In this report, we aimed to describe the status quo of gastroenterology and digestive endoscopy in the Chinese mainland based on the data from the National Clinical Improvement System (NCIS) and Hospital Quality Monitoring System (HQMS). This study guides future quality improvements in gastroenterology and digestive endoscopy in China.
Methods
Data source
NCIS and HQMS are national databases launched by the National Health Commission of the People’s Republic of China. The NCIS annually collects quality-related data through predesigned structured questionnaires from tertiary and secondary hospitals, which would encompass information on infrastructure, staffing, and the volume and quality data of clinical services (including inpatient and outpatient services). The HQMS collects mandatory discharge records and includes demographic factors and hospitalization metrics. The details of these databases are widely described in the literature.[8–10] NCIS and HQMS did not cover hospitals in Hong Kong, Macao, or Taiwan of China.
Data collection
A questionnaire involving gastroenterology and digestive endoscopy in NCIS was developed by the NGQIS. In 2024, it mainly included three aspects: (1) infrastructure and staff of the Department of Gastroenterology and Endoscopy Centers, such as bed capacity and number of endoscopists; (2) annual volume and quality indicators of digestive endoscopy [Table 1]; and (3) management of acute upper gastrointestinal (GI) bleeding and gastroesophageal reflux disease (GERD). All data were reported based on the full year 2023.
Table 1.
Quality indicators of digestive endoscopy in China (2022 edition) and those included in the current survey.
| Indicators | Types | Definitions | Included in NCIS 2024 |
|---|---|---|---|
| General issue | |||
| Workload of endoscopists | Structure | Average annual workload of an individual endoscopist | √ |
| Proportion of fourth-level endoscopy* | Structure | Proportion of the volume of fourth-level endoscopies to the total volume of endoscopies in the same period | √ |
| Proportion of third-level endoscopy* | Structure | Proportion of the volume of third-level endoscopies to the total volume of endoscopies in the same period | √ |
| EGD quality indicator | |||
| Complete examination rate of EGD | Process | Determined by photo-documentation of the upper, middle, and lower segments of the esophagus, cardia, fundus, body, angularis, and antrum of the stomach, pylorus, duodenal bulb, descending part, etc | |
| Proportion of early cancer among esophageal cancer | Outcome | Proportion of early cancer in all esophageal cancers during diagnostic EGD | √ |
| Proportion of early cancer among gastric cancer | Outcome | Proportion of early cancer in all gastric cancers during diagnostic EGD | √ |
| Colonoscopy quality indicator | |||
| Adequate bowel preparation | Process | According to the Boston bowel preparation scale, the score of each intestinal segment is ≥2 points, with a total score ≥6 points | √ |
| CIR | Process | Determined by photo-documentation of the ileocecal valve, appendiceal orifice, and/or terminal ileum | √ |
| Proportion of early cancer among colorectal cancer | Outcome | Proportion of early cancer in all colorectal cancers during diagnostic colonoscopy | √ |
| ADR | Outcome | Proportion of colonoscopies with at least one histologically confirmed adenoma among all average-risk screening colonoscopies with adequate bowel preparation and confirmation of cecal intubation | √ |
| Rate of colonoscopy withdrawal time ≥6 minutes | Process | Defined as the time spent from reaching the cecum or terminal ileum till the end of the procedure in colonoscopies, with a duration of ≥6 minutes | |
| ESD quality indicator | |||
| Complete resection rate of ESD | Outcome | Proportion of R0 resection removal of gastrointestinal early cancer during ESD | √ |
| ERCP quality indicator | |||
| Success rate for ERCP selective biliary cannulation | Process | Proportion of achieving deep cannulation of the desired duct during ERCP | √ |
| Complete extraction rate of common bile duct stones (<1 cm) | Outcome | Proportion of common bile duct stones (<1 cm) extraction confirmed by cholangiography and fluoroscopy | √ |
| Capsule endoscopy indicator | |||
| Complete examination rate of capsule endoscopy | Process | Determined by photo-documentation of the cardia, fundus, body, angularis, and antrum of the stomach | |
| EUS quality indicator | |||
| Complete examination rate of EUS | Process | Determined by photo-documentation and a detailed record of the digestive tract or biliopancreatic structures | |
| Positive rate of EUS-FNA | Outcome | Proportion of EUS-FNA specimens with pathologically identified atypical cells or cancer cells among the total volume of EUS-FNA procedures performed in patients clinically diagnosed with pancreatic malignancies | √ |
| Safety indicator | |||
| Severe adverse event rate | Outcome | Proportion of severe bleeding, postoperative severe pancreatitis, systemic infection, perforation referred for surgical repair, disability, death, or other conditions requiring surgical intervention |
*In China, advanced digestive endoscopy procedures are classified into third-level and fourth-level endoscopy. Third-level endoscopy includes procedures such as endoscopic mucosal resection, endoscopic stenting, endoscopic dilation, endoscopic foreign body retrieval, and diagnostic small bowel enteroscopy. Fourth-level endoscopy includes ERCP, ESD, EUS-FNA, therapeutic small bowel enteroscopy, and natural orifice transluminal endoscopic surgery. ADR: Adenoma detection rate; CIR: Cecal intubation rate; EGD: Esophagogastroduodenoscopy; ERCP: Endoscopic retrograde cholangiopancreatography; ESD: Endoscopic submucosal dissection; EUS: Endoscopic ultrasound; EUS-FNA: EUS-guided fine needle aspiration; NCIS: National Clinical Improvement System.
Data retrieval was performed using the HQMS database, targeting all inpatients with a primary diagnosis of digestive disease between January 1 and December 31, 2023, which were identified using International Classification of Diseases, Tenth Revision codes. Data on inpatient volume, male-to-female sex ratio, median length of stay, and median hospitalization costs were collected and calculated. During the analysis of the management of digestive diseases, the expert committee of the NGQIS voted to identify acute pancreatitis, gastrointestinal (GI) bleeding, inflammatory bowel disease (IBD), and cirrhosis as priority diseases in the survey 2024. The hospitalization indicators for these priority diseases encompassed hospital-specific inpatient volumes, median length of stay, 31-day unplanned readmission rates, median hospitalization costs, median proportion of medication costs, and median proportion of antimicrobials to total medication costs.
Key indicator data were extracted from reports of previous years and compared with data from 2023.[2,3,11,12]
Data quality control
Computer logical tests and manual inspections were conducted to assess the quality of the original data. If the data were incomplete or failed to pass any verification, the questionnaire was returned to the provincial digestive endoscopy quality control centers and revisited until all verifications were passed.
Statistical analysis
Categorical data are presented as the number of each category and its percentage. Quantitative data are expressed as medians and ranges from maximum to minimum. During the calculation of indicators, if fewer than four hospitals provided relevant data for a province, the indicators for that province were not calculated. Statistical analyses were performed using Statistical Package for the Social Sciences (version 26.0; IBM Corp., Armonk, NY, USA) and Statistical Analysis System (SAS) 9.4 (SAS Institute Inc., Cary, NC, USA).
Results
General information about surveys
In 2023, data of 3855 and 11,946 tertiary and secondary hospitals, respectively, were analyzed in the Chinese mainland. Among the hospitals that submitted data to the NCIS, 5738 hospitals had established gastroenterology departments or provided digestive endoscopy services. After the initial screening, 4620 (80.5%) hospitals were included in the analysis. These hospitals comprised 1574 public tertiary general hospitals (hereinafter referred to as tertiary general hospitals), 2245 public secondary general hospitals (hereinafter referred to as secondary general hospitals), 621 private general hospitals, 37 children’s hospitals, 81 cancer hospitals, and 54 other specialty hospitals. The HQMS database covered 7074 hospitals in 2023, including 2346 tertiary and 4728 secondary hospitals. Detailed information regarding the hospitals is presented in Table 2.
Table 2.
Characteristics of hospitals included in the analysis on gastroenterology and digestive endoscopy in 2019 and 2023.
| Hospital grading | NCIS | HQMS | ||
|---|---|---|---|---|
| 2019 | 2023 | 2019 | 2023 | |
| Tertiary | 1606 (63.2) | 1792 (38.8) | 2131 (30.2) | 2346 (33.2) |
| Secondary | 935 (36.8) | 2808 (60.8) | 4933 (69.8) | 4728 (66.8) |
| Ungraded | 20 (0.4) | |||
| Total | 2541 | 4620 | 7064 | 7074 |
Data were shown as n (%). HQMS: Hospital Quality Monitoring System; NCIS: National Clinical Improvement System.
In 2023, the NCIS included 172,172 gastroenterology beds and 44,166 gastroenterologists nationwide, of whom 70.3% (n = 31,027) were qualified to perform endoscopic procedures. On average, 37.3 gastroenterology beds, 9.6 gastroenterologists, and 6.7 endoscopists per hospital were observed. Tertiary general hospitals possessed more abundant medical resources (58.4 gastroenterology beds, 16.5 gastroenterologists, and 12.6 endoscopists per hospital) than secondary general hospitals (27.0 gastroenterology beds, 5.9 gastroenterologists, and 3.7 endoscopists per hospital).
Management of digestive diseases
Overview of inpatients and outpatients
In 2023, the NCIS reported 89.0 million outpatient visits nationwide. On average, 19,252.4 outpatients per hospital nationwide, 39,297.8 in tertiary general hospitals, and 9184.7 in secondary general hospitals were observed.
In 2023, the HQMS included 11.4 million hospitalizations with a primary diagnosis of digestive diseases who were discharged from the Department of Gastroenterology. On average, 1615.2 hospitalizations per hospital nationwide were observed, with 3308.8 and 774.8 hospitalizations in tertiary and secondary hospitals, respectively. The most common diagnoses were colorectal polyps or benign neoplasms (17.7%), cirrhosis (6.3%), and gastric or duodenal polyps (5.8%) in tertiary hospitals and noninfectious gastroenteritis and colitis (26.6%), colorectal polyps or benign neoplasms (10.2%), and GI bleeding (6.1%) in secondary hospitals. The male-to-female sex ratios of hospitalizations were 1.31 in the tertiary hospitals and 1.17 in secondary hospitals. The median lengths of stay were 6 and 5 days in tertiary and secondary hospitals, respectively. The median hospitalization costs for digestive diseases were ¥6574 and ¥4166 in tertiary and secondary hospitals, respectively.
Acute pancreatitis
Between 2019 and 2023, hospitalizations for acute pancreatitis recorded in the HQMS increased from 477,854 (67.6 per hospital) to 686,125 (97.0 per hospital). The hospitalizations per hospital for acute pancreatitis increased from 137.2 to 194.7 in tertiary hospitals and increased from 37.6 to 48.5 in secondary hospitals [Figure 1A and Figure 2A]. The median length of stay decreased from 8 to 7 days in tertiary hospitals and remained at 7 days in secondary hospitals [Figure 1B and Figure 2B]. The 31-day unplanned readmission rate decreased from 10.8% to 10.6% in tertiary hospitals and from 6.4% to 4.8% in secondary hospitals [Figure 1C and Figure 2C]. The median hospitalization costs decreased by 26.1%, from ¥10,960 to ¥8101 in tertiary hospitals and by 14.0%, from ¥6415 to ¥5520 in secondary hospitals [Figure 1D and Figure 2D]. The median proportion of medication costs decreased from 45.8% to 36.7% in tertiary hospitals and from 43.9% to 36.0% in secondary hospitals [Figure 1E and Figure 2E]. The median proportion of antimicrobials to total medication costs decreased from 16.8% to 14.6% in tertiary hospitals and from 16.3% to 15.9% in secondary hospitals [Figure 1F and Figure 2F].
Figure 1.
Characteristics of hospitalizations in tertiary hospitals in 2019 and 2023. (A) Inpatient volume per hospital of priority diseases in tertiary hospitals. (B) The median length of stay of priority diseases in tertiary hospitals. (C) The 31-day unplanned readmission rate of priority diseases in tertiary hospitals. (D) The median costs of hospitalization of priority diseases in tertiary hospitals. (E) The median proportion of medication costs of priority diseases in tertiary hospitals. (F) The median proportion of antimicrobial medication of priority diseases in tertiary hospitals. GI: Gastrointestinal bleeding; IBD: Inflammatory bowel disease.
Figure 2.
Characteristics of hospitalizations in secondary hospitals in 2019 and 2023. (A) Inpatient volume per hospital of priority diseases in secondary hospitals. (B) The median length of stay of priority diseases in secondary hospitals. (C) The 31-day unplanned readmission rate of priority diseases in secondary hospitals. (D) The median costs of hospitalization of priority diseases in secondary hospitals. (E) The median proportion of medication costs of priority diseases in secondary hospitals. (F) The median proportion of antimicrobial medication for priority diseases in secondary hospitals. GI: Gastrointestinal bleeding; IBD: Inflammatory bowel disease.
GI bleeding
Between 2019 and 2023, the number of hospitalizations for GI bleeding recorded in the HQMS increased from 885,773 (125.4 per hospital) to 1,033,346 (146.1 per hospital). The hospitalizations per hospital for GI bleeding increased from 231.9 to 278.1 in tertiary hospitals and increased from 79.4 to 80.6 in secondary hospitals [Figure 1A and Figure 2A]. The median length of stay was 7 days in tertiary hospitals and decreased from 7 to 6 days in secondary hospitals [Figure 1B and Figure 2B]. The 31-day unplanned readmission rate decreased from 7.3% to 6.9% in tertiary hospitals and from 5.1% to 3.8% in secondary hospitals [Figure 1C and Figure 2C]. The median hospitalization costs decreased by 11.7%, from ¥8231 to ¥7268 in tertiary hospitals and by 8.3%, from ¥5474 to ¥5020 in secondary hospitals [Figure 1D and Figure 2D]. The median proportion of medication costs decreased from 34.3% to 23.6% in tertiary hospitals and from 32.4% to 23.7% in secondary hospitals [Figure 1E and Figure 2E]. The median proportion of antimicrobials to total medication costs decreased from 5.7% to 5.6% in tertiary hospitals and increased from 5.4% to 5.6% in secondary hospitals [Figure 1F and Figure 2F]. In 2023, the NCIS reported 657,049 cases of acute upper GI bleeding, of which 34.4% received endoscopic intervention within 24 h.
Inflammatory bowel disease
Between 2019 and 2023, hospitalizations for IBD recorded in the HQMS increased from 118,140 (16.7 per hospital) to 284,643 (40.2 per hospital). The hospitalizations per hospital for IBD increased from 45.0 to 107.9 in tertiary hospitals and increased from 4.5 to 6.7 in secondary hospitals [Figure 1A and Figure 2A]. The median length of stay decreased from 5 days to 1 day in tertiary hospitals and from 7 days to 5 days in secondary hospitals [Figure 1B and Figure 2B]. The 31-day unplanned readmission rate decreased from 12.8% to 10.9% in tertiary hospitals and increased from 7.2% to 8.6% in secondary hospitals [Figure 1C and Figure 2C]. The median hospitalization costs increased by 11.9%, from ¥6041 to ¥6760 in tertiary hospitals, and by 20.8%, from ¥4434 to ¥5358 in secondary hospitals [Figure 1D and Figure 2D]. The median proportion of medication costs increased from 29.2% to 62.7% in tertiary hospitals and from 32.3% to 36.4% in secondary hospitals [Figure 1E and Figure 2E]. The median proportion of antimicrobials to total medication costs decreased from 6.7% to 3.3% in tertiary hospitals and from 11.1% to 7.2% in secondary hospitals [Figure 1F and Figure 2F].
Cirrhosis
Between 2019 and 2023, the number of hospitalizations for cirrhosis recorded in the HQMS increased from 725,143 (102.7 per hospital) to 788,285 (111.4 per hospital). The hospitalizations per hospital for cirrhosis increased from 231.6 to 251.9 in tertiary hospitals and decreased from 46.9 to 41.8 in secondary hospitals [Figure 1A and Figure 2A]. The median length of stay decreased from 10 to 8 days in tertiary hospitals and from 9 to 8 days in secondary hospitals [Figure 1B and Figure 2B]. The 31-day unplanned readmission rate decreased from 13.4% to 12.0% in tertiary hospitals and from 12.3% to 11.1% in secondary hospitals [Figure 1C and Figure 2C]. The median hospitalization costs decreased by 8.1%, from ¥10,386 to ¥9540 in tertiary hospitals and increased by 2.2%, from ¥5644 to ¥5760 in secondary hospitals [Figure 1D and Figure 2D]. The median proportion of medication costs decreased from 34.7% to 27.5% in tertiary hospitals and from 37.6% to 31.4% in secondary hospitals [Figure 1E and Figure 2E]. The median proportion of antimicrobials to total medication costs decreased from 6.6% to 5.4% in tertiary hospitals and from 5.4% to 5.0% in secondary hospitals [Figure 1F and Figure 2F].
Gastroesophageal reflux disease
In 2023, the number of patients newly diagnosed with GERD in outpatient settings reached 3.9 million nationwide, with an average of 1119.8 patients per hospital, according to the NCIS report. The proportion of ambulatory 24-h esophageal potential of hydrogen monitoring was 3.8%.
Volume and quality of digestive endoscopy
Annual volume of digestive endoscopy
In 2023, hospitals participating in the NCIS performed 43.3 million digestive endoscopic procedures [Table 3]. Tertiary general hospitals performed the majority (72.5%) of digestive endoscopic procedures, particularly advanced endoscopic techniques such as endoscopic submucosal dissection (ESD) (83.7%), endoscopic retrograde cholangiopancreatography (ERCP) (90.5%), and endoscopic ultrasound (EUS) (84.5%). The average annual volume of endoscopies per hospital in 2023 was 9432.7, which is a 14.0% increase compared with that in 2019 (8273.0). Across the provinces, the average annual volume per hospital ranged from 2639.3 to 22,100.0.
Table 3.
Endoscopic procedures performed by the hospitals participating in NCIS in 2023.
| Procedures | Tertiary general hospital, n (%) | Secondary general hospital, n (%) | Nationwide, n |
|---|---|---|---|
| Diagnostic EGD | 16,115,744 (70.9) | 4,974,605 (21.9) | 22,737,025 |
| Therapeutic EGD | 2,133,715 (72.5) | 575,238 (19.5) | 2,944,035 |
| Diagnostic colonoscopy | 9,209,204 (74.1) | 2,280,436 (18.3) | 12,428,502 |
| Therapeutic colonoscopy | 3,107,416 (73.8) | 774,849 (18.4) | 4,210,721 |
| ESD | 192,155 (83.7) | 18,491 (8.0) | 229,593 |
| ERCP | 182,184 (90.5) | 10,789 (5.4) | 201,322 |
| EUS | 385,578 (84.5) | 18,691 (4.1) | 456,379 |
| Small bowel endoscopy | 18,019 (87.0) | 1586 (7.7) | 20,699 |
| Small bowel capsule endoscopy | 28,356 (87.6) | 2406 (7.4) | 32,388 |
| Capsule endoscopy | 20,624 (89.0) | 840 (3.6) | 23,164 |
| Total | 31,392,995 (72.5) | 8,657,931 (20.0) | 43,283,828 |
EGD: Esophagogastroduodenoscopy; ESD: Endoscopic submucosal dissection; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; NCIS: National Clinical Improvement System.
Workload of endoscopists
The average annual volume of endoscopies per endoscopist was 1189.4 cases nationwide, with provincial averages ranging from 360.3 to 1811.9. The annual volume of endoscopists was higher in tertiary general hospitals (1579.1 cases) than in secondary general hospitals (981.9 cases).
Proportion of third-level and fourth-level endoscopy
The proportion of third-level endoscopies was 7.2% nationwide, with provincial averages ranging from 2.9% to 15.2%. This proportion was higher in tertiary general hospitals (7.8%). The proportion of fourth-level endoscopies was 0.5% nationwide, with provincial averages ranging from 0.2% to 1.6%. This proportion was higher in tertiary general hospitals (0.9%).
Detection rate of GI cancers
The detection rate of esophageal cancer during diagnostic esophagogastroduodenoscopy (EGD) was 0.9%, with provincial averages ranging from 0.3% to 1.8%. The proportion of early cancer among esophageal cancer was 23.0%, with provincial averages ranging from 10.4% to 32.0%. The detection rate of gastric cancer during diagnostic EGD was 1.3%, with provincial averages ranging from 0.5% to 3.6%. The proportion of patients with early cancer among those with gastric cancer was 21.9%, with provincial averages ranging from 9.5% to 33.0%. The detection rate of colorectal cancer during diagnostic colonoscopy was 3.2%, with provincial averages ranging from 2.0% to 7.0%. The proportion of early cancer among colorectal cancer was 24.8%, with provincial averages ranging from 14.3% to 36.0%. Overall, the proportion of early GI cancers detected during endoscopy was 23.4%, with provincial averages ranging from 11.7% to 34.1%. The proportion of early cancer among GI cancers in China has been increasing since 2015 [Figure 3].
Figure 3.
The proportion of early cancer among gastrointestinal cancers in endoscopy in China, 2015–2023.
Colonoscopy quality indicators
The rate of adequate bowel preparation for colonoscopy was 90.1%, with provincial averages ranging from 85.4% to 93.9%. This rate was higher in secondary general hospitals (90.5%) than that in tertiary general hospitals (90.1%). The nationwide cecal intubation rate (CIR) was 96.2 %, with provincial averages ranging from 93.1% to 97.4%. This rate was higher in tertiary general hospitals (96.5%) than that in secondary general hospitals (95.8%). The overall adenoma detection rate (ADR) was 26.9%, with provincial averages ranging from 19.5% to 38.4%. The ADR during colonoscopy was higher in the tertiary general hospitals (27.4%) than that in secondary general hospitals (25.2%) [Table 4].
Table 4.
Quality indicators of digestive endoscopy in 2019 and 2023.
| Items | 2019 | 2023 |
|---|---|---|
| General issue | ||
| Workload of endoscopists | 1189.4 | |
| Proportion of fourth-level endoscopy | 0.5% | |
| Proportion of third-level endoscopy | 7.2% | |
| Colonoscopy quality indicators | ||
| Adequate bowel preparation | 85.8% | 90.1% |
| CIR | 95.0% | 96.2% |
| ADR | 19.3% | 26.9% |
| ESD quality indicators | ||
| Complete resection rate | 94.9% | 96.0% |
| ERCP quality indicators | ||
| Success rate for ERCP selective biliary cannulation | 96.3% | 91.7% |
| Complete extraction rate of common bile duct stones (<1 cm) | 94.2% | 95.2% |
| EUS quality indicators | ||
| Positive rate of EUS-FNA | 74.3% |
ADR: Adenoma detection rate; CIR: Cecal intubation rate; ERCP: Endoscopic retrograde cholangiopancreatography; ESD: Endoscopic submucosal dissection; EUS: Endoscopic ultrasound; EUS-FNA: EUS-guided fine needle aspiration.
Advanced endoscopy quality indicators
For advanced endoscopy, the complete resection rate of ESD is 96.0% nationwide, with provincial averages ranging from 89.8% to 98.3%. The nationwide success rate of ERCP-selective biliary cannulation is 91.7%, with provincial averages ranging from 80.9% to 98.4%. The complete extraction rate of common bile duct stones (<1 cm) was 95.2% nationwide, with provincial averages ranging from 88.1% to 99.4%. The positive rate of EUS-guided fine-needle aspiration was 74.3%, with provincial averages ranging from 53.3% to 94.3% [Table 4].
Discussion
Systematic audits and feedback on quality indicators are essential to improve healthcare outcomes.[13] This report integrates data from the NCIS and HQMS, provides a comprehensive evaluation of the quality of gastroenterology and digestive endoscopy in China, and compares key quality indicators with those of previous years. The results showed that both the volume and quality of gastroenterology and digestive endoscopy had developed substantially in the previous years.
In 2019 and 2023, the tertiary and secondary hospitals included in the HQMS were similar, with the hospitalization indicators of tertiary and secondary hospitals from these two years exhibiting a certain degree of comparability. Our analysis reveals significant progress in managing priority digestive diseases. First, between 2019 and 2023, hospitalizations for acute pancreatitis, cirrhosis, GI bleeding, and IBD increased. This increase in hospitalizations is related to the rising incidence and indicates that the accessibility of medical services and patients’ willingness to seek medical treatment have improved in China. Notably, a substantial increase is observed in hospitalizations for IBD (2.4-fold) in tertiary and secondary hospitals, which aligns with recent epidemiological data on IBD in China.[14] This indicates that healthcare resources for IBD should be substantially increased. Second, the 31-day unplanned readmission rates for acute pancreatitis, cirrhosis, IBD, and GI bleeding decreased. Given the absence of established and feasible quality indicators for GI disease care in China, a reduction in the 31-day unplanned readmission rates may indicate quality improvement. Third, the decreased median hospitalization costs and proportion of medication costs for acute pancreatitis, cirrhosis, and GI bleeding suggest that diagnosis, treatment, and medication use have become more standardized.
However, the median hospitalization costs and medication costs among inpatients with IBD have increased. Similar trends have also emerged in Canada and Europe, where IBD treatment costs have increased, with medication expenses and costs for biological agents accounting for a larger share of the overall hospitalization costs.[15,16] Over the past few years, the number of biological agents approved for IBD treatment in China has increased significantly, providing more options for clinicians and patients. The latest IBD treatment guidelines in China show a more positive inclination towards biological agents, even advocating for early intervention with these agents.[17,18] This shift in treatment strategy, combined with the greater availability of biological agents, likely contributes to the rise in IBD treatment costs.[15,19,20] Early intervention with biological agents, while potentially improving long-term outcomes, also adds to the short-term financial burden due to the high cost of these medications.
In China, HQMS reported 11.4 million GI hospitalizations in 2023, and the United States documented a considerably lower figure of 2.9 million in 2021. The median lengths of stay for acute pancreatitis (7 days), GI bleeding (7 days), and IBD (1 day) in tertiary hospitals in China were different from those in the United States (3 days, 3 days, and 4 days, respectively). The median cost of hospitalization for acute pancreatitis (¥8101), GI bleeding (¥7268), and IBD (¥6760) in tertiary hospitals in China was substantially lower than those in the United States ($7941, $9866, and $9852, respectively), with cost ratios ranging from 0.10- to 0.15-fold.[21] This shows disparities in medical resource utilization efficiency and cost burden between China and the United States.
The quality of digestive endoscopy has always been the focus of the NGQIS, particularly for the detection of early GI cancer during EGD and colonoscopy. Between 2023 and 2025, enhancing the proportion of patients with early esophageal cancer during EGD was set as the target of the National Quality Improvement Program. This study observed that the proportion of early cancer among patients with GI cancers achieved consistent progress, from 11.1% in 2015 to 21.9% in 2023. Specifically, the proportion of early cancer among patients with esophageal cancer increased from 12.0% to 23.0%. This progress may contribute to the improved capability of endoscopists to detect early cancer, the adoption of new endoscopic equipment, and the enhanced awareness of endoscopic screening in the general population. Despite the notable increase in this field, the overall rate remains suboptimal, with significant disparities observed across regions and hospitals.[5,12] The proportion of early cancer among patients with esophageal and gastric cancer in China remains lower than that in Japan (52% for esophageal cancer and 76% for gastric cancer),[22] which suggests the importance of strengthening public awareness of regular health check-ups, implements screening programs for high-risk populations, and advances training initiatives for endoscopists. Moreover, significant regional disparities existed in early cancer detection rates across provinces, with averages ranging from 11.7% to 34.1%. The NGQIS and provincial digestive endoscopy quality control centers have implemented multifaceted strategies to address this variation and increase the national detection rate. Key interventions include incorporating early cancer detection rates into provincial evaluation metrics, upgrading outdated endoscopic equipment, and providing specialized training to primary care physicians. Furthermore, the NGQIS and provincial digestive endoscopy quality control centers have prioritized strengthening the endoscopy center infrastructure in underdeveloped regions and enhancing primary care diagnostic capabilities. Public engagement efforts have been intensified through health education lectures and social media campaigns to increase screening awareness and willingness.
Colonoscopy quality has been the focus of quality improvements in digestive endoscopy worldwide. The rate of adequate bowel preparation for colonoscopy in China (90.1%) meets the target of 85% according to international guidelines.[23] The CIR increased from 95.0% to 96.2% between 2019 and 2023 in China, surpassing those of the United Kingdom (92.3%), Netherlands (92.4%), Italy (83.0%), and Brazil (94.0%).[6,7,24,25] ADR is widely recognized as a key outcome quality indicator for colonoscopy. The ADR has increased from 19.3% to 26.9% in China since 2019. The ADR is lower than the performance target for patients aged 45 years in the United States (35%); however, considering the lower incidence of colorectal cancer in China, this performance reflects substantial progress in colonoscopy practice.[26]
Regarding the ERCP quality indicators between 2019 and 2023, the success rate of ERCP-selective biliary cannulation exhibited a modest decline (96.3% to 91.7%), whereas the complete extraction rate of common bile duct stones (<1 cm) increased from 94.2% to 95.2%. According to the guidelines of the American Society for GI Endoscopy and the European Society of GI Endoscopy, cannulation success exceeding 90% remains clinically acceptable.[27,28] China’s rate declined from 96.3% to 91.7% during this period; however, it consistently met recommended standards. These results may be attributed to two key factors within the NCIS dataset. First, the number of hospitals contributing data significantly increased from 2541 in 2019 to 4620 in 2023. This substantial expansion introduced greater heterogeneity among participating endoscopists, potentially leading to variable cannulation success rates across diverse clinical settings and levels of individual experience. Second, the composition of participating hospitals underwent a marked shift during this period. Particularly, the proportion of secondary hospitals within the NCIS increased from 36.8% in 2019 to 78.2% in 2023. Third, while ERCP is performed at secondary and tertiary hospitals, the concentration of highly complex cases, availability of advanced techniques, and specialized training for endoscopists often differ between these levels, contributing to observed variations in procedural outcomes such as selective cannulation success.[29,30]
This study had some limitations. First, neither the NCIS nor the HQMS databases include all hospitals in China, and this study does not represent a national census of gastroenterology and digestive endoscopy. We analyzed the data on a per-hospital basis. Second, a data check was conducted to assess the quality of the original data; however, it was compromised owing to inconsistent NCIS and HQMS collection protocols. In the future, prospective studies with standardized data collection protocols should be conducted in sentinel hospitals to monitor the key indicators of gastroenterology and digestive endoscopy.
In conclusion, this report indicates significant developments in gastroenterology and digestive endoscopy in the Chinese mainland in recent years. This report provides a roadmap for future quality improvement and enhancement.
Funding
This research was supported by the Science and Technology Commission of Shanghai Municipality (No. 21Y31900100) and the National Natural Science Foundation of China (No. 82270679).
Conflicts of interest
None.
Footnotes
Zheran Chen, Yusi Xu, Lei Xin, and Yifei Song contributed equally to this work.
How to cite this article: Chen ZR, Xu YS, Xin L, Song YF, Xu JF, Chu C, Yu CT, Gao Y, Ma XD, Li ZS, Wang LW. Summary of the 2024 report on gastroenterology and digestive endoscopy in China. Chin Med J 2025;138:2693–2701. doi: 10.1097/CM9.0000000000003810
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