The AGREE classification: A useful new tool or just a procrustean bed?

Abstract

We read the study by Nass et al1Nass K.J. Zwager L.W. van der Vlugt M. et al.Novel classification for adverse events in GI endoscopy: the AGREE classification.Gastrointest Endosc. 2022; 95: 1078-1085.e8Abstract Full Text Full Text PDF Scopus (3) Google Scholar with interest. The authors proposed a new classification for adverse events (AEs) in GI endoscopy based on the Clavien-Dindo classification, widely used in surgery,2Dindo D. Demartines N. Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg. 2004; 240: 205-213Crossref PubMed Scopus (18972) Google Scholar and compared it with the current American Society for Gastrointestinal Endoscopy (ASGE) classification.3Cotton P.B. Eisen G.M. Aabakken L. et al.A lexicon for endoscopic adverse events: report of an ASGE workshop.Gastrointest Endosc. 2010; 71: 446-454Abstract Full Text Full Text PDF PubMed Scopus (1125) Google Scholar Although an update of the previous classification is needed, we have several methodologic concerns. In fact, the definition of AE was related to “any deviation from the standard postprocedural course.” The concept of postprocedural course is not always “standardized,” and it may be influenced by local policies or the availability of resources, thus adding a subjective aspect with the risk of jeopardizing its applicability on a large scale. Another element of concern is the relation between the procedure and AE occurrence within 30 days “irrespective of the likelihood of a potential link between both events.” This statement, based on the aforementioned surgical tool,2Dindo D. Demartines N. Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg. 2004; 240: 205-213Crossref PubMed Scopus (18972) Google Scholar appears too deterministic in a setting where a clear cause-and-effect relation between minimally invasive or even simple diagnostic procedures and delayed events is not as glaring as after major surgery, with the risk of significantly overestimating the AE rate and creating a “procrustean bed” (a situation where a definition is altered to make it fit a standard solution). Furthermore, the lack of blinding represents a major issue in the assessment of highly subjective outcomes such as the reproducibility and acceptability of the new classification in comparison with the ASGE lexicon. Because novelty attracts attention, even at the cost of saliency effects,4Schomaker J. Meeter M. Short- and long-lasting consequences of novelty, deviance and surprise on brain and cognition.Neurosci Biobehav Rev. 2015; 55: 268-279Crossref PubMed Scopus (97) Google Scholar a newer tool may induce a strong attentional prioritization with higher acceptability. Finally, given the high agreement between the 2 classifications, the improvement due to the newer tool appears unclear. In conclusion, we believe that blinding the validation process and a more precise definition of the nature of AEs is needed to assess this important issue. Dr Repici is the recipient of consulting fees from Boston Scientific and Medtronic and of grant support from Fujifilm. The other authors disclosed no financial relationships. Novel classification for adverse events in GI endoscopy: the AGREE classificationGastrointestinal EndoscopyVol. 95Issue 6PreviewStandardized registration and evaluation of adverse events (AEs) are essential to assess the safety of endoscopic procedures. We propose a novel classification system, named adverse events in GI endoscopy (AGREE), adapted from a widely accepted surgical tool. Full-Text PDF Open AccessErratumGastrointestinal EndoscopyVol. 96Issue 2PreviewIn the article, “The AGREE classification: A useful new tool or just a procrustean bed?” by A. Facciorusso, et al (Gastrointest Endosc 2022;95:1280), the correct author affiliation for Alessandro Repici is: Full-Text PDF ResponseGastrointestinal EndoscopyVol. 95Issue 6PreviewWe thank Facciorusso et al1 for their thoughtful comments on our article,2 and we are pleased that they agree that a new classification for adverse events (AEs) in GI endoscopy is needed. We will do our utmost to address their rightful concerns. Full-Text PDF