The Classification for Adverse Events in GastRointEstinal Endoscopy (AGREE): Three-Year Evaluation and Additional Recommendations.

Abstract

Background In 2021, a novel classification for gastrointestinal endoscopy-related adverse events (AEs) was introduced: the AGREE classification. This classification was developed to minimize subjectivity in AE assessment and facilitate more robust comparisons of endoscopic and surgical procedures. We conducted a comprehensive review of the classification three years after its introduction. Methods A citation analysis of the original AGREE publication was performed through March, 2025. Identified articles were reviewed to evaluate the classification's adoption, application, use for intra- and interdisciplinary comparisons, and comparability with other classifications. Accuracy of AE classifications was assessed based on review of unique scenarios reported across identified articles. Variability in the definition and reporting of AEs across studies was evaluated. Results In total, 167 unique articles, involving 33 countries across 5 continents, were identified. A notable year-over-year increase was observed. Available studies illustrated feasibility of the AGREE to facilitate both intra- and interdisciplinary comparisons, alongside significant correlations between AGREE-based AE severity assessments and assessments using other classifications. Accuracy of gradings was estimated at 85%. Misclassifications mostly involved overclassification of events without sequelae for the patient. Inconsistencies in grading, definition, and reporting of AEs were identified. Findings were used to establish recommendations for grading specific (challenging) AE scenarios and develop a checklist to support more standardized AE reporting. Conclusions A gradual increase in the annual citations of the AGREE classification was observed, suggesting growing awareness and academic interest. The recommendations provided could support more consistent grading, definition, and reporting of AEs, thereby improving opportunities for endoscopy quality evaluation.