Combined GI endoscopy is already standard practice across many US health systems. When both procedures are clinically indicated, around 65% of patients undergo them in the same session or close window: one prep, one sedation, consolidated throughput.
The efficiency logic is sound, but what the operational analysis hasn’t fully accounted for is the risk that sits inside that efficiency gain. Upper GI and lower GI are not equivalent procedures in their quality infrastructure. Colonoscopy has decades of standardized performance metrics and a now-documented AI-assisted detection record. Upper GI has neither at equivalent maturity. That gap isn’t new, but the scale at which health systems are now running combined procedures is. And scale changes what a quality gap means institutionally.
The Rules Are Being Written. Now.
The colonoscopy component of a combined session has standardized performance benchmarks, documented outcomes, and an established record to point to if a result is questioned. The upper GI component, in many programs, does not. That asymmetry is the exposure, and most health system risk frameworks have not yet named it.
Upper GI cancer miss rates exceed 8%, with some estimates reaching 11.3% over a three-year window. In 69% of missed cases, the endoscopist had already recorded an abnormality at the exact anatomical site where cancer was later diagnosed. The failure mode is not detection, but systematic coverage: whether every required anatomical landmark was examined before the scope was withdrawn. Without a structured quality program for the upper GI component of combined sessions, there is no mechanism to demonstrate that standard was met.
That is the context in which the American Society for Gastrointestinal Endoscopy published new upper GI quality indicators in early 2025, the most comprehensive attempt to standardize performance measurements for the procedure. The clinical community has recognized the gap and is working to close it. The operational implications for health systems are less well understood. Quality indicators, once published and adopted by professional societies, tend to follow a predictable trajectory: they inform credentialing standards, shape accreditation expectations, and establish the benchmark that risk and legal teams reach for when outcomes are questioned. Health systems building toward those standards now are in a stronger position than those waiting for them to carry formal weight.
Volume Turns a Gap Into a Pattern
A single missed upper GI finding in a combined session is a clinical question about an individual case. A health system running thousands of combined sessions without a defined quality assurance mechanism for the upper GI component is a different category of question: whether the institution had the processes in place to meet an emerging standard of care, applied consistently, across its entire program. One is an adverse outcome. The other is an institutional policy question, and the two land differently when results are reviewed.
The reimbursement structure explains why that pattern forms and goes uncorrected. US endoscopy billing is largely binary: a base payment for the diagnostic procedure, with an increment if biopsy or resection occurs, and no financial signal for thorough anatomical landmark coverage in the upper GI component. In practice, the colonoscopy carries the clinical weight; the upper GI exam is completed first and quickly. Without a mechanism to flag incomplete coverage, that tendency accumulates across every combined session a program performs without producing a visible signal until an outcome forces the question.
At scale, that is what converts a documented clinical gap into a consistent institutional practice. And consistent institutional practices are what risk and legal teams are asked to defend.
What Getting Ahead of It Looks Like
AI-assisted colonoscopy gained institutional traction because quality metrics and detection technology were developed in parallel, creating an auditable record of procedural performance that served both clinical improvement and institutional accountability. A 2024 meta-analysis of 28 randomized controlled trials involving nearly 24,000 patients found a 20% increase in adenoma detection rate and a 55% reduction in miss rate with AI assistance. That evidence base gave health system operators a defensible basis for adoption and gave risk teams something concrete to point to.
Upper GI AI is earlier on that curve, but it is being built on the same logic. Landmark verification comes first: real-time confirmation that all anatomically required areas were examined before scope withdrawal, creating a structured coverage baseline that did not previously exist. Detection of precancerous conditions, dysplasia in Barrett’s esophagus and gastric intestinal metaplasia, follows from that baseline. The sequencing is deliberate because coverage and detection are not interchangeable; you cannot reliably catch what you have not systematically examined.
What that sequence produces, for a health system running combined sessions at scale, is an auditable record that the upper GI examination met a defined standard, generated at the point of care, for every procedure performed. That record has institutional value before upper GI quality indicators carry formal weight. It has considerably more once they do. Health systems that build toward it now are establishing that standard on their own terms, before volume makes its absence a harder conversation to have.
Act Before the Window Closes
Consolidating GI procedures was a rational operational decision, and it remains one. What has changed is what that decision now requires. Combined GI endoscopy at scale is not just a scheduling and throughput question. It is a quality assurance question, and for the upper GI component of every combined session being run, most health systems do not yet have a complete answer to it.
The standards are being written. The evidence is forming. Neither will wait. Health system leaders who treat this as an institutional risk question now, rather than a clinical consideration for later, are the ones who will have a defensible answer when it is asked of them.
About Dror Zur
Dror Zur, PhD, is the CEO of Magentiq Eye, an AI-powered colonoscopy platform focused on improving procedural quality in GI endoscopy.
