Current Sustainability Policies in Gastrointestinal Endoscopy: Insights from a Survey of Swiss Endoscopists

Abstract

Gastrointestinal (GI) endoscopy is a daily procedure in clinical practice but contributes substantially to healthcare’s environmental footprint. Data on sustainability policies in Switzerland, however, remain scarce. This study aimed to assess the implementation of sustainability practices among members of the Swiss Society of Gastroenterology (SGG-SSG). We conducted a web-based cross-sectional survey between September 2023 and January 2024, targeting all 463 practicing Swiss gastroenterologists listed in the latest SGG-SSG roster. The survey comprised eleven questions covering four domains: respondent demographics; waste and single-use device management and procurement; digitalization; and work–life balance. A total of 161 respondents participated (response rate: 34.8%). Less than half (45.1%) reported waste sorting, while policies for single-use device reduction (23.5%) and waste minimization initiatives (27.8%) were even less common. Nearly half (48.8%) reported including sustainability considerations in procurement policies. In contrast, 52.8% reported having policies to promote work–life balance, and 88.2% reported policies requiring the use of electronic health records, reflecting significant progress in digitalization. While procurement and digitalization efforts are more widely implemented, further coordinated action is needed. Future research should investigate professional attitudes, institutional barriers, and strategies to enhance the adoption of environmentally responsible practices in GI endoscopy. Furthermore, professional societies (particularly SGG-SSG), hospital administrators, and cantonal health authorities must coordinate to establish national standards, integrate sustainability into accreditation, and implement incentives and accountability to reduce the environmental impact of GI endoscopy without compromising quality of care.

1. Introduction

Gastrointestinal (GI) endoscopy is a cornerstone of modern digestive healthcare, providing essential diagnostic and therapeutic capabilities. However, its environmental footprint has become an increasing concern. GI endoscopy ranks among the top three hospital procedures generating hazardous waste, contributing significantly to greenhouse gas (GHG) emissions and medical waste due to the widespread use of single-use devices, energy-intensive equipment, and water-demanding decontamination processes [1,2,3]. Specifically, a recent US study estimated that 100 GI endoscopy procedures generate approximately 303 kg of solid waste, around 5240 litres of liquid waste, and consume 1980 kW·h of energy [3].

Globally, professional societies have begun advocating for more sustainable endoscopy practices. Several organizations, including the Asian Pacific Association of Gastroenterology, the British Society of Gastroenterology [2], the Multi GI Society Task Force [4], the European Society of Gastrointestinal Endoscopy (ESGE) [5], and the Swiss Group for Sustainable Gastroenterology [6], have issued position statements urging healthcare providers to integrate sustainability into routine care. These recommendations include reducing unnecessary procedures, minimizing waste streams, and adopting environmentally friendly technologies. Notably, the UK consensus focuses on practical changes within endoscopy units [2], the US plan sets out a broader strategic roadmap [4], the ESGE statement offers harmonized clinical guidance across Europe [5], and the Swiss framework takes a holistic approach that uniquely incorporates digitalisation and workforce sustainability [6].

While global frameworks for sustainable healthcare exist, data on their actual implementation remain scarce, particularly in Switzerland. Within Switzerland’s well-resourced but decentralized healthcare system, coordinating sustainability efforts across cantonal boundaries poses distinct challenges [7]. To address this gap, we asked to what extent gastroenterology practices in Switzerland have implemented environmental and workforce sustainability policies. To explore this question, we conducted a nationwide survey among gastroenterologists affiliated with the Swiss Society of Gastroenterology (SGG-SSG). The survey assessed the presence of sustainability policies outlined in the Swiss framework, including (1) waste management, (2) single-use device management, (3) guidelines to minimize waste, and (4) procurement strategies, as well as policies related to (5) digitalization and (6) work–life balance.

2. Materials and Methods

We conducted a web-based cross-sectional survey between September 2023 and January 2024, targeting all 463 practicing gastroenterologists in Switzerland listed in the most recent SGG-SSG roster. Individuals were invited to participate in the survey via email containing a direct link to the questionnaire, and two reminders were distributed at four-week intervals to maximize response rates. Participation was voluntary, anonymous, and without remuneration. To ensure accessibility, the survey was available in German, French, and Italian.

The survey was designed to inform a national workshop on green endoscopy by assessing sustainable gastroenterology practices in Switzerland. To reduce the workload for endoscopists, it was intentionally kept brief and included eleven close-ended questions. Sustainability-related items were aligned with the key elements of the Swiss framework to ensure consistency with national priorities.

The full questionnaire is presented in Table S1 in the Supplementary Materials and was pilot-tested by three gastroenterologists to ensure relevance and clarity. No modification were required after the pilot test.

Demographic items included canton of practice and years of professional experience (0–5, 6–10, 11–15, or >15 years). Other questions addressed the presence of waste-sorting and recycling initiatives, policies to reduce single-use devices, guidelines to minimize waste generation, sustainability considerations in procurement, adoption of electronic health records (EHRs), availability of telemedicine services, use of remote monitoring technologies, and initiatives to prevent burnout or promote work–life balance. Response options were “Yes,” “No,” or “I don’t know.” This third option was included because physicians may work in institutions without being fully aware of administrative sustainability policies. Due to small cell counts, work experience was aggregated into three categories (0–10, 11–15, and >15 years), and canton-level data were combined into seven regions as defined by the Swiss Federal Statistical Office [8]. All statistical analyses were conducted using Stata/IC 16.0 (StataCorp, College Station, TX, USA). We reported descriptive statistics for all variables in the main text and used Fisher’s exact test to compare categorical outcomes across regions, with statistical significance defined as p < 0.05. Given the exploratory design, no a priori hypotheses were formulated, and inferential testing was limited to Fisher’s exact test due to small cell counts and categorical data. Differences in policy implementation across regions are shown in Tables S2–S4 in the Supplementary Materials.

3. Results

3.1. Study Participants

A total of 161 gastroenterologists completed the survey, yielding a 34.8% response rate.

Table 1. Description of the study sample (N = 161).

Variable	N	%
Language in which survey was completed
German	91	56.5
French	37	23.0
Italian	33	20.5
Major region in which they practice
Région lémanique	17	10.6
Espace Mittelland	21	13.0
Norwestschweiz	10	6.2
Zürich	82	50.9
Ostschweiz	16	9.9
Zentralschweiz	12	7.5
Ticino	3	1.9
Work experience
Up to 10 years	65	40.4
Between 11 and 15 years	26	16.1
More than 15 years	70	43.5

shows that the majority of questionnaires (56.5%) were answered in German. With respect to professional experience, 70 respondents (43.5%) had more than 15 years in practice, and 65 (40.4%) reported up to 10 years of experience. Geographically, 82 participants (50.9%) practiced in the Zurich region, an overrepresentation that reflects the broader distribution of Swiss gastroenterologists and SGG-SSG members.

3.2. Environmental Sustainability Policies

In terms of environmental sustainability policies, Figure 1 shows that 45.3% of respondents reported active waste-sorting and recycling initiatives in their departments, while 32.3% indicated none. Policies to reduce single-use devices were in place for 23.0% of participants, absent for 51.5%, and unknown to 25.5%. Regarding procurement decisions, 49.1% of gastroenterology units incorporated sustainability criteria, 22.4% did not, and 28.6% were unsure. Finally, guidelines to minimize waste were said to be adopted by 27.9% of respondents, not adopted by 42.9%, and unknown to 29.2%, the highest proportion of unawareness among all environmental measures. Comparison across major regions revealed no significant differences in implementation of environmental policies (see Table S2 in the Supplementary Materials).

Notably, between 22.4% and 29.2% of respondents were unaware of their institution’s environmental policies across all four measures, suggesting limited communication of these initiatives to practicing clinicians.

3.3. Digitalization and Work-Life Balance Policies

Figure 2 illustrates the self-reported uptake of digital tools. 88.2% of respondents reported having an EHR system in place, 6.8% did not, and 5.0% were unsure. Telemedicine for gastroenterology consultations was reported as available by 29.8% of participants, and 13.0% reported having remote patient monitoring in place.

Workload and burnout-prevention initiatives were reported as present by 42.9% of respondents and as absent in 42.2%. Efforts to promote work–life balance were reported to be in place in 52.8% of units, absent in 27.9%, and unknown to 19.3%.

4. Discussion

This study represents the first systematic assessment of sustainability policies in Swiss gastroenterology practices. Despite Switzerland’s well-resourced healthcare system, fewer than half of respondents reported having basic waste-sorting initiatives, and fewer than one in four indicated the presence of policies to reduce single-use devices. These findings mirror those of the British Society of Gastroenterology’s Green Endoscopy consensus [2], which noted that even when practical measures, such as waste stream segregation or reusable accessory adoption, are known, implementation is often inconsistent due to knowledge gaps, financial disincentives, and institutional inertia. Similar challenges have been reported in a recent UK survey of the endoscopy workforce [9], in the European SAGES–EAES sustainability survey of surgical practice [10], and in international reviews and strategic plans [1], all of which highlight the gap between awareness of sustainable practices and their consistent implementation. In line with these findings, our results show that a substantial proportion of Swiss gastroenterologists remain unaware of their institution’s environmental policies, pointing to limited communication of such initiatives and underscoring ongoing knowledge gaps at the clinical level.

A recent global review further emphasizes that, although professional societies now offer comprehensive “green endoscopy” frameworks, real-world adoption frequently stalls at the planning stage [1].

In contrast, our data indicate stronger progress in procurement and digitalization. Nearly half of respondents indicated that sustainability criteria were considered in purchasing decisions, and almost all reported EHR adoption. This pattern is consistent with the Swiss Group for Sustainable Gastroenterology’s recommendations that digitalization can reduce paper use, streamline workflows, and lower travel-related emissions, particularly when telehealth replaces routine follow-up visits [6]. while telemedicine adoption remains voluntary. Yet, remote patient monitoring, another digital tool with clear sustainability benefits, is still underused, suggesting that infrastructure and training barriers limit the full environmental potential of eHealth solutions, a challenge also reported in large healthcare systems abroad [11].

Although no significant regional differences were found, Switzerland’s decentralized healthcare system may complicate the uniform adoption of environmental initiatives across cantons [7]. Implementation science literature identifies barriers spanning individual (knowledge, attitudes), institutional (budget, strategic priorities), infrastructural (facility readiness), and policy (regulatory, incentives) domains. Without leadership commitment at multiple levels, environmentally sustainable practices in healthcare are unlikely to be scaled or sustained [12,13,14].

The strengths of our study include targeting the entire population of Swiss gastroenterologists and achieving a relatively high response rate for a non-incentivized survey, thereby providing a broad overview of current practices. Furthermore, the geographic distribution reflects the concentration of SGG-SSG members, with half practicing in the Zürich region. This distribution is unlikely to bias the findings given the absence of significant regional differences in policy implementation shown in Table S2.

This study has several limitations. First, although the questionnaire was pilot-tested, it was not formally validated, which may affect the reliability of some measures. Second, the cross-sectional design restricts our ability to examine changes over time or the sequence in which sustainability practices are adopted. Third, a considerable proportion of respondents reported being unaware of institutional policies, which could reflect limited communication within hospitals or response bias, though our data cannot distinguish between these explanations. Future research could examine how sustainability initiatives are communicated to clinical staff, whether awareness influences practice behaviors, and whether physician knowledge predicts implementation success. Fourth, we did not collect demographic or practice-related information such as age, gender, or setting, which limits analysis of subgroup differences in policy awareness. Fifth, selection bias is possible, as physicians with a stronger interest in sustainability may have been more likely to participate, potentially inflating reported awareness and implementation. Sixth, we lacked institutional-level data, including hospital size, endoscopy volume, availability of sustainability personnel, and financial resources, which may explain variation in policy adoption. Seventh, the absence of qualitative insights into implementation experiences limits our ability to identify causal factors or design targeted interventions. Finally, the study did not assess how sustainability initiatives affect clinical outcomes, an important area for future research.

Future research should explore professional attitudes toward sustainability, identify organizational facilitators, and evaluate targeted strategies such as appointing dedicated sustainability leads, fostering partnerships with manufacturers for reusable device development, and embedding environmental criteria into accreditation standards. Moving forward, Swiss gastroenterology must shift from aspirational statements to systematic policy adoption. Achieving this will require coordinated action by professional societies, healthcare leaders, and policymakers to establish clear national standards, align incentives, and integrate sustainability into everyday clinical workflows.

5. Conclusions

This study shows that while Swiss GI endoscopy has made notable progress in digitalization and sustainable procurement, essential measures such as waste sorting and single-use device reduction remain uncommon. To address this, the Swiss Society of Gastroenterology should collaborate with the federal health authorities to develop national sustainability guidelines that set minimum standards for waste management, procurement, and reporting. The successful adoption of electronic health records illustrates that standardized practices can be implemented when supported by clear mandates; this model should guide the integration of sustainability metrics into digital platforms. Because many clinicians remain unaware of institutional policies, hospitals could appoint sustainability champions and establish regular communication protocols. Ultimately, only through coordinated action by professional societies, hospital administrators, and policymakers, including the establishment of national standards, the integration of sustainability criteria into accreditation processes, the provision of financial incentives for green practices, and the implementation of accountability mechanisms, can Swiss gastroenterology reduce its environmental footprint while maintaining clinical excellence.