The effect of gender-specific invitation letters on utilization of colorectal cancer screening.

BACKGROUND AND AIM: Colorectal cancer (CRC) screening can effectively reduce cancer-associated mortality. In Germany, individuals over the age of 50 or 55 have access to CRC screening services. However, utilization rates are persistently low, particular in the male population. This observational study investigates the effect of standard versus gender-specific invitation letters on utilization of CRC screening services. METHODS: We analyzed utilization rates of individuals who were insured by a large health insurance fund in Bavaria, Germany. Persons who became eligible for CRC screening received a standard (2013-2014) or a gender-specific invitation letter (2015-2016). We compared utilization rates within 6 months after receipt of the invitation letter using billing codes of the health insurance fund. RESULTS: Invitation letters were sent to 49 535 individuals, of which 48.8 % were gender-specific. The overall utilization rate did not differ between recipients of the standard versus gender-specific invitation letter (11.6 % vs 11.1 %; RR: 0.97 [0.92-1.02], p = 0.19). However, uptake of screening colonoscopy was significantly higher among recipients of gender-specific invitations (2.9 % vs 3.5 %; RR: 1.21 [1.04-1.39], p = 0.01), whereas utilization of fecal occult blood tests declined (10.4 % vs 9.7 %; RR: 0.93 [0.88-0.99], p = 0.016). CONCLUSIONS: Gender-specific design of invitation letters can modify the patients' preference for specific CRC screening services and increase the acceptance of screening colonoscopy.

Invitation letters increase participation in colorectal cancer screening - results from an observational study.

Background and Aim Participation rates in the German colorectal cancer screening program are low. Starting in 2013, a large health insurance plan in Bavaria, Germany, is sending an additional invitation letter to insured individuals when they turn 50 or 55 years and become eligible for participation in the program. The letter provides detailed information on colorectal cancer screening. We assessed the impact of the invitation letter on utilization rates. Methods Insurance claims data of a total of 48 343 individuals who had turned 50 or 55 years between 2012 to 2014 were reviewed for utilization rates of screening colonoscopy and fecal blood tests. Utilization rates 1 year prior (2012) and 2 years after introduction of the invitation letter (2013 and 2014) were compared. Furthermore, providers of colorectal cancer screening were determined. Results Within 6 months after turning 50 or 55 years, 8.8 - 10.2 % of all insured individuals participated in colorectal cancer screening, with the majority being females. After the introduction of the invitation letter, a moderate increase in participation rates could be observed (increase to 109 % [RR 101.7 - 117.3 %, p = 0.02] in 2014). The uptake rate of screening colonoscopy was significantly higher in recipients of the letter (increase to 138.4 % [RR 110.4 - 173.8 %, p = 0.0043] in 2013 and to 149 % [RR 119.5 - 186.3 %, p = 0.0003] in 2014). Furthermore, a significantly higher proportion of general practitioners and gastroenterologists provided colorectal cancer screening in individuals receiving the invitation letter. Conclusions Introduction of an invitation letter can improve participation rates for colorectal cancer screening.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group.

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. METHODS: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. RESULTS: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. CONCLUSIONS: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Determining scope position during colonoscopy without use of ionizing radiation or magnetic imaging: the enhanced mapping ability of the NeoGuide Endoscopy System.

BACKGROUND: Knowledge of the position and shape of the endoscope could overcome many challenges of performing colonoscopy, e.g., loop formation. A novel computer-assisted colonoscope (NeoGuide Endoscopy System) delivers a real-time, three-dimensional map of the tip position and insertion tube shape in addition to the video image of the colon lumen. The aim of this study is to evaluate the mapping capabilities of the NeoGuide Endoscopy System in terms of colonic looping, insertion depth, tip position, and tip angle formation. METHODS: Ten endoscopists with various levels of experience were each shown 70 map images generated by the NeoGuide endoscopy system in a benchtop anatomical colon model. First endoscopists were asked to determine the tip angle based on the map image and the system's corresponding tip positioning aid (20 images). In the second part they had to identify the scope-tip position in the colon model (40 images). In the third part ten images were presented for identification of colonic loops. RESULTS: The tip angle was correctly identified in 99% (198/200) of images. Using only the map images the scope position was accurately determined in 87.5% (350/400). Identification of colonic looping of the scope was appropriate in 99% (99/100). Overall accuracy was 92.4%, and overall positive predictive value was 94.9%. CONCLUSION: Three-dimensional map images generated by the NeoGuide endoscopy system provide accurate information regarding tip position, insertion tube position, and colonic looping.

Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group.

Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires. Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites. Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received. Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively. Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing. Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

[Colon cancer screening in times of COVID-19]. / Darmkrebsvorsorge zu COVID­19­Zeiten.

The coronavirus pandemic has a lasting influence on the healthcare landscape particularly in Germany, even though this crisis has currently been effectively managed. Patient visits to primary care physicians as well as to specialists and admissions to hospitals have been significantly reduced with the possible effect of reduced early diagnosis and treatment. Colon cancer screening has been on the increase for many years but now in the pandemic numerous screening colonoscopies have been cancelled. Now more than ever in the declining phase of the pandemic the public should be aware that the nationwide invitation procedure for colon cancer screening should be taken seriously because prevention of colon cancer also saves numerous lives.

Second-generation argon plasma coagulation: two-center experience with 600 patients.

BACKGROUND AND AIM: Second-generation argon plasma coagulation (APC; APC 2/VIO APC) with its modes 'forced', 'pulsed', and 'precise' is a further development of the ICC/APC 300 system (first-generation APC). Until now, only limited data has existed on the use of APC 2. METHODS: Fundamental data on the characteristics of the various APC 2 modes and clinical data from more than 600 patients treated in two high-volume endoscopy centers were analyzed. On the basis of these data, recommendations for the use of APC in daily gastroenterological practice were made. RESULTS: In comparison to the ICC system, second-generation APC offers a broadened bandwidth of settings including different APC modes and a range of power settings from 1 to 120 W. Using the various modes of APC 2 in a variety of gastrointestinal diseases, minor complications were observed in 9-21% of patients. Major complications occurred in 1-7% of patients. CONCLUSIONS: In a two-center experience treating a large group of patients with a wide variety of gastrointestinal conditions, the different APC 2 modes appeared to be safe and effective. Certain preventive measures before and during clinical application are recommended in order to avoid complications.

Invitation to Screening Colonoscopy in the Population at Familial Risk for Colorectal Cancer.

BACKGROUND: Screening colonoscopy can lower the incidence of colorectal cancer (CRC), yet participation rates are low even in groups at high risk. The goal of this study was to double the rate of participation in screening colonoscopy among persons at familial risk and then to determine the frequency of neoplasia in this risk group. METHODS: In a nationwide, cluster-randomized, multicenter study, first-degree relatives (FDR) of patients with CRC across Germany received written informational materials concerning the familial risk of CRC, along with an invitation to undergo colonoscopy. Participants in the intervention group were additionally counseled by nurses over the telephone. The primary endpoint of the study was colonoscopy uptake within 30 days. RESULTS: The participants' mean age was 50.8 years. The colonoscopy uptake rates were 99/125 (79%) in the intervention group and 97/136 (71%) in the control group (RR = 1.11; 95% confidence interval [0.97; 1.28]). A polypectomy was performed in 72 of 196 asymptomatic persons (37%). In 13 cases (7%), an advanced neoplasia was detected; two of these persons had colon cancer (stages T0 and T1). 42% of the participants expressed barriers against colonoscopy. 22 reported mild side effects; there were no serious side effects. CONCLUSION: Additional counseling by nurses over the telephone does not increase the participation rate. Approaching patients who have CRC is an opportunity to increase the participation of their first-degree relatives in screening colonoscopy. The frequency of neoplasia that was found in this study underscores the need to screen relatives even before they reach the usual age threshold for screening.

[MRI in gastrointestinal diseases]. / MRT in der Gastroenterologie.

Magnetic resonance imaging (MRI) has been called the most important development in medical diagnosis since the discovery of the X-ray more than 100 years ago. The effectiveness of MRI has been expanded to a variety of gastrointestinal disorders. The gastroenterologist's attention is currently focused on biliopancreatic and bowel diseases. Magnetic resonance cholangiopancreatography (MRCP) has become a competitive replacement for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in a variety of hepatobiliary and pancreatic diseases. MR enteroscopy has the potential to become the preferred method for evaluating the entire small bowel, while on the other hand virtual colonoscopy is far from being promoted as a tool for general screening purposes in suspected colon diseases. In summary, whether or not the survival of endoscopy is under debate, MRI could mark a historic turning point in gastroenterology. So, MRI hardware might interdisciplinarily be used by, e. g., radiologists and gastroenterologists.

[Percutaneous Endoscopic Gastrostomy (PEG)]. / Die perkutane endoskopische Gastrostomie (PEG).

Percutaneous endoscopic gastrostomy represents a standard for long-term enteral nutrition. In our detailed instructions indications and contra-indications of the method are listed and the correct procedure is explained step-by-step.

Illness experience before and after an initiative to identify, treat, and prevent Helicobacter pylori-related diseases in the workplace.

Objective outcome measures are needed to confirm the merits of large-scale health initiatives in the workplace. We used aggregate medical claims data to evaluate the illness experience of 5160 employees during the 2 years after versus the 2 years before an intervention intended to identify, treat, and prevent Helicobacter pylori-related illnesses. Across all participants, a 2.1-fold reduction (95% confidence interval 1.4-3.1) in ulcer-related illness episodes and a marginal 1.1-fold reduction (95% confidence interval 0.9-1.4) in episodes due to other stomach and duodenal diseases were achieved. Improvement in claims experience was most notable among 250 employees with ulcer findings on the screening examination. This H. pylori health initiative appears to have contributed to a cost-effective reduction in subsequent illness episodes due to ulcer and possibly due to other stomach and duodenal disease.

[Quality of hygiene in endoscope reprocessing--the fundamentals of indicator-assisted quality management in gastroenterology]. / Qualität der Hygiene bei der Endoskop-Aufbereitung--die Grundlage eines indikatorengestützten Qualitätsmanagements in der Gastroenterologie.

High level disinfection and infection control in reprocessing gastrointestinal endoscopes is a critical security factor for patients in gastrointestinal health care. National and international guidelines for an adequate high quality disinfection of gastrointestinal endoscopes have been developed aiming to obtain infection control. The German Medical Association has recently published recommendations on quality assurance in gastrointestinal endoscopy including standardised procedures for disinfection and infection control. A prospective study was carried out in a large urban area in both private practices and hospitals to identify and characterise flaws and limitations in disinfection of gastrointestinal endoscopes by measuring a set of indicators of the quality of structures, processes and outcomes. Moreover, the influence of information and continuous medical education on the quality of disinfection and infection control were to be evaluated. The bacterial contamination of endoscopes after reprocessing was measured as a relevant outcome quality indicator. The results revealed substantial flaws in cleaning and disinfection procedures in gastrointestinal endoscopy under routine clinical conditions. Overall, 49 and 39 percent of all (pre- and post-interventionally, resp.) checked endoscopes were contaminated by one or more bacteria. More often failures were discovered in the optic rinse system than in the cleaning/disinfection and the final rinse and drying process. A substantial failure rate was detected in gastrointestinal endoscope reprocessing under routine conditions according to the reprocessing procedure. Compared to manual and semi-automatic cleaning and disinfection, the full automatic cleaning and disinfection machines (RDG-E) showed the best results. Though their cleaning process remains improveable, it seems advisable to prefer RDG-E-machines for disinfection and infection control in gastrointestinal endoscopy. Continuous quality control of disinfection should be obtained by introducing regular microbiological examinations of the reprocessed endoscopes. Negative microbiological controls of the contamination of endoscopes are suitable quality indicators of a quality management system aiming to improve the quality of structures, processes and outcomes in gastroenterological health care.

[Optimized diabetes therapy in type 2 diabetics]. / Optimierte Diabetestherapie beim Typ-2-Diabetiker.

BACKGROUND: With the prevalence of type 2 diabetes mellitus having increased to approximately 8% during recent years and a further rise likely, type 2 diabetes will develop into a major health care problem in Europe. There are roughly 8 million diabetics in Germany, with another 4 million estimated unknown case. CLINICAL FEATURES: Diabetes is an accepted risk factor in the development of micro- and macrovascular complications. These complications generate enormous costs in our health care system. The optimal treatment of diabetic complications will minimize the cost to the health care system in the long run. Therefore, it is necessary to relay current therapeutic guidelines to medical personnel on a widespread basis. AIMS AND CONCLUSION: This publication summarizes current therapeutic options in glycemic control of type 2 diabetics which correspond to 95% of all diabetics. Recently, a national guideline has been developed by the "Arzneimittelkommission der deutschen Arzteschaft", the "Deutsche Diabetes- Gesellschaft", the "Fachkommission Diabetes Sachsen", the "Deutsche Gesellschaft für Innere Medizin e. V.", and the "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften". In this guideline, treatment recommendations are made according to the criteria of evidence-based medicine. It is the basis of this review. In addition, the significance of the modern option of functional insulin therapy (FIT) in the treatment of type 2 diabetes will be explained. In closing, innovative alternatives of applying insulin will be discussed. Unquestionably, all other risk factors such as hypertension and/or hyperlipidemia also have to be treated optimally. These risk factors will not be discussed in this publication.

[Dyspepsia and Helicobacter pylori infection in employees of a large industry. Results of a prospective BASF Helicobacter pylori prevention campaign]. / Dyspepsie und Helicobacter-pylori-Infektion bei Beschäftigten eines grossen Industrieunternehmens. Ergebnisse der prospektiven BASF-Helicobacter-pylori-Vorsorgeaktion.

BACKGROUND: The role of Helicobacter pylori (H. pylori) infection in dyspepsia is controversial. In the course of a health initiative within a large industrial corporation, we investigated the prevalence of both dyspepsia and positive H. pylori serology and the outcome of eradication therapy in symptomatic H. pylori positive employees. TEST PERSONS AND METHODS: H. pylori serology (IgG ELISA) was determined in 6,143 employees of BASF AG Ludwigshafen/Germany who were also asked to complete a standardized health history administered by a physician. Peptic ulcer disease (PUD) and dyspepsia subgroups were defined based on past medical history and symptom profiles using the criteria of Heading. Upper GI endoscopy, abdominal ultrasound and eradication therapy (Italian Triple Therapy) was recommended for symptomatic H. pylori positive individuals. The prognostic value of antibodies against CagA and VacA was evaluated in 37 and 39 employees with PUD and non-ulcer dyspepsia (NUD) confirmed by endoscopy, respectively. RESULTS: Of 6,143 employees, 1,255 (20.4%) were classified as dyspeptic, 492 (39.2%) of whom were H. pylori positive. The seroprevalence of H. pylori in asymptomatic employees was 35.8%. There were no significant differences in H. pylori seroprevalence among dyspepsia subgroups (reflux only, dysmotility only, reflux/dysmotility, ulcer-like and non-specific). However, individuals reporting severe dyspeptic symptoms were significantly more likely to be H. pylori positive (OR 2.09, CI 1.43-3.05). The seroprevalence of CagA and VacA was not significantly different among employees with NUD compared to referents or among employees with NUD compared to those with PUD. 330 (72%) of 458 employees with dyspepsia received eradication therapy, 128 persons refused therapy. Based on a 12-month follow-up of 402 individuals (300 of whom had received therapy), eradication success was 81.5% as judged by serology. Of the successfully treated employees, 33.2% reported a total absence and 42.8% reported a decrease in symptoms. Among the employees who refused therapy, the corresponding percentages were 37.3% and 16.7%, respectively. An increase in reflux complaints was not observed among treated employees. CONCLUSION: In a large active employee population, at most a very weak association was observed between the prevalence of H. pylori seropositivity and dyspepsia. Frequent and severe dyspeptic symptoms were associated with an increased rate of H. pylori seropositivity. The analysis of the virulence factors is not particularly helpful in discriminating PUD or NUD. Eradication of H. pylori infection leads to a decrease in dyspeptic symptoms after 12 months, but not more often to their complete absence compared to untreated individuals.