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Quality assurance activities in Germany have a long tradition of being oriented to structural quality. For many years quality assurance in hospitals was limited to pathologist's examinations and ward rounds. The separation of health care services into in-patient and out-patient sectors has made it difficult to introduce a total quality management system. After passage of a revised social security act on quality assurance, physicians' organizations started quality management projects, which for the most part are still in the pilot phase. Many institutions and commissions are trying to develop quality assurance activities focusing on formulating practice guidelines. However, in order to make quality management a truly vital part of health care in Germany, adequate computerized documentation systems will need to be introduced.

SUMMARY Screening colonoscopy is an effective means for early detection of colorectal carcinoma. Any exhaustive evaluation of the method must take further factors into account: epidemiology of colorectal adenomas and carcinomas in the target population, acceptance by the patients, structure, process, and outcome quality, and health economics. Methods: The internet-based colonoscopy database of the Bavarian Association of Statutory Health Insurance Physicians (ASHIP) for the year 2006 includes data on 86.05% of all outpatient colonoscopies performed in Bavarian ASHIP patients, or a total of 245 263 documented examinations. Results: The rate of participation in preventive colonoscopies was low (1.5%) and showed considerable geographical variation. The rate of detection of histologically confirmed colorectal neoplasia in symptom-free screened individuals was almost 26.0%. Some 1.3% of those screened had colorectal carcinoma. In 76.31% of the participants a completely clean gut was achieved. The incidence of bleeding, perforation, and cardiorespiratory complications was 0.22%, 0.03%, and 0.06%, respectively. Discussion: The complication rate of outpatient colonoscopy is on the order of tenths of a percent, while the process quality is high. The rate of detection of colorectal adenoma and carcinoma is high and the projected benefits for public health are considerable, but the rate of participation is too low. Dtsch Arztebl Int 2008; 105(24): 434-40 DOI: 10.3238/arztebl.2008.0434

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.

Quality Performance of Screening Colonoscopy in Germany Berndt R. Birkner, Jorn Knopnadel, Lutz Altenhofen, Gerhard Brenner, Wolf Schmiegel, Meinhard Classen Introduction: In Germany enrolees of the statuatory health insurances are entitled to undergo a screening colonoscopy beginning with the age of 56 since October 1st 2002. Quality assurance issues are important, because healthy people are exposed to a substantial risk of adverse events. Only experienced endoscopists are allowed to perform the screening colonoscopy after approval. The minimum standards for approval are a license as internist or gastroenterologist and profound experiences in at least 200 total colonoscopies and 50 polypectomies performed during the last 24 months. A documentation form has to be filled out by the endoscopist for each procedure to evaluate quality performance. The forms have to be sent to the Central Research Institute of Ambulatory Health Care in Germany for data processing. Methods: The data of 303,052 documented screening colonoscopies, performed from January 03 to December 03, were analyzed. Main focus here was on a set of performance measures e.g. completeness, video documentation, polypectomies and complications. Results: Colonoscopies reached the cecum and ileum in 71.8% and 23.9%, but the completeness was documented by video printing in 96.0%. Polyps were found in 28.3 % consisting of adenomas in 17.7%. Size was differentiated in !5, 5-10, 11-30 and O30 mm, detected in 14.2%, 9.5%, 3.8% and 0.8%, respectively. In total 1264 (0.4%) adverse events were documented. No case fatality was reported. 78,697 (26%) polypectomies were carried out. Thereafter 732 (0.9%) bleedings and 86 perforations were noted immediately, resulting in surgery in 2.7% and 91.5%, respectively. There is a strong increasing risk of complications depending on polyp size (OR 6.5 for 11-30 mm and OR 9.5 for O30 mm) even after control for age. In 446 (0.1%) cases cardio-pulmonary adverse events occurred, with 357 (80.0 %) in combination with sedation. Conclusion: Screening colonoscopy seems to be safe with a high completion rate. Even if only polypectomies are taken into account, the bleeding and perforation rates seem to be lower in all age strata than with curative colonoscopies. Notable is the perforation rate without polypectomy, which occurred in 1 out 10,000 screening colonoscopy. Predominantly, sedation was associated with cardio-pulmonary adverse events. W1090 Colonoscopic Features of Graft-Versus-Host Disease After Allogeneic Bone Marrow Transplantation Jeong-Sik Byeon, Suk-Kyun Yang, Seung-Jae Myung, Ji Yoon Cho, Kyu-Jong Kim, Seong Soo Hong, Gin Hyug Lee, Hwoon-Yong Jung, Weon-Seon Hong, Jin-Ho Kim, Young Il Min Background: Graft-versus-host disease (GVHD) is a frequent cause of morbidity and mortality after allogeneic bone marrow transplantation (BMT) and often involves gastrointestinal tract. However, the colonoscopic findings of GVHD have not been described clearly. The purpose of this study was to analyze the endoscopic features and biopsy results of colorectal GVHD. Methods: We analyzed the endoscopic features, biopsy results, and clinical findings of 21 patients (M:F Z 9:12, 18-50 years) who underwent colonoscopy or sigmoidoscopy due to unexplained gastrointestinal symptoms after allogeneic BMT and were diagnosed with colorectal GVHD by the histologic evaluation of biopsy specimen. Results: The mean duration from BMT to the diagnosis of GVHD was 2.4i/41.1 months. Twelve patients complained of abdominal pain, 18 diarrhea, and 3 hematochezia. Twelve patients underwent colonoscopy and 9 sigmoidoscopy. The endoscopic findings were divided into 3 categories, which were (a) hyperemic type showing multiple, variable shaped, hyperemic patches, (b) irregular shallow ulcer type showing several, small, irregular, shallow ulcers, and (c) round ulcer type showing several, about 1-3 cm sized, round ulcers. Among 12 patients who underwent colonoscopy, 4 showed hyperemic type, 4 irregular shallow ulcer type, and 4 round ulcer type. Among 9 patients who underwent sigmoidoscopy, 7 were hyperemic type, 1 round ulcer type, and 1 showed normal finding. There was no difference in the distribution of hyperemia, irregular shallow ulcer, and round ulcer according to the terminal ileal and colorectal segments including cecum, ascending/transverse/ descending/sigmoid colon, and rectum. Fifty three (91.4%) of 58 biopsy specimen from each segments demonstrated the typical histologic features of GVHD. All 45 biopsy specimen (100.0%) from 45 hyperemic or ulcer lesions and 8 biopsy specimen (61.5%) from 13 grossly normal segments revealed the histologic findings of GVHD. Thirteen patients demonstrated the skin involvement of GVHD, 13 the hepatic involvement, and 8 both the skin and hepatic involvement. Three patients had only terminal ileal or colorectal GVHD without the skin or hepatic involvement. Conclusion: Colonoscopic features of GVHD may be categorized into hyperemic, irregular shallow ulcer, and round ulcer type. Histologic evaluation of biopsy specimen not only from grossly abnormal lesions but also from normal segments may increase the diagnostic yield.