Setup of a Contamination Control Strategy Using the Hazard Analysis Critical Control Point (HACCP) Methodology

A Contamination Control Strategy (CCS) is a document that focuses on how to prevent contaminations with microorganisms, particles, and pyrogens within sterile and/or aseptic and preferably also in nonsterile manufacturing facilities. This document determines to what extent measures and controls in place are efficient in preventing contamination. In order to efficiently evaluate and control all potential hazards associated with sources of contamination within a CCS, the Hazard Analysis Critical Control Point (HACCP) methodology could be a useful tool to monitor all Critical Control Points (CCPs) related to various sources of contamination. This article describes a way to set up the CCS within a pharmaceutical sterile and aseptic manufacturing facility (GE HealthCare Pharmaceutical Diagnostics) by applying the HACCP methodology. In 2021, a global CCS procedure and a general HACCP template became effective for the GE HealthCare Pharmaceutical Diagnostics sites having sterile and/or aseptic manufacturing processes. This procedure guides the sites through the setup of the CCS by applying the HACCP methodology and helps each site to evaluate whether the CCS is still effective taking all (proactive and retrospective) data following the CCS into account. A summary of setting up a CCS using the HACCP methodology, specifically for the pharmaceutical company GE HealthCare Pharmaceutical Diagnostics Eindhoven site, is provided in this article. Use of the HACCP methodology enables a company to include proactive data within the CCS, making use of all identified sources of contamination, associated hazards, and/or control measures and CCPs. The constructed CCS allows the manufacturer to identify whether all included sources of contamination are under control and, if not, which mitigatory actions need to be performed. All current states are reflected by a traffic light color to reflect the level of residual risk, thereby providing a simple and clear visual representation of the current contamination control and microbial state of the manufacturing site.

Prevalence of Colorectal Neoplasia 10 or More Years After a Negative Screening Colonoscopy in 120 000 Repeated Screening Colonoscopies

Importance

Screening colonoscopy to prevent and early detect colorectal cancer is recommended to be repeated in 10-year intervals, which goes along with high demands of capacities and costs. Evidence of findings at screening colonoscopies conducted 10 or more years after a negative colonoscopy result is sparse, and it remains unclear whether screening colonoscopy intervals could possibly be prolonged.

Objective

To assess the prevalence of advanced colorectal neoplasms (ADNs) at least 10 years after a negative screening colonoscopy in a very large cohort of repeated screening colonoscopy participants in Germany.

Design, Setting, and Participants

This registry-based cross-sectional study on screening colonoscopy findings reported to the German screening colonoscopy registry during January 2013 to December 2019 included data on screening colonoscopies that were offered to the German general population 55 years or older since 2002; virtually all screening colonoscopies among individuals covered by Statutory Health Insurance (approximately 90% of eligible adults) are reported to the national registry. A total of 120 298 repeat screening colonoscopy participants 65 years or older were identified who had a previous negative screening colonoscopy at least 10 years prior. The findings were compared with all screening colonoscopies conducted at 65 years or older during the same period (1.25 million). The data were analyzed from March to July 2022.

Main Outcomes and Measures

Prevalence of colorectal cancers and ADNs (advanced adenomas and cancers).

Results

Of 120 298 participants, 72 349 (60.1%) were women. Prevalence of ADN was 3.6% and 5.2% among women and men 10 years after a negative screening colonoscopy and gradually increased to 4.9% and 6.6%, respectively, among those who had a negative colonoscopy 14 years or longer prior compared with 7.1% and 11.6% among all screening colonoscopies. Sex-specific and age-specific prevalence of ADNs at repeated colonoscopies conducted 10 or more years after a negative colonoscopy were consistently at least 40% lower among women than among men, lower at younger vs older ages, and much lower than among all screening colonoscopies (standardized prevalence ratios for cancers: 0.22-0.38 among women, 0.15-0.24 among men; standardized prevalence ratios for ADNs: 0.49-0.62 among women, 0.50-0.56 among men).

Conclusions and Relevance

The results of this cross-sectional study suggest that ADN prevalence at screening colonoscopies conducted 10 or more years after a negative screening colonoscopy is low. Extension of the currently recommended 10-year screening intervals may be warranted, especially for female and younger participants without gastrointestinal symptoms.

Database Supported Long-term Management of Chronic Diseases - Data from the German Disease Management Programmes as a Source for Continuing Medical Education

Disease Management Programmes (DMPs) have been introduced by German Federal Government in 2002 to improve long-term care for patients with specific chronic diseases. Digitisation has been a requirement to reliably document patient data in DMPs. This report presents data from six DMPs in the German federal state of North Rhine-Westphalia. It demonstrates that high level long-term quality of care can be achieved and maintained. But beyond clinical purposes DMP data are also an invaluable source to supply content in CME.

Frequency of antiplatelet therapy in coronary artery disease. Data from the disease management programme CAD

Background

Physicians always aim to improve their patients' health and consequently also improve community health. Continued medical education (CME) should be designed to support this goal and thus not only provide knowledge transfer, but also influence clinical decision-making and close performance gaps. However, the relative weight of CME in this process needs to be determined.

Purpose

Main purpose of the study was to analyse APT prescription rates and differences between subgroups of patients in a disease management programme (DMP) for coronary artery disease (CAD).

Methods

In a retrospective study we analysed prescription rates for APT in 254,932 CAD patients (male: 64.4%), treated in a total of 3,405 practices in 2019 in a DMP in the region of North Rhine, Germany, to delineate the potential for change by CME to further improve community health. Analyses were run for the whole study population stratified by sex as well as for subgroups of patients suffering from myocardial infarction / acute coronary syndrome (MI/ACS), or who have been treated with percutaneous coronary intervention (PCI) or bypass surgery. Subgroup differences were analysed in a logistic regression model.

Results

Patients mean age was 72.7±11.2 years (mean ± 1SD), mean duration of DMP participation was 7.2±4.7 years and mean cumulative number of DMP visits was 27±17. APT prescription rates were 85.0% in male and 78.8% in female CAD patients. In subgroups of male CAD patients APT prescription rates were between 89.7% and 92.8%, in the same subgroups of female CAD patients the corresponding rates were between 87.8% and 92.0%. Rates for a missing APT prescription per practice were between 0.0044% and 0.0062% for male and female CAD patients respectively. Rates for a missing APT prescription per practice and DMP visit were 0.0002% for both sexes. In a multivariate model significant positive predictors of APT prescription were male sex (OR=1.37, 95% CI: 1.34–1.40), age ≥76 yrs (OR=1.11, 95% CI: 1.08–1.14), participation in DMP ≥4 and <10 yrs (OR=1.19, 95% CI: 1.16–1.22), MI/ACS (OR=1.14, 95% CI: 1.08–1.20), PCI (OR=1.97, 95% CI: 1.88–2.06) and bypass surgery (OR=1.14, 95% CI: 1.08–1.21).

Conclusion

Our study demonstrates that a multifaceted intervention, like a DMP, can achieve high attainment rates for APT in CAD. To describe the benchmark for CME to further improve attainment rates, consideration of absolute numbers of eligible patients per practice or physician is probably more appropriate than expression of performance as percentage values. This is especially true if attainment rates show substantial variations between subgroups, if subgroups show substantial variation in size, if attainment rates are already in the order of magnitude of 80% or higher, and if there are disparities in the evidence base underlying treatment recommendations related to subgroups.

Funding Acknowledgement

Type of funding sources: None.

A pragmatic randomised controlled trial referring to a Personalised Self-management SUPport Programme (P-SUP) for persons enrolled in a disease management programme for type 2 diabetes mellitus and/or for coronary heart disease

BACKGROUND

Type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD) are two chronic diseases that cause a tremendous burden. To reduce this burden, several programmes for optimising the care for these diseases have been developed. In Germany, so-called disease management programmes (DMPs), which combine components of Disease Management and the Chronic Care Model, are applied. These DMPs have proven effective. Nevertheless, there are opportunities for improvement. Current DMPs rarely address self-management of the disease, make no use of peer support, and provide no special assistance for persons with low health literacy and/or low patient activation. The study protocol presented here is for the evaluation of a programme that addresses these possible shortcomings and can be combined with current German DMPs for T2DM and CHD. This programme consists of four components: 1) Meetings of peer support groups 2) Personalised telephone-based health coaching for patients with low literacy and/or low patient activation 3) Personalised patient feedback 4) A browser-based web portal METHODS: Study participants will be adults enrolled in a DMP for T2DM and/or CHD and living in North Rhine-Westphalia, a state of the Federal Republic of Germany. Study participants will be recruited with the assistance of their general practitioners by the end of June 2021. Evaluation will be performed as a pragmatic randomised controlled trial with one intervention group and one waiting control group. The intervention group will receive the intervention for 18 months. During this time, the waiting control group will continue with usual care and the usual measures of their DMPs. After 18 months, the waiting control group will also receive a shortened intervention. The primary outcome is number of hospital days. In addition, the effects on self-reported health-state, physical activity, nutrition, and eight different psychological variables will be investigated. Differences between values at month 18 and at the beginning will be compared to judge the effectiveness of the intervention.

DISCUSSION

If the intervention proves effective, it may be included into the DMPs for T2DM and CHD.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) in early 2019 under the number 00020592. This registry has been affiliated with the WHO Clinical Trials Network ( https://www.drks.de/drks_web/setLocale_EN.do ) since 2008. It is based on the WHO template, but contains some additional categories for which information has to be given ( https://www.drks.de/drks_web/navigate.do?navigationId=entryfields&messageDE=Beschreibung%20der%20Eingabefelder&messageEN=Description%20of%20entry%20fields ). A release and subsequent number assignment only take place when information for all categories has been given.

Gender differences in heart failure: results from disease-management-programs

Introduction

Among cardiovascular conditions, heart failure shows the highest rate of mortality. Despite increased awareness, striking differences in prognosis between men and women with HF still exist in ambulatory health care. In Germany, disease-management-programs (DMP) recognized this need and launched a structured treatment program especially for HF. Indicators assessing successful prevention and quality of care within DMP include among others, referral and prescription rates of prognosis-relevant medications (beta-blockers, AC-I, AT-1-antagonists).

Aim

To evaluate gender differences in heart failure therapy in the State of North-Rhine Westfalia, Germany.

Methods

Cross sectional analysis of the 2018 cohort (n=84.398, mean age 79±10.2 yrs., male 61.5%). Logistic regression analyses were run on referrals and prescription of beta-blockers, ACE-I and AT-1-antagonists (all, yes/no). Models tested for gender effects and included known covariates e.g. age and duration of participation (in yrs.) and comorbidities (diabetes, lipid disorder, hypertension, smoking, all yes/no).

Results

Logistic regression models indicated that gender significantly affected referral rates, OR 1.15, CI-95% 1.09–1.20 and OR 1.15, CI-95% 1.09–1.20, for referrals to hospitals and other physicians. Men received higher rates of referrals to other physicians and other institutions (26.5 vs. 14.2%) and (6.4 vs. 3.5%) than women. Prescription rates were also significantly associated with gender: OR 1.23, CI-95% 1.19–1.27, OR 1.36, CI-95% 1.29–1.43, and OR 0.79, CI-95% 0.72–0.87, for beta-blockers, ACE-I and AT-1-antagonists, respectively. Men received beta-blocker and ACE-I more often (33.8 vs. 4.4% and 28.6 and 8.1%); women had higher rates of AT-1- antagonist prescription (1.2 vs. 5.5%).

Conclusion

Although, as previously shown work indicated, differences decrease over time, marked gender differences in referral and prescription rates in heart failure still exist in ambulatory health care settings. These results indicate that secondary prevention in women with HF needs to improve.

Funding Acknowledgement

Type of funding source: None

Relationship between previous HbA1c value and subsequent severe hypoglycaemia in patients with coronary artery disease and type 2 diabetes. Data from the DMP in North Rhine, Germany

Background and purpose

Based on the documentation data of DMP type 2 diabetes in North Rhine from 2018, it was examined to what extent the HbA1c value from 2012 influenced the emergence of severe hypoglycaemia from 2013 in patients with coronary artery disease (CAD).

Methods

The predictors were determined in separate logistic regression models. The database was the last follow-up documentation of 2018. For all patients it was determined which HbA1c value was available in 2012 and whether severe hypoglycaemia has been documented for the first time since 2013.

Results

Within a group of a total of 98,950 patients, 2,520 new cases of severe hypoglycaemia have been documented since 2013. Treatment with insulin (odds ratio OR 7.00; 95-%-CI 5.80–8.44), HbA1c over 8.5% in 2012 (OR 1.66; 1.43–1.93), and the presence of diabetic complications (OR 1.37; 1.23–1.52) were the greatest risk factors, adjusted for age, gender, duration of DMP care and blood pressure. When the up to 70-year-old patients were analyzed separately, the two main predictors turned out to be somewhat weaker (insulin OR 5.40; 3.76–7.76; HbA1c >8.5% OR 1.61; 1.23–2, 11), on the other hand, they were somewhat more pronounced for patients over 70 years of age (insulin OR 7.58; 6.09–9.44; HbA1c >8.5% OR 1.72; 1.42–2.07). The influence of comorbidity was comparably high in both subgroups (≤70 years, OR 1.45; 1.16–1.79; >70 years OR 1.34; 1.19–1.51).

Conclusion

In patients with CAD and type 2 diabetes, the insulin prescription, a previously high HbA1c value and comorbidity are significant predictors for the later recurrence of severe hypoglycaemia; these influences are somewhat weaker in younger patients and somewhat more pronounced in older patients. A association between low HbA1c values and an increased risk of new onset of severe hypoglycaemia could not be demonstrated even in older patients with CAD and T2D.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Joint Establishment Disease Management Programs North Rhine

Prescription Rates for Antiplatelet Therapy (APT) in Coronary Artery Disease (CAD) - What Benchmark are We Aiming at in Continuing Medical Education (CME)?

Physicians always aim to improve their patients' health. CME should be designed not only to provide knowledge transfer, but also to influence clinical decision-making and to close performance gaps. In aretrospective study we analysed prescription rates for APT in 254,932 CAD patients (male: 64.4%), treated in atotal of 3,405 practices in 2019 in aDMP in the region of North Rhine, Germany. Analyses were run for the whole study population stratified by sex as well as for subgroups of patients suffering from myocardial infarction/acute coronary syndrome, or who have been treated with percutaneous coronary intervention or bypass surgery. Patients mean age was 72.7 ± 11.2 years (mean ± 1SD), mean duration of DMP participation was 7.2 ± 4.7 years, and mean cumulative number of DMP visits was 27 ± 17. APT prescription rates were 85.0% in male and 78.8% in female CAD patients. In subgroups of male CAD patients APT prescription rates were between 89.7% and 92.8%, in the same subgroups of female CAD patients the corresponding rates were between 87.8% and 92.0%. Rates for amissing APT prescription per practice were between .0044% and .0062% for male and female CAD patients, respectively. Rates for amissing APT prescription per practice and DMP visit were .0002% for both sexes. These results suggest that a DMP can achieve high attainment rates for APT in CAD. To further improve attainment rates, consideration of absolute numbers of eligible patients per practice or physician is probably more appropriate than expression of performance as percentage values. This is especially true if attainment rates show substantial variations between subgroups, if subgroups show substantial variation in size, if attainment rates are already in the magnitude of 80% or higher, and if there are disparities in the evidence base underlying treatment recommendations related to subgroups.

Secondary data in diabetes surveillance - co-operation projects and definition of references on the documented prevalence of diabetes

In addition to the Robert Koch Institute's health surveys, analyses of secondary data are essential to successfully developing a regular and comprehensive description of the progression of diabetes as part of the Robert Koch Institute's diabetes surveillance. Mainly, this is due to the large sample size and the fact that secondary data are routinely collected, which allows for highly stratified analyses in short time intervals. The fragmented availability of data means that various sources of secondary data are required in order to provide data for the indicators in the four fields of action for diabetes surveillance. Thus, a milestone in the project was to check the suitability of different data sources for their usability and to carry out analyses. Against this backdrop, co-operation projects were specifically funded in the context of diabetes surveillance. This article presents the results that were achieved in co-operation projects between 2016 and 2018 that focused on a range of topics: from evaluating the usability of secondary data to statistically modelling the development of epidemiological indices. Moreover, based on the data of the around 70 million people covered by statutory health insurance, an initial estimate was calculated for the documented prevalence of type 2 diabetes for the years 2010 and 2011. To comparably integrate these prevalences over the years in diabetes surveillance, a reference definition was established with external expertise.

Risk of Malignancy in Adenomas Detected During Screening Colonoscopy

BACKGROUND & AIMS

A higher incidence of proximal interval cancers after colonoscopy has been reported in several follow-up studies. One possible explanation for this might be that proximally located adenomas have greater malignant potential. The aim of the present study was to assess the risk of malignancy in proximal versus distal adenomas in patients included in a large screening colonoscopy database; adenoma shape and the patients' age and sex distribution were also analyzed.

METHODS

Data for 2007-2012 from the German National Screening Colonoscopy Registry, including 594,614 adenomas identified during 2,532,298 screening colonoscopies, were analyzed retrospectively. The main outcome measure was the rate of high-grade dysplasia (HGD) in adenomas, used as a surrogate marker for the risk of malignancy. Odds ratios (ORs) for the rate of HGD found in adenomas were analyzed in relation to patient- and adenoma-related factors using multivariate analysis.

RESULTS

HGD histology was noted in 20,873 adenomas (3.5%). Proximal adenoma locations were not associated with a higher HGD rate. The most significant risk factor for HGD was adenoma size (OR 10.36 ≥1 cm vs <1 cm), followed by patient age (OR 1.26 and 1.46 for age groups 65-74 and 75-84 vs 55-64 years) and sex (OR 1.15 male vs female). In comparison with flat adenomas as a reference lesion, sessile lesions had a similar HGD rate (OR 1.02) and pedunculated adenomas had a higher rate (OR 1.23). All associations were statistically significant (P ≤ .05).

CONCLUSIONS

In this large screening database, it was found that the rates of adenomas with HGD are similar in the proximal and distal colon. The presence of HGD as a risk marker alone does not explain higher rates of proximal interval colorectal cancer. We suggest that certain lesions (flat, serrated lesions) may be missed in the proximal colon and may acquire a more aggressive biology over time. A combination of endoscopy-related factors and biology may therefore account for higher rates of proximal versus distal interval colorectal cancer.

Selecting and defining indicators for diabetes surveillance in Germany

Mainly because of the large number of people affected and associated significant health policy implications, the Robert Koch Institute (RKI) is developing a public health surveillance system using diabetes as an example. In a first step to ensure long-term and comparable data collection and establish efficient surveillance structures, the RKI has defined a set of relevant indicators for diabetes surveillance. An extensive review of the available literature followed by a structured process of consensus provided the basis for a harmonised set of 30 core and 10 supplementary indicators. They correspond to the following four fields of activity: (1) reducing diabetes risk, (2) improving diabetes early detection and treatment, (3) reducing diabetes complications, (4) reducing the disease burden and overall costs of the disease. In future, in addition to the primary data provided by RKI health monitoring diabetes surveillance needs to also consider the results from secondary data sources. Currently, barriers to accessing this data remain, which will have to be overcome, and gaps in the data closed. The RKI intentends to continuously update this set of indicators and at some point apply it also to further chronic diseases with high public health relevance.

[Is There an Association Between DMP Enrollment and Disability Pension in Rehabilitants With Type 2 Diabetes?]

Efficacy of treatment of working-age patients with diabetes mellitus can be increased by rehabilitative measures. This treatment option is explicitly mentioned in the guidelines of the disease management program (DMP) for type 2 diabetes (T2D). With research data from the pension insurance fund, it is shown that for rehabilitation patients with T2D and DMP enrolment, the chance of disability pension is 23% lower than without DMP enrolment, irrespective of relevant covariates.

[Integration of secondary data into national diabetes surveillance : Background, aims and results of the secondary data workshop at the Robert Koch Institute]

Epidemiological data provide evidence that diabetes mellitus is a highly relevant public health issue in Germany as in many other countries. The Robert Koch Institute (RKI) is in the process of building a national diabetes surveillance system that is aimed at establishing indicator-based public health monitoring of diabetes population dynamics using primary and secondary data. The purpose of the workshop was to conduct an inventory of available secondary data sources and to discuss data contents, data access, data analysis examples in addition to the options for ongoing data use for diabetes surveillance.

[Integration of secondary data into national diabetes surveillance : Background, aims and results of the secondary data workshop at the Robert Koch Institute]

Epidemiological data provide evidence that diabetes mellitus is a highly relevant public health issue in Germany as in many other countries. The Robert Koch Institute (RKI) is in the process of building a national diabetes surveillance system that is aimed at establishing indicator-based public health monitoring of diabetes population dynamics using primary and secondary data. The purpose of the workshop was to conduct an inventory of available secondary data sources and to discuss data contents, data access, data analysis examples in addition to the options for ongoing data use for diabetes surveillance.

Abstract P4-12-10: Prognostic relevance of caspase 8 polymorphisms for breast cancer

Background: The minor allele of two caspase 8 polymorphisms, namely CASP8 -652 6N InsDel (rs3834129) and CASP8 Asp302His (rs1045485), were repeatedly associated with reduced breast cancer susceptibility. Contrarily, the presence of the -652 6N Del or the CASP8 302His variant was reported to be an unfavorable prognostic factor in colorectal cancer or neuroblastoma. However, prognostic relevance of these genetic variants for breast cancer is completely unknown and is therefore adressed by the current study.

Methods: Genotyping was performed by pyrosequencing. Caspase 8 mRNA expression was quantified by comparative RT-qPCR.

Results: We observed an allele-dose dependent association between CASP8 -652 6N InsDel and caspase 8 mRNA expression in breast cancer tissue, with homozygous deletion carriers showing lowest relative caspase 8 expression (p=0.0131). Intriguingly, the presence of the -652 6N Del or the 302His variant was shown to be a negative prognostic factor for breast cancer in terms of an allele-dose dependent influence on overall survival (OS, p=0.0018, p=0.0150, respectively). Moreover, both polymorphisms were independent predictors of OS after adjusting for co-variats (p=0.007, p=0.037, respectively). Prognostic relevance of both polymorphisms was independent from ER or Her2/Neu receptor status and a combined analysis of diplotypes revealed an additive influence on OS (p=0.0002).

Conclusion: This is the first report, showing negative and independent prognostic impact of the CASP8 -652 6N Del and the 302His variant for breast cancer. Our data provide rationale to further validate clinical utility of these polymorphisms for breast cancer and to extend this investigation to a broad scope of other malignancies.

Citation Format: Wimberger P, Jan Dominik K, Agnes B, Kurt S, Rainer C, Rainer K, Winfried S, Hagen B. Prognostic relevance of caspase 8 polymorphisms for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-12-10.

Iliac Artery Stenting — Clinical Experience with the Palmaz Stent, Wallstent, and Strecker Stent

A total of 82 iliac artery lesions (62 stenoses and 20 occlusions) were treated with 3 different types of endovascular metallic stents (12 lesions with the Palmaz stent, 36 with the Wallstent, and 34 with the Strecker stent). The complication rate was 12%. Occlusion of 2 Wallstents occurred 4 and 12 weeks after stent placement, respectively. Both stents were recanalized by local fibrinolysis. One Strecker stent occluded after 8 months. The observation period was 3 to 26 months (mean 9.7 months). The patency rate with secondary intervention (fibrinolysis) was 100% after 3 and 6 months, and 98% after 9 months. All 3 stent designs turned out to be effective in the treatment of complicated iliac artery occlusive disease.