Direct costs of care in germany for children and adolescents with diabetes mellitus in the early course after onset

BACKGROUND AND OBJECTIVE

Prospective population-based cost-of-illness study to evaluate diabetes mellitus (DM)-related direct costs in German pediatric DM care in the early course after onset (perspective: statutory health insurers).

PATIENTS AND METHODS

573 patients with DM <15 years of age were followed for up to 2 years after onset. DM-related hospitalization and ambulatory care, insulin and self-testing regimen were ascertained. Costs per patient-year were estimated (2000 prices). Using multivariate regression, associations between costs and families' socioeconomic status was evaluated.

RESULTS

Mean total costs per patient-year were 7,069 euro (interquartile range 5,414-8,127). Onset hospitalization accounted for the majority of costs (4,908 euro, 3,728-6,213). Within post-onset costs, most were attributable to blood glucose self measurement and hospitalization (36% and 32%). Costs were significantly higher in children from families with lower compared to highest educated parents and in children from non-German families (p <0.01).

CONCLUSIONS

Among the direct medical costs of childhood DM in the early course after onset, the greatest economic burden was due to hospitalization, in particular at onset. Blood glucose self measurement accounted for the majority of the post-onset costs. Costs were associated with the socio-economic status. It is recommended to evaluate the cost-effectiveness of outpatient programs targeting children from families with lower social status.

Cost-effectiveness analysis of different screening procedures for type 2 diabetes: the KORA Survey 2000

OBJECTIVE

To compare the cost-effectiveness of different type 2 diabetes screening strategies using population-based data (KORA Survey; Augsburg, Germany; subjects aged 55-74 years), including participation data.

RESEARCH DESIGN AND METHODS

The decision analytic model, which had a time horizon of 1 year, used the following screening strategies: fasting glucose testing, the oral glucose tolerance test (OGTT) following fasting glucose testing in impaired fasting glucose (IFG) (fasting glucose + OGTT), OGTT only, and OGTT if HbA(1c) was >5.6% (HbA(1c) + OGTT), all with or without first-step preselection (p). The main outcome measures were costs (in Euros), true-positive type 2 diabetic cases, incremental cost-effectiveness ratios (ICERs), third-party payers, and societal perspectives.

RESULTS

After dominated strategies were excluded, the OGTT and HbA(1c) + OGTT from the perspective of the statutory health insurance remained, as did fasting glucose + OGTT and HbA(1c) + OGTT from the societal perspective. OGTTs (4.90 per patient) yielded the lowest costs from the perspective of the statutory health insurance and fasting glucose + OGTT (10.85) from the societal perspective. HbA(1c) + OGTT was the most expensive (21.44 and 31.77) but also the most effective (54% detected cases). ICERs, compared with the next less effective strategies, were 771 from the statutory health insurance and 831 from the societal perspective. In the Monte Carlo analysis, dominance relations remained unchanged in 100 and 68% (statutory health insurance and societal perspective, respectively) of simulated populations.

CONCLUSIONS

The most effective screening strategy was HbA(1c) combined with OGTT because of high participation. However, costs were lower when screening with fasting glucose tests combined with OGTT or OGTT alone. The decision regarding which is the most favorable strategy depends on whether the goal is to identify a high number of cases or to incur lower costs at reasonable effectiveness.

Direct Costs of Pediatric Diabetes Care in Germany and Their Predictors

INTRODUCTION

Cost-of-illness study to evaluate diabetes-related direct costs for the care of diabetic children and adolescents in Germany from the perspective of the statutory health insurance.

MATERIAL AND METHODS

For all continuously treated patients < 20 years of age from 89 pediatric departments (n = 6437, 52 % male, mean age 12.5 [SD 3.8], diabetes duration 5.2 [3.3] years), diabetes-related hospitalization, ambulatory care, insulin management, glucose self measurement, and treatment with antihypertensive drugs in 2000 were ascertained, as well as metabolic control (HbA1c). Costs per patient-year were calculated in Euros (EUR) based on year 2000 prices. Using multivariate regression, the associations between costs and age, sex, diabetes duration, and metabolic control were evaluated.

RESULTS

Mean total costs per patient-year were EUR 2611 (interquartile range 1665 - 2807). Blood glucose self measurement, hospitalization, and insulin accounted for 37 %, 26 %, and 21 % of the costs, respectively, followed by ambulatory care (9 %), injection equipment and glucagon sets (7 %), and treatment with antihypertensive drugs (0.1 %). The total costs were significantly increased for higher age, longer diabetes duration, and higher HbA1c (p < 0.01). The costs for hospitalization were significantly associated with pubertal age (10 - 14 years) and poor metabolic control (HbA1c SDS > 5) (p < 0.001). Based on the present estimations, the total direct costs for the care of all diabetic subjects in Germany < 20 years would be EUR 66.8 (95 % CI 65.4 - 68.1) million in 2000.

DISCUSSION

Among the direct medical costs of childhood diabetes, the highest economic burden was due to glucose self measurement, hospitalization, and insulin. The costs were considerably higher in adolescents with poor metabolic control, especially the costs for hospitalization. Outpatient education programs in pediatric diabetes care, in particular targeting children with poor metabolic control, should be encouraged, including their evaluation with respect to cost and effectiveness.

High prevalence of undiagnosed diabetes mellitus in Southern Germany: target populations for efficient screening. The KORA survey 2000

AIMS/HYPOTHESIS

To estimate the prevalence of undiagnosed diabetes mellitus, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), and their relations with cardiovascular risk factors in the general population aged 55 to 74 years in Southern Germany.

METHODS

Oral glucose tolerance tests were carried out in a random sample of 1353 subjects aged 55 to 74 years participating in the KORA (Cooperative Health Research in the Region of Augsburg) Survey 2000. Prevalences of glucose tolerance categories (1999 WHO criteria) were adjusted for sample probabilities. The numbers needed to screen (NNTS) to identify one person with undiagnosed diabetes were estimated from age-adjusted logistic regression models.

RESULTS

Sample design-based prevalences of known and unknown diabetes, IGT, and IFG were 9.0%, 9.7%, 16.8%, 9.8% in men, and 7.9%, 6.9%, 16.0%, 4.5% in women, respectively. In both sexes, participants with undiagnosed diabetes had higher BMI, waist circumference, systolic blood pressure, triglycerides, uric acid, and lower HDL-cholesterol than normoglycaemic subjects. A combination of abdominal adiposity, hypertension, and parental diabetes in men resulted in a NNTS of 2.9 (95%CI: 2.0-4.6). In women, the combination of increased triglycerides, hypertension and parental diabetes history yielded a NNTS of 3.2 (95%CI: 2.2-5.1).

CONCLUSION/INTERPRETATION

About 40% of the population aged 55 to 74 years in the Augsburg region have disturbed glucose tolerance or diabetes. Half of the total cases with diabetes are undiagnosed. Cardiovascular risk factors worsen among glucose tolerance categories, indicating the need for screening and prevention. Screening for undiagnosed diabetes could be most efficient in individuals with abdominal adiposity (men), hypertriglyceridaemia (women), hypertension, and parental diabetes history.

Incidence and prevalence of childhood type 1 diabetes mellitus in Germany--model-based national estimates

Fitting a Poisson model to national data on the incidence of type 1 diabetes mellitus (T1DM) under 5 years (1993-95) and to age-specific incidence data from three different German regions (age groups 0-4, 5-9, 10-14, 15-19 years, 1988-1995), national age-specific incidences of T1DM in childhood were estimated. From these the age-standardized national incidence and prevalence were derived for age groups 0-15 and 0-19 years. In 1993-95 the age-standardized national incidences (95% CIs) in the age groups 0-14 and 0-19 years were 14.2 (12.9-15.5) and 17.0 (15.2-18.8) per 100,000 person-years, respectively. The respective national prevalences were 86.7 (83.4-90.0) and 140.2 (134.3-146.1) per 100,000 persons. These estimates of the national incidence and prevalence of T1DM for the mid-1990s were about twofold higher than estimates from the former Eastern Germany in the late 1980s. This striking high frequency of T1DM in Germany has an important impact on clinical and economic aspects of diabetes care in childhood and adolescence.

Health-related quality of life in subjects with functional bowel disorders in Germany

OBJECTIVES

A low health-related quality of life (HRQL) was reported in subjects with functional bowel disorders (FBD). The aim of the present study was to investigate the association between HRQL and FBD within a three year period in a population-based sample in Germany.

DESIGN

A panel-study based on an age- and sex-stratified random sample of subjects aged 21 - 80 years in Düsseldorf, Germany (about 500,000 population).

METHODS

The presence of FBD, in particular lower abdominal pain, was assessed annually over a three year period using a postal questionnaire. With the last questionning, HRQL was assessed using the Medical Outcome Short Form (SF36) in 305 subjects responding all three questionnaires (49 % males, mean age (SD) 54 (15) years). HRQL was analyzed based on SF36 scores and component summary scores, adjusted for age and sex using regression models.

RESULTS

Twenty-eight percent (28 %; 95 % confidence interval 23 - 33 %) of the respondents reported FBD in at least one year of the study period. HRQL was significantly lower in study subjects with FBD in all scores compared to subjects without any FBD during observation time and compared to the German general population. No significant differences between subjects with persistent and those with intermittent FBD could be evaluated.

CONCLUSIONS

Subjects with FBD within a three-year period had impaired HRQL compared to subjects without FBD and the general population in Germany. HRQL seemed to be less impaired than in subjects with IBS from the UK and the US.

Clinical characteristics and predictors of severe ketoacidosis at onset of type 1 diabetes mellitus in children in a North Rhine-Westphalian region, Germany

Diabetic ketoacidosis is the most serious complication at the onset of type 1 diabetes mellitus (DM). In Germany, population-based data on its occurrence at DM onset are not yet available. In a population-based study in a North Rhine-Westphalian region, Germany, during 1993-95, data on the clinical presentation at type 1 DM onset were obtained from hospital records for 262 patients under 15 years of age (81% of eligible patients). Information on social status was obtained from 148 families by a standardized questionnaire. The most frequently reported symptoms were polyuria (93.9%), fatigue (64.2%) and weight loss (59.4%). Mean duration of symptoms was 3.5 weeks. At diagnosis 18.3% of the children presented impaired consciousness and 3.5% coma. Mean glucose level was 25.1 mmol/l. Severe ketoacidosis (pH < or = 7.2) was present in 16.0% of the children. Metabolic derangement was more severe in children under 5 years. Low social status was significantly associated with increased risk of severe ketoacidosis (OR = 3.54, 95% CI: 1.10-11.35). Frequency of ketoacidosis at DM onset needs to be reduced through increased public and medical awareness of the presenting characteristics of childhood DM.

Undiagnosed diabetes mellitus among patients with prior myocardial infarction

OBJECTIVE

To determine the prevalence of undiagnosed diabetic subjects in a group of long-term myocardial infarction (MI) survivors and to investigate their cardiovascular risk factors and medical care.

METHODS

Glucose tolerance (OGTT WHO 1985), cardiovascular risk factors (blood pressure, lipids, urinary albumin), and primary medical care during the previous year were assessed among 244 patients without previously known diabetes (mean age +/- SD: 70.5 +/- 6.9 yrs; 75% males; time since incident infarction: 6.5 years (median), inter-quartile range: 4-9 years) from the population-based MONICA myocardial infarction registry in Augsburg (Germany).

RESULTS

Proportion of undiagnosed diabetes among MI registry patients was 29/244, 12% (95%CI: 8-17%); impaired glucose tolerance was found in 27% (22-34%). Using fasting glucose according to ADA 1997 criteria, 11% (7-16%) had diabetes and 17% (12-22%) impaired fasting glucose. MI registry patients with newly detected diabetes (WHO or ADA) showed a more adverse risk factor profile (higher triglycerides, lower HDL-cholesterol, increased urinary albumin) than subjects with normal glucose tolerance after controlling for possible confounders (age, sex, time since MI, antihypertensive and lipid-lowering medication). No significant differences were observed for self-reported medical care during the previous year among diabetic compared to non-diabetic subjects (number of physician visits and basic investigations).

CONCLUSIONS

There was a high prevalence of undiagnosed diabetes mellitus among the selected elderly long-term MI survivors. Because mortality rate after MI has been previously shown to be increased in diabetic patients, screening for glucose intolerance appears to be as essential as for standard cardiovascular risk factors.

Prevalence of functional bowel disorders and related health care seeking: a population-based study

OBJECTIVES

There are few population-based studies on prevalence of functional bowel disorders (FBD) and related health care seeking. The aim of the present study was to evaluate the prevalence of FBD in a population-based sample and to assess FBD-related health care seeking and medication in Germany.

MATERIAL

Cross-sectional study, based on an age- and sex-stratified random sample of 2,400 subjects aged 21-80 years in Düsseldorf, Germany (about 500,000 population). Assessment was performed using a postal written questionnaire.

METHODS

Prevalence of gastrointestinal pain or discomfort in the past 12 months was assessed, in particular, lower abdominal pain and irritable bowel syndrome (IBS). Furthermore, health care seeking and medication (prescribed and over-the-counter) due to FBD was assessed. Multiple logistic regression (survey estimated) was performed to evaluate associations of FBD with age, sex, and the socioeconomic status (SES).

RESULTS

1,281 subjects (53.4 %) were analyzed. Standardized prevalences were 22.6 % (95 %-CI: 20.3 - 25.1 %) for lower abdominal pain and 12.5 % (10.7-14.5 %) for IBS. Both lower abdominal pain and IBS were significantly less frequent in the older population compared to younger subjects. No significant differences were found for gender and SES. Among subjects with lower abdominal pain and IBS, 55.1 % and 49.3 % reported health care seeking due to their GI disorders, and 63.9 % and 56.2 % reported use of medication, respectively.

CONCLUSIONS

A high prevalence of functional bowel disorders was found in this population-based study in Germany. Only about half of the subjects reported health care seeking due to their bowel disorders. Self-medication with over-the-counter agents was frequently performed.

Hospitalization among diabetic children and adolescents and non-diabetic control subjects: a prospective population-based study

AIM/HYPOTHESIS

Data comparing the hospitalization of diabetic paediatric patients with the non-diabetic population is scarce. We undertook a population-based incidence study to compare hospitalization in a cohort of Type I diabetic children and adolescents. in Germany, in the first course of treatment after diabetes onset, with hospitalization in non-diabetic control subjects matched for age, sex, and region.

METHODS

A total of 373 subjects with newly diagnosed diabetes (onset between 1 and under 15 (<15) years of age in 1996 and 1997; 54% male, mean age at diagnosis 7.6 +/- 3.8 years) and 783 non-diabetic control subjects matched for age, sex, and region were followed for 1 year on average. Hospital admissions and the length of stay (days) were assessed by written questionnaires. Incidence rates of hospitalization and the expected number of hospital days per person-year were estimated for both cohorts. Using Poisson regression, we estimated ratios of hospitalization incidence rates (IRRs) and of expected numbers of hospital days (DRRs) in the diabetic cohort compared to the non-diabetic cohort, adjusting for age, sex and social status.

RESULTS

Hospitalization incidence rates and hospital days, expressed per person-year (95%-CI). were 0.34 (0.29-0.39) and 2.36 (2.22-2.50) in the diabetic cohort and 0.07 (0.05-0.09) and 0.29 (0.26-0.33) in the non-diabetic cohort, respectively. Among diabetic subjects, both parameters were associated with higher age and female sex. IRR and DRR (95%-CI) were 4.7 (3.5-6.5) and 7.7 (6.7-8.9).

CONCLUSION/INTERPRETATION

In the first year after onset, children and adolescents with diabetes had a 4.7 times higher hospitalization risk and spent 7.7 times more days in hospital than non-diabetic subjects. The ratios were smaller than those in Finland and Denmark in the 1980s, most likely due to differences between health care systems and time trends.

Low fecal elastase-1 in type I diabetes mellitus

BACKGROUND

Previous studies suggested impaired pancreatic exocrine function in type I diabetes patients, but have been limited by small or highly selected samples. Fecal elastase-1 has facilitated evaluation of pancreatic dysfunction in population-based studies.

METHODS

112 type I diabetic patients (age +/- SD: 37 +/- 11 years; 47 % males; diabetes duration: 12.5 +/- 10.5 years) were consecutively selected from main regional diabetes centers in Essen, West-Germany. 116 non-diabetic control subjects, similar with respect to age and sex, were recruited from the same geographical region. Elastase-1 measurement was performed centrally by ELISA (ScheboTech, Germany).

RESULTS

Elastase-1 concentrations in type I diabetic patients were significantly lower than in control subjects (median; inter-quartile range: diabetic patients: 227, 98-386 microgram/g stool; non-diabetic subjects: 544, 377-702 microgram/g stool) (p < 0.01). Elastase-1 < 100 microgram/g stool (E1 < 100) was found in 25.9 % of diabetic and 5.2 % of non-diabetic subjects, yielding an age-sex-adjusted prevalence Odds ratio (POR; 95 % CI) for diabetes and E1 < 100 of 6.9 (2.8-19.6). After adjusting for potential confounders (history of gastrointestinal diseases, smoking, alcohol consumption) the strong association remained (POR: 6.7; 2.7-19.2). Among patients with diabetes, E1 < 100 was associated with quality of glycemic control (HbA1c, change per 1 %: POR 1.5; 1.1-2.0), diabetes duration (per year: POR 1.1; 1.03-1.2), and age at diabetes onset (per age year: POR 1.1; 1.02-1.1). No association was found with history of gastrointestinal diseases, smoking, or alcohol consumption (current, life-time).

CONCLUSIONS

Fecal elastase-1 concentrations were lower in type I diabetes patients compared to control subjects, indicating impaired pancreatic exocrine function. Low elastase-1 was associated with poor metabolic control and longer diabetes duration.

Low faecal elastase 1 concentrations in type 2 diabetes mellitus

BACKGROUND

Previous studies have suggested an association between impaired pancreatic exocrine function and diabetes, but the evidence is weak because the invasive nature of the tests used to define exocrine function has led to small studies on selected patients. The availability of faecal elastase 1 as a non-invasive test has aided the detection of impaired exocrine function in population studies. We describe the association between levels of faecal elastase 1 and Type 2 diabetes.

METHODS

544 Type 2 diabetic patients (age: 63 +/- 8 years) were randomly selected from local diabetes registers in Cambridgeshire, UK and individually matched for age, sex and practice to 544 controls in whom diabetes was excluded by HbA1c measurement.

RESULTS

Faecal elastase 1 concentrations were significantly lower in cases than controls (median: cases 308 microg/g; controls 418 microg/g; P < 0.01). Low levels of faecal elastase 1 (< 100 microg/g) were found in 11.9% of cases and 3.7% of controls (age-sex-adjusted odds ratio; 95% CI: 3.6; 2.2-6.2). After adjustment for potential confounding factors, the OR was 4.5 (2.6-8.3). Among patients with diabetes, poor glycaemic control (HbA1c > or = 7%) was associated with a higher risk of low elastase 1 level (OR 5.6; 1.5-37). No significant association was found with diabetes duration, peripheral neuropathy, alcohol intake, or prior gastrointestinal diseases.

CONCLUSIONS

Faecal elastase 1 concentrations are lower in Type 2 diabetic patients than in non-diabetic controls, suggesting the co-existence of diabetes and impaired pancreatic exocrine function. Among the diabetic patients, the risk of having low elastase 1 levels was associated with glycaemic control.

Hospitalization among diabetic children and adolescents and the general population in Germany. German Working Group for Pediatric Diabetology

OBJECTIVE

To compare hospitalization in a multicenter-based cohort of diabetic children and adolescents (aged 1-19 years) in Germany with that of the general population.

RESEARCH DESIGN AND METHODS

Based on standardized documentation, hospital stays after manifestation were ascertained in diabetic subjects 1-19 years of age in 1997. Hospitalization data in the general German population were derived from official statistics. Incidence rates and numbers of hospital days were estimated. Ratios of hospitalization incidences and numbers of hospital days between the diabetic and the general population were calculated. Costs for hospital care in the German diabetic population in 1997 were determined.

RESULTS

A total of 5,874 patients came from 61 pediatric centers (52% male, age [mean +/- SD] 12.2 +/- 4.3 years, diabetes duration 4.6 +/- 4.4 years). Hospitalization incidence rates and hospital days per person-year (95% CI) were 0.27 (0.25-0.29) and 1.80 (1.75-1.84) in the diabetic population and 0.0948 (0.0946-0.0949) and 0.6416 (0.6412-0.6420) in the general population. The standardized ratio of hospital incidences was 3.1 (2.9-3.2), and the ratio of numbers of hospital days was 2.8 (2.7-2.9). Costs for hospital care after manifestation were estimated to be $506 (U.S. dollars) per person-year and $12.4 million in the whole German diabetic population aged 1-19 years in 1997; including hospital stays at diabetes onset, total annual costs were $24 million ($970 per person-year).

CONCLUSIONS

Diabetic children and adolescents in Germany had an approximately three times higher hospitalization risk and three times more hospital days than the age-matched general population. Including hospitalization at diabetes onset, the annual costs of hospital care for the German diabetic population aged 1-19 years amounted to approximately 1% of all costs for hospital care in this age-group. Thus, costs were largely overproportional (diabetes prevalence 0.1%).

Incidence of blindness in relation to diabetes. A population-based study

OBJECTIVE

A reduction of diabetes-related blindness was declared a primary objective for Europe (St. Vincent Declaration). We collected data about incidence rates of blindness in the diabetic population compared with the nondiabetic population. Up to now, such data are scarce-even worldwide.

RESEARCH DESIGN AND METHODS

A complete list of newly registered blindness allowance recipients was drawn up in the district of Württemberg-Hohenzollern, Germany, between 1990 and 1993. From these data, we estimated age-specific and standardized incidence rates of blindness in the entire, the diabetic, and the nondiabetic population, as well as relative and attributable risks due to diabetes.

RESULTS

There were 2,714 people meeting the inclusion criteria; 1,823 (67.2%) were female and 781 (28.8%) had diabetes. In 318 subjects, diabetes was likely to be the only cause of blindness; in 192 subjects, it was one of several contributory causes. Age of women was 73.9 +/- 19.4 years (mean +/- SD) and of men 63.3 +/- 25.5 years. Results standardized to the (West) German population are as follows: incidence rates (per 100,000 person-years): total population: 13.5; diabetic population: 60.6; nondiabetic population: 11.6; relative risk: 5.2; attributable risk among exposed: 0.81; and population attributable risk: 0.14. The relative risks decreased considerably with increasing age. When the study is repeated to monitor the St. Vincent targets, a reduction in the incidence rate of blindness in the diabetic population by 17% will be detected with 95% power.

CONCLUSIONS

Great relative and attributable risks, especially in younger age-groups, indicate the need for increased attention to preventive measures for microvascular complications.

Blindness due to diabetes: population-based age- and sex-specific incidence rates

Reducing the incidence of diabetic retinopathy and blindness was declared one of the main objectives in St Vincent. To date, hardly any valid data are available on the age- and sex-specific incidence of diabetes-related blindness. They are necessary, however, to evaluate intervention activities. Therefore, we used a population-based registry of blindness to calculate incidence of blindness due to diabetes. In one German district (Rhineland) we obtained complete lists of cases of blindness newly registered in 1990 and 1991 and coded as blind due to diabetes (n = 589). We estimated age-specific incidence rates in the entire as well as in the diabetic population. Incidence rates of blindness due to diabetes (100,000(-1) * year(-1)), standardized to the West-German population, were 3.2 (CI 95%: 2.9;3.4) in the entire population and 60.5 (CI 95%: 45.7;75.4) in the diabetic population. Incidence rates in the diabetic population showed a peak between 20 and 40 years of age, probably due to complications of Type 1 diabetes. Incidence was higher in diabetic women than in diabetic men (p < 0.05 at ages > or =40 years). Repeating the study will detect a decrease in the incidence of blindness due to diabetes by one-third with over 99% power.

Diabetes as a predictor of mortality in a cohort of blind subjects

BACKGROUND

There is only a little information about survival in newly registered blind subjects.

METHODS

A closed cohort of blind subjects (n = 2680, 1803 of them women), newly registered between 1990 and 1993 in the district of Württemberg-Hohenzollern, Germany, was observed for up to 48 months. Mortality was compared to that of the general population. Predictors of mortality within that cohort were identified by Cox proportional hazards regression analysis.

RESULTS

Before 1 February 1994, 582 of the subjects had died. Diabetes had been diagnosed in 772 of the subjects, 226 of them died. The overall incidence rate of death was 12179 per 100,000 per year. The probability of survival after 47 months was 0.64 (95% confidence interval (CI): 0.59-0.70) in the non-diabetic, and 0.46 (95% CI: 0.37-0.55) in the diabetic subjects. Predictors of mortality in the regression model were age (risk ratio [RR] per year of age 1.047), sex (RR for men 1.247) and diabetes (RR when blindness was unrelated to diabetes: 1,448, RR when diabetes was the only cause of blindness: 2,253). Compared with the entire population, mortality was considerably increased in the blind cohort (comparative mortality figure [CMF] 4.79), particularly in individuals with diabetes (CMF = 6.55). The relative risks decreased with increasing age.

CONCLUSIONS

Overall mortality in this cohort was high, even higher than in previous studies on the mortality of the blind. Diabetes increased the risk of death. In addition, the cause of blindness in diabetic individuals was a major predictor of mortality.

[Evaluation of measures for improving patient management in diabetes]

In diabetes mellitus as a chronic disease the success of treatment depends largely on the patient's cooperation. Therefore, over the last ten years, a number of models for the improvement of diabetes care were developed in Germany. These models were described and evaluated in this study. Only measures focussed on structural and organizational features were included in the analysis. After identifying the 69 relevant methods, they were described in terms of structures, aims, target groups and results. In a second step, effectiveness, efficiency and generalizability of the models were analyzed. Some of the programs proved to be effective and should be implemented in the whole country. More attention should be paid to the prevention of complications. The strict separation between in-patient and out-patient care should be eliminated. Patients should be informed about results of quality monitoring. In many models, no appropriate evaluation was carried out. Therefore, this study emphasized the importance of a thorough evaluation of future models for the improvement of diabetes care. Instruments for evaluation should be determined already when the intervention is being planned.

[Epidemiology of blindness, especially in diabetes--overview of current studies]

The main targets of the St. Vincent declaration of 1989 and of the WHO programme Health for All 2000 are reduction of loss of sight and especially of blindness associated with diabetes. However, hardly any data on blindness are available that describe a basic situation and would be suitable as a starting point for planning interventions and assessing them from the viewpoints of efficacy and efficiency. Only few studies have been conducted so far with detailed population-related data on the incidence and relative risks of blindness, as well as the associated mortality. The article reviews these studies and presents investigations that are presently being conducted in our department in this regard. The results obtained so far point to an increased incidence of blindness in peoples with diabetes, high relative and attributable risks especially in the young and middle-aged, and increased mortality rates subsequent to blindness, compared to the total population.