Prescribing of valproate and oral antiepileptics for women of childbearing age and during pregnancy in Germany between 2010 and 2020

PURPOSE

To examine prescriptions of valproate and oral antiepileptic drugs (OAED) in Germany irrespective of the indication in women in general and particularly in women of childbearing age (13-49 years) and during pregnancy between 2010 and 2020, that is, before, during and after the implementation of the EU risk minimization measures (RMMs).

METHODS

Analysis of claims data.

STUDY POPULATION

all women continuously insured with the AOK health insurance fund in the respective observation year (2010-2020) and the previous year. OAED were identified by ATC code N03. Period of pregnancy was calculated based on birth information in claims data.

MAIN OUTCOMES MEASURES

(i) prevalent use of valproate/OAED: number of women with at least one prescription of valproate/OAED per year divided by all women of the study population (rate per 1000 women); (ii) percentage of OAED recipients with at least one valproate prescription during pregnancy (13-49 years) in the respective observation year.

RESULTS

Prevalence rate/1000 women for valproate use decreased by -31.33% across all age groups (2010-2014: -7.48%; 2014-2018: -16.47%; 2018-2020: -11,17%) with a strong reduction in women 13-49 years between 2014 and 2018 (-28.74%). The rate for OAED across all age groups rose from 33.43/1000 women in 2010 to 41.03/1000 (+22,73%). Valproate use during pregnancy of women with OAED declined from 1.29% in 2010 to 0.59% in 2020 (-54,26%) (2010-2014: -5.14%; 2014-2018: -42.31%; 2018-2020: -16.69%).

CONCLUSION

Even if, due to the descriptive nature of the study, no causal relationship can be postulated between the RMMs and the strong decrease in valproate prescriptions, our results are compatible with the hypothesis that the measures have improved drug therapy safety.

[Development and Internal Validation of Case Definitions for Prevalence Estimation of Microvascular Complications of Diabetes in Routine Data]

BACKGROUND

Surveillance of diabetes requires up-to-date information on the prevalence of diabetes and its complications over time. For this purpose, statutory health insurance (SHI) data is being increasingly used, as the data is available in a timely fashion and case numbers enable detailed estimates also of diabetes complications. The aim of the present study was the development and internal validation of case definitions for the prevalence estimation of diabetic retinopathy (DRP), diabetic polyneuropathy (DPN) and diabetic foot syndrome (DFS).

METHODS

Persons with diabetes differentiated by type 1, type 2, and other diabetes in an age- and sex-stratified sample of persons insured by Barmer SHI in 2018 (n=72,744) comprised the study popuation. Based on the central ICD codes for microvascular complications (DRP: H36.0; DPN: G63.2; DFS: E1X.74/.75), case definitions were developed including additional ICD codes for complications without direct diabetes reference. Subsequently, the case definitions were internally validated. For the validation, coding in the inpatient setting (m1S) or repeatedly in the outpatient setting (m2Q) as well as coding of specific procedures (EBM, OPS) and drug prescriptions or by relevant specialists were considered. Additionally, we analysed the documentation of the diagnoses in the previous years.

RESULTS

In 2018, the prevalence of the central ICD codes was 8.4% for DRP (H36.0), 18.9% for DPN (G63.2) and 13.4% for DFS (E1X.74/.75). After inclusion of additional ICD codes in the case definition, prevalence increased significantly for DRP (9.6%) and DPN (20.7%), and barely for DFS (13.5%). Internal validation confirmed the majority of diagnoses (DRP: 96.7%; DPN: 96.5% DFS: 95.8%) and m2Q represented the most relevant criterion. When up to four previous years were considered, prevalences were up to 30% higher for DPN and DFS and up to 64% higher for DRP.

CONCLUSION

The inclusion of additional ICD codes in the case definition of microvascular complications of diabetes appears meaningful, as this increases the sensitivity of the prevalence estimate. Internal validation suggests that the documented diagnoses are plausible. However, not all diagnoses are documented annually, leading to an underestimation of the prevalence using a cross-sectional study design of one year.

[Algorithm for the Classification of Type 1 and Type 2 Diabetes Mellitus for the Analysis of Routine Data]

BACKGROUND

Diabetes mellitus is a disease of high public health relevance. To estimate the temporal development of prevalence, routine data of statutory health insurances (SHI) are being increasingly used. However, these data are primarily collected for billing purposes and the case definition of specific diseases remains challenging. In this study, we present an algorithm for differentiation of diabetes types analyzing SHI routine data.

METHODS

The basis for the analysis was an age and sex-stratified random sample of persons of the Barmer SHI with a continuous insurance duration from 2010 to 2018 in the magnitude of 1% of the German population. Diabetes was defined in the reporting year 2018, as documentation of (1) a "confirmed" ICD diagnosis E10.- to E14.- in at least two quarters, (2) a "confirmed" ICD diagnosis E10.- to E14.- in one quarter with an additional prescription of an antidiabetic drug (ATC codes A10), or (3) an ICD diagnosis E10.- to E14.- in the inpatient sector, outpatient surgery, or work disability. Individuals were assigned to a diabetes type based on the specific ICD diagnosis E10.- to E14.- and prescribed medications, differentiated by insulin and other antidiabetics. Still unclear or conflicting constellations were assigned on the basis of the persons' age or the frequency and observation of the diagnosis documentation over more than one year. The participation in a disease management program was considered in a sensitivity analysis.

RESULTS

The prevalence of documented diabetes in the Barmer sample was 8.8% in 2018. Applying the algorithm, 98.5% of individuals with diabetes could be classified as having type 1 diabetes (5.5%), type 2 diabetes (92.6%), or another specific form of diabetes (0.43%). Thus, the prevalence was 0.48% for type 1 diabetes and 8.1% for type 2 diabetes in 2018.

CONCLUSION

The vast majority of people with diabetes can be classified by their diabetes type on the basis of just a few characteristics, such as diagnoses, drug prescription, and age. Further studies should assess the external validity by comparing the results with primary data. The algorithm enables the analysis of important epidemiological indicators and the frequency of comorbidities based on routine data differentiated by type 1 and type 2 diabetes, which should be considered in the surveillance of diabetes in the future.

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project

BACKGROUND

The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years.

METHODS

This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented.

RESULTS

A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest.

CONCLUSIONS

We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

[Operationalization of Quality Indicators with Routine Data Using the Example of the Evaluation of "Integrated Care Healthy Kinzigtal"]

AIM

As part of the 10-year evaluation of Gesundes Kinzigtal Integrated Care (IVGK, Innovation Fund Project 01VSF16002), a multidisciplinary group of experts agreed on 101 quality indicators (QI) to evaluate the quality of regionally integrated care with its focus on health and prevention programs. One criterion was that the selected QI should in principle be suitable for mapping using routine data. The aim of the study was to investigate how many and in what way the QI developed can actually be mapped in Germany with routine data and for what reasons operationalization was restricted or not possible.

MATERIAL AND METHODS

The operationalization of the QIs was performed using pseudonymized billing data of the AOK Baden-Württemberg from 2006 to 2015, which the Scientific Institute of the AOK (WIdO) provided to the evaluation team. All operationalized indicators were binary coded (criterion fulfilled yes/no). The diagnoses, procedures, or drugs named in the numerator and denominator definitions were operationalized using ICD-10 codes (inclusion and exclusion diagnoses), EBM codes, OPS codes, ATC codes. Indicator prevalences were examined over time to check for abnormalities as an indication of possible misscoding.

RESULTS

Ninety of the 101 indicators were operationalizable with routine data. Fourteen of the 90 indicators could only be operationalized with restrictions, as corresponding service codes were only introduced or existing codes were changed during the observation period. Seventy-six of 90 indicators could be operationalized without restrictions. In this context, 15 of these 76 indicators required pre- and follow-up periods, which meant that they could not be presented for all years. Eleven of 101 QIs could not be operationalized because EBM codes were only introduced after 2015 or were not recorded as individual services for all physician groups (e. g., spirometry and long-term ECG). Striking trends in indicator prevalences could be explained.

CONCLUSION

Routine data enable resource-saving quality monitoring. A change in the data basis during the observation period, for example through the introduction or deletion of billing codes, makes the longitudinal, routine data-based quality assessment more difficult, but enables further or new indicators to be operationalized for later periods.

Ten-Year Evaluation of the Population-Based Integrated Health Care System "Gesundes Kinzigtal"

BACKGROUND

The population-based integrated health care system called "Gesundes Kinzigtal" (Integrierte Versorgung Gesundes Kinzigtal, IVGK) was initiated more than 10 years ago in the Kinzig River Valley region, which is located in the Black Forest in the German state of Baden-Württemberg. IVGK is intended to optimize health care while maximizing cost-effectiveness. It consists of programs for promoting health and for enabling cooperation among service providers, as well as of a shared-savings contract that has enabled resources to be saved every year. The goal of the present study was to investigate trends in the quality of care provided by IVGK over the past ten years in comparison to conventional care.

METHODS

This is a non-randomized observational study with a control-group design (Kinzig River Valley versus 13 structurally comparable control regions), employing data collected by AOK, a large statutory health-insurance provider in Germany, over the period 2006-2015. Quality assessment was conducted with the aid of a set of indicators, developed by the authors, that was based exclusively on claims data. The statistical analysis of the trends in these indicators over time was conducted with preset criteria for the relevance of any observed changes, as well as preset mechanisms of controlling for confounding factors.

RESULTS

For 88 of the 101 evaluable indicators, no relevant difference was seen between the trend over time in the region of the intervention and the average trend in the control regions. Relevant differences in favor of the IVGK were observed for six indicators, and negatively divergent trends compared to the controls were observed for seven indicators. In the main summarizing statistical analysis, no positive or negative difference was found between the Kinzig River Valley and the other regions with respect to trends in the health-care indicators over time.

CONCLUSION

An evaluation based on 101 indicators derived from health-insurance data did not reveal any improvement of the quality of care by IVGK and the totality of the programs that were implemented under it. However, under the conditions of the shared-savings contract, no relevant diminution in the quality of care was observed over a period of 10 years either, compared with structurally similar control regions without an integrated care model.

[Development of an indicator set for the evaluation of the population-based integrated healthcare model 'Gesundes Kinzigtal' (Healthy Kinzigtal)]

INTRODUCTION

The project "INTEGRAL-10-year evaluation of the population-based integrated health care model 'Gesundes Kinzigtal' (Healthy Kinzigtal)" (ICM-GK) is funded by the Innovation Committee of the Federal Joint Committee (G-BA) (grant no. 01VSF16002). The evaluation is to be based on a set of indicators that can be captured in routine data. On the one hand, they can be used to assess ICM-GK programs that are program-specific and geared towards prevention and disease management. On the other hand, possible negative side effects of the ICM-GK, which is designed as a "shared savings contract", are to be examined by also observing care needs not covered by the ICM-GK contract. Since an indicator set for the evaluation of regional integrated care (IC) programs in Germany is not yet available, a suitable indicator set should be developed.

METHODS

RESULTS: The methodological framework links the OECD concept for quality assessment of health systems with Kessner's tracer methodology. Disease groups with a high prevalence ("common diseases"), prevention potential and potential for improvement through IC were selected as tracers. The literature search resulted in 239 QIs and the QI database search in 293 QIs, which were supplemented by 21 QIs from the focus groups. Out of a total of 553 QIs, 251 QIs remained after removal of duplicates and comparison with the data basis. This preliminary QI set was reduced to 101 QIs by consensus. In addition, 48 health reporting indicators were supplemented which serve to classify regional quality results. The final QI set maps the following 19 disease categories/tracers: heart failure (16 QIs), myocardial infarction (4 QIs), CHD (10 QIs), stroke (6 QIs), metabolic syndrome (7 QIs of which 5 were diabetes-related), COPD (6 QIs), asthma (3 QIs), chronic pain (5 QIs), back pain (3 QIs), geriatrics (7 QIs), dementia (8 QIs), osteoporosis (3 QIs), rheumatism (3 QIs), multiple sclerosis (2 QIs), depression (4 QIs), antibiotic therapy (3 QIs), drug safety (1 QI), child care (5 QIs), early detection/prevention (5 QIs). 33 of these QIs are dedicated to five tracers that are not explicitly ICM-GK programs. Most QIs assess aspects of the effectiveness of care for the chronically ill and measure process quality.

DISCUSSION

The set of indicators initially enables the quality assessment of regional, cross-indication care quality in the population-based integrated health care model 'Gesundes Kinzigtal' on the basis of routine data. Although the QI set focuses on effectiveness and process quality, it also includes QIs for preventive and acute care, coordination of care, patient orientation and safety, and outcomes. In contrast to other QI sets, both primary care and specialist health care and integrated, cross-sectoral and cross-professional care aspects have been considered. The benefits of the QI set for comparisons of regional quality and the evaluation of different IC programs remain to be tested.

CONCLUSION

On the basis of a broadly based research and participatory development process, a set of indicators has been developed that enables comprehensive evaluation of the regional quality of care of cross-indication, integrated care models focusing on common diseases. In order to be able to increasingly evaluate aspects of care coordination and patient orientation, health promotion as well as nursing, palliative and emergency care in the future, it would be helpful if routine data were collected or made accessible in these areas as well.

Performance of the adapted Diabetes Complications Severity Index translated to ICD-10

OBJECTIVES

To assess the performance of the adapted Diabetes Complications Severity Index (aDCSI) translated to International Classification of Diseases, Tenth Revision (ICD-10) in predicting hospitalizations, mortality, and healthcare-associated costs.

STUDY DESIGN

Retrospective closed cohort study based on secondary data analysis.

METHODS

We translated the aDCSI to ICD-10 and calculated aDCSI scores based on health insurance claims data. To assess predictive performance, we used multivariate regression models to calculate risk ratios (RRs) of hospitalizations and mortality and linear predictors of cost.

RESULTS

We analyzed a sample of 157,115 patients with diabetes mellitus. RRs of hospitalizations (total and cause specific) rose with increasing aDCSI scores. Predicting total hospitalizations over a 4-year period, unadjusted RRs were 1.22 for an aDCSI score of 1 (compared with a score of 0), 1.55 for a score of 2, 1.77 for a score of 3, 2.11 for a score of 4, and 2.72 for scores of 5 and higher. Cause-specific hospitalizations and mortality showed similar results. Costs clearly increased in each successive score category.

CONCLUSIONS

Our study supports the validity of the aDCSI as a severity measure for complications of diabetes, as it correlates to and predicts total and cause-specific hospitalizations, mortality, and costs. The aDCSI's performance in ICD-10-coded data is comparable with that in International Classification of Diseases, Ninth Revision-coded data.

Study protocol for a quasi-experimental claims-based study evaluating 10-year results of the population-based integrated healthcare model 'Gesundes Kinzigtal' (Healthy Kinzigtal): the INTEGRAL study

INTRODUCTION

Patients often experience interface problems when treated by different specialists and in different healthcare sectors. Integrated care concepts aim to reduce these problems. While most integrated healthcare models focus on individual diseases, the integrated care model 'Gesundes Kinzigtal' applies a population-based approach and addresses the full spectrum of morbidities for a population defined by area of residence-the Kinzigtal. A special feature of the model is the joint savings contract between the regional management company and the statutory health insurers. The INTEGRAL study aims at assessing the effectiveness of 'Gesundes Kinzigtal' under routine conditions in comparison to conventional care over a period of 10 years in order to understand the benefits but also the potential for (unintended) harms. METHODS AND ANALYSIS: Database Claims data from statutory health insurance funds 2005-2015. The evaluation consists of a quasi-experimental study, with Kinzigtal as intervention region, at least 10 further regions with a similar population and healthcare infrastructure as primary controls and an additional random sample of insurees from the federal state of Baden-Württemberg as secondary controls. Model-specific and 'non-specific' indicators adopted from the literature and enriched by focus group interviews will be used to evaluate the model's effectiveness and potential unintended consequences by analysing healthcare utilisation in general. Temporal trends per indicator in the intervention region will be compared with those in each control region. The overall variation in trends for the indicators across all regions provides information about the potential to modify an indicator due to local differences in the healthcare system.

ETHICS AND DISSEMINATION

Ethic Commission of the Faculty of Medicine, Philipps-University Marburg (ek_mr_geraedts_131117). Results will be discussed in workshops, submitted for publication in peer-review journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00012804.

[Severity assessment strategies based on administrative data using stroke as an example]

BACKGROUND AND OBJECTIVES

Information on disease severity is relevant for many studies with claims data in health service research, but only limited information is available in routine data. Stroke serves as an example to analyse whether the combination of different information in claims data can provide insight into the severity of a disease.

METHOD

As a first step, a literature search was conducted. Strategies to assess the severity of a disease by means of routine data were examined with regard to approval and applicability to German sickness fund data. In order to apply and extend the identified procedures, the statutory health insurance sample AOK Hessen/KV Hessen (VSH) served as data source. It is an 18.75 % random sample of persons insured by the AOK Hessen, with 2013 being the most recent year. Stroke patients were identified by the ICD-10 GM code I63 and I64. Patients with said diagnoses being coded as a hospital discharge diagnosis in 2012 were included due to an acute event in 2012 (n=944). The follow-up time was one year.

RESULTS

Ten studies covering seven different methods to assess stroke severity were identified. Codes for coma (4.2 % of stroke patients in the SHI sample) as well as coma and/or the application of a PEG tube (9.8 % of the stroke patients) were applied as a proxy for disease severity of acute cases. Taking age, sex and comorbidity into consideration, patients in a coma show a significantly increased risk of mortality compared to those without coma. Three operationalisations were chosen as possible proxies for disease severity of stroke in the further course of disease: i) sequelae (hemiplegia, neurological neglect), ii) duration of the index inpatient stay, and iii) nursing care/ care level 3 for the first time after stroke. The latter proxy has the highest explanatory value for SHI costs.

CONCLUSION

The studies identified use many variables mainly based on hospital information in order to describe disease severity. With the exception of coma, these proxies were neither validated nor did the authors provide more detailed grounds for their use. An identified score for stroke severity could not be applied to SHI data. To develop a comparable score requires a linkage of clinical and administrative data. Since routine data include information from all sectors of care, it should be explored whether these data (for example, the patients' care needs) are suitable to assess disease severity. For validation, separate databases and, optimally, primary patient data are necessary.

Evaluation einer regionalen integrierten Vollversorgung mit GKV-Routinedaten – Probleme und Herausforderungen

Die Integrierte Versorgung Gesundes Kinzigtal (IVGK) ist eine regionale integrierte Vollversorgung und wird umfassend extern evaluiert. In einer kontrollierten Längsschnittstudie wird anhand von GKV-Routinedaten untersucht, wie sich die Versorgungsqualität in der Region Kinzigtal im Vergleich zu einer Kontrollgruppe aus dem restlichen Baden-Württemberg entwickelt. Hierfür wurden insgesamt 37 Kennziffern gebildet. An drei Beispielen zeigen wir, dass die Eignung einer Kennziffer als Qualitätsindikator und Endpunkt regional vergleichender Studien sehr voraussetzungsvoll ist.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]

BACKGROUND

The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care.

OBJECTIVES

To evaluate the impact of the ICSGK on the Triple Aim.

MATERIALS AND METHODS

The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension.

RESULTS AND CONCLUSIONS

Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Prevalence of inflammatory bowel disease: estimates for 2010 and trends in Germany from a large insurance-based regional cohort

OBJECTIVE

A worldwide increase in prevalence of inflammatory bowel disease (IBD) has been reported. For Germany, latest publications not restricted to actively treated disease present data of the 1980s. This study estimates the administrative 1-year period IBD prevalence in 2010 and investigates the trend in prevalence of actively treated disease between 2001 and 2010.

MATERIAL AND METHODS

Utilizing an insurance-based cohort (n = 311,001 in 2001 to 265,102 in 2010), case definition was based on ICD-10 codes. The prevalence of active treatment was based on internally validated IBD cases of the respective year. The 1-year period prevalence in 2010 accounts for cases actively treated in at least one of the years between 2001 and 2010. Estimates were directly standardized by age and sex to the population of Germany. The change in prevalence of actively treated disease over the years was evaluated by means of Poisson regression.

RESULTS

The IBD prevalence in 2010 was 744 (95% confidence interval [CI]: 707-775) per 100,000 (Crohn's disease: 322 [95% CI: 302-346], ulcerative colitis: 412 [95% CI: 389-436] per 100,000). The prevalence of actively treated disease increased significantly between 2001 (344 [95% CI: 324-364] per 100,000) and 2010 (493 [95% CI: 464-519] per 100,000; increase in prevalence by 42% [95% CI: 31%-53%], p trend = 6.0 × 10(-19)).

CONCLUSION

In line with worldwide reports, our results based on a large insurance cohort suggest a considerable increase in IBD prevalence in Germany since the 1980s. The significant increase in prevalence of actively treated disease in our cohort highlights the need to adapt healthcare services and deal with the burden associated with increasing numbers of IBD patients.

Costs of Diabetes Mellitus (CoDiM) in Germany, direct per-capita costs of managing hyperglycaemia and diabetes complications in 2010 compared to 2001

INTRODUCTION

To identify direct health care costs of patients with diabetes in Germany in 2010, with focus on costs of treating hyperglycaemia and costs caused by diabetes complications, and to compare findings with results from the CoDiM study 2001.

MATERIAL AND METHODS

The cost analysis was based on administrative data (18.75% random sample of 1.5 million insured persons). Medical costs covered by statutory health insurance and costs covered by nursing care insurance were included. Incremental differences in costs of patients with diabetes (n=30 987) and age and sex-matched subjects without a diagnosis of diabetes (controls) were estimated according to the number and type of complications. Costs were standardised to the German population.

RESULTS

In 2010, incremental medical costs attributed to diabetes were € 2 391 (95% confidence interval: 2 257-2 524) per patient with diabetes. Of that amount, 26.5% were spent for the management of hyperglycaemia (€ 633 (622-644)) and 73.5% for the treatment of comp-lications (€ 1 758 (1 627-1 889)). Nursing care contributed incremental costs of € 289 (249-330), of which 98.8% was due to complications. From 2001 to 2010 the incremental per-capita costs for medical and nursing care decreased by 4.8% (controls: +3.9%), the per-capita costs for treating hyperglycaemia increased by 2.0% and the per-capita costs for complications decreased by 7.0%.

CONCLUSION

Cost for diabetes is largely caused by management of complications. It is important to prevent complications by consequent management of diabetes as well as by primary prevention of its onset.

Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany

After acquiring a varicella virus infection, the virus can reactivate and cause herpes zoster (HZ)--a painful skin rash. A complication of HZ is long-term persistence of pain after the rash has resolved (so-called postherpetic neuralgia, PHN). We aimed to describe the epidemiology of HZ/PHN and to estimate HZ/PHN-related costs in the German statutory health insurance (SHI) system (~85% of the total population). Treatment data of one large SHI was utilized, containing data on approximately 240,000 insured and their utilisation of services in 2004-2009. Identification of HZ- and PHN-cases was performed based on 'International Statistical Classification of Diseases' and specific medications using a control-group design. Incidences per 1,000 person-years (PY) and cost-of-illness for 1 year following HZ-onset considering the payer and societal perspective were calculated. All amounts were inflated to 2010 Euros. Population-figures were standardised and extrapolated to the total SHI-population in Germany in 2010. A mean annual incidence of 5.79 HZ-cases per 1,000 PY was observed, translating into an estimated 403,625 HZ-cases per year in the total SHI-population. Approximately 5% of HZ-cases developed PHN. One HZ-case caused on average euro 210 and euro 376 of costs from the payer and societal perspective, respectively. The development of PHN generated additional costs of euro 1,123 (euro 1,645 societal perspective). Total annual HZ/PHN-related costs were estimated at euro 182 million (euro 105 million) to society (payer). HZ and PHN place a considerable burden on the German SHI-system. Since HZ-vaccines will soon be available, a health-economic evaluation of these vaccines should be conducted.

Incidence estimate and guideline-oriented treatment for post-stroke spasticity: an analysis based on German statutory health insurance data

Background

Spasticity after stroke has been internationally recognized as an important health problem causing impairment of mobility, deformity, and pain. The aim of this study was to assess the frequency of first-ever and recurrent stroke and of subsequent spastic and flaccid paresis. Factors influencing the development of spasticity were analyzed. A further major aim was to provide a “real-life” assessment of the treatment of spasticity in Germany and to discuss this in view of the treatment recommended by German and international clinical guidelines.

Methods

The database used in this study comprised a cohort of 242,090 insurants from a large statutory health insurance fund in the federal state of Hesse, Germany. A first hospital discharge diagnosis in 2009 with any of the International Classification of Diseases, Tenth Revision (ICD-10) codes I60–I64 was used to identify patients with acute stroke (hemorrhage and ischemic). These patients were followed up six months after stroke to monitor whether they developed spastic or flaccid paresis (hospital or ambulatory care diagnoses ICD-10 code G81–G83 [excluding G82.6/G83.4/G83.8]). For patients with spastic paresis after stroke the spasticity treatment was analyzed for a six-month period (physiotherapy, oral muscle relaxants, intrathecal baclofen, and botulinum toxin).

Results

Standardized to the population of Germany, 3.7 per 1000 persons suffered a stroke in 2009 (raw 5.2/1000). Of all surviving patients, 10.2% developed spasticity within 6 months. Cox regression revealed no significant influence of patient age, gender, morbidity (diabetes, hypertensive diseases, ischemic heart diseases) or type of stroke on development of spasticity. 97% of surviving patients with spasticity received physiotherapy (inpatient care 89%, ambulatory care 48%). Oral muscle relaxants were prescribed to 13% of the patients. No patient received intrathecal baclofen or botulinum toxin.

Conclusion

Claims data enabled analysis of the occurrence of stroke and post-stroke spasticity. These data provide insight into real-life treatment for spasticity in Germany. The proportion of patients who receive physiotherapy, which is the international guideline-recommended basic therapy after transition into ambulatory care, can be improved on. Botulinum toxin as an international guideline-based treatment option for focal spasticity has not been implemented in practice in Germany as yet.

Estimation of disease incidence in claims data dependent on the length of follow-up: a methodological approach

OBJECTIVE

To analyze the impact of the length of disease-free intervals on incidence estimation.

DATA SOURCE

Statutory health insurance sample in Germany.

STUDY DESIGN

Overestimation of the incidence in the first quarter of 2008 for three selected diseases, diabetes mellitus, colorectal cancer, and heart failure, depending on different lengths of preceding disease-free intervals.

DATA COLLECTION/EXTRACTION METHODS

Continuously insured from 2000 until 2008 ≥ 18 years (N = 144,907).

PRINCIPAL FINDINGS

Compared with an 8-year disease-free period, incidence overestimations for diabetes, colorectal cancer, and heart failure were 40, 23, and 43 percent defining a 1-year, and 5, 9, and 5 percent defining a 5-year disease-free period, respectively.

CONCLUSIONS

Depending on the specific disease, caution has to be taken while using short disease-free periods because incidence estimates may be extremely overestimated.

[Follow up of the CoDiM-Study: Cost of diabetes mellitus 2000-2009]

Cost of illness studies create transparency on the economic dimension of diseases. By now, the CoDiM study, based on administrative data of AOK Hesse und KV Hesse, identifies costs of people with diabetes and diabetes related excess costs in Germany for a period of 10 years. To date, additionally adjusted results are available by accounting for effects caused by inflation and ageing of the population. From 2000 to 2009 the number of treated patients with diabetes increased by 49 %, adjusted for age by 31 %. Mean cost of patients with diabetes and diabetes related excess costs per capita turned out to be relatively stable over the time period observed. The relation of cost per patient with diabetes to cost of patients without diabetes didn't change. Due to the increase of the number of treated patients with diabetes in the past 10 years, the total direct cost, dependant on the approach of calculation (adjusting or not for inflation and ageing effects), rose by 28 % to 70 %, the therein included diabetes excess cost by 24 % to 61 %.

Direct costs of diabetes mellitus in Germany - CoDiM 2000-2007

INTRODUCTION

The prevalence of treated diabetes in Germany and direct health care costs of individuals with diabetes were analysed for the 8-year period from 2000 to 2007, based on administrative data. Special interest was given to the incremental costs attributed to diabetes.

MATERIAL AND METHODS

An 18.75% sample of all members of a large local German statutory health insurance provider, "AOK - Die Gesundheitskasse" in the federal state of Hesse was analysed with regard to cases of treated diabetes. To assess the incremental diabetes-related direct costs, the cost data of individuals with diabetes was compared to that of an age- and sex-matched group of persons without diabetes. Prevalence and costs were standardized according to the gender and age distribution of the German population.

RESULTS

Between 2000 and 2007, the administrative prevalence of treated diabetes rose continuously in Germany, from 6.5 to 8.9% (+36.8%). The number of patients treated with 'insulin' or 'insulin & oral antidiabetic agents' increased by +54.7 and +61.7%, respectively. Direct costs per patient with diabetes, calculated using the unit costs reimbursed by statutory health and nursing care insurances, rose from € 5 197 to € 5 726 (+10.2%). Incremental per-capita costs were € 2 400 in 2000 and € 2 605 in 2007 (+8.5%). However, the total direct cost burden of diabetes in Germany grew from € 27.8 billion to € 42.0 billion (+51.1%). The incremental diabetes-related cost burden increased from € 12.9 billion to € 19.1 billion (+48.6%).

CONCLUSIONS

There was a continuous increase in the prevalence of diabetes in Germany during the 8-year period. Although there was only a modest increase in annual diabetes-related per-capita costs, total healthcare expenditure rose substantially due to the growing number of patients being treated for diabetes.

Does integrated care lead to both improved service quality and lower care cost

Purpose and context

‘Gesundes Kinzigtal’ is one of the few population-based integrated care approaches in Germany, organising care across all health service sectors and indications. The management company and its contracting partners (the physicians’ network in the region and two statutory health insurers) strive to reach a higher quality of care at a lower overall cost as compared with the German standard. During its first two years of operation (2006–2007), the Kinzigtal project achieved surprisingly positive financial results compared with its reference value. To gain independent evidence on the quality aspects of the system, the management company and its partners provided a remarkable budget for its evaluation by independent scientific institutions.

Case description and data sources

We will present interim results of a population-based controlled cohort study. In this study, quality of care is checked by relying on health and service quality indicators that have been constructed from health insurers’ administrative data (claims data). Interim results are presented for the intervention region (Kinzigtal area) and the control region (the rest of Baden-Württemberg, i.e., Southwest Germany).

Preliminary conclusions and discussion

The evaluation of ‘Gesundes Kinzigtal’ is in full progress. Until now, there is no evidence that the surprisingly positive financial results of the Kinzigtal system have been achieved at the expense of care quality. Rather, Gesundes Kinzigtal Integrated Care seems to be about to increasingly realize comparative advantages regarding health service quality (in comparison to the control region).

The changing prevalence of attention-deficit/hyperactivity disorder and methylphenidate prescriptions: a study of data from a random sample of insurees of the AOK Health Insurance Company in the German State of Hesse, 2000-2007

BACKGROUND

The goal of this study is to assess changes in the prevalence of attention-deficit/hyperactivity disorder (ADHD) and methylphenidate prescriptions over the period 2000 to 2007 on the basis of data from a German statutory health insurance carrier.

METHODS

In a cross-sectional study, we analyzed data from a random sample of insurees of the AOK health insurance company in the German state of Hesse for the years 2000 to 2007. Per calender year, 50,000 to 63,000 children and adolescents were retrospectively observed with respect to the documentation of ADHD diagnosis (ICD-10 diagnosis F90) and the prescribing of methylphenidate (ATC: N06BA04).

RESULTS

In 2007, the overall prevalence of ADHD in all age groups (0-18 years) was 2.21% (95% CI: 2.09-2.34). This figure was 45% greater than the corresponding figure for the year 2000. The prevalence increased by a larger amount among girls aged 6 to 18 years than among boys in the same age group (+69% vs. +53%). In 2007, 1.06% (95% CI: 0.98-1.16) of the children/adolescents received at least one prescription for methylphenidate; this was a 96% increase over the prescription rate for 2000. A comparison of the two years 2000 and 2007 reveals a clear prevalence shift towards the older age groups, as well as an 82% increase in the average number of daily doses per recipient. Outpatient departments of child and adolescent psychiatry initiated more treatments in 2007 than in 2000.

CONCLUSION

The 1% prevalence of methylphenidate use among children and adolescents that was found in this study is the same as that reported in other European countries, such as Switzerland, the Netherlands, and Norway. A drawback of our study is its limitation to a single insurance carrier in a single region. Nonetheless, data of this type are useful for monitoring. The findings suggest further issues worth studying, e.g., off-label use or the indications for treatment in older age groups.

[Herpes zoster in Germany. A retrospective analyse of SHL data]

The incidence of herpes zoster in the elderly (50 years and older) 2004 in Germany was determined by retrospectively analysing representative treatment data of the statutory health insurance sample of AOK Hesse/KV Hesse. The overall observed incidence rate of herpes zoster was 9.4 cases per 1,000 person-years (PY). 10.1% of herpes-zoster-patients suffered at least 1 month from pain, the so called postherpetic neuralgia (PHN1), 6.9% had at least 3 months pain (PHN3). Incidence rate of herpes zoster rose markedly with age: from 6.8 per 1,000 PY in 50 to 54 year-olds to 12.4 PY in persons 80 years and older. Incidence rate in the immunocompromised was higher (11.6 per 1,000 PY) than in the immunocompetent (9.1 per 1,000 PY). According to a standardized extrapolation of the sample to the German population, about 300,000 persons 50 years and older suffered from acute herpes zoster on the year 2004 in Germany.

Lower health care cost by superior (integrated) care management? Evaluation of a population-based integrated care system in Germany—first results

Purpose and context

‘Gesundes Kinzigtal’ is one of the few population-based integrated care approaches in Germany, organising care across all health service sectors and indications. The system is run by a regional health management company (Gesundes Kinzigtal GmbH) in cooperation with the regional physicians' network and with two statutory health insurers (among them is the biggest health insurer in Southwest Germany: AOK Baden-Württemberg). Membership is optional for insured persons in the Kinzigtal area. The management company and its partners maintain to reach a higher quality of organisational, coordination and interaction processes (among the concerned physicians, therapists, pharmacists, hospitals, patients and health insurers) at a lower overall cost as compared with the German standard. During its first two years of operation (2006–2007), the Kinzigtal project actually achieved positive financial results as compared with its reference value. To gain independent evidence on the quality aspects of the system, the management company and the two cooperating health insurers provided a remarkable budget for the evaluation of the system by independent scientific institutions. Since 2006–2007 several evaluation projects have started, investigating different quality aspects of the Kinzigtal system. In our presentation we will outline the overall evaluation concept and report some preliminary results.

Case description and data sources

Preliminary results of the following studies will be presented. A controlled cohort study, beginning in 2007, investigates the assureds' attitudes towards quality of care, shared-decision-making and overall patient satisfaction both in the Kinzigtal region as well as in a control region. In a second controlled cohort study the quality of care is checked by relying on health insurers' administrative data which are routinely collected on all reimbursed health care services. A third study, pursuing a simple cohort study design, investigates the attitudes of the cooperating physicians, physiotherapists, psychotherapists as well as pharmacists.

Preliminary conclusions and discussion

The evaluation of the integrated care system in the Kinzigtal area in Germany is still in progress. Up until now, there is no evidence that the positive financial results of the Kinzigtal system have been achieved at the expense of the quality of care. If these results were confirmed at the time of study completion (or if an even improved quality of care in the Kinzigtal region were demonstrated), the Kinzigtal integrated care system could become a role model for many other similar regions in Germany and Europe.

Medical costs of diabetic complications total costs and excess costs by age and type of treatment results of the German CoDiM Study

AIMS

This study examined the medical costs of diabetic complications by age, type of treatment, and type of complication and researched the relationship between total and excess costs with respect to type of complications.

METHODS

Patients with diabetes (n=26,971) were identified from a German statutory health insurance database by glucose-lowering drug prescriptions and ICD-10 diagnoses. Diabetes complications were defined as microvascular (eye and kidney diseases), foot complications (peripheral neuropathy, peripheral vascular disease), macrovascular (cardio- and cerebrovascular diseases), and uncontrolled glucose metabolism (glycaemic complications). Estimates of frequency and medical costs of complications were calculated for diabetic patients and an age- and sex-matched control group of persons without diabetes.

RESULTS

Half (53%) of the medical costs per diabetes patient in 2001 (euro4,457) were spent for management of complications (euro2,380). In the control group, costs of these diseases were euro761 per person. Consequently excess costs of complication due to diabetes were estimated at euro1,619 (36%) and were caused for treatment of macrovascular (euro643, 14%), microvascular (euro458, 10%), foot complications (euro430, 10%) and glycaemic complications (euro88, 2%). Furthermore 12% were spent for management of hyperglycaemia (euro542). Excess costs for complications per diabetic patient were higher for insulin (euro4,395) versus non-insulin treated patients (euro587). Eye, kidney and foot complications were encountered 3 - 4 times more often in diabetic patients than in non-diabetic controls, whereas macrovascular diseases were only 1.6 times more frequent. Therefore the proportion of diabetes dependent excess costs of microvascular and foot complications was high (78%), and was considerably lower (56%) for macrovascular complications.

CONCLUSIONS

A close relationship exists between diabetes related excess costs and the presence of microvascular and foot complications. It is important to identify these patients early in order to incorporate them into diabetes management programs. A better care of diabetes patients and subsequent prevention of these late complications promises not only to improve quality of life but also to be highly cost-effective.

[Costs of the treatment of hyperglycemia in patients with diabetes mellitus. The impact of age, type of therapy and complications: results of the German CoDiM study]

BACKGROUND AND PURPOSE

Diabetes mellitus is a chronic progressive disease with multiple complications and due to its high prevalence represents a true economic challenge to the health care system. However, the specific cost structure is not known. It was the aim of this study to analyze the costs of antihyperglycemic treatment in relation to age, treatment regimen and presence of complications.

MATERIAL AND METHODS

This study is part of the CoDiM study. The analysis was based on the data of a random sample (n = 306,736) of all members of the "Allgemeine Ortskrankenkasse Hessen" (AOK Hessen, Local Statutory Health Insurance of Hessen) and data provided by the "Kassenärztliche Vereinigung Hessen" (KV Hessen, Association of Statutory Health Insurance Physicians in Hessen). Patients with diabetes were identified by the ICD-10 classification and prescriptions of blood glucose-lowering drugs. Costs of antihyperglycemic therapy were calculated per patient and year computing procedures and antidiabetic drugs in outpatient care as well as hospital costs.

RESULTS

The mean costs of treatment of hyperglycemia were 542 Euros per patient in 2001 and represented 10% of total costs. The major parts in this segment were expenses for hypoglycemic drugs (46%) and for blood glucose self-monitoring (21%). The costs were highest in the groups treated by either insulin alone or a combination of insulin and oral hypoglycemic agents (1,366 Euros and 1,479 Euros, respectively) as compared to patients on oral hypoglycemic agents alone or on diet (296 Euros and 59 Euros, respectively). Stripes for blood glucose self-monitoring were almost exclusively prescribed to insulintreated patients and caused average costs in this group of 446 Euros. By contrast, costs for self-monitoring were almost negligible in the two other groups. A subdivision of costs according to complications revealed that patients with microangiopathy (retinopathy, nephropathy) and foot complications caused twice as much expenses as patients with macroangiopathy (vascular diseases) or without complications (779 Euros vs. 370 Euros and 401 Euros, respectively).

CONCLUSION

The expenses for the antihyperglycemic treatment of patients with diabetes represent only a minority of total per capita costs and these were slightly more than half due to insulin treatment and blood glucose self-monitoring.

The cost burden of diabetes mellitus: the evidence from Germany--the CoDiM study

AIMS/HYPOTHESIS

The aim of this study was to identify the health care costs of diabetic patients in Germany in 2001, focusing on the influence of age, sex, and type of treatment.

SUBJECTS AND METHODS

Annual direct costs of medical care and indirect costs of inability to work and early retirement in diabetic subjects were compared with costs of age- and sex-matched non-diabetic control subjects. The analysis was based on routine health care data from a random sample (18.75%) taken from a database of 1.9 million insured persons. Incremental differences in medical and national expenditure between subjects with and without diabetes were calculated.

RESULTS

Annual direct mean costs per diabetic patient were 5,262 Euro, and indirect costs were 5,019 Euro. In the control group, mean direct and indirect costs were 2,755 Euro and 3,691 Euro, respectively. Analysis of cost components revealed that the high costs associated with the care of diabetic patients could be largely attributed to inpatient care and overall medication costs. Hypoglycaemic drugs amounted to only one-quarter of the medication costs. The total health care costs were correlated with the type of treatment. Direct excess costs increased with increasing age in insulin-treated patients, but were unaffected by age in patients receiving other types of treatment.

CONCLUSIONS/INTERPRETATION

The Costs of Diabetes Mellitus (CoDiM) study is the first comprehensive study to provide estimates of costs associated with diabetes care in Germany. Direct costs of diabetic patients account for 14.2% of total health care costs, which includes the proportion that specifically accounts for diabetes-related costs (6.8%).

[Heterogeneity of costs of diabetic patients: the Cost of Diabetes Mellitus Study]

BACKGROUND AND OBJECTIVE

Health economic studies in patients with diabetes mellitus have demonstrated that a large proportion of the excess cost is caused by the treatment of specific complications. It was the aim of this study to analyse the distribution of per capita cost of a large cohort of diabetic patients in order to develop new strategies for a better identification and care of high-risk patients.

METHODS

The analysis was based on anonymous data on patients with diabetes and an age-matched control group from a large cohort of subjects insured by a large statutory health insurance fund (AOK Hesse) (n=305736). Costs were fully assessed and related to the state of complications and other criteria.

RESULTS

The average cost was 5262 euros per diabetic patient and year. Excess costs due to the diabetes were estimated at 2507 euros. Costs were unevenly distributed, depending on the presence of complications. The average excess cost of patients with at least one complication was i 3730 euros (469 for patients without complication). In particular, patients on hemodialysis, after kidney transplantation or with lower leg amputation, stroke or with gangrene or foot ulcer incurred great costs. 5.3% of all diabetic patients incurred costs of > or = 20000 euros per year, totalling up to 33.6% of all costs of diabetic patients. Another 9.5% of patients incurred costs of between 10000 euros and 20000 euros per year. Both groups were responsible for 59.6% of total costs. In contrast, 55% of the patients incurred costs of < 2500 euros per year, amounting to 11.8% of all costs.

CONCLUSIONS

There is a considerable variation of cost incurred in the management of diabetic patients, as demonstrated in a large population-based cohort of diabetics. This increased cost was largely due to the presence of complications. High-risk patients should be identified as early as possible so that they can receive intensive care to avoid the expensive complications of the disease.

Versichertenstichprobe AOK Hessen/KV Hessen - Konzeption und Umsetzung einer personenbezogenen Datenbasis aus der Gesetzlichen Krankenversicherung

Statutory health insurance data are being increasingly used for secondary data research. Longitudinal data can be prepared for research in health care, epidemiology or demand planning, in particular through the person-related nature of the data which is a precondition for the creation of inter-sector and inter-period data sets. This application possibility was introduced in a method study "person-related sampling of statutory health insurance data" and is now translated into practice on a larger scale for the first time in the regional sample "Versichertenstichprobe AOK Hessen/KV Hessen". For the collection and use of these data, model procedures were designed which take account of organisational (data access, contractual agreement, advisory board), technical (sampling, collection and storage of data) and confidentiality (data protection concept, pseudonymisation) aspects. The insured person-related sample may thus serve as a basis for the data pool planned for the national health system (Social Security Regulation 303 a-SGB V).

Hyperkinetische Störungen bei Kindern und Jugendlichen: Zur Häufigkeit des Behandlungsanlasses in der ambulanten Versorgung nach den Daten der Versichertenstichprobe AOK Hessen/KV Hessen (1998-2001)

Zusammenfassung: Fragestellung: Für die Jahre 1998 bis 2001 wird untersucht, wie häufig und von welchen Arztgruppen der Behandlungsanlass «Hyperkinetische Störung» (HKS) bei Kindern und Jugendlichen in der ambulanten Versorgung als Abrechnungsdiagnose dokumentiert wird. Methode: Die Untersuchung basiert auf personenbezogen erhobenen pseudonymisierten Daten der Gesetzlichen Krankenversicherung. Die Stichprobe umfasst n = 41930 Kinder/Jugendliche bis zu 15 Jahren (1998). Für die Jahre 1998 und 1999 wurden Klartextdiagnosen, für die Jahre 2000 und 2001 die HKS-Kodierung ICD-10: F90.0-F90.9 zur Definition herangezogen. Ergebnisse: In der Altersgruppe der 3- bis 15-Jährigen steigt der Anteil mit einer HKS-Krankenscheindiagnose von 1,6% (1998) auf 2,4% (2001). Jungen erhalten ca. vier mal häufiger eine HKS-Diagnose als Mädchen (2001: 3,8% vs. 1,0%). Die höchste administrative Prävalenz liegt sowohl für Jungen (2001: 5,8%) wie für Mädchen (2001: 1,4%) in der Altersgruppe der 7- bis 10-Jährigen. Bei 54% der Kinder mit HKS wurde 2001 die Diagnose beim Kinderarzt dokumentiert, es folgen Allgemeinärzte (29%) und Kinder- und Jugendpsychiater (15%). Über vier Jahre betrachtet, zeigt sich bei den Kinder- und Jugendpsychiatern und Polikliniken eine deutliche Zunahme in der Behandlungshäufigkeit des HKS. Schlussfolgerung: Die Daten zeigen eine Zunahme in der administrativen Prävalenz des HKS im Zeitraum 1998 und 2001. Diese liegt im unteren Bereich der in repräsentativen Bevölkerungsstichproben ermittelten Prävalenzen.

[Outpatient care of patients with diabetes mellitus in 2001. Analysis of a health insurance sample of the AOK in Hesse/KV in Hesse]

AIM

Aim of this retrospective case-control study was to assess the quality of out-patient care in patients with diabetes mellitus by analysing health insurance data from a large cohort of members of a regional statutory health insurance fund in Hesse.

METHODS

The study was carried out in the 'Versichertenstichprobe AOK Hessen/KV Hessen', a 18.75% random sample of the AOK Hesse, for the year 2001 corresponding to 306,736 subjects and 26,972 diabetics. All medical services and prescriptions provided by primary-care physicians were documented.

RESULTS

Compared to an age- and sex-matched control group patients with diabetes received more out-patient medical services (diabetics: 126 +/- 0.8, controls: 76 +/- 0.4 per year, p < 0.0001) and more prescriptions (diabetics: 39.9 +/- 0.3, controls: 20.0 +/- 0.3 per year, p < 0.0001) in 2001. HbA (1c) measurements were performed in 69.5% of the insulin-treated patients, in 64.3% of the patients under monotherapy with oral hypoglycaemic agents and in 41.1% of the patients under dietary treatment. 78.1% of the insulin-treated patients, 12.0% of those under oral hypoglycaemic agents and 2.0% of patients under dietary treatment received prescriptions for material for blood glucose self-monitoring. In contrast, a retinal examination was performed in only 45.8%, 31.1% and 22.5% of the patients in the three treatment groups throughout the year. The respective figures for screening for microalbuminuria in the three treatment groups were 12.7%, 7.1% and 3.6%.

CONCLUSIONS

The results of this retrospective analysis suggest that the out-patient medical care of subjects with diabetes is in some respect unsatisfactory and does not comply with the accepted recommendations for appropriate diabetes care.

Prävalenz des Diabetes mellitus in Deutschland 1998 - 2001

AIMS

The aim of this population-based study was to assess the prevalence of subjects with diabetes mellitus by retrospectively analysing routine health insurance data.

METHODS

This analysis comprised a 18.75% random sample of all members of the largest regional statutory health insurance (Allgemeine Ortskrankenkasse, AOK) in Hesse. Patients with diabetes were identified by criteria such as ICD-10 diagnoses and regular prescriptions of insulin and oral antidiabetic agents. The data were corrected for the age and gender distribution of the German population.

RESULTS

Over the 4-year observation period there was a continuous increase in the prevalence of subjects with known diabetes mellitus, from 7.24% in 1998 to 8.79% in 2001. After correction for the German population the last figure corresponded to a prevalence rate of 6.00% in 1998 and 6.91% in 2001. During this period, there was an overproportional increase in the percentage of subjects treated with insulin, from 1.49% in 1998 to 1.91% in 2001, while there was only a moderate increase in the percentage of subjects under oral medication and under dietary treatment, respectively. In the age group of 70 and above roughly 25% of all subjects had known diabetes. In this age group, more than 6% of all people were treated with insulin.

CONCLUSIONS

This data suggests that there was a continuous increase in the prevalence of individuals treated for diabetes between 1998 and 2001 in Germany by approximately 5% per year. After correction for the total German population the pre-valence of diagnosed diabetes is nearly 7%.

[Turkish and German patients of general practitioners--diseases, drug expectations and drug prescriptions]

AIM OF THE STUDY

to assess the diseases and complaints and the concepts for treatment of patients and drug prescriptions relative to their ethnic origin: Turkish immigrants (T) or German citizens (D).

METHODS

Questionnaire survey of patients of general practitioners before and after consultation. The survey was conducted separately for Turkish and German patients, involving nine GP's practices for each group. Sample sizes were 253 Turkish and 637 German patients, respectively. Only responses of patients younger than 60 years of age were evaluated (T: 216/G: 357). Reason: Relative to the entire Turkish population in Germany the number of ethnic Turks older than 60 is too small for comparative purposes.

RESULTS

The two most frequent reasons for a visit to the doctor by Turkish migrants were pain of varied origin (T: 44 % / G: 21 %; p > 0.001) and colds or diseases of the respiratory tract (T: 41 % / G: 25 %; p > 0.001). Turkish and German patients differ significantly with respect to their mentioning of pain and colds. The concept of treatment of the Turkish patients is compared to German patients more adjusted to medicaments and less to counselling and discussion with the doctor. The physicians' prescribing frequency on the other hand conforms primarily to the disease of the patients and not to their ethnic group. To confirm this, compare the share of drug recipients per disease group: Respiratory tract: T: 79 % / D: 84 %, alimentary system: T: 58 % / D: 60 % and locomotor system: T: 49 % / D: 39 %. Secondly the physicians' prescribing frequency conforms to the patients' expectations of medicaments: Of the patients who expected a prescription T: 79 % and D: 77 % respectively were given a prescription and of those who did not expect a prescription T: 55 % / D: 51 % did receive it. Again the patients' ethnic group had no influence on the prescribing frequency. Significantly more Turkish than German patients (T: 23 % / D: 9 %; p < 0.001) received pain-relieving drugs. This is especially true for Turkish patients with illnesses of the respiratory, alimentary and locomotor system. This is the explanation: More Turkish than German patients name pain as their consulting reason. Again the prescribing frequency does not depend on the ethnic group. It depends on the patient' s pain.

CONSEQUENCES

The treatment concept of Turkish patients is more directed to drugs. They request a drug more intensively and are more convinced of the medicaments' effectiveness than German patients are. In spite of this, physicians give a prescription according to the indication of the patient independent of his ethnic origin. The insistence on a prescription is significantly higher in Turkish than in German patients.

Patient variables associated with expectations for prescriptions and general practitioners' prescribing behaviour: an observational study

OBJECTIVES

To determine patients' needs and expectations for prescriptions as a function of demographic and illness-associated variables versus outcome of consultation.

DESIGN

Questionnaire study consisting of patient interview before and after consultation with general practitioner.

SETTING

A total of 618 consecutive patients in the waiting room of nine general practices in Germany (Hesse).

MAIN OUTCOME MEASURES

Patient needs and expectations for prescriptions and agreement between expected outcome and prescriptions received.

RESULTS

As their top priority for consultation (33% of group), patients expected to receive information about their illness. Their needs for prescriptions (26%) and expectations of receiving them (41%) were clearly lower than physician prescribing (56%). Marked interpatient differences emerged with regard to need/expectation for medication according to age, minor versus chronic illness, duration of treatment, and first-time attendance, but this was not reflected in how often physicians prescribed. A total of 85% of patients expecting a prescription received one; 44% not expressing a need for medication were issued one. Although only 4% of patients would want a drug with questionable effectiveness, doctors wrote such prescriptions to no less than 21% of patients--and especially to those with minor, newly arisen ailments (33%). Nevertheless, patient satisfaction with their visit was very high (98%).

CONCLUSIONS

In Germany, patient needs and expectations for medication are clearly lower than prescribing tendencies, and marked differences between patient groups in their needs or expectations for prescriptions are not reflected in the rates of prescriptions received. Above all, patients with minor illnesses wish to receive information about their illness, and they do not expect prescriptions of drugs with questionable effectiveness.

Pharmacotherapeutic circles. Results of an 18-month peer-review prescribing-improvement programme for general practitioners

OBJECTIVE

To assess the effectiveness of the pharmacotherapeutic circle (PTC), a general practitioner (GP) prescribing-improvement programme to enhance prescribing quality and reduce drug costs.

DESIGN

Combined pre- and post-intervention time-series design using an internal comparison of subgroups and an external comparative control.

SETTING

Small discussion groups meeting 8 times over 18 months.

PARTICIPANTS

79 GPs exceeding the mean drug costs/patient of all Hessian physicians by > or = 40%; 10 moderators.

INTERVENTIONS

Peer-review feedback of prescription patterns based on guidelines targeting 3 suboptimal prescribing areas: drug prescriptions lacking evidence-based efficacy (target A); presumptive prescribing habits (target B); and underprescribing of new, effective therapies (target C).

MAIN OUTCOME MEASURES AND RESULTS

Significant decreases in prescription rates for target A drugs were recorded for varicose vein medications (p = 0.006), peripheral vasodilators (p = 0.0001) and topical antirheumatics (p = 0.0145), but not for prokinetics/enzymes/digestives. Prescribing of target B drugs such as benzodiazepines and nonsteroidal anti-inflammatory drugs declined markedly (p = 0.0019 and 0.0014, respectively). Target C drug prescriptions such as for opioids and proton pump inhibitors were not significantly increased. Highly significant reductions in prescription costs were observed for target A and B drugs, irrespective of whether GPs were stratified into high, medium or low prescribers. When mean prescribing costs for PTC participants were compared with those of a control group comprising 8000 GPs over a 21-month period, PTC GPs decreased their costs by 2%, whereas drug costs for all Hessian physicians rose by 10%.

CONCLUSIONS

PTCs appear to be an effective method to optimise the quality of drug prescribing and reduce drug costs.