Ingrid Köster

The cost burden of diabetes mellitus: the evidence from Germany—the CoDiM Study

Aims/hypothesisThe 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 methodsAnnual 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.ResultsAnnual direct mean costs per diabetic patient were €5,262, and indirect costs were €5,019. In the control group, mean direct and indirect costs were €2,755 and €3,691, 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/interpretationThe 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%).

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.

Prevalence and incidence of diagnosed endometriosis and risk of endometriosis in patients with endometriosis-related symptoms: findings from a statutory health insurance-based cohort in Germany

OBJECTIVE The objectives were: (a) to determine the administrative prevalence and incidence of endometriosis and (b) to assess the risk of endometriosis associated with endometriosis-related symptoms. STUDY DESIGN The study is based on inpatient and outpatient data from a statutory health insurance fund in Germany. For prevalence and incidence definition 62,323 women aged 15-54 continuously insured in 2007 were identified. The prevalence and incidence of endometriosis in 2007 were calculated standardized to the age distribution in Germany. In a further prospective cohort study based within the health insurance sample 2095 patients with endometriosis-related symptoms and 8380 age-matched asymptomatic controls were identified. Endometriosis follow-up was from 2004 to 2008. Cox proportional hazard regression was used to examine the risk of endometriosis associated with endometriosis-related symptoms, such as pelvic pain, dysmenorrhoea, dyspareunia, menorrhagia, post-coital bleeding, inter-menstrual pain and ovarian cysts. Relative risks (RR) and 95% confidence intervals (CI) were calculated. RESULTS Standardized prevalence and incidence rates were 8.1 and 3.5 per 1000 women, respectively. The highest prevalence was observed in women aged 35-44 with 12.8 per 1000 women. Median follow-up was 4.5 years. Risk of endometriosis associated with endometriosis-related symptomatology was RR (95% CI)=4.95 (3.67-6.68); 4.5% of all symptomatic women were diagnosed with endometriosis in a median follow-up of 4.5 years. The highest risk was observed in women aged 35-44 [RR (95% CI)=6.29 (4.00-9.90)] with 7.6% of all symptomatic women receiving a diagnosis of endometriosis during the follow-up. CONCLUSION Prevalence estimates based on population-based administrative data were lower than described in the literature. Risk of endometriosis was increased in women with endometriosis-related symptoms. However, those symptoms were of limited predictive value for endometriosis as only a small proportion of symptomatic patients were diagnosed with endometriosis in the follow-up.

Versorgungsforschung mit GKV-Routinedaten

Conducting health services research requires a wealth of real-life health service data. A source of data which is for the most part free of bias is the data collected for administrative purposes by the statutory health insurance fund. These data have been increasingly used over the past few years. Based on these insuree-related and where possible cross-sector data, descriptive and analytic studies can be conducted. The focus of use thus far has primarily been the generation of basic data on morbidity, the utilization of benefits, and costs. As a rule, this information is presented according to sociodemographic variables and where applicable in terms of temporal trends and according to region. A further domain of interest is the evaluation of interventions (health political measures, legislation, programs) and the assessment of health service quality. Initial outcome studies have been published. Despite the growing acceptance and use of these data, a series of methodological and information technical challenges remain to be addressed: To be mentioned are, in addition to validation studies, the methodological requirements of analytic study designs and the possibility of a data linkage with primary data in order to increase the explanatory power of studies and to facilitate links with other databases such as records and survey data.ZusammenfassungVersorgungsforschung benötigt eine Fülle von Daten aus dem realen Versorgungsgeschehen. Eine weitgehend verzerrungsfreie Datenquelle stellen die zu administrativen Zwecken erhobenen Daten der gesetzlichen Krankenversicherung (GKV) dar, die in den letzten Jahren verstärkt genutzt werden. Mithilfe dieser versichertenbezogen und nach Möglichkeit auch sektorübergreifend erhobenen Daten sind sowohl deskriptive als auch analytische Studien durchführbar. Der Schwerpunkt der bisherigen Nutzung liegt auf der Bereitstellung von Grunddaten zur Morbidität, Inanspruchnahme von Leistungen und Kosten. Diese Angaben erfolgen in der Regel nach soziodemographischen Variablen und ggf. im zeitlichen Trend sowie nach Regionen. Ein weiteres Themenfeld stellt die Evaluation von Interventionen (gesundheitspolitischen Maßnahmen, Gesetzen, Programmen) und die Bewertung der Qualität der Versorgung dar. Erste Studien liegen zu Outcome-Untersuchungen vor. Trotz der inzwischen gewachsenen Akzeptanz und Nutzung der Daten besteht noch eine Reihe methodischer und datentechnischer Herausforderungen: Zu nennen sind hier neben Validierungsstudien die methodischen Anforderungen der analytischen Studiendesigns und die Möglichkeit eines Daten-Linkages mit Primärdaten, um die Erklärungskraft der Untersuchungen zu erhöhen und um Verbindungen zu anderen Datenbeständen wie Register und Surveydaten zu ermöglichen.AbstractConducting health services research requires a wealth of real-life health service data. A source of data which is for the most part free of bias is the data collected for administrative purposes by the statutory health insurance fund. These data have been increasingly used over the past few years. Based on these insuree-related and where possible cross-sector data, descriptive and analytic studies can be conducted. The focus of use thus far has primarily been the generation of basic data on morbidity, the utilization of benefits, and costs. As a rule, this information is presented according to sociodemographic variables and where applicable in terms of temporal trends and according to region. A further domain of interest is the evaluation of interventions (health political measures, legislation, programs) and the assessment of health service quality. Initial outcome studies have been published. Despite the growing acceptance and use of these data, a series of methodological and information technical challenges remain to be addressed: To be mentioned are, in addition to validation studies, the methodological requirements of analytic study designs and the possibility of a data linkage with primary data in order to increase the explanatory power of studies and to facilitate links with other databases such as records and survey data.

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.

Pharmacotherapeutic Circles: Results of an 18-Month Peer-Review Prescribing-Improvement Programme for General Practitioners

AbstractObjective: 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 ≥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.

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.

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: Fur die Jahre 1998 bis 2001 wird untersucht, wie haufig und von welchen Arztgruppen der Behandlungsanlass «Hyperkinetische Storung» (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). Fur die Jahre 1998 und 1999 wurden Klartextdiagnosen, fur 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-Jahrigen steigt der Anteil mit einer HKS-Krankenscheindiagnose von 1,6% (1998) auf 2,4% (2001). Jungen erhalten ca. vier mal haufiger eine HKS-Diagnose als Madchen (2001: 3,8% vs. 1,0%). Die hochste administrative Pravalenz liegt sowohl fur Jungen (2001: 5,8%) wie fur Madchen (2001: 1,4%) in der Altersgruppe der 7- bis 10-Jahrigen. Bei 54% der Kinde...

Health services research based on routine data generated by the SHI. Potential uses of health insurance fund data in health services research

Conducting health services research requires a wealth of real-life health service data. A source of data which is for the most part free of bias is the data collected for administrative purposes by the statutory health insurance fund. These data have been increasingly used over the past few years. Based on these insuree-related and where possible cross-sector data, descriptive and analytic studies can be conducted. The focus of use thus far has primarily been the generation of basic data on morbidity, the utilization of benefits, and costs. As a rule, this information is presented according to sociodemographic variables and where applicable in terms of temporal trends and according to region. A further domain of interest is the evaluation of interventions (health political measures, legislation, programs) and the assessment of health service quality. Initial outcome studies have been published. Despite the growing acceptance and use of these data, a series of methodological and information technical challenges remain to be addressed: To be mentioned are, in addition to validation studies, the methodological requirements of analytic study designs and the possibility of a data linkage with primary data in order to increase the explanatory power of studies and to facilitate links with other databases such as records and survey data.ZusammenfassungVersorgungsforschung benötigt eine Fülle von Daten aus dem realen Versorgungsgeschehen. Eine weitgehend verzerrungsfreie Datenquelle stellen die zu administrativen Zwecken erhobenen Daten der gesetzlichen Krankenversicherung (GKV) dar, die in den letzten Jahren verstärkt genutzt werden. Mithilfe dieser versichertenbezogen und nach Möglichkeit auch sektorübergreifend erhobenen Daten sind sowohl deskriptive als auch analytische Studien durchführbar. Der Schwerpunkt der bisherigen Nutzung liegt auf der Bereitstellung von Grunddaten zur Morbidität, Inanspruchnahme von Leistungen und Kosten. Diese Angaben erfolgen in der Regel nach soziodemographischen Variablen und ggf. im zeitlichen Trend sowie nach Regionen. Ein weiteres Themenfeld stellt die Evaluation von Interventionen (gesundheitspolitischen Maßnahmen, Gesetzen, Programmen) und die Bewertung der Qualität der Versorgung dar. Erste Studien liegen zu Outcome-Untersuchungen vor. Trotz der inzwischen gewachsenen Akzeptanz und Nutzung der Daten besteht noch eine Reihe methodischer und datentechnischer Herausforderungen: Zu nennen sind hier neben Validierungsstudien die methodischen Anforderungen der analytischen Studiendesigns und die Möglichkeit eines Daten-Linkages mit Primärdaten, um die Erklärungskraft der Untersuchungen zu erhöhen und um Verbindungen zu anderen Datenbeständen wie Register und Surveydaten zu ermöglichen.AbstractConducting health services research requires a wealth of real-life health service data. A source of data which is for the most part free of bias is the data collected for administrative purposes by the statutory health insurance fund. These data have been increasingly used over the past few years. Based on these insuree-related and where possible cross-sector data, descriptive and analytic studies can be conducted. The focus of use thus far has primarily been the generation of basic data on morbidity, the utilization of benefits, and costs. As a rule, this information is presented according to sociodemographic variables and where applicable in terms of temporal trends and according to region. A further domain of interest is the evaluation of interventions (health political measures, legislation, programs) and the assessment of health service quality. Initial outcome studies have been published. Despite the growing acceptance and use of these data, a series of methodological and information technical challenges remain to be addressed: To be mentioned are, in addition to validation studies, the methodological requirements of analytic study designs and the possibility of a data linkage with primary data in order to increase the explanatory power of studies and to facilitate links with other databases such as records and survey data.

Development of indicators for assessing the quality of prescribing of lipid-lowering drugs: data from the pharmacotherapeutic quality circles in Hesse, Germany.

OBJECTIVE To develop indicators based on prescription analysis in order to assess adherence using guidelines and to monitor prescribing behavior. SETTING AND MATERIAL: Eleven pharmacotherapeutic circles (PTC) of the Association of Statutory Health Insurance Physicians (KV Hesse; 10 PTCs including 155 GPs as participants, mostly high prescribers; one circle with 11 moderators trained in pharmacology). These provided a total of 183,997 drug prescriptions involving 54,970 patients (prescriptions reimbursed by the substitute fund--Ersatzkassen--II. quarter 2000); claims form from 151 GPs. On average, 5.1% of the patients with prescriptions received lipid-lowering drugs. METHOD Development and application of indicators based on the guideline for the treatment of hypercholesterolemia developed by a GPs guideline group of the quality circles in Hesse (Hausärztliche Leitliniengruppe Hessen). The ratio of prescribing for primary and secondary prevention was chosen as a top indicator for measuring adherence to the guideline. Prescribing for secondary prevention was assessed by a set of special diagnoses. The second indicator relates to patient groups (here: older than 75 years) where the benefit of prescribing is not clear. Further indicators measure the prescribing of first choice drugs, avoidance of risk combinations and costconscious prescribing. The indicators are presented in the prescription analysis and will be discussed during the circle meeting. RESULTS On average, the moderators prescribed 34% of the lipid-lowering drugs for primary prevention, the GP circle participants 36.7%. On average, moderators and GP participants prescribed lipid-lowering drugs for 4.9% and 7.5% of patients older than 75 years, respectively (6% and 22% in primary prevention). Approximately, 28% of all lipid-lowering drugs issued by the participants involved simvastatin and pravastatin as first-choice drugs compared to 36.5% in the case of the moderators. The prescribing of statins with fibrates or macrolides in combination is seldom. Cost-conscious prescribing can be assessed for each GP by the percentage of generic prescribing and the number of different brands per active agent. Both, moderators and participants used generics when prescribing fibrates, bile acid sequestrants or other types of lipid-lowering drugs (moderators 53.8% and GP participants 78.5%). Three months is too short a period for assessing compliance of lipid-lowering drug prescribing. CONCLUSION It is possible to derive indicators from the guidelines and to integrate them into prescription analysis. The indicators reveal prescribing problems. The evaluation of PTCs in 2002 will involve the use of indicators as an instrument to assess the success in the implementation of guidelines.