Ingrid Schubert

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%).

Community Pharmacy–Based Pharmaceutical Care for Asthma Patients

BACKGROUND Despite significant progress in asthma drug therapy in recent years, there has been no major change in asthma morbidity and mortality. It is still important to determine whether pharmaceutical care (PC) influences health outcomes. OBJECTIVE To evaluate the effectiveness of PC with regard to clinical, humanistic, and economic outcomes in adults with asthma. METHODS An intervention study was conducted over 12 months. At baseline, 39 community/retail pharmacies, 84 primary care physicians (general practitioners, internal specialists, chest physicians), and 183 patients (aged 18–65 y) diagnosed with asthma were included. To evaluate economic outcomes, 2 German statutory health insurance funds provided 2 years of claims data for their insured patients (n = 55). A 1:10 matching was carried out to compare the data of this intervention subgroup with those of a control group (n = 550). RESULTS Significant improvements were found for all humanistic outcomes (eg, asthma-specific quality of life, self-efficacy, knowledge, medication adherence). In addition, asthma severity, self-reported symptoms, peak expiratory flow, and patients’ inhalation technique improved. Increases in forced expiratory volume in 1 second and vital capacity were not significant over time. Evaluation of the insurance claims data revealed a shift toward better adherence to evidence-based therapy. CONCLUSIONS The study shows that PC for people with asthma has a positive impact on humanistic and, to some extent, on clinical outcomes. To determine potential economic benefits, future research should focus on patients with more severe asthma.

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.

Adverse events requiring hospitalization within 30 days after outpatient screening and nonscreening colonoscopies.

BACKGROUND The incidence of adverse events (AEs) is a crucial factor when colonoscopy is considered for mass screening, but few studies have addressed delayed and non-GI AEs. OBJECTIVES To investigate the risk of AEs requiring hospitalization after screening and nonscreening colonoscopies compared with control subjects who did not undergo colonoscopy. DESIGN Retrospective matched cohort. SETTING Statutory health insurance fund in Germany. PATIENTS A total of 33,086 individuals who underwent colonoscopy as an outpatient (8658 screening, 24,428 nonscreening) and 33,086 matched controls who did not undergo colonoscopy. INTERVENTIONS Outpatient screening and nonscreening colonoscopies. MAIN OUTCOMES MEASUREMENTS Risk of AEs (perforation, bleeding, myocardial infarction, stroke, splenic injury, and others) requiring hospitalization within 30 days after colonoscopy/index date and risk differences between the group that underwent colonoscopy and the group that did not. RESULTS The incidence of perforation was 0.8 (95% confidence interval [CI], 0.3-1.7) and 0.7 (95% CI, 0.4-1.1) per 1000 screening and nonscreening colonoscopies, respectively. Hospitalizations because of bleeding occurred in 0.5 (95% CI, 0.1-1.2) and 1.1 (95% CI, 0.8-1.7) per 1000 screening and nonscreening colonoscopies, respectively. The incidence of myocardial infarction, stroke, and other non-GI AEs was similar in colonoscopy and control groups. No splenic injury was observed. Those with AEs generally had a higher mean age and comorbidity rate than the overall study population. LIMITATIONS The analysis relies on health insurance claims data. CONCLUSIONS This study provides further evidence of the safety of colonoscopy in routine practice with regard to delayed and non-GI AEs. Hospitalizations because of the investigated AEs were uncommon or rare for both screening and nonscreening colonoscopies.

Prescribing potentially inappropriate medication (PIM) in Germany's elderly as indicated by the PRISCUS list. An analysis based on regional claims data.

The aim of this study was to estimate the prevalence of potentially inappropriate medication (PIM) in the elderly as indicated by Germanys recently published list (PRISCUS) and to assess factors independently associated with PIM prescribing, both overall and separately for therapeutic groups.

Colonoscopy and fecal occult blood test use in Germany: Results from a large insurance-based cohort

BACKGROUND AND STUDY AIMS Colonoscopy and guaiac-based fecal occult blood tests (FOBT) are recommended and offered for colorectal cancer (CRC) screening in Germany. We aimed to explore their utilization in a large insurance-based cohort. PATIENTS AND METHODS Claims data from between 2000 and 2008 were collected for 170493 individuals who were insured by a large health insurance plan in the federal state of Hesse, Germany. The percentages of individuals who had recently utilized CRC screening-related procedures were calculated. Additionally, multiple test use and identification of CRC screening providers were ascertained. RESULTS Following the inception of the current CRC screening program in 2002, colonoscopy utilization rates varied only slightly and FOBT use decreased in individuals aged ≥50 years. At the end of 2008, the age-standardized percentages of individuals who had undergone colonoscopy within ≤10 years were 23% for men and 26% for women. The proportions of individuals who had used FOBT within ≤1 year were 14% for men and 22% for women. Patient education had been utilized by 38% of eligible persons and was increasingly followed by screening colonoscopy. For women, practices that specialized in gynecology were the main providers of FOBT (93%) and patient education (61%). CONCLUSIONS This study provides new insights into the inter-related utilization of colonoscopy, FOBT, and patient education in Germany, and may be particularly informative for the design of strategies to increase CRC screening uptake. It indicates that sex differences in CRC screening test use could result to a large extent from general visits to different types of specialist physicians involved in the CRC screening process.

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.