Louis Jacob

Risk factors for dementia diagnosis in German primary care practices.

BACKGROUND Dementia is a psychiatric condition the development of which is associated with numerous aspects of life. Our aim was to estimate dementia risk factors in German primary care patients. METHODS The case-control study included primary care patients (70-90 years) with first diagnosis of dementia (all-cause) during the index period (01/2010-12/2014) (Disease Analyzer, Germany), and controls without dementia matched (1:1) to cases on the basis of age, sex, type of health insurance, and physician. Practice visit records were used to verify that there had been 10 years of continuous follow-up prior to the index date. Multivariate logistic regression models were fitted with dementia as a dependent variable and the potential predictors. RESULTS The mean age for the 11,956 cases and the 11,956 controls was 80.4 (SD: 5.3) years. 39.0% of them were male and 1.9% had private health insurance. In the multivariate regression model, the following variables were linked to a significant extent with an increased risk of dementia: diabetes (OR: 1.17; 95% CI: 1.10-1.24), lipid metabolism (1.07; 1.00-1.14), stroke incl. TIA (1.68; 1.57-1.80), Parkinsons disease (PD) (1.89; 1.64-2.19), intracranial injury (1.30; 1.00-1.70), coronary heart disease (1.06; 1.00-1.13), mild cognitive impairment (MCI) (2.12; 1.82-2.48), mental and behavioral disorders due to alcohol use (1.96; 1.50-2.57). The use of statins (OR: 0.94; 0.90-0.99), proton-pump inhibitors (PPI) (0.93; 0.90-0.97), and antihypertensive drugs (0.96, 0.94-0.99) were associated with a decreased risk of developing dementia. CONCLUSIONS Risk factors for dementia found in this study are consistent with the literature. Nevertheless, the associations between statin, PPI and antihypertensive drug use, and decreased risk of dementia need further investigations.

Prevalence of depression in type 2 diabetes patients in German primary care practices

AIMS To analyse depression in German type 2 diabetes patients with or without diabetes complications. METHODS Longitudinal data from nationwide general practices in Germany (n=1,202) were analysed. People initially diagnosed with type 2 diabetes (2004-2013) were identified and 90,412 patients were included (age: 65.5 years, SD: 11.7). The main outcome measure was the first diagnosis of depression (ICD 10: F32, F33) within ten years after index date in patients with and without diabetes complications. Cox proportional hazards models were used to adjust for confounders. RESULTS At baseline, most patients had diabetes complications and 6.4% of them had private insurance. Ten years after type 2 diabetes diagnosis, 30.3% of patients showed symptoms of depression. The prevalence of depression was higher in women than in men (33.7% versus 26.8%), in patients with high HbA1c levels (31.3% when Hb1Ac ≥ 9 versus 27.5% when HbA1c < 7) and in patients with diabetes complications (37.7% when there were more than two complications versus 29.1% when there were no complications). Women and patients without private health insurance were at a higher risk of developing depression. Retinopathy, neuropathy, nephropathy, coronary heart disease, stroke and HbA1c levels higher than 7 were also positively associated with depression. CONCLUSIONS Diabetes complications and high HbA1c levels had a substantial impact on depression in primary care patients with type 2 diabetes.

Impact of metformin on metastases in patients with breast cancer and type 2 diabetes

AIM To analyze the impact of glucose-lowering drugs on metastases in women living in Germany who have been diagnosed with breast cancer (BC) and type 2 diabetes mellitus (T2DM). METHODS Women initially diagnosed with BC (2004-2013) were identified in the IMS Disease Analyzer database. Patients with a documentation of metastases at index date or during the following six months were excluded. We selected T2DM women between 40 and 90years of age who received glucose-lowering therapy (metformin, sulfonylureas, incretins, insulins, other medications). The primary outcome was the diagnosis of metastases recorded in the database between the index date and the end of follow-up. A multivariate Cox regression model was used to predict BC metastases on the basis of patient characteristics and glucose-lowering medication. RESULTS A total of 4,953 women with BC and diabetes were included in the study. The mean age was 71.4years and 4.7% of patients had private health insurance coverage. Mean HbA1C was 7.1% and mean BMI was 30.6kg/m(2). After 5years follow-up, 9.2% of patients with metformin and 12.3% of patients without exhibited metastases (log-rank p-value=0.011), whereas 6.2% of patients with incretins and 11.0% of patients without incretins exhibited metastases (both log-rank p-values <0.001). Metformin (HR=0.73, 95% CI: 0.58-0.92) and incretins (HR=0.62, 95% CI: 0.45-0.84) both significantly decreased the risk of metastases. None of the other variables were significantly associated with diagnosis of metastases. CONCLUSION The use of metformin and incretins in women with T2DM and BC may reduce the risk of metastases.

Hip fracture risk in patients with dementia in German primary care practices.

The aim was to analyze the risk of hip fracture in German primary care patients with dementia. This study included patients aged 65–90 from 1072 primary care practices who were first diagnosed with dementia between 2010 and 2013. Controls were matched (1:1) to cases for age, sex, and type of health insurance. The primary outcome was the diagnosis of hip fracture during the three-year follow-up period. A total of 53,156 dementia patients and 53,156 controls were included. A total of 5.3% of patients and 0.7% of controls displayed hip fracture after three years. Hip fracture occurred more frequently in dementia subjects living in nursing homes than in those living at home (9.2% versus 4.3%). Dementia, residence in nursing homes, and osteoporosis were risk factors for fracture development. Antidementia, antipsychotic, and antidepressant drugs generally had no significant impact on hip fracture risk when prescribed for less than six months. Dementia increased hip fracture risk in German primary care practices.

Changes in Type 2 Diabetes Mellitus Patients in German Primary Care Prior to (2006) and After (2010, 2014) Launch of New Drugs

Aims: The aim was to analyze the changes in a German type 2 diabetes population prior to (2006) and after (2010, 2014) launch of new drugs. Methods: Patients with T2DM in 2006, 2010, and 2014 were recruited for the study. Demographic data included age, gender, and health insurance type (private/statutory). Drug prescription, mean costs per patient, HbA1c levels, macrovascular complications, and time before first insulin prescription were analyzed. Results: In all, 64 098, 77 219, and 85 004 T2DM patients were included for 2006, 2010, and 2014, respectively. The mean age (65.9-66.9 years), proportion of men (50.8%-53.8%), and proportion of patients with private health insurance (6.6%-7.2%) differed significantly for each of the 3 years. There was a 1.25-fold increase in the total costs per patient, linked with an increase in the costs associated with the use of new drugs and a decrease in those associated with the use of old drugs, respectively. HbA1c levels were slightly better regulated in 2014 than in 2006 and 2010. The share of macrovascular complications decreased significantly over time, dropping from 27.4% in 2006 to 24.6% in 2014. The mean duration before first insulin treatment increased from 1225 days in 2006 to 1406 days in 2014. Conclusions: The new drugs analyzed in this study had positive effects on HbA1c levels, macrovascular complications, and mean time before first insulin treatment.

Impact of Disease Management Programs on HbA1c Values in Type 2 Diabetes Patients in Germany

Background: The aim was to analyze the impact of disease management programs on HbA1c values in type 2 diabetes mellitus (T2DM) patients in Germany. Methods: This study included 9017 patients followed in disease management programs (DMPs) who started an antihyperglycemic treatment upon inclusion in a DMP. Standard care (SC) patients were included after individual matching (1:1) to DMP cases based on age, gender, physician (diabetologist versus nondiabetologist care), HbA1c values at baseline, and index year. The main outcome was the share of patients with HbA1c <7.5% or 6.5% after at least 6 months and less than 12 months of therapy in DMP and SC groups. Multivariate logistic regression models were fitted with HbA1c level as a dependent variable and the potential predictor (DMP versus SC). Results: The mean age was 64.3 years and 54.7% of the patients were men. The mean HbA1c level at baseline was equal to 8.7%. In diabetologist practices, 64.7% of DMP patients and 55.1% of SC patients had HbA1c levels <7.5%, while 23.4% of DMP patients and 16.9% of SC patients had HbA1c levels <6.5% (P values < .001). By comparison, in general practices, 72.4% of DMP patients and 65.7% of SC patients had HbA1c levels <7.5%, while 29.0% of DMP patients and 25.4% of SC patients had HbA1c levels <6.5% (P values < .001). DMPs increased the likelihood of HbA1c levels lower than 7.5% or 6.5% after 6 months of therapy in both diabetologist and general care practices. Conclusion: The present study indicates that the enrollment of T2DM patients in DMPs has a positive impact on HbA1c values in Germany.

Prescription Patterns and the Cost of Antihyperglycemic Drugs in Patients With Type 2 Diabetes Mellitus in Germany

Aims: The goals were to analyze prescription patterns and the cost of antihyperglycemic drugs in patients with type 2 diabetes (T2DM) treated in Germany in 2015. Methods: This study included 36382 patients aged 40 years or over treated in general practices (GPs) and diabetologist practices who were diagnosed with T2DM in 2015. Nine different families of antihyperglycemic therapy were included in the analysis. Demographic data included age, gender, and type of health insurance coverage. Clinical data included HbA1c level, body mass index (BMI), and the number of T2DM complications. The annual antihyperglycemic treatment cost per patient was calculated based on pharmacy retail prices. The multivariate regression analysis was fitted to estimate the adjusted treatment cost differences. Results: The percentage of T2DM patients receiving antihyperglycemic treatments was 87.6. This share was slightly higher in men than in women (89.1% vs 86.0%). Interestingly, the share of people treated with antihyperglycemic drugs decreased with age yet increased with HbA1c levels, BMI, and the number of complications. The average annual cost of antihyperglycemic drugs amounted to €498. It was significantly higher in men than in women (difference of €22). It was also significantly higher in individuals with private health insurance coverage than in people with public health insurance coverage (difference of €153). The annual cost decreased with age. It is compelling to note that this cost increased with HbA1c levels and BMI. Finally, the annual cost also increased with the number of complications. Conclusions: The share and the cost of antihyperglycemic treatments vary with gender, age, type of health insurance coverage, HbA1c levels, BMI, and the number of complications.

Treatment of depression in cancer and non-cancer patients in German neuropsychiatric practices

The aim of this study is to analyze the use of antidepressants in German patients with and without cancer.

Persistence With Oral Antihyperglycemic Drugs in Type 2 Diabetes Mellitus Patients With Dementia in Germany

Background: The aim of this study was to analyze the persistence with oral antihyperglycemic drugs in type 2 diabetes mellitus (T2DM) patients with dementia in Germany. Methods: This study included adults with T2DM who were treated with oral antihyperglycemic drugs and were diagnosed with dementia in 1262 German general practices between January 2013 and December 2015 (index date). Dementia cases were matched (1:1) to controls without dementia by age, gender, type of practice, type of residence, physician, and initial antihyperglycemic therapy, using a propensity score method. The primary outcome of the study was the rate of persistence with oral antihyperglycemic drugs in dementia cases and controls without dementia in the year following the index date. Persistence was estimated as therapy time without treatment discontinuation, which was defined as at least 90 days without oral antihyperglycemic therapy. Cox regressions were used to determine the impact of dementia on persistence with oral antihyperglycemic treatment in the entire population and in different subgroups. Results: This study included 848 T2DM patients with dementia and 848 T2DM patients without dementia. In the dementia group, 39.2% of patients were men, while the control group included 40.8% men. After 12 months of follow-up, 72.7% of dementia cases and 71.4% of controls without dementia were persistent (P = .291). No significant association was found between dementia and persistence with oral antihyperglycemic drugs in the entire population and in different subgroups (HR ranging from 0.84 to 1.25). Conclusions: Dementia did not have a significant impact on persistence with oral antihyperglycemic drugs in T2DM patients in Germany.

Psoriasis risk in patients with type 2 diabetes in German primary care practices

AIM To analyze psoriasis risk in type 2 diabetes mellitus (T2DM) patients treated in German primary care practices. METHODS The study included 87,964 T2DM patients aged 40 years or over who received their initial diabetes diagnosis between 2004 and 2013. Patients were excluded if they had been diagnosed with psoriasis prior to diabetes diagnosis or if the observation period prior to the index date was less than 365 days. After applying these exclusion criteria, 72,148 T2DM patients were included. A total of 72,148 non-diabetic controls were matched (1:1) to T2DM cases based on age, gender, type of health insurance (private or statutory), number of medical visits, and index date. The primary outcome was the diagnosis of psoriasis. Skin infections, dermatitis/eczema, hyperlipidemia, and medications associated with psoriasis (beta blockers, angiotensin-converting enzyme (ACE) inhibitors, lithium, antimalarials, nonsteroidal anti-inflammatory drugs, and benzodiazepines) were included as potential confounders. RESULTS The mean age was 68.7 years (SD=12.7 years) and 48.6% of subjects were men. Hyperlipidemia, dermatitis/eczema, and skin infections were more frequent in T2DM patients than in controls. Beta blockers, ACE inhibitors, and nonsteroidal anti-inflammatory drugs were also more commonly used in people with T2DM than in controls. A total of 3.4% of T2DM patients and 2.8% of matched controls developed psoriasis within ten years of follow-up (p-value <0.001). T2DM patients were at a higher risk of developing psoriasis than controls (HR=1.18, 95% CI: 1.08-1.29). CONCLUSION T2DM was positively associated with psoriasis in patients treated in German primary care practices.