[Perceptions of GPs and community pharmacists on hypnotic prescribing on private prescriptions]

BACKGROUND AND AIM

Zolpidem and zopiclone ("Z-drugs") and benzodiazepine hypnotics are reimbursed by the statutory health insurance for short-term use and in exceptional cases for longer periods. A large proportion is prescribed on private prescriptions. The aim of this study was to assess the perceptions of general practitioners (GPs) and community pharmacists (CPs) on private prescriptions of hypnotics regarding frequency, reasons and measures for reduction.

METHODS

A questionnaire was mailed to a random sample of 1,350 GPs and 600 CPs in 2012.  Questions were partly identical. Due to multiple testing, only p-values ≤ 0.01 were considered statistically significant.

RESULTS

458 GPs and 202 CPs returned questionnaires (response 33.9 % and 33.7 %). According to the CPs, the proportions of private prescriptions was higher for Z-drugs than for benzodiazepines (57.5 vs. 47.4 %; p < 0.0001). The proportion of private prescriptions of Z-drugs was higher in the eastern than in the western part of Germany (78.2 vs. 52.3 %; p < 0.0001). For benzodiazepines no such differences were found. As most relevant reasons for private prescriptions, the specifications of the Arzneimittel-Richtlinie and patients' demands were named. Patients with long-term use receive more often private prescriptions.

CONCLUSIONS

A switch to private prescriptions for patients with long-term use seems conflicting, because such patients with (iatrogenic) dependence are indicated exceptional cases. Practicable changes of the regulatory framework are needed, their benefits and harms should be evaluated.

Reduced magnetisation transfer ratio in cognitively impaired patients at the very early stage of multiple sclerosis: a prospective, multicenter, cross-sectional study

OBJECTIVES

Cognitive impairment belongs to the core symptoms in multiple sclerosis (MS) and can already be present at the very early stages of the disease. The present study evaluated cognitive functioning after the first clinical presentation suggestive of MS and brain tissue damage in a non-lesion focused MRI approach by using magnetisation transfer imaging (MTI).

SETTING AND PARTICIPANTS

47 patients (15 men and 32 women; mean age: 31.17 years) after the first clinical event suggestive of MS were recruited in six different MS centres in Germany and underwent a neuropsychological test battery including tests for attention, memory and executive function as well as depression and fatigue. MTI and conventional MRI measures (T1/T2 lesion load) were assessed. In addition, Magnetisation Transfer Ratio (MTR) maps were calculated. Primary outcome measure was the investigation of cognitive dysfunction in very early MS in correlation to MRI data.

RESULTS

55.3% of patients with MS failed at least one test parameter. Specifically, 6% were reduced in working memory, 14.9% in focused attention, 25.5% in figural learning and up to 14.9% in executive function. When the sample was subdivided into cognitively impaired and preserved, MTR scores within the cognitively impaired subgroup were significantly lower compared with the preserved group (t(43)=2.346, p=0.02*). No significant differences between the two groups were found in T2-weighted and T1-weighted lesion volume.

CONCLUSIONS

After the first MS-related clinical event, 55.3% of patients showed distinct cognitive deficits. Cognitively impaired patients had significantly lower whole brain MTR, but no differences in focal brain lesion volumes supporting the idea that early cognitive deficits may be related to diffuse loss of brain tissue integrity.

Mechanisch induziertes Härten*

Seit dem Jahr 2001 wird an der Stiftung Institut für Werkstofftechnik Bremen (IWT) ein neues endwärmebehandlungsfreies Verfahren zur Herstellung von randschichtgehärteten Stahlbauteilen erforscht. Bei diesem Verfahren wird die Randschichthärtung durch eine mechanisch induzierte martensitische Phasenumwandlung in die Fertigungslinie integriert. Neben einer deutlichen Verkürzung der Produktionsdauer wird die lokale Härtung von Funktionsflächen eines Bauteils ermöglicht. Zudem kommt es durch die Einsparung einer abschlieβenden Wärmebehandlung zu einer signifikanten Reduzierung des Energieverbrauchs und der damit verbundenen CO2-Emission.

Um eine spannungs- bzw. dehnungsinduzierte martensitische Phasenumwandlung aufgrund von rein mechanischen Effekten zu ermöglichen, wird zunächst ein bei Raumtemperatur metastabiles austenitisches Gefüge hergestellt. Dieser Werkstoffzustand soll so stabil sein, dass eine spanende Bearbeitung keine ausgedehnte martensitische Phasenumwand-lung auslöst und das Werkstück somit noch “weich” bearbeitet werden kann. In einem anschlieβenden mechanischen Verfahren, wie z. B. einem Festwalzprozess, soll die auf die Werkstückoberfläche ausgeübte Pressung so weit gesteigert werden, dass die zur martensitischen Umwandlung des Austenits benötigte Spannung in der Bauteilrandzone erreicht wird.

Age hardening of forged aluminum components – distortion behavior after gas quenching∗

In quenching of age hardenable aluminum alloys, today predominantly aqueous quenching media are used, which can lead to a non-uniform cooling of the components due to the Leidenfrost phenomenon, and thus to distortion. In relation to the conventional quenching procedures in aqueous media, gas quenching has a number of technological, ecological, and economical advantages. The quenching intensity can be adjusted by the variable parameters gas pressure, gas velocity as well as the kind of gas and thus can be adapted to the requirements of the component. By the higher uniformity and the better reproducibility, gas quenching offers a high potential for reducing distortion. It could be demonstrated that characteristic shape and dimension changes of forged components of the spray formed aluminum alloy DISPAL S232 (Al-17Si-4Fe-3Cu-0.5Mg-0.4Zr) are clearly lower after gas quenching than after water quenching. Thereby suitable processes proved to be high-pressure gas quenching with nitrogen at 10 bar as well as air quenching in a gas nozzle field. Cost saving would be possible, because of reduced distortion and therefore less reworking.

Perceptions of German GPs on benefits and risks of benzodiazepines and Z-drugs

QUESTIONS UNDER STUDY

In many countries newer non-benzodiazepines, zolpidem and zopiclone ("Z-drugs"), are prescribed instead of benzodiazepine hypnotics. This is not supported by current evidence and guidelines. The aim of this study was to compare the perceptions of GPs on the benefits and harms of benzodiazepines and Z-drugs.

METHODS

A questionnaire was mailed to a random sample of 1,350 German GPs between May and June 2012. GPs were asked to rate their perceptions on a five-point Likert scale for 12 items asked for both benzodiazepines and Z-drugs. Wilcoxon signed rank test for paired observations was used for comparison between groups. Due to multiple testing, only p values ≤0.01 were considered statistically significant.

RESULTS

A total of 458 questionnaires were returned (response 33.9%). The mean age of participants was 53.3 years (59.4% males). GPs perceived that Z-drugs were significantly more effective in terms of reduced night-time waking, feelings of being rested on waking and improved daytime functioning than benzodiazepines (p <0.0001 for all comparisons), but not in terms of reduced time to get to sleep and increased total sleep time. All studied side effects were believed to be less often for patients receiving Z-drugs (p <0.0001 for all comparisons). A total of 73.4% and 80.4% answered that tolerance or withdrawal effects on stopping occur often or very often/always for benzodiazepines, whereas these values were only 30.6% and 28.7% for Z-drugs.

CONCLUSIONS

German GPs perceived that Z-drugs were more effective and safer compared to benzodiazepines, which is not supported by current evidence. The results are quite comparable to a British survey conducted seven years before.

Variation in antibiotic prescriptions: is area deprivation an explanation? Analysis of 1.2 million children in Germany

PURPOSE

Inadequate use of antibiotics can lead to problems such as resistance. Overuse is especially a problem for children, since they are more affected by acute (often virus-caused) infections. While the problem has been addressed internationally over the past several years, regional variations in prescriptions are striking. Therefore, the present study aims to analyze regional variations in antibiotic prescription on a district level in Germany and tries to identify reasons for those variations through adding possible influencing factors to the analysis on individual and district levels.

METHODS

We analyzed 1.2 million children insured in a German health insurance fund. Antibiotic prescriptions were quantified in 2010 and reasons for prescriptions were analyzed in multilevel regressions based on the district of residence, regional deprivation, and age and sex of the child.

RESULTS

Thirty-six percent of all children aged 0-17 years received an antibiotic prescription in 2010. In the south, prevalences are generally lower, and also to the very north. The highest prevalences are found in the close-to-border districts in the west, as well as in a band throughout the middle of Germany, in rather low population density areas. Regional variation in the prevalence range from 19 to 53 % between districts. Regional deprivation can explain part of this variation.

CONCLUSIONS

Including area deprivation measures helped identify an influence of especially regional income and occupational deprivation on antibiotic prescriptions for children. Regional analysis such as this can help identify specific regions and groups of persons to address information programs on the risks of preventable antibiotic consumption and alternative treatment methods.

[Prescription of TNF-alpha inhibitors and regional differences in 2010]

Tumor necrosis factor alpha (TNF-α) inhibitors are an important treatment option for rheumatoid arthritis and other chronic inflammatory diseases. However, attention should be paid to severe adverse drug reactions and very high costs of therapy. The objective of this study was to examine the prescription and costs of TNF-α inhibitors as well as regional differences at the district level in Germany. For this purpose, prescription claims data of a German health fund with 9.1 million insured persons from the year 2010 were analyzed. A total of 45,229 packs (0.1% of all prescribed drugs) and 3.15 million defined daily doses (DDD) of TNF-α inhibitors were prescribed. This leads to a total pharmacy revenue of 163.18 million Euro (share 4.1%) and 1 DDD costs on average 51.61 Euro. For 10,078 patients at least one TNF inhibitor was prescribed (prescription prevalence 111 per 100,000) with a higher proportion of women (125 vs. 92 per 100,000). The average revenue per insured person was often higher in districts of eastern Germany (>30 Euro) for reasons unknown. Provided that use is appropriate to indications there are only low saving potentials.

Diabetes prevalence based on health insurance claims: large differences between companies

AIMS

We investigated if there are substantial differences in the prevalence of diabetes between members of different health insurance funds in Germany and, if so, which variables might explain these differences.

METHODS

Ten representative surveys (conducted between 2004 and 2008) of the Bertelsmann Healthcare Monitor, comprising 15 089 participants aged 18-79 years, were analysed. Our main independent variable was membership in one of eight health insurance funds. We first estimated the crude prevalence of diabetes stratified by these funds. We further fitted logistic regression models and stepwise adjusted for age and sex, further co-morbidities and anthropometric measures and factors influencing health awareness and lifestyle.

RESULTS

The overall prevalence of diabetes was 6.9%. Stratified by health insurance funds, prevalences ranged between 3.9% within the Innungskrankenkassen to 11.4% within the Allgemeine Ortskrankenkassen. Adjusting for age and sex only led to minor changes. After controlling for all mentioned variables, these differences remained. Compared with those who were privately insured, persons within the Allgemeine Ortskrankenkassen (OR 1.73; 95% CI 1.30-2.29), the Betriebskrankenkassen (OR 1.54; 95% CI 1.15-2.07) and the Barmer (OR 1.39; 95% CI 1.01-1.91) had a higher prevalence.

CONCLUSIONS

We found considerable differences in diabetes prevalence between German health insurance funds that remained after controlling for several relevant variables.

[Structural differences between health insurance funds and their impact on health services research: results from the Bertelsmann Health-Care Monitor]

AIM

Claims data of health insurance companies are an important database for health services research. We investigated if there are differences in baseline characteristics and prevalence of chronic diseases between members of several health insurance funds in Germany, and if so, whether adjusting for age and sex could explain these differences.

METHODS

10 representative surveys (conducted between 2004 and 2008) of the 'Bertelsmann Health-Care Monitor' comprising 15 089 participants aged 18 to 79 years were analysed. Our main independent variable was membership in one of 8 health insurance funds. The prevalence of self-reported hypertension, diabetes, atopic diseases, coronary heart disease and heart failure was studied. We first estimated the crude prevalence of chronic diseases stratified by these funds. We further fitted logistic regression models and adjusted for age and sex as well as for further comorbidities and health related factors.

RESULTS

Most respondents were insured in the BKK (Betriebskrankenkassen; 20.1%), the AOK (Allgemeinen Ortskrankenkassen; 19.2%) and private health insurances (15.3%). Substantial differences were found according to age, sex, educational level and prevalences of chronic diseases. Stratified by health insurance funds, prevalences ranged between 17.1-29.6% for hypertension, between 3.9-11.4% for diabetes, between 4.3-6.7% for atopic diseases, between 3.4-6.7% for coronary heart disease and between 2.6-5.7% for heart failure. When adjusting for sex and age, estimates for all 5 diseases were significant higher in AOK members compared to privately insured persons (3 diseases within the BAMER and the DAK, accordingly). In total, this was the case for 17 out of 35 comparisons. Even after adjusting for further comorbidities and health related factors 6 out of 35 comparisons showed significant increased estimates compared to privately insured persons.

CONCLUSION

We found considerable differences in the prevalence of chronic diseases between German health insurance funds that remained after controlling for age and sex, and even after adjustment for further health-related variables. Further methodological studies are urgently needed to assess strengths and weaknesses of German claim data.