Do Persons that Changed Health Insurance Differ From those Who did not? The Case of Diabetes

Comparative Analysis of Outpatient Antibiotic Prescribing in Early Life: A Population-Based Study Across Birth Cohorts in Denmark and Germany

INTRODUCTION

Comparing antibiotic prescribing between countries can provide important insights into potential needs of improving antibiotic stewardship programs. We aimed to compare outpatient antibiotic prescribing in early life between children born in Denmark and Germany.

METHODS

Using the Danish nationwide healthcare registries and a German claims database (GePaRD, ~ 20% population coverage), we included children born between 2004 and 2016, and followed them regarding outpatient antibiotic prescriptions until end of enrollment or the end of 2018. We then determined the median time to first antibiotic prescription. Based on all prescriptions in the first 2 years of life, we calculated the rate of antibiotic treatment episodes and for the children's first prescriptions in this period, we determined established quality indicators. All analyses were stratified by birth year and country.

RESULTS

In the 2016 birth cohorts, the median time to first antibiotic prescription was ~ 21 months in Denmark and ~ 28 in Germany; the rate of antibiotic treatment episodes per 1000 person-years was 537 in Denmark and 433 in Germany; the percentage of prescribed antibiotics with higher concerns regarding side effects and/or resistance potential was 6.2% in Denmark and 44.2% in Germany. In the 2016 birth cohorts, the age at first antibiotic prescription was 50-59% higher compared to the 2004 birth cohorts; the rate of antibiotic treatment episodes was 43-44% lower.

CONCLUSIONS

Infants in Denmark received antibiotics markedly earlier and more frequently than in Germany, while quality indicators of antibiotic prescribing were more favorable in Denmark. Although both countries experienced positive changes towards more rational antibiotic prescribing in early life, our findings suggest potential for further improvement. This particularly applies to prescribing antibiotics with a lower potential for side effects and/or resistance in Germany.

The effects of different lookback periods on the sociodemographic structure of the study population and on the estimation of incidence rates: analyses with German claims data

BACKGROUND

Defining incident cases has always been a challenging issue for researchers working with routine data. Lookback periods should enable researchers to identify and exclude recurrent cases and increase the accuracy of the incidence estimation. There are different recommendations for lookback periods depending on a disease entity of up to 10 years. Well-known drawbacks of the application of lookback periods are shorter remaining observation period in the dataset or smaller number of cases. The problem of selectivity of the remaining population after introducing lookback periods has not been considered in the literature until now.

METHODS

The analyses were performed with pseudonymized claims data of a German statutory health insurance fund with annual case numbers of about 2,1 million insured persons. Proportions of study population excluded due to the application of lookback periods are shown according to age, occupational qualification and income. Myocardial infarction and stroke were used to demonstrate changes in incidence rates after applying lookback periods of up to 5 years.

RESULTS

Younger individuals show substantial dropouts after the application of lookback periods. Furthermore, there are selectivities regarding occupational qualification and income, which cannot be handled by age standardization. Due to selective dropouts of younger individuals, crude incidence rates of myocardial infarction and stroke increase after applying lookback periods. Depending on the income group, age-standardized incidence rates changed differentially, leading to a decrease and possible underestimation of the social gradient after applying lookback periods.

CONCLUSIONS

Selectivity analyses regarding age and sociodemographic structure should be performed for the study population after applying lookback periods since the selectivity can affect the outcome especially in health care research. The selectivity effects might occur not only in claims data of one health insurance fund, but also in other longitudinal data with left- or right-censoring not covering the whole population. The effects may also apply to health care systems with a mix of public and private health insurance. A trade-off has to be considered between selectivity effects and eliminating recurrent events for more accuracy in the definition of incidence.

Lower-extremity amputations in people with and without diabetes in Germany, 2008-2012 - an analysis of more than 30 million inhabitants

Background and purpose

Lower-extremity amputations (LEAs) in people with diabetes are associated with reduced quality of life and increased health care costs. Detailed knowledge on amputation rates (ARs) is of utmost importance for future health care and economics strategies. We conducted the present cohort study in order to estimate the incidences of LEA as well as relative and attributable risk due to diabetes and to investigate time trends for the period 2008–2012.

Methods

On the basis of the administrative data from three large branches of German statutory health insurers, covering ~34 million insured people nationwide (about 40% of the German population), we estimated age-sex-standardized AR (first amputation per year) in the populations with and without diabetes for any, major, and minor LEAs. Time trends were analyzed using Poisson regression.

Results

A total of 108,208 individuals (diabetes: 67.3%; mean age 72.6 years) had at least one amputation. Among people with diabetes, we observed a significant reduction in major and minor ARs during 2008–2012 from 81.2 (95% CI 77.5–84.9) to 58.4 (55.0–61.7), and from 206.1 (197.3–214.8) to 177.0 (169.7–184.4) per 100,000 person-years, respectively. Among people without diabetes, the major AR decreased significantly from 14.3 (13.9–14.8) to 11.6 ([11.2–12.0], 12.0), whereas the minor AR increased from 15.8 (15.3–16.3) to 17.0 (16.5–17.5) per 100,000 person-years. The relative risk (RR) comparing the diabetic with the nondiabetic populations decreased significantly for both major and minor LEAs (4% and 5% annual reduction, respectively).

Conclusion

In this large nationwide population, we still found higher major and minor ARs among people with diabetes compared with those without diabetes. However, AR and RR of major and minor LEAs in the diabetic compared with the nondiabetic population decreased significantly during the study period, confirming a positive trend that has been observed in smaller and regional studies in recent years.

[Differences in chronic back pain and joint disorders among health insurance funds : Results of a cross-sectional study based on the data of the Socioeconomic Panel from 2013]

BACKGROUND

Health services research uses increasingly data from health insurance funds. It is well known that the funds differ with regard to sociodemographic characteristics and morbidity. It is uncertain if there are also differences in the prevalence of musculoskeletal disorders.

OBJECTIVE

To compare the sociodemographic characteristics in various health insurance funds and the prevalence of joint disorders and chronic back pain.

METHOD

The 30^th wave (2013) of the German Socioeconomic Panel served as a database. Average age, sex distribution, nationality, education, and employment status were evaluated according to the health insurance funds. The prevalence of joint disorders and chronic back pain were also stratified according to the insurance funds and standardized according to age and sex.

RESULTS

A total of 19,146 participants were included. Most participants (4,934) were insured by AOK, followed by BKK (2,632) and BARMER GEK (2,398). There were huge differences among the health insurance funds with regard to the sociodemographic characteristics. For example, the proportion of unemployed insurants was between 33.3 % (IKK) and 50.6 % (AOK). The prevalence of joint disorders standardized according to age and sex (20.7 %; 95 % CI: 20.1-21.3) was between 17.4 % (95 % CI: 15.8-19.0; PKV) and 22.4 % (95 % CI: 21.1-23.6; AOK). The prevalence of chronic back pain (18.0 %; 95 % CI: 17.4-18.5) was between 13.5 % (95 % CI: 12.2-14.9; PKV) and 20.6 % (95 % CI: 19.4-21.8; AOK).

CONCLUSION

There are differences in the prevalence of musculoskeletal disorders among health insurance funds. The extrapolation of analyses of one health insurance fund to the German population is thus limited.

Excess Mortality After Pelvic Fractures Among Older People

The study aimed to estimate excess mortality in patients aged 60 years or older up to 1 year after pelvic fracture compared with a population without pelvic fracture. In this retrospective population-based observational study, we use routine data from a large health insurance in Germany. For each patient with a first pelvic fracture between 2008 and 2010 (n = 5685 cases, 82% female, mean age 80 ± 9 years), about 34 individuals without pelvic fracture (n = 193,159 controls) were frequency matched by sex, age at index date, and index month. We estimated survival probabilities in the first year after the index date separated for cases (further stratified into inpatient/outpatient treated or minor/major pelvic fractures) and controls using Kaplan-Meier curves. Additionally, time-dependent hazard ratios (HRs) measuring excess mortality in 4-week intervals up to 52 weeks were estimated by fitting Cox regression models including adjustment for relevant confounders. Twenty-one percent of cases and 11% of controls died within 1 year. HRs (95% confidence intervals) decreased from 3.9 (3.5-4.5) within the first 4 weeks to 1.4 (1.1-1.9) within weeks 49 to 52 after the index date. After full adjustment, HRs lowered substantially (3.0 [2.6-3.4] and 1.0 [0.8-1.4]) but were still significantly increased up to week 32. Adjusted HRs in women were lower than in men: 2.8 (2.4-3.2) and 1.0 (0.7-1.4) versus 3.8 (2.9-5.0) and 1.2 (0.6-2.3). We found a clear excess mortality among older people in the first 8 months after pelvic fracture even after full adjustment. Excess mortality was higher among men in the beginning as well as for inpatient-treated persons. Absence of excess mortality was noticed for outpatient-treated persons within the first 3 months. When broken down into site-specific data, excess mortality was no longer significant for most pelvic fractures classified as minor. The only exception was fracture of pubis within the first 4 weeks. © 2017 American Society for Bone and Mineral Research.

Measuring customer preferences in the German statutory health insurance

This paper investigates consumer preferences in the German statutory health insurance market. It further aims to test whether preferences differ by age and health status. Evidence is provided by a discrete choice experiment conducted in 2014 using the six most important attributes in sickness fund competition and ten random generated choice sets per participant. Price is found to be the most important attribute followed by additional benefits, managed care programmes, and distance to nearest branch. Other positive attributes of sickness funds are found to balance out a higher price, which would allow a sickness fund to position itself as high quality. However, significant differences in preferences were found between age and health status group. In particular, compromised health is associated with higher preference for illness-related additional benefits and less distance to the lowest branch, but lower preference for a lower price. Based on these differences, a distinct sickness fund offer could be constructed that would allow passive risk selection.

The number of patients with chronic hepatitis C in times of new therapy options: a retrospective observational study on German health insurance funds data

AIM/OBJECTIVES/BACKGROUND

Chronic hepatitis C (CHC) virus infection is a leading cause of liver-related morbidity and mortality. In Germany, as in many other countries, there is a lack of comprehensive epidemiological data. Routine data from sickness funds can support the estimation of the true prevalence and incidence of CHC.

METHODS

In this article, the results of annual and quarterly analyses of prevalence and incidence for the years 2007-2013 are presented using data of several German sickness funds.

RESULTS

Overall, the prevalence rate remained relatively stable at 0.2%, which is lower than the general assumption for Germany of 0.3%.

CONCLUSION

We found that despite the introduction of the breakthrough designated triple therapies with telaprevir or boceprevir in 2011, there was no increase of prevalence or incidence between 2010 and 2011.

Epidemiology of Pelvic Fractures in Germany: Considerably High Incidence Rates among Older People

Epidemiological data about pelvic fractures are limited. Until today, most studies only analyzed inpatient data. The purpose of this study was to estimate incidence rates of pelvic fractures in the German population aged 60 years or older, based on outpatient and inpatient data. We conducted a retrospective population-based observational study based on routine data from a large health insurance company in Germany. Age and sex-specific incidence rates of first fractures between 2008 and 2011 were calculated. We also standardized incidence rates with respect to age and sex in the German population. Multiple Poisson regression models were used to evaluate the association between the risk of first pelvic fracture as outcome and sex, age, calendar year and region as independent variables. The total number of patients with a first pelvic fracture corresponded to 8,041 and during the study period 5,978 insured persons needed inpatient treatment. Overall, the standardized incidence rate of all first pelvic fractures was 22.4 [95% CI 22.0-22.9] per 10,000 person-years, and the standardized incidence rate of inpatient treated fractures 16.5 [16.1-16.9]. Our adjusted regression analysis confirmed a significant sex (RR 2.38 [2.23-2.55], p < 0.001, men as reference) and age effect (higher risk with increasing age, p < 0.001) on first fracture risk. We found a slight association between calendar year (higher risk in later years compared to 2008, p = 0.0162) and first fracture risk and a further significant association with region (RR 0.92 [0.87-0.98], p = 0.006, Westfalen-Lippe as reference). The observed incidences are considerably higher than incidences described in the international literature, even if only inpatient treated pelvic fractures are regarded. Besides which, non-inclusion of outpatient data means that a relevant proportion of pelvic fractures are not taken into account. Prevention of low energy trauma among older people remains an important issue.

Switching rates in health insurance markets decrease with age: empirical evidence and policy implications from the Netherlands

All consumer groups with specific preferences must feel free to easily switch insurer in order to discipline insurers to be responsive to consumers’ heterogeneous preferences. This paper provides insight into the switching behaviour of low-risks (i.e. young or healthy consumers) and high-risks (i.e. elderly or unhealthy consumers) in the Netherlands in the period 2009–2012. We analysed: (1) administrative data with objective health status information (i.e. medically diagnosed diseases and pharmaceutical use) and information on health care expenses of nearly the entire Dutch population (n=15.3 million individuals) and (2) three-year sample data (n=1152 individuals). Our findings indicate that switching rates strongly decrease with age. For example, in 2009, consumers aged 25–44 switched 10 times more than consumers aged 75 or older. Another finding is that switching rates decrease as the predicted health care expenses increase. Although healthy consumers switch twice as much as unhealthy consumers, this difference becomes much smaller after adjusting for age. We conclude that our findings can be explained by higher perceived switching costs by elderly consumers than by young consumers. Consequently, insurers have low incentives to act as quality-conscious purchasers of care for the elderly consumers. Therefore, strategies should be developed to increase the choice of insurer of elderly consumers.

Mortality in the German Pharmacoepidemiological Research Database (GePaRD) compared to national data in Germany: results from a validation study

Background

Electronic healthcare databases are of increasing importance in health research and mortality is one of the most relevant outcomes. However, data in these databases need to be validated, since they are often generated for reimbursement purposes. The aims of this study were to compare mortality figures from the German Pharmacoepidemiological Research Database (GePaRD) on an aggregated level with external data from the Federal Statistical Office of Germany (FSOG) and to assess consistency of records of death from core data and hospital data within GePaRD.

Methods

The study population comprised insurants of four statutory health insurances providing data for GePaRD with either continuous insurance coverage from January 1^st to December 31^st 2006 or until death. The sex-specific mortality rate, stratified and standardized by age, and the percentage of hospital deaths among all deaths was compared with data from the FSOG. Furthermore, the agreement between the dates of death according to hospital data and core data was assessed within GePaRD.

Results

The study population comprised 12,033,622 insurants. Compared to FSOG data, the age-standardised mortality rate in GePaRD was 21 % and 29 % lower in women and men, respectively. Regional analyses also indicated lower mortality rates in all federal states except for Bremen, where the age-standardised mortality rate was similar to FSOG data for both sexes. The percentage of hospital deaths among all deaths corresponded well with external data. The proportion of inpatient deaths also recorded in the health insurance core data was 98.5 %. Furthermore, 94 % of dates of death documented in hospital agreed with the dates of death according to the health insurance core data.

Conclusions

The lower mortality rates in almost all federal states might result from the higher socioeconomic status of the GePaRD study population compared to the overall population in Germany. In the federal state of Bremen, where socioeconomic representativeness is higher due to additional inclusion of two local health insurances, the mortality rates were in good accordance with external data. Agreement of the percentage of hospital deaths among all deaths between GePaRD and national statistics suggested completeness of outpatient mortality information.