[Systematic analysis of diabetic patient care in Germany]

Personalized diabetes management: what do patients with diabetes mellitus prefer? A discrete choice experiment

BACKGROUND

There are unresolved procedural and medical problems in the care of diabetes, which cause high costs for health systems. These include the inadequate glycemic adjustment, care gaps, therapeutic inertia, and a lack of motivation. Personalized diabetes management can be seen as a kind of "standard process" that provides both physicians and patients with a framework. The aim of this empirical survey is the evaluation of patient preferences regarding personalized diabetes management. The purpose of this experiment is to demonstrate the properties of the programs that are relevant for the choice of insulin-based therapy regimens for patients with type II diabetes mellitus.

METHODS

A discrete choice experiment (DCE) was applied to identify preferences for a personalized diabetes management in patients with type II diabetes mellitus. Six attributes were included. The DCE was conducted in June 2017 using a fractional factorial design, and the statistical data analysis used random effect logit models.

RESULTS

N = 227 patients (66.1% male) were included. The preference analysis showed dominance for the attribute "occurrence of severe hypoglycemias per year" [level difference (LD) 2765]. Preference analysis also showed that participants weight the "risk of myocardial infarction (over 10 years)" (LD 1.854) highest among the side effects. Within the effectiveness criterion of "change in the long-term blood glucose level (HbA1c)" a change at an initial value of 9.5% (LD 1.146) is weighted slightly higher than changes at 7.5% (LD 1.141). Within the random parameter logit estimation, all coefficients proved to be significantly different from zero at the level p ≤ 0.01. The latent class analysis shows three heterogeneous classes, each showing clearly different weights of the therapeutic properties. This results in a clear three-folding: for 1/3 of the respondents the change of the long-term blood sugar (HbA1c value) is the top objective. Another third is solely interested in the short-term effectiveness of the therapy in the sense of the occurrence of severe hypoglycemias per year. The last third of the interviewees finally focuses on the follow-up regarding cardiovascular events. Overall, there were five structural and personality traits which have an influence on the respective probability of the class membership.

DISCUSSION/CONCLUSION

This study identifies and weights the key decision-making criteria for optimal management of diabetes from the perspective of patients. It was shown that the effectiveness of a care program is the most important from the perspective of the patient and avoiding severe a hypoglycemia has the greatest influence on the choice. The risk of myocardial infarction as a follow-up disease and the long-term adjustment of the blood glucose follow the importance. In the analysis of possible subgroup differences by means of latent class analysis, it was found that three preference patterns exist within the sample. The generated preference data can be used for the design of personalized management approaches. It remains open to the extent to which expert opinions and patient preferences diverge.

Prevalence of nephropathy in the German diabetes population-Is early referral to nephrological care a realistic demand today?

In Germany, diabetes mellitus in the general population has increased to ∼8 million people. The implication of this trend for future nephrological care is not well known, as data on this issue are rather limited. Results from different population-based studies suggest that microalbuminuria in diabetic patients is present in 20–30% of the cases. Findings from the diabetes disease management programme in the North-Rhine area revealed the prevalence of chronic kidney disease (CKD) stage II in half of the participants (CKD stage III was present in ∼20%). Only a small proportion of this cohort (∼1–2%) will reach end-stage renal failure, probably due to the excess mortality risks attributed to advanced kidney disease. Results from the QUASI-Niere registry, which reports on renal replacement therapy in Germany, indicate almost constant incidence and prevalence rates of diabetes in the last 5 years (30.6–34.2% and 23.6–27.1%, respectively). The high percentages of early stages of CKD in the diabetes population indicate a potentially high burden of future nephrological care, especially if patients are referred to nephrologists at an early stage. In reality, in nephrological care, bearing this burden is impossible without expanding the resources for this patient group.