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

Epidemiology and health care of hyperhidrosis in Germany: claims data analysis

BACKGROUND AND OBJECTIVES

Data on the population-based epidemiology of hyperhidrosis (HH) are scarce. This study investigated the epidemiology and healthcare of HH in Germany.

DESIGN AND SETTING

Claims data of adult persons insured by a German statutory health insurance (DAK-Gesundheit) between 2016 and 2020 were analysed. Included were persons aged 18 years and older with a diagnosis of HH (confirmed inpatient or outpatient diagnosis in the observation year) who were continuously insured. Following outcomes were measured: prevalence and incidence rates, severity of hyperhidrosis and inpatient and outpatient care by a group of specialists.

RESULTS

In 2020, 0.70% of insured adults were confirmed to have HH (mean age 59.5 years, SD 18.9, 61.6% female), with 9.24% having a 'localised' form, 8.65% a 'generalised' form and 84.80% an 'unspecified' form. 0.04% of the total population had a severe form. The incidence was 0.35%. Localised HH was more common in younger age groups (18 to <30 years), while older age groups (70 to <80 years) were significantly more likely to suffer from generalised HH. Systemic anticholinergics were used in 4.55%, and botulinum toxin injection therapy in 0.81%. General practitioners were most frequently involved in care. Inpatient stays due to HH were very rare, with 0.14% in 2019 and 0.04% in 2020.

CONCLUSION

Multisource data analysis connecting primary and secondary data will be needed for a complete picture of the healthcare and epidemiology of HH.

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Epidemiology, Comorbidity and Risk Factors for Psoriatic Arthritis: a Health Insurance Claims Database Analysis

Psoriatic arthritis is a frequent manifestation of psoriasis, and has a high level of impact on physical functioning, work ability and quality of life. However, there have been few studies of the epidemiology, development of and risk factors for concomitant psoriatic arthritis in patients with psoriasis. This study analysed data from a German public health insurance database of > 2 million individuals. Factors influencing the development of psoriatic arthritis were determined by descriptively analysing comorbidities and Cox regression modelling. The prevalences of psoriasis and psoriatic arthritis were 2.63% and 0.29% in adults (18+ years) and, respectively, 0.30% and 0.01% in children (0–17 years). The proportion of adult patients with incident psoriasis who developed concomitant psoriatic arthritis within five years after diagnosis of psoriasis (mean 2.3 years) was 2.6%. Cardiovascular diseases are the most frequent comorbidity in patients with psoriasis with or without concomitant psoriatic arthritis. Depression and neurosis/stress disorder were identified as indicators for the development of psoriatic arthritis.

Diabetes mellitus and comorbidities - A cross-sectional study with control group based on nationwide ambulatory claims data

As a condition, diabetes mellitus is associated with risk factors and diseases such as obesity. At the same time, cardiovascular diseases are a frequent consequence of diabetes. There have yet to be any findings on the Germany-wide prevalence of diabetes and diabetes comorbidities based on statutory health insurance data. This study estimates the documented prevalence of diabetes in 2019 on the basis of all ambulatory physicians' claims data of German statutory health insurance. In addition, the prevalence of obesity, high blood pressure, coronary heart disease, heart failure, stroke and depression is calculated for diabetes and non-diabetes patients, and the prevalence ratio (PR) is determined as a quotient. The approach used was a case-control design, which assigns a control person without diabetes to each diabetes patient who is similar in terms of age, region and sex. In diabetes patients, a PR greater than 1 was observed for all examined diseases across all age groups, thus demonstrating a higher prevalence compared to persons without diabetes. The highest PR across all age groups for women (3.8) and men (3.7) was found for obesity. In a comparison over time, documented prevalence figures of diabetes in Germany stagnate. With the exception of depression, the documented prevalences of comorbidities correspond well with the prevalences found in population-wide examination surveys.

Renal Replacement Therapy in People With and Without Diabetes in Germany, 2010-2016: An Analysis of More Than 25 Million Inhabitants

OBJECTIVE

Epidemiological studies have shown contradictory results regarding the time trend of end-stage renal disease (ESRD) in people with diabetes. This study aims to analyze the incidence of ESRD, defined as chronic renal replacement therapy (RRT), to investigate time trends among people with and without diabetes in Germany and to examine whether these patterns differ by age and sex.

RESEARCH DESIGN AND METHODS

The data were sourced from nationwide data pooled from two German branches of statutory health insurances covering ∼25 million inhabitants. We estimated age- and sex-standardized incidence rates (IRs) for chronic RRT among people with and without diabetes in 2010-2016 and the corresponding relative risks. Time trends were analyzed using Poisson regression.

RESULTS

We identified 73,638 people with a first chronic RRT (male 60.0%, diabetes 60.6%, mean age 71.3 years). The IR of chronic RRT among people with diabetes (114.1 per 100,000 person-years [95% CI 110.0-117.2]) was almost six times higher than among people without diabetes (19.6 [19.4-19.8]). A consistent decline in IR was observed among people with diabetes (3% annual reduction, P < 0.0001) for both sexes and all age classes. In contrast, no consistent change of IR was identified in people without diabetes. Only among women aged <40 years (P = 0.0003) and people aged ≥80 years (P < 0.0001) did this IR decrease significantly.

CONCLUSIONS

Incidence of chronic RRT remained significantly higher among people with diabetes. The IR decreased significantly in people with diabetes independent of age and sex. Time trends were inconsistent in people without diabetes.

[Epistaxis and anticoagulation therapy: an analysis based on health insurance data from Lower Saxony]

Hintergrund

Die Epistaxis ist ein häufiges Symptom in der Arztpraxis und assoziiert mit verschiedenen Komorbiditäten und Medikamenten, insbesondere Antikoagulanzien. Trotz ihrer Alltäglichkeit gibt es nur wenige Daten zur Häufigkeit ihres Auftretens und möglichen Risikofaktoren.

Methoden

Die Studie untersuchte anhand einer großen Patientenpopulation (AOK Niedersachsen) über 10 Jahre (2007–2016) die Versorgung von Epistaxis in Niedersachsen. Alter bei Diagnose, Begleitmedikation und Komorbiditäten wurden analysiert und die Prävalenz dargestellt.

Ergebnisse

162.167 Versicherte der AOK Niedersachen wurden zwischen 2007 und 2016 aufgrund einer Epistaxis in 308.947 Fällen ärztlich vorstellig. Die meisten Patienten wurden ausschließlich ambulant behandelt (96,6 %). Über den Studienzeitraum stieg die Prävalenz um 21 % (Anstieg von 8,7 auf 9,3 pro 1000 Versicherte/Jahr) bei stabiler Prävalenz für stationäre Vorstellungen (0,2 pro 1000 Versicherte/Jahr). Die höchsten Prävalenzen fanden sich bei Personen bis 20 und über 80 Jahre. In 17,5 % aller Epistaxisfälle wurden Antithrombotika erfasst (9,5 % orale Antikoagulanzien). Über den Studienzeitraum konnte eine erhöhte Verschreibung von Antikoagulanzien (7,7 % in 2007 auf 11,8 % in 2016, insbesondere NOAK) dokumentiert werden.

Schlussfolgerung

Neben der arteriellen Hypertonie, dem männlichen Geschlecht sowie der typischen Altersverteilung bestand auch häufig eine Medikation mit Antikoagulanzien. Über den untersuchten Zeitraum zeigte sich eine Zunahme von Epistaxisfällen bei gleichzeitig ansteigender Verschreibungshäufigkeit von NOAK, nicht jedoch von schweren hospitalisationsbedürftigen Epistaxisfällen. Eine abschließende Beurteilung hinsichtlich eines möglichen kausalen Zusammenhangs muss in weiteren Studien untersucht werden.

Assessment of excess medical costs for persons with type 2 diabetes according to age groups: an analysis of German health insurance claims data

AIM

This cross-sectional study used a large nationwide claims data set to assess the excess medical costs of people with type 2 diabetes according to age group in 2015.

METHODS

Data from 291 709 people with diabetes and 291 709 age- and sex-matched controls were analysed. Total costs (expressed as 2015 euros) of outpatient and inpatient services, medication, rehabilitation, and the provision of aids and appliances were examined. Overall and age-stratified excess costs of people with diabetes were estimated using gamma regression with a log-link.

RESULTS

Overall, the estimated total direct costs of a person with type 2 diabetes are approximately double those of a person without diabetes: €4727 vs. €2196, respectively. Absolute excess costs were approximately the same in all age groups (around €2500), however, relative excess costs of persons with diabetes were much higher in younger (~ 334% for < 50 years) than in older age groups (~ 156% for ≥ 80 years). Regional costs, both absolute and excess, partly differed from the national level.

CONCLUSIONS

This study complements and updates previous studies on the excess medical costs of people with diabetes in Germany. The results indicate the importance of preventing the development of type 2 diabetes, especially in younger age groups. Longitudinal and regional studies examining changes in prevalence and the development of excess costs in groups with different types of diabetes, and according to age, would be of interest to validate our findings and better understand the avoidable burden of having diabetes.

Incidence of stroke in the diabetic compared with the non-diabetic population: A systematic review protocol

People with diabetes have a largely increased risk of stroke compared with people without diabetes. Exact data on incidence of stroke in people with and without diabetes are important for improvements in preventive diabetes care, avoidance of fatal outcomes and as a solid basis for health policy and the economy. However, published data are conflicting, underlining the necessity for this systematic review of population-based studies on incidence, relative risks (RRs) and changes in stroke rates over time. The purpose of our review is to evaluate the incidence of stroke in the diabetic population and its differences with regard to sex, ethnicity, age and regions; to compare the incidence rate (IR) in the diabetic and non-diabetic populations and to investigate time trends. We will perform a systematic literature search in MEDLINE, Embase and LILACS designed by an experienced information scientist. Two review authors will independently screen the abstracts and full texts of all references on the basis of inclusion criteria regarding types of study, types of population and the main outcome. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess IR or cumulative incidence (CumI) and RR of stroke comparing the diabetic and non-diabetic populations. The attributable risk (AR = proportion of stroke among persons with diabetes that is attributable to diabetes) and the population attributable risk (PAR = proportion of stroke in the whole population that is attributable to diabetes) will be considered where available. In conclusion, this review will help to summarize the available evidence for incidence of stroke in the diabetic and nondiabetic population. The publication of this protocol will contribute to making the search strategy, methods, and assessment of reviews transparent and accessible for all involved professional groups.

Changes in incidence of severe hypoglycaemia in people with type 2 diabetes from 2006 to 2016: analysis based on health insurance data in Germany considering the anti-hyperglycaemic medication

AIM

To investigate the incidence of severe hypoglycaemia over the past 10 years, taking into account changes in anti-hyperglycaemic therapy.

METHODS

This retrospective population-based study used German health insurance data. All adults diagnosed with documented type 2 diabetes (extrapolated to the German population: 6.6 million in 2006; 7.9 million in 2011; 8.86 million in 2016) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by Anatomical Therapeutic Chemical (ATC) code.

RESULTS

The event rate for severe hypoglycaemia was 460 per 100 000 people in 2006, 490 per 100 000 in 2011 and 360 per 100 000 in 2016. The proportion of people with severe hypoglycaemia receiving sulfonylureas, as well as receiving combination therapy of metformin and sulfonylureas decreased from 2006 to 2016 (23.6% vs. 6.2%) Among those with severe hypoglycaemia in 2006, there were no prescriptions for dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose co-transporter 2 (SGLT2) agonists. The proportions of people with severe hypoglycaemia receiving DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 agonists in 2011 and 2016 were low. The proportion of people receiving human insulin also decreased (from 11.3% in 2006 to 10.3% in 2011 and 4.3% in 2016); the proportion of people receiving insulin analogues increased from 5.4% in 2006 to 11.5% in 2016. Therapy with mixed insulins was used by 19.7% of people with severe hypoglycaemia in 2006, by 14.0% in 2011 and by 7.3% in 2016. People undergoing therapy with insulin analogues have the highest risk of severe hypoglycaemia adjusted by age, gender, nephropathy diagnosis and year of survey [odds ratio (OR) 14.4, 95% confidence interval (95% CI) 13.5-15.5].

CONCLUSION

The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, and decreased in 2016.

Adjusting selection bias in German health insurance records for regional prevalence estimation

BACKGROUND

Regional prevalence estimation requires epidemiologic data with substantial local detail. National health surveys may lack in sufficient local observations due to limited resources. Therefore, corresponding prevalence estimates may not capture regional morbidity patterns with the necessary accuracy. Health insurance records represent alternative data sources for this purpose. Fund-specific member populations have more local observations than surveys, which benefits regional prevalence estimation. However, due to national insurance market regulations, insurance membership can be informative for morbidity. Regional fund-specific prevalence proportions are selective in the sense that the morbidity structure of a fund's member population cannot be extrapolated to the national population. This implies a selection bias that marks a major obstacle for statistical inference. We provide a methodology to adjust fund-specific selectivity and perform regional prevalence estimation from health insurance records. The methodology is applied to estimate regional cohort-referenced diabetes mellitus type 2 prevalence in Germany.

METHODS

Records of the German Public Health Insurance Company from 2014 and Diagnosis-Related Group Statistics data are combined within a benchmarked multi-level model. The fund-specific selectivity is adjusted in a two-step procedure. Firstly, the conditional expectation of the insurance company's regional prevalence given related inpatient diagnosis frequencies of its members is quantified. Secondly, the regional prevalence is estimated by extrapolating the conditional expectation using corresponding inpatient diagnosis frequencies of the Diagnosis-Related Group Statistics as benchmarks. Model assumptions are validated via Monte Carlo simulation. Variable selection is performed via multivariate methods. The optimal model fit is determined by analysis of variance. 95% confidence intervals for the estimates are constructed via semiparametric bootstrapping.

RESULTS

The national diabetes mellitus type 2 prevalence is estimated at 8.70% with a 95% confidence interval of [8.48%, 9.35%]. This indicates an adjustment of the original fund-specific prevalence from - 32.79 to - 25.93%. The estimated disease distribution shows significant morbidity differences between regions, especially between eastern and western Germany. However, the cohort-referenced estimates suggest that these differences can be partially explained by regional demography.

CONCLUSIONS

The proposed methodology allows regional prevalence estimation in remarkable detail despite fund-specific selectivity. This enhances and encourages the use of health insurance records for future epidemiologic studies.

Social inequality and diabetes mellitus - developments over time among the adult population in Germany

The connection between social disadvantage and the presence of known diabetes and specific risk factors is well documented. This article summarises the results from the Robert Koch Institute examination surveys that were conducted between 1997 and 1999 as well as 2008 and 2011 to address social inequality - operationalised by level of education - with regard to prevalences of known and unknown diabetes, risk of diabetes and care of diabetes as well as their development over time. Both survey periods showed that the low education group has higher prevalences of known and unkown diabetes as well as a higher risk of developing diabetes within the next five years compared to the medium and high education group. Over time, prevalence tended to increase for known diabetes and to decrease for unknown diabetes for all education groups. For the 5-year diabetes risk, only the high education group showed a clear decrease over time. The chosen indicators of diabetes care indicated no clear differences between education groups and an improvement of diabetes care over time. For some indicators of care (foot examination, statins), improvements were only seen in the low education group. In conclusion, social inequalities in the prevalence of known and unknown diabetes as well as in diabetes risk remain in Germany; for the indicators of care, however, no clear education gradient is evident. Over time, inequality regarding the prevalence of diabetes has not increased further. However, with regard to diabetes risk, inequality has become slightly more evident. For individual care indicators, improvements are limited to specific education groups.

Health inequalities in terms of myocardial infarction and all-cause mortality: a study with German claims data covering 2006 to 2015

OBJECTIVES

International comparisons are suggesting that mortality inequalities may have changed in the last years, although not always into the same direction. Only a few studies examined myocardial infarction (MI). In our study, long-term developments of MI and all-cause mortality were considered by analysing social gradients by income.

METHODS

German claims data covering 2006 to 2015 (N = 2,474,448) were used with myocardial infarction and all-cause mortality as outcomes. Socio-economic position was depicted by individual income. Health inequalities were measured by hazard ratios between and within income groups for 10 consecutive calendar years.

RESULTS

In men, income gradients of MI and all-cause mortality were decreasing. In women, no income gradients emerged for MI, and they disappeared in mortality. In men, hazard ratios of MI and mortality decreased in the intermediate and in the lowest income thirds, thus leading to a reduction of MI-related health inequalities.

CONCLUSIONS

Income inequalities in terms of myocardial infarction and of mortality have narrowed in men, and those in the lowest income third were profiting most. No such changes were observed in women.

Health Care Costs Associated With Incident Complications in Patients With Type 2 Diabetes in Germany

OBJECTIVE

The aim of this study is to provide reliable regression-based estimates of costs associated with different type 2 diabetes complications.

RESEARCH DESIGN AND METHODS

We used nationwide statutory health insurance (SHI) data from 316,220 patients with type 2 diabetes. Costs for inpatient and outpatient care, pharmaceuticals, rehabilitation, and nonmedical aids and appliances were assessed in the years 2013-2015. Quarterly observations are available for each year. We estimated costs (in 2015 euro) for complications using a generalized estimating equations model with a normal distribution adjusted for age, sex, occurrence of different complications, and history of complications at baseline, 2012. Two- and threefold interactions were included in an extended model.

RESULTS

The base case model estimated total costs in the quarter of event for the example of a 60- to 69-year-old man as follows: diabetic foot €1,293, amputation €14,284, retinopathy €671, blindness €2,933, nephropathy €3,353, end-stage renal disease (ESRD) €22,691, nonfatal stroke €9,769, fatal stroke €11,176, nonfatal myocardial infarction (MI)/cardiac arrest (CA) €8,035, fatal MI/CA €8,700, nonfatal ischemic heart disease (IHD) €6,548, fatal IHD €20,942, chronic heart failure €3,912, and angina pectoris €2,695. In the subsequent quarters, costs ranged from €681 for retinopathy to €6,130 for ESRD.

CONCLUSIONS

Type 2 diabetes complications have a significant impact on total health care costs in the SHI system, not only in the quarter of event but also in subsequent years. Men and women from different age-groups differ in their costs for complications. Our comprehensive estimates may support the parametrization of diabetes models and help clinicians and policy makers to quantify the economic burden of diabetes complications in the context of new prevention and treatment programs.

[Integration of secondary data into national diabetes surveillance : Background, aims and results of the secondary data workshop at the Robert Koch Institute]

Epidemiological data provide evidence that diabetes mellitus is a highly relevant public health issue in Germany as in many other countries. The Robert Koch Institute (RKI) is in the process of building a national diabetes surveillance system that is aimed at establishing indicator-based public health monitoring of diabetes population dynamics using primary and secondary data. The purpose of the workshop was to conduct an inventory of available secondary data sources and to discuss data contents, data access, data analysis examples in addition to the options for ongoing data use for diabetes surveillance.

[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.

Change in life expectancy with type 2 diabetes: a study using claims data from lower Saxony, Germany

Background

This study estimates life expectancy with and without type 2 diabetes for individuals in Lower Saxony, Germany in order to detect a trend in population health.

Methods

Morbidity and mortality data derived from German administrative claims data (statutory health insurance, AOK Niedersachsen, N = 2,900,065) were used covering 10 years from 2005 to 2014. Life table analysis was applied for calculating life expectancy, life expectancy free of type 2 diabetes, life expectancy with type 2 diabetes, and the proportion of life expectancy free of diabetes to total life expectancy using the Sullivan method.

Results

The total life expectancy increase is stronger in men than in women: At the age of 20, total life expectancy was 55.0 years in 2005 and 56.3 years in 2014 for men, whereas it was 61.7 years in 2005 and 62.5 years in 2014 for women. Decreases in life expectancy without type 2 diabetes were more pronounced in women than in men. Accordingly, life expectancy with type 2 diabetes increased in both women and in men. The proportion of life expectancy without diabetes to total life expectancy decreased, indicating a similar development in both. For example, at the age of 60, the proportion of life expectancy without diabetes to total life expectancy decreased from 0.75 in 2005 to 0.66 in 2014 for men, while it decreased from 0.77 in 2005 to 0.70 in 2014 for women.

Conclusions

Against the background of increasing total life expectancy, the time spent in morbidity increased for the case of type 2 diabetes in Lower Saxony, Germany.

Temporal changes in the prevalence of diagnosed diabetes, undiagnosed diabetes and prediabetes: findings from the German Health Interview and Examination Surveys in 1997-1999 and 2008-2011

AIMS

Nationally representative data on temporal changes in the prevalence of diagnosed diabetes, as well as undiagnosed diabetes and prediabetes, have been lacking in Germany as in most other European countries. We aimed to fill this gap using data from nationwide examination surveys of German adults.

METHODS

The study population comprised 18-79-year-old participants from the German Health Interview and Examination Surveys in 1997-1999 (GNHIES98, n = 6655) and 2008-2011 (DEGS1, n = 7017). Participants were classified as having diagnosed diabetes based on self-reported physician-diagnosed diabetes or the use of anti-diabetes agents. Among those without diagnosed diabetes, HbA1c measures were used to define undiagnosed diabetes [≥ 48 mmol/mol (≥ 6.5%)] or prediabetes [39-47 mmol/mol (5.7-6.4%)].

RESULTS

Although the age- and sex-standardized prevalence of total diabetes remained stable between 1997-1999 at 9.3% (95% CI 8.3-10.5%) and 2008-2011 at 9.2% (8.3-10.3%), the prevalence of diagnosed diabetes increased from 5.6% (4.9-6.3%) to 7.2% (6.5-8.0%), whereas the prevalence of undiagnosed diabetes decreased from 3.8% (3.1-4.6%) to 2.0% (1.5-2.7%), resulting in a decreased proportion of undiagnosed diabetes (40.9% vs. 21.7%). Over the same period, the prevalence of prediabetes decreased from 27.7% (25.6-29.8%) to 20.8% (18.2-23.7%). Observed temporal changes were not explained by changes in BMI, sport activity and educational level.

CONCLUSIONS

The two nationwide surveys indicate a shift from undiagnosed to diagnosed diabetes. However, the unchanged prevalence of total diabetes and the considerably high proportion of prediabetes strongly call for a continued and concerted effort in diabetes prevention among German adults.

Overutilization of ambulatory medical care in the elderly German population?--An empirical study based on national insurance claims data and a review of foreign studies

BACKGROUND

By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healthcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008.

METHODS

The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases.

RESULTS

Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent.

CONCLUSION

We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.

Incidence of Tube Feeding in 7174 Newly Admitted Nursing Home Residents With and Without Dementia

BACKGROUND

Tube feeding is a common form of long-term nutritional support, especially for nursing home residents, of whom many have dementia.

OBJECTIVE

Estimating the incidence of feeding tube placement in nursing home residents with and without dementia.

METHODS

Using claims data, we studied a cohort of newly admitted nursing home residents aged 65 years and older between 2004 and 2009. Analyses were stratified by dementia. We estimated incidence rates and performed multivariate Cox regression analyses.

RESULTS

The study cohort included 7174 nursing home residents. Over a mean follow-up of 1.3 years, 273 people received a feeding tube. The incidence per 1000 person-years was 28.4, with higher estimates for patients with dementia. When adjusting for age, sex, and level of care as a time-dependent covariate, influence of dementia decreased to a nonsignificant hazard ratio.

CONCLUSION

It seems that not dementia itself but the overall clinical condition might be a predictor of tube feeding placement.

Direct costs in impaired glucose regulation: results from the population-based Heinz Nixdorf Recall study

OBJECTIVE

For the first time, this population-based study sought to analyze healthcare utilization and associated costs in people with normal fasting glycemia (NFG), impaired fasting glycemia (IFG), as well as previously undetected diabetes and previously diagnosed diabetes linking data from the prospective German Heinz Nixdorf Recall (HNR) study with individual claims data from German statutory health insurances.

RESEARCH DESIGN AND METHODS

A total of 1709 participants of the HNR 5-year follow-up (mean age (SD) 64.9 (7.5) years, 44.5% men) were included in the study. Age-standardized and sex-standardized healthcare utilization and associated costs (reported as € for the year 2008, perspective of the statutory health insurance) were stratified by diabetes stage defined by the participants' self-report and fasting plasma glucose values. Cost ratios (CRs) were estimated using two-part regression models, adjusting for age, sex, sociodemographic variables and comorbidity.

RESULTS

The mean total direct healthcare costs for previously diagnosed diabetes, previously undetected diabetes, IFG, and NFG were €2761 (95% CI 2378 to 3268), €2210 (1483 to 4279), €2035 (1732 to 2486) and €1810 (1634 to 2035), respectively. Corresponding age-adjusted and sex-adjusted CRs were 1.53 (1.30 to 1.80), 1.16 (0.91 to 1.47), and 1.09 (0.95 to 1.25) (reference: NFG). Inpatient, outpatient and medication costs varied in order between people with IFG and those with previously undetected diabetes.

CONCLUSIONS

The study provides claims-based detailed cost data in well-defined glucose metabolism subgroups. CRs of individuals with IFG and previously undetected diabetes were surprisingly low. Data are important for the model-based evaluation of screening programs and interventions that are aimed either to prevent diabetes onset or to improve diabetes therapy as well.

Prevalence, incidence and concomitant co-morbidities of type 2 diabetes mellitus in South Western Germany--a retrospective cohort and case control study in claims data of a large statutory health insurance

Background

Type 2 diabetes mellitus (T2DM) has become a world-wide epidemic. This chronic metabolic disease has a major impact on life expectancy and on quality of life. The burden of this disease includes a number of co-morbidities. However, estimates of prevalence, incidence and associated diseases as well as the current temporal development and regional differences are largely missing for South Western Germany.

Methods

Lifetime diagnosis-based prevalence, incidence and presence of concomitant co-morbidities were examined between the years 2007 and 2010 in the claims data set of all insured persons of the AOK Baden-Wuerttemberg, a large statutory health insurance. The analysis was based on the respective WHO-ICD-10 codes. Data were standardized for age and sex on the residential population of about 10 million inhabitants of South Western Germany.

Results

The total study cohort involved approximately 3.5 million persons each year. The standardized diagnosis-based prevalence (SDP) of T2DM rose from 6.6 %, 7.4 %, 8.0 %, up to 8.6 % in the years 2007 to 2010. Yearly SDP was between 14.0 % and 18.9 % at an age range of 60 to 64 years and between 26.7 % and 31.8 % at an age of 75 years or older. In the year 2010 the regional distributions of standardized diagnosis-based prevalence were between 7.6 % and 11.6 %, respectively. Incidence rates were 8.3 in 2008, 7.8 in 2009, and 8.7 in 2010 (all rates per 1000). The excess disease risk (odds ratio) of T2DM was for adiposity 2.8 to 3.0, hypertension 2.4 to 3.7, coronary heart disease 1.8 to 1.9, stroke 1.7 to 1.8, renal insufficiency 2.8 to 3.4, and retinopathy 2.8 to 2.9 in the years 2007 to 2010. These co-morbidities appeared several years earlier compared to the non-diabetic population.

Conclusions

T2DM is common and increasing in South Western Germany. In particular a quarter of the population in higher ages was afflicted by T2DM. Interestingly a region-specific pattern was observed as well as an increase in numbers during earlier years in life. Our data underline the need for diabetes awareness programmes including early diagnosis measures as well as structured and timely health surveys for major diseases such as T2DM and its concomitant co-morbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2188-1) contains supplementary material, which is available to authorized users.

Healthcare utilization of people with type 2 diabetes in Germany: an analysis based on health insurance data

AIMS

This population-based study assesses the healthcare utilization of people with Type 2 diabetes by analysing routine data from Allgemeine Orts-Krankenkasse (AOK), the largest statutory health insurance provider in Germany.

METHODS

Anonymized billing data from all AOK-insured persons with at least one day of insurance during the evaluation year 2010 were analysed. Treatment and cost data from all areas of inpatient and outpatient care were available, as was information regarding patient age and sex. International Classification of Diseases (ICD-10) diagnosis and Anatomical Therapeutic Chemical (ATC) classification were used to identify 2.7 million insured persons with diabetes.

RESULTS

The age- and sex-standardized prevalence of Type 2 diabetes was 9.8%. Of those patients identified, 33.9% had at least one diabetes-related complication and 83.0% had a diagnosis of hypertension. Almost two-thirds (63.1%) received antihyperglycaemic medication. Metformin and sulfonylurea were prescribed most often; medications without proof of benefit in endpoint studies were prescribed much less frequently. People without diabetes were admitted to hospital only half as often as those with Type 2 diabetes. The projected total expenditure in Germany for all people with Type 2 diabetes amounted to approximately €33.3 billion in 2010.

CONCLUSIONS

This study shows an increase in both the prevalence of diabetes and treatment costs. The majority of people with Type 2 diabetes were aged 70 years or older. One third of this group has diabetes-related complications. Antihyperglycaemic medications without proof of benefit in endpoint studies were prescribed much less frequently than drugs with proof of benefit.

[Differences in sociodemographic characteristics, health, and health service use of children and adolescents according to their health insurance funds]

Differences in the socioeconomic characteristics and morbidity between members of German private and statutory health insurance funds and also between several statutory health insurances have been shown for adults. We used data from the National Health Survey for Children and Adolescents (KiGGS) to study differences in sociodemographic characteristics, health risks, morbidity, and health service use in child and adolescent insurants of different types of health insurance funds (Ersatzkasse, Allgemeine Ortskrankenkasse, Betriebskrankenkasse , Innungskrankenkasse, other statutory health insurance funds, private health insurance). Differences in the proportion of respondents with a migration background, somatic diseases, psychopathological problems, and contact with a dentist between the different health insurance fund types were found. These results should be considered in studies on health inequalities, which often focus solely on differences between statutory and private health insurance. Our results are also of relevance for health services research using the claims data of health insurance funds.

Institutionalization in incident dementia cases in comparison to age- and sex- matched controls: a 5-year follow-up from Germany

BACKGROUND

Dementia is a main reason for nursing home admission. Information on institutionalization is often based on studies of limited methodological quality. We aimed to analyze time until nursing home admission since first coding of dementia diagnosis and factors associated with institutionalization in incident dementia patients compared to non-demented controls.

METHODS

We analyzed claims data of a German Health insurance company including a cohort of 1,440 patients with a first diagnosis of dementia and 6,988 age- and sex-matched controls aged 65 years and older. The follow-up was up to 5 years. We used Kaplan-Meier analysis for examining time until nursing home admission and cox regression for estimating crude and adjusted Hazard ratios.

RESULTS

Dementia patients and controls were on average 78 years and about 55 % were males. The mean time to nursing home admission was 4.0 years in patients with dementia and 4.6 years for controls. After the 5-years observation-period 62.7 % (95 % CI 59.0-66.1) of dementia patients still lived in the community in comparison to 86.2 % (95 % CI 85.2-87.2) of controls. Cox regression models show that the risk for institutionalization is 3.45 (95 % CI 3.05-3.90) times higher in dementia patients in comparison to controls when adjusted for sex, age, and comorbidity.

CONCLUSIONS

Our analysis shows a significant influence of dementia on institutionalization in comparison to age- and sex-matched controls, especially in the youngest age groups. Hence, the results add substantial information on the disease progression of dementia and are, therefore, of great importance for health-care as well as long-term care planning.

Prevalence of dementia in nursing home and community-dwelling older adults in Germany

BACKGROUND/AIM

We compared the prevalence of dementia in nursing home residents and community-dwelling older adults .

METHODS

Using health insurance claims data for the year 2009, we estimated the prevalence of at least three of four quarters with a diagnosis of dementia in persons aged ≥65 years.

RESULTS

Of 213,694 persons aged 65+ years, 4,584 (2.2 %) lived in nursing homes. The prevalence of dementia was 51.8 % (95 % CI 50.4-53.3) in nursing home residents and 2.7 % (95 % CI 2.6-2.8) in community-dwelling elderly. Increasing prevalences with age were found in both sexes in community-dwelling elderly. These trends were not seen in nursing home residents where prevalences were already high for the age group 65-69 years (35.7 % in males and 40.9 % in females, respectively).

CONCLUSIONS

More than half of nursing home residents suffer from dementia, which is about 19-fold higher than the prevalence in insured living in the community.

[Prevalence and temporal trend of known diabetes mellitus: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

The first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1, 2008-2011) allows for up-to-date, representative prevalence estimates of known diabetes amongst the 18- to 79-year-old resident population of Germany. Temporal trends can be shown by comparing the survey findings with those of the "German National Health Interview and Examination Survey 1998" (GNHIES98). The definition of known diabetes was based on self-reports in physician-administered interviews that asked respondents if they had ever been diagnosed with diabetes by a doctor or were on anti-diabetic medication. Overall, diabetes had been diagnosed in 7.2 % of the adults (7.4 % of the women; 7.0 % of the men). The prevalence increased substantially with advancing age and was higher in persons of low than of high socioeconomic status. Prevalence varied depending on the type of health insurance held and was highest amongst those insured with AOK health insurance funds. In comparison with GNHIES98, there was a 38 % increase in prevalence, of which approximately one third is to be attributed to demographic ageing. In the context of other nationwide studies, the results indicate a figure of at least 4.6 million 18- to 79-year-olds having been diagnosed with diabetes at some point. Planned analyses of undiagnosed diabetes will contribute to the interpretation of the observed increase in the prevalence of known diabetes. An English full-text version of this article is available at SpringerLink as supplemental.

[How "representative" are SHI (statutory health insurance) data? Demographic and social differences and similarities between an SHI-insured population, the population of Lower Saxony, and that of the Federal Republic of Germany using the example of the AOK in Lower Saxony]

Using data obtained from a statutory health insurance (AOK) in the federal state of Lower Saxony, this study examined whether there were differences between the insured population compared with that of Lower Saxony (Niedersachsen) and of Germany with respect to social structural characteristics. Data for the comparisons were provided by the statistical office of Germany, and all datasets were coded according to the same criteria. The differences in gender distribution and age distribution between the AOK, Lower Saxony, and Germany were small. The share of employed individuals among the insured compared with those of Lower Saxony and Germany did not differ for males, but it was lower in women. In the insured population a higher proportion of individuals had lower qualification levels than in Lower Saxony or in Germany; the number of individuals with higher qualifications was, however, sufficient to permit statistical analyses. There were differences in the distributions of social structural characteristics between the health insurance population on the one hand and the populations of Lower Saxony and of Germany on the other. Due to the high number of cases, it is nevertheless possible to analyze associations between social structural variables, health impairments, and patterns of health care utilization.

Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany

After acquiring a varicella virus infection, the virus can reactivate and cause herpes zoster (HZ)--a painful skin rash. A complication of HZ is long-term persistence of pain after the rash has resolved (so-called postherpetic neuralgia, PHN). We aimed to describe the epidemiology of HZ/PHN and to estimate HZ/PHN-related costs in the German statutory health insurance (SHI) system (~85% of the total population). Treatment data of one large SHI was utilized, containing data on approximately 240,000 insured and their utilisation of services in 2004-2009. Identification of HZ- and PHN-cases was performed based on 'International Statistical Classification of Diseases' and specific medications using a control-group design. Incidences per 1,000 person-years (PY) and cost-of-illness for 1 year following HZ-onset considering the payer and societal perspective were calculated. All amounts were inflated to 2010 Euros. Population-figures were standardised and extrapolated to the total SHI-population in Germany in 2010. A mean annual incidence of 5.79 HZ-cases per 1,000 PY was observed, translating into an estimated 403,625 HZ-cases per year in the total SHI-population. Approximately 5% of HZ-cases developed PHN. One HZ-case caused on average euro 210 and euro 376 of costs from the payer and societal perspective, respectively. The development of PHN generated additional costs of euro 1,123 (euro 1,645 societal perspective). Total annual HZ/PHN-related costs were estimated at euro 182 million (euro 105 million) to society (payer). HZ and PHN place a considerable burden on the German SHI-system. Since HZ-vaccines will soon be available, a health-economic evaluation of these vaccines should be conducted.

Impact of diabetes on costs before and after major lower extremity amputations in Germany

AIMS

To compare direct medical costs 1 year before up to 3 years after first major lower extremity amputation (LEA) between patients with and without diabetes.

METHODS

We used health insurance claims data and included patients with a first major LEA between 2005 and 2009. Costs for hospitalization, rehabilitation, outpatient care, outpatient drug prescriptions, non-physician services, durable medical equipment and long-term care were assessed. We estimated cost ratios (CR) for diabetes status using generalized linear models adjusted for age, sex, amputation level, care dependency as well as observation time and mortality within the corresponding period and costs before LEA.

RESULTS

We included 444 patients with first major LEA (58.3% had diabetes), 71.8% were male and the average age was 69.1 years. Total mean costs for 1 year before LEA were higher in patients with diabetes (24,504 vs. 18,961 Euros), which was also confirmed by the multivariate analysis (CR: 1.27; 95% CI: 1.06-1.52). Costs up to 24 weeks after LEA were virtually the same in both groups (36,686 vs. 35,858 Euros), but thereafter differences increase again with higher costs for diabetics. Costs for 3 years after LEA were 115,676 vs. 92,862 Euros, respectively (CR: 1.26; 95% CI: 1.12-1.42). Hospitalizations accounted for more than 50% of total costs irrespective of diabetes status and period.

CONCLUSIONS

Costs up to 24 weeks after first major LEA are mainly driven by the amputation itself irrespective of diabetes. Thereafter, costs for diabetic patients were higher again, which underlines the importance of studying long-term costs.

Impact of safety warnings on antipsychotic prescriptions in dementia: nothing has changed but the years and the substances

Dementia patients suffering from behavioral and psychological symptoms (BPSD) are often treated with antipsychotics. Trial results document an increased risk for serious adverse events and mortality in dementia patients taking these agents. Furthermore, the efficacy of treating BPSD with antipsychotics seems to be only modest. Using data of a German statutory health insurance company, we examined prescription trends of antipsychotics in prevalent dementia patients in the context of official warnings. The study period is 2004-2009. We studied trends in demographics, age and sex, as well as need of care and the intake of typical and atypical antipsychotics. Seeking for linear trends adjusted for age, sex and level of care between 2004 and 2009, we obtained p-values from a multivariate logistic regression. Prescription volumes were calculated by number of packages as well as defined daily doses (DDDs) using multiple linear regressions for trends in prescriptions amount. We included 3460-8042 patients per year (mean age 80 years). The prescription prevalence of antipsychotics decreased from 35.5% in 2004 to 32.5% in 2009 (multivariate analysis for linear trend: p=0.1645). Overall prescriptions for typical antipsychotics decreased (from 27.2% in 2004 to 23.0% in 2009, p<0.0001) and prescriptions for atypical antipsychotics increased from 17.1% to 18.9% (p<0.0001). The mean DDD per treated patient increased from 80.5 to 91.2 (2004-2009; p=0.0047). Our findings imply that warnings of international drug authorities and manufacturers against adverse drug events in dementia patients receiving antipsychotics did not impact overall prescription behavior.

Psychopharmacological treatment in children and adolescents with autism spectrum disorders in Germany

Data on psychopharmacological treatment of individuals with autism spectrum disorder (ASD) are scarce, especially for European countries. This study evaluated psychopharmacotherapy utilisation in children and adolescents with a diagnosis of ASD in Germany. Data of a large statutory health insurance company were analysed and outpatients aged 0-24 years with a diagnosis of ASD during a 1-year-period (2009) were identified. For this cohort, the prescription of psychopharmacotherapy was evaluated. Aditionally, we analysed time trends in prescriptions from 2004 to 2009. One thousand one hundred twenty-four patients (75.4% male; mean age: 11.1 years) matched the inclusion criteria. The prevalence of ASD was 0.37% in males and 0.12% in females, respectively. Of all ASD patients, 33.0% were prescribed psychotropic drugs in 2009. 12.5% of ASD patients were treated with stimulants or atomoxetine, 11.7% with antipsychotics, 9.1% with antiepileptics, 6.8% with benzodiazepines, and 3.8% with antidepressants/SSRI. Regarding substances, methylphenidate (24.4% of all psychotropic prescriptions), risperidone (13.3%) and valproate (9.1%) were most frequently prescribed. Psychopharmacologic treatment prevalence was age-related and increased from 16.3% in individuals aged 0-4 years to 55.1% in 20-24 year olds. From 2004 to 2009, the proportion of ASD patients treated with psychotropic drugs rose from 25.9% to 33.0%. This naturalistic study furnishes evidence that the proportion of ASD patients treated with psychotropic drugs has grown considerably in Germany over the least years, with methylphenidate and risperidone being the most frequently prescribed substances. Compared with data from the USA, the proportion of ASD patients with psychopharmacological treatment is noticeably lower in Germany.

Prevalence, comorbidities and outpatient treatment of anorexia and bulimia nervosa in German children and adolescents

OBJECTIVE

This study aimed at investigating the prevalence, psychiatric comorbidity and outpatient treatment in a sample of German children and adolescents with eating disorders (EDs).

METHOD

Data of a large German statutory health insurance company were analysed and outpatients aged between 10 and 21 years with an ED diagnosis in 2009 were identified.

RESULTS

Of 248,558 insured children and adolescents, 1,404 patients (79.9 % females, mean age: 16.7; SD: 3.3 years) matched the inclusion criteria. The large majority of patients with anorexia nervosa (AN) and bulimia nervosa (BN) were females (94.7 and 92.7 %), on which we focus in the following analyses. The prevalence in females was 0.28 % (AN) and 0.20 % (BN). Psychiatric comorbidity was diagnosed in 59.8 % (AN) and 64.1 % (BN) of patients, respectively. Most patients were treated with psychotherapy (AN: 75.7 %, BN: 78.5 %), 16.4 % (AN) and 20.2 % (BN) of our patients received pharmacotherapy with either antidepressants or antipsychotics. 23.5 % (AN) and 21.1 % (BN) received no treatment with psychotherapy, antidepressants or antipsychotics.

DISCUSSION

This naturalistic study suggests that in young ED outpatients, EDs seem to be underdiagnosed and treatment does not necessarily comply with current guidelines. Therefore, dissemination of state-of-the-art knowledge on diagnosis and treatment in children and adolescents with EDs constitutes an important educational goal.

Type 2 diabetes: prevalence and relevance of genetic and acquired factors for its prediction

BACKGROUND

The epidemiology of type 2 diabetes in Germany is of major societal interest, as is the question of the predictive value of genetic and acquired risk factors.

METHODS

We present clinically relevant aspects of these topics on the basis of a selective review of pertinent literature retrieved by a PubMed search that centered on population-based studies.

RESULTS

The German Health Interview and Examination Survey for Adults (Studie zur Gesundheit Erwachsener in Deutschland [DEGS1], 2008-2011) revealed that diabetes was diagnosed in 7.2% of the population aged 18 to 79 years (women 7.4%, men 7.0%). These figures are two percentage points higher than those found in the preceding national survey (1998). The percentage of cases that were not captured by these surveys is estimated at 2% to 7% depending on the method. Independently of personal factors (the individual's life style), it seems that living in a disadvantaged region characterized by high unemployment, air pollution, and poor infrastructure raises the risk of diabetes. Moreover, type 2 diabetes has a substantial hereditary component. More than 60 genetic regions have been identified to date that affect the risk of type 2 diabetes, yet all of them together account for only 10% to 15% of the genetic background of the disease.

CONCLUSION

The prevalence of type 2 diabetes in Germany has risen in recent years. The discovery of new genetic variants that confer a higher risk of developing the disease has improved our understanding of insulin secretion in diabetes pathogenesis rather than the prediction of individual diabetes risk ("personalized medicine").

Incidence estimate and guideline-oriented treatment for post-stroke spasticity: an analysis based on German statutory health insurance data

Background

Spasticity after stroke has been internationally recognized as an important health problem causing impairment of mobility, deformity, and pain. The aim of this study was to assess the frequency of first-ever and recurrent stroke and of subsequent spastic and flaccid paresis. Factors influencing the development of spasticity were analyzed. A further major aim was to provide a “real-life” assessment of the treatment of spasticity in Germany and to discuss this in view of the treatment recommended by German and international clinical guidelines.

Methods

The database used in this study comprised a cohort of 242,090 insurants from a large statutory health insurance fund in the federal state of Hesse, Germany. A first hospital discharge diagnosis in 2009 with any of the International Classification of Diseases, Tenth Revision (ICD-10) codes I60–I64 was used to identify patients with acute stroke (hemorrhage and ischemic). These patients were followed up six months after stroke to monitor whether they developed spastic or flaccid paresis (hospital or ambulatory care diagnoses ICD-10 code G81–G83 [excluding G82.6/G83.4/G83.8]). For patients with spastic paresis after stroke the spasticity treatment was analyzed for a six-month period (physiotherapy, oral muscle relaxants, intrathecal baclofen, and botulinum toxin).

Results

Standardized to the population of Germany, 3.7 per 1000 persons suffered a stroke in 2009 (raw 5.2/1000). Of all surviving patients, 10.2% developed spasticity within 6 months. Cox regression revealed no significant influence of patient age, gender, morbidity (diabetes, hypertensive diseases, ischemic heart diseases) or type of stroke on development of spasticity. 97% of surviving patients with spasticity received physiotherapy (inpatient care 89%, ambulatory care 48%). Oral muscle relaxants were prescribed to 13% of the patients. No patient received intrathecal baclofen or botulinum toxin.

Conclusion

Claims data enabled analysis of the occurrence of stroke and post-stroke spasticity. These data provide insight into real-life treatment for spasticity in Germany. The proportion of patients who receive physiotherapy, which is the international guideline-recommended basic therapy after transition into ambulatory care, can be improved on. Botulinum toxin as an international guideline-based treatment option for focal spasticity has not been implemented in practice in Germany as yet.

Prevalence and comorbidity of diabetes mellitus among non-institutionalized older adults in Germany - results of the national telephone health interview survey 'German Health Update (GEDA)' 2009

Background

Despite the major public health impact of diabetes, recent population-based data regarding its prevalence and comorbidity are sparse.

Methods

The prevalence and comorbidity of diabetes mellitus were analyzed in a nationally representative sample (N = 9133) of the non-institutionalized German adult population aged 50 years and older. Information on physician-diagnosed diabetes and 20 other chronic health conditions was collected as part of the national telephone health interview survey ‘German Health Update (GEDA)’ 2009. Overall, 51.2% of contacted persons participated. Among persons with diabetes, diabetes severity was defined according to the type and number of diabetes-concordant conditions: no diabetes-concordant condition (grade 1); hypertension and/or hyperlipidemia only (grade 2); one comorbidity likely to represent diabetes-related micro- or macrovascular end-organ damage (grade 3); several such comorbidities (grade 4). Determinants of diabetes severity were analyzed by multivariable ordinal regression.

Results

The 12-month prevalence of diabetes was 13.6% with no significant difference between men and women. Persons with diabetes had a significantly higher prevalence and average number of diabetes-concordant as well as diabetes-discordant comorbidities than persons without diabetes. Among persons with diabetes, 10.2%, 46.8%, 35.6% and 7.4% were classified as having severity grade 1–4, respectively. Determinants of diabetes severity included age (cumulative odds ratio 1.05, 95% confidence interval 1.03-1.07, per year) and number of discordant comorbidities (1.40, 1.25-1.55). With respect to specific discordant comorbidities, diabetes severity was correlated to depression (2.15, 1.29-3.56), respiratory disease (2.75, 1.72-4.41), musculoskeletal disease (1.53, 1.06-2.21), and severe hearing impairment (3.00, 1.21-7.41).

Conclusions

Diabetes is highly prevalent in the non-institutionalized German adult population 50 years and older. Diabetes comorbidities including diabetes-concordant and diabetes-discordant conditions need to be considered in epidemiological studies, in order to monitor disease burden and quality of diabetes care. Definitional standards of diabetes severity need to be refined and consented.

Prevalence and comorbidities of adolescent depression in Germany. An analysis of Health Insurance Data

OBJECTIVE

Data on the prevalence of depressive disorders in adolescents are scarce. We aimed to examine the administrative prevalence of depressive disorders and related comorbidities in German adolescents. A second objective of was to assess potential regional (East vs. West Germany) differences in depression prevalence.

METHOD

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years of age with diagnosed depression during a one-year-period (2009) were identified.

RESULTS

The population at risk consisted of 140,563 adolescents. Of these, 4,295 (41.2% male; mean age: 15.5 years) had a diagnosis of depression. This equates to a prevalence of 3.1% (females: 3.7%, males: 2.5%). There were no significant differences between East and West Germany. Of all adolescents with depression, 62.5% had at least one comorbid psychiatric diagnosis, with anxiety and emotional disorders (23.7%), somatoform disorders (16.8%), hyperkinetic disorders (16.2%) and posttraumatic stress disorder (10.0%) being most frequently diagnosed.

CONCLUSIONS

The depression prevalence in this sample was lower than that in studies of clinical samples. There was a marked prevalence of psychiatric comorbidities, especially of internalizing disorders. In adolescents, the risk of depression seems to be comparable in both East and West Germany.

Increase in opiate prescription in Germany between 2000 and 2010: a study based on insurance data

BACKGROUND

Insufficient data have been available to date on the prevalence of opioid treatment in Germany, physicians' prescribing habits, and the percentages of cancer patients and non-cancer patients among those receiving opioids for an evaluation of the quality of care and an assessment of possible underuse or misuse.

METHODS

The data analyzed in this study were derived from the statutory health insurance sample of the AOK health insurance company in the German state of Hesse / ASHIP Hesse for the years 2000-2010. For the purpose of this study, prevalence was defined as the percentage of insurees who received at least one outpatient prescription of an opioid (ATC N02A, excluding codeine, levomethadone and methadone). In order to control for population aging, the prevalence was standardized to the German population on December 31(st) of the preceding year and to the age-structure of the population as it was in 1999. Opioid prescribing for cancer was assumed when a cancer diagnosis was documented in the same year in which the opioid prescription was issued.

RESULTS

The percentage of insurees receiving at least one opioid prescription rose over the period of the study from 3.31% in 2000 to 4.53% in 2010, a relative gain of 37%. Opioids were mostly prescribed to patients with non-cancer pain (2010: about 77% of opioid recipients). The percentage of non-cancer patients receiving long-term opioid treatment has also increased over the period of the study.

CONCLUSION

As opioids are frequently prescribed for non-cancer pain, it cannot be inferred from the observed increase in opioid prescribing that cancer patients are now receiving better opioid treatment than they were before. Further issues of concern are the observed increases in the prescribing of potent immediate release opioids and in the long-term opioid treatment for non-cancer patients, the benefit of which is currently debated.

Time-dependent impact of diabetes on mortality in patients with stroke: survival up to 5 years in a health insurance population cohort in Germany

OBJECTIVE

To estimate the impact of diabetes on mortality in patients after first stroke event.

RESEARCH DESIGN AND METHODS

Using claims data from a nationwide statutory health insurance fund (Gmünder ErsatzKasse), we assessed all deaths in a cohort of 5,757 patients with a first stroke between 2005 and 2007 (69.3% male, mean age 68.1 years, 32.2% with diabetes) up to 2009. By use of Cox regression, we estimated time-dependent hazard ratios (HRs) to compare patients with and without diabetes stratified by sex.

RESULTS

The cumulative 5-year mortality was 40.0 and 54.2% in diabetic men and women, and 32.3 and 38.1% in their nondiabetic counterparts, respectively. In males, mortality was significantly lower in diabetic compared with nondiabetic patients in the first 30 days (multiple-adjusted HR 0.67 [95% CI 0.53-0.84]). After approximately a quarter of a year, the diabetes risk increased, yielding crossed survival curves. Later on, mortality risk tended to be similar in diabetic and nondiabetic men (1-2 years: 1.42 [1.09-1.85]; 3-5 years: 1.00 [0.67-1.41]; time dependency of diabetes, P = 0.008). In women, the pattern was similar; however, time dependency was not statistically significant (P = 0.89). Increasing age, hemorrhagic stroke, renal failure (only in men), levels of care dependency, and number of prescribed medications were significantly associated with mortality.

CONCLUSIONS

We found a time-dependent mortality risk of diabetes after first stroke in men. Possible explanations may be type of stroke or earlier and more intensive treatment of risk factors in diabetic patients.

Outpatient treatment in German adolescents with depression: an analysis of nationwide health insurance data

PURPOSE

Data on medical treatment of adolescents with depression are scarce. This study aimed to examine outpatient health services utilisation of depressive disorders in adolescents.

METHODS

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years old with diagnosed depression during a 1-year period (2009) were identified. For this cohort, the prescription of antidepressants and psychotherapy was evaluated with respect to age and sex.

RESULTS

A total of 4295 patients (41.2% males; mean age, 15.5 years) matched the inclusion criteria. Of the patients, 29.7% consulted a child and adolescent psychiatrist. A total of 59.6% were treated with psychotherapy only, 9.6% were treated with a combination of psychotherapy and antidepressants, and 1.9% received only antidepressants. For 28.8% of patients, no specific depression-related treatment was prescribed. A total of 1357 packages of antidepressants were analysed, of which fluoxetine (24.4% of prescriptions), citalopram (14.0%), and mirtazapine (9.7%) were the most frequently prescribed substances. Regarding substance classes, selective serotonin reuptake inhibitors (SSRIs; 55.6%), tricyclic antidepressants (TCAs; 17.9%), and hypericum (St. John's wort; 8.5%) were most common.

CONCLUSIONS

Although the underlying data were coded for insurance purposes, which might result in some data impreciseness, this naturalistic study furnishes evidence that outpatient treatment of adolescents with depressive disorders in Germany only partly complies with guideline recommendations for first-line treatment: Although the prescriptions of SSRI for adolescent depression have risen over recent years, still, a quarter of antidepressant prescriptions for adolescents with depression were TCA or hypericum. Therefore, dissemination of knowledge on state-of-the-art treatment for adolescent depression remains a major educational goal.

[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.

Impact of geriatric comorbidity and polypharmacy on cholinesterase inhibitors prescribing in dementia

BACKGROUND

Although most guidelines recommend the use of cholinesterase inhibitors (ChEIs) for mild to moderate Alzheimer's Disease, only a small proportion of affected patients receive these drugs. We aimed to study if geriatric comorbidity and polypharmacy influence the prescription of ChEIs in patients with dementia in Germany.

METHODS

We used claims data of 1,848 incident patients with dementia aged 65 years and older. Inclusion criteria were first outpatient diagnoses for dementia in at least three of four consecutive quarters (incidence year). Our dependent variable was the prescription of at least one ChEI in the incidence year. Main independent variables were polypharmacy (defined as the number of prescribed medications categorized into quartiles) and measures of geriatric comorbidity (levels of care dependency and 14 symptom complexes characterizing geriatric patients). Data were analyzed by multivariate logistic regression.

RESULTS

On average, patients were 78.7 years old (47.6% female) and received 9.7 different medications (interquartile range: 6-13). 44.4% were assigned to one of three care levels and virtually all patients (92.0%) had at least one symptom complex characterizing geriatric patients. 13.0% received at least one ChEI within the incidence year. Patients not assigned to the highest care level were more likely to receive a prescription (e.g., no level of care dependency vs. level 3: adjusted Odds Ratio [OR]: 5.35; 95% CI: 1.61-17.81). The chance decreased with increasing numbers of symptoms characterizing geriatric patients (e.g., 0 vs. 5+ geriatric complexes: OR: 4.23; 95% CI: 2.06-8.69). The overall number of prescribed medications had no influence on ChEI prescription and a significant effect of age could only be found in the univariate analysis. Living in a rural compared to an urban environment and contacts to neurologists or psychiatrists were associated with a significant increase in the likelihood of receiving ChEIs in the multivariate analysis.

CONCLUSIONS

It seems that not age as such but the overall clinical condition of a patient including care dependency and geriatric comorbidities influences the process of decision making on prescription of ChEIs.