Regional differences in health care of patients with inflammatory bowel disease in Germany

Health care utilizations and costs of Campylobacter enteritis in Germany: A claims data analysis

OBJECTIVE

The number of reported cases of Campylobacter enteritis (CE) remains on a high level in many parts of the world. The aim of this study was to analyze the health care utilizations and direct and indirect costs of CE and sequelae of patients insured by a large health insurance with 26 million members in Germany.

METHODS

Claims data of insurants with at least one CE diagnosis in 2017 (n = 13,150) were provided, of which 9,945 were included in the analysis of health care utilizations and costs. If medical services were not diagnosis-linked, CE-associated costs were estimated in comparison to up to three healthy controls per CE patient. Indirect costs were calculated by multiplying the work incapacities by the average labor costs. Total costs of CE in Germany were extrapolated by including all officially reported CE cases in 2017 using Monte Carlo simulations.

RESULTS

Insurants showed a lower rate of 56 CE diagnoses per 100,000 than German surveillance data for 2017, but with a similar age, gender and regional distribution. Of those CE cases, 6.3% developed post-infectious reactive arthritis, Guillain-Barré syndrome (GBS), inflammatory bowel disease (IBD) and/or irritable bowel syndrome (IBS). Health care utilizations differed depending on CE severity, age and gender. Average CE-specific costs per patient receiving outpatient care were € 524 (95% CI 495-560) over a 12-month period, whereas costs per hospitalized CE case amounted to € 2,830 (2,769-2,905). The analyzed partial costs of sequelae ranged between € 221 (IBS) and € 22,721 (GBS) per patient per 12 months. Total costs of CE and sequelae extrapolated to Germany 2017 ranged between € 74.25 and € 95.19 million, of which 10-30% were due to sequelae.

CONCLUSION

CE is associated with a substantial economic burden in Germany, also due to care-intensive long-lasting sequelae. However, uncertainties remain as to the causal relationship of IBD and IBS after CE.

Urban-Rural Differences in Health Care Utilization for Inflammatory Bowel Disease in the USA, 2017

BACKGROUND

Urban-rural differences in IBD-specific health care utilization at the national level have not been examined in the USA.

AIMS

We compared urban and rural rates of IBD-related office visits and IBD-specific (Crohn's disease (CD) or ulcerative colitis (UC)) hospitalizations and emergency department (ED) visits.

METHODS

From multiple national data sources, we compared national rates using Z test and compared estimates of patient and hospital characteristics and hospitalization outcomes between urban and rural areas using Chi-square and t tests.

RESULTS

In 2015 and 2016, digestive disease-related office visit rates, per 100 adults, were 3.1 times higher in urban than in rural areas (8.7 vs 2.8, P < 0.001). In 2017, age-adjusted rates per 100,000 adults were significantly higher in rural than urban areas for CD-specific hospitalizations (26.3 vs 23.6, P = 0.03) and ED visits (49.3 vs 39.5, P = 0.002). Compared with their urban counterparts, rural adults hospitalized for CD or UC in 2017 were more likely to be older and non-Hispanic white, have lower household income, Medicare coverage, and an elective admission, and were discharged from hospitals that were large, non-federal government owned, and in the Midwest or South. There were no significant urban-rural differences in length of stay and 30-day readmission rate.

CONCLUSIONS

While IBD or digestive disease-related office visit rates were lower in rural compared to urban areas, CD-specific hospitalization and ED visit rates were higher. Strategies that improve office-based care among rural patients with IBD may help to avoid more costly forms of health care use.

OUP accepted manuscript

Background

Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada.

Methods

We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported.

Results

From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts.

Conclusion

We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.

Real-world evaluation of adverse pregnancy outcomes in women with gestational diabetes mellitus in the German health care system

AIMS

This study aims to estimate the incidence of adverse pregnancy outcomes in women with gestational diabetes mellitus (GDM) in Germany.

METHODS

Pregnant women were identified from a health claims database for the year of 2016. Three groups were defined: general population without GDM, women with GDM without treatment and women with GDM and insulin treatment. Operationalisation of outcomes was aligned with the hyperglycaemia and adverse pregnancy outcomes (HAPO) study.

RESULTS

The cohort consisted of 58,297 mother-child pairs. Of those, 7245 had a GDM diagnosis and 1407 had a GDM diagnosis with a prescription of insulin. Adverse pregnancy outcomes were higher in both GDM groups compared to the control group. Birthweight (OR 2.08 [95% CI 1.50-2.90]), primary caesarean section (OR 1.70 [95% CI 1.48-1.95]), intensive neonatal care (OR 1.25 [95% CI 1.04-1.50]), preeclampsia (OR 1.51 [95% CI 1.23-1.85]), and clinical neonatal hypoglycaemia (OR 5.32 [95% CI 4.27-6.62]) were higher in the GDM+insulin group in comparison to a control group after adjustment for potential confounders.

CONCLUSION

Most of the adverse pregnancy outcomes were moderately higher in both identified GDM groups in comparison to women without GDM. Women receiving insulin treatment are at an increased risk of most of the defined adverse pregnancy outcomes.

Claims Data Analysis on the Dispensing of Tricyclic Antidepressants Among Patients With Dementia in Germany

Objective: A restrictive use of tricyclic antidepressants (TCA) in patients with dementia (PwD) is recommended due to the hazard of anticholinergic side effects. We evaluated the frequency of TCA dispensing in PwD over a period of 1 year and the use of TCA before and after the incident diagnosis of dementia.

Methods: This analysis was based on administrative data from a German statutory health insurance for a period of 2 years. Totally, 20,357 patients with an incident diagnosis of dementia in 2014 were included. We evaluated the dispensing of TCA in 2015. Subgroup analyses were conducted to evaluate associations between the incident diagnosis of dementia and modifications in TCA dispensing.

Results: In 2015, 1,125 dementia patients (5.5%) were treated with TCA and 31% were medicated with TCA in all four quarters of 2015. Most dispensings were conducted by general practitioners (67.9%). On average, patients received 3.7 ± 2.6 dispensings per year. Amitriptyline (56.3%), doxepin (26.8%), and trimipramine (16.8%) were dispensed most often. Subgroup analyses revealed that the dispensing of TCA remained mainly unchanged following the incident diagnosis.

Conclusion: A relevant number of PwD were treated with TCA. To maintain the patients’ safety, an improved implementation of guidelines for the pharmaceutical treatment of PwD in healthcare institutions might be required. Since 68% of the patients suffered from depression, future studies should further evaluate the indications for TCA.

Rural and urban disparities in the care of Canadian patients with inflammatory bowel disease: a population-based study

BACKGROUND AND AIMS

Canada's large geographic area and low population density pose challenges in access to specialized health care for remote and rural residents. We compared health services use, surgical rate, and specialist gastroenterologist care in rural and urban inflammatory bowel disease (IBD) patients in Canada.

METHODS

We used validated algorithms that were applied to population-based health administrative data to identify all people living with the following three Canadian provinces: Alberta, Manitoba, and Ontario (ON). We compared rural residents with urban residents for time to diagnosis, hospitalizations, outpatient visits, emergency department (ED) use, surgical rate, and gastroenterologist care. Multivariable regression compared the outcomes in rural/urban patients, controlling for confounders. Provincial results were meta-analyzed using random-effects models to produce overall estimates.

RESULTS

A total of 36,656 urban and 5,223 rural residents with incident IBD were included. Outpatient physician visit rate was similar in rural and urban patients. IBD-specific and IBD-related hospitalization rates were higher in rural patients (incidence rate ratio [IRR] 1.17, 95% CI 1.02-1.34, and IRR 1.27, 95% CI 1.04-1.56, respectively). The rate of ED visits in ON were similarly elevated for rural patients (IRR 1.53, 95% CI 1.42-1.65, and IRR 1.33, 95% CI 1.25-1.40). There were no differences in surgical rates or prediagnosis lag time between rural and urban patients. Rural patients had fewer IBD-specific gastroenterologist visits (IRR 0.79, 95% CI 0.73-0.84) and a smaller proportion of their IBD-specific care was provided by gastroenterologists (28.3% vs 55.2%, P<0.0001). This was less pronounced in children <10 years at diagnosis (59.3% vs 65.0%, P<0.0001), and the gap was widest in patients >65 years (33.0% vs 59.2%, P<0.0001).

CONCLUSION

There were lower rates of gastroenterologist physician visits, more hospitalizations, and greater rates of ED visits in rural IBD patients. These disparities in health services use result in costlier care for rural patients. Innovative methods of delivering gastroenterology care to rural IBD patients (such as telehealth, online support, and remote clinics) should be explored, especially for communities lacking easy access to gastroenterologists.

Continuity of treatment with benzodiazepines in dementia patients: an analysis of German health insurance claims data

Long-term treatment with benzodiazepines (BZD) should be avoided in dementia patients because of an increased risk of adverse events. We evaluated how continuously dementia patients were prescribed BZD over 12 months. For this observational study, we used claims data from a large German public sickness fund for 2014 and 2015, including patients with an incident diagnosis of dementia in 2014. The aim was to evaluate the continuity of treatment, the frequency of BZD prescriptions and defined daily doses were evaluated. In total, 1298 (5.6%) patients received 4.7±5.2 BZD prescriptions in 2015 on average. Thereof, lorazepam (47.5%), oxazepam (18.6%), diazepam (14.5%), and bromazepam (12.2%) were most often prescribed. 30.7% of the patients received at least one BZD prescription in each quarter of 2015. Although the total number of patients receiving BZD decreased in 2015, defined daily doses for single substances remained mainly unchanged. The incident diagnosis of dementia was not associated with modifications of prescription behavior. The treatment with BZD was not discontinued in a large proportion of dementia patients, increasing the risk of adverse events. Physicians' awareness of avoiding BZD should be improved and further evidence for the appropriate treatment of psychiatric symptoms in dementia (e.g. sleep disturbances, anxiety) is required.