Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

Clinical efficacy and safety outcomes of bempedoic acid for LDL-C lowering therapy in patients at high cardiovascular risk: a systematic review and meta-analysis

Background

Bempedoic acid (BA) is a novel oral low-density lipoprotein cholestrol (LDL-C) lowering drug. Its efficacy and safety for clinical outcomes in high cardiovascular risk patients remains unknown.

Objectives and methods

A systematic review was performed and randomized controlled trials (RCTs) of BA vs. placebo in high cardiovascular risk patients reporting clinical efficacy and safety outcomes were included in a meta-analysis. Cumulative odds ratios (OR) and mean differences with 95% confidence intervals (CI) were reported as summary statistics.

Results

Six RCTs with a total of 3,956 patients and follow-ups of four to 52 weeks were identified. There was no difference in MACE (OR 0.84; CI 0.61, 1.15), all-cause mortality (OR 2.37; CI 0.80, 6.99) and cardiovascular mortality (OR 1.66; CI 0.45, 6.04) for BA vs. placebo. BA showed beneficial trends for nonfatal myocardial infarction (OR 0.57; CI 0.32, 1.00) and was associated with a lower risk of new-onset or worsening of diabetes mellitus (OR 0.68; CI 0.49, 0.94) and non-coronary revascularization (OR 0.41; CI 0.18, 0.95), but higher risk of gout (OR 3.29; CI 1.28, 8.46) and a trend for worsening of renal function (OR 4.24; CI 0.98, 18.39) and muscular disorders (OR 2.60; CI 1.15, 5.91).

Conclusion

Bempedoic acid in high cardiovascular risk patients showed no significant effects on major cardiovascular outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and the incidence of gout sound a note of caution. Hence, further studies with longer-term follow-up are needed to clarify the risk/benefit ratio of this novel therapy.

Funding Acknowledgement

Type of funding sources: None.

Health care utilization and excess costs after pelvic fractures among older people in Germany

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment.

INTRODUCTION

We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture.

METHODS

In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures.

RESULTS

Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture.

CONCLUSION

Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

Standardized risk management in catheterization procedures for non-ST-segment elevation myocardial infarction: associations with in-hospital clinical outcomes

Introduction and purpose

Patient risk in non-ST-segment elevation myocardial infarction (NSTEMI) depends on clinical setting, individual patient variables and procedural characteristics. Standardized risk-adjusted periprocedural management for catheterization procedures using a Standard Operating Procedure (SOP) was investigated to evaluate associations with in-hospital clinical outcomes.

Methods

In 01/2018, our heart center established an SOP for coronary catheterization procedures in NSTEMI, targeting 1) standardized pre-procedural risk assessment using National Cardiovascular Data Registry (NCDR) risk models, and 2) standardized post-procedural risk-adjusted safety measures, including advanced patient monitoring (intermediate/intensive care) and use of vascular closure devices. All patients presenting with invasively-managed NSTEMI in 2018 were retrospectively evaluated for SOP-based pre-procedural risk scoring, SOP-based post-procedural management and in-hospital clinical outcomes of mortality, major bleeding (MB, according to BARC ≥3) and acute kidney injury (AKI, according to KDIGO).

Results

A total of 430 patients (age 72±12 years, 71% male, BMI 27±5) presenting with NSTEMI from 01 to 12/2018 were included, 9.8% presented in cardiogenic shock and 4.7% had suffered a preclinical cardiac arrest. Overall in-hospital mortality was 3.7%, MB occurred in 6.5%. 207 patients (48.1%, SOP+ group) had received both 1) pre-procedural risk assessment and 2) post-procedural risk-adjusted safety measures; the other 223 patients (51.9%, SOP- group) had not received either 1) or 2). There were no significant differences in baseline characteristics and prior-existing medical conditions between groups, however, significantly more patients in SOP- group were treated in emergency settings (39.9% vs. 21.7%, p=0.004). However, significantly more patients in SOP- were treated in emergency settings at higher risk (39.9% (SOP-) vs. 21.7% (SOP+); p<0.001). In univariate analysis, all in-hospital clinical outcomes of mortality (1.4% (SOP+) vs. 5.8% (SOP-); p=0.016), MB (2.9% (SOP+) vs. 9.9% (SOP-); p=0.003) and AKI were significantly lower in the SOP+ group (15.9% (SOP+) vs. 24.2% (SOP-); p=0.033). After correction for the difference in risk between groups due to emergency settings by multivariate logistic regression analysis, MB remained significantly lower in SOP+ (p=0.02), while mortality (p=0.14) and AKI (p=0.19) were not significantly associated with SOP-status anymore.

Conclusion

Standardized risk management in invasively managed NSTEMI was associated with significantly lower rates of in-hospital major bleedings.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Junior Clinician Scientist Track, Medical faculty, Heinrich-Heine-University Düsseldorf, Germany

Time spent on self-management by people with diabetes: results from the population-based KORA survey in Germany

AIMS

Time needed for health-related activities in people with diabetes is assumed to be substantial, yet available data are limited. Time spent on self-management and associated factors was analysed using cross-sectional data from people with diagnosed diabetes enrolled in a population-based study.

METHODS

Mean total time spent on self-management activities was estimated using a questionnaire for all participants with diagnosed diabetes in the KORA FF4 study (n = 227, 57% men, mean age 69.7, sd 9.9 years). Multiple two-part regression models were fitted to evaluate associated factors. Multiple imputation was performed to adjust for bias due to missing values.

RESULTS

Some 86% of participants reported spending time on self-management activities during the past week. Over the entire sample, a mean of 149 (sd 241) min/week were spent on self-management-activities. People with insulin or oral anti-hyperglycaemic drug treatment, better diabetes education, HbA_1c 48 to < 58 mmol/mol (6.5% to < 7.5%) or lower quality of life, spent more time on self-management activities. For example, people without anti-hyperglycaemic medication invested 66 min/week in self-management, whereas those taking insulin and oral anti-hyperglycaemic drugs invested 269 min/week (adjusted ratio 4.34, 95% confidence interval 1.85-10.18).

CONCLUSIONS

Time spent on self-management activities by people with diabetes was substantial and varied with an individual's characteristics. Because of the small sample size and missing values, the results should be interpreted in an explorative manner. Nevertheless, time needed for self-management activities should be routinely considered because it may affect diabetes self-care and quality of life.

The association of self-reported diabetes with impaired social functioning in low-, middle- and high-income countries: findings from the World Health Survey

AIM

Epidemiological studies from high-income countries show that diabetes is associated with impaired social functioning. As healthcare systems in middle- and low-income countries offer fewer resources to curtail the potential social impact of diabetes, we performed a comparative study on the diabetes-social impairment link in low-, middle- and high-income countries.

METHODS

We use data from the cross-sectional World Health Survey (n = 235 428 from 10 low-income, 29 middle-income and 9 high-income countries). Diabetes was defined by self-reports of a diagnosis. Impaired social functioning was considered present if participants reported severe or extreme difficulties with personal relationships or participation in the community. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) in the overall sample and by income regions. ORs were corrected for demographics and health-related lifestyles, and then additionally adjusted for impairments that may explain any observed association (i.e. impaired vision, mood, cognition and mobility).

RESULTS

In the overall sample, we confirmed an association between self-reported diabetes and impaired social functioning (OR = 1.47, 95% CI = 1.18-1.83). The strength of that relationship increased with decreasing country income (e.g. OR in low-income countries = 2.23, 95% CI = 1.14-4.37). Associations were substantially attenuated by further correction for impairments, in particular mood problems, in the overall sample (OR = 0.92, 95% CI = 0.72-1.16) and all income regions.

CONCLUSIONS

Self-reported diabetes is associated with impaired social functioning in high- and middle-income countries, and this relationship is even stronger in low-income countries. Associations are largely explained by physical and mental impairments, which may be due to diabetes.

Healthcare costs of Type 2 diabetes in Germany

AIM

To describe for the first time the direct costs of Type 2 diabetes treatment by analysing nationwide routine data from statutory health insurance in Germany.

METHODS

This cost-of-illness-study was based on a 6.8% random sample of all German people with statutory health insurance (4.3 out of 70 million people). The healthcare expenses show direct per capita costs from the payer perspective. Healthcare expenses for physicians, dentists, pharmacies, hospitals, sick benefits and other healthcare costs were considered. Per capita costs, cost ratios for people with Type 2 diabetes and without diabetes as well as diabetes-attributable costs were calculated.

RESULTS

Per capita costs for people with Type 2 diabetes amounted to €4,957 in 2009 and €5,146 in 2010. People with Type 2 diabetes had 1.7-fold higher health expenses than people without diabetes. The largest differences in health expenses were found for prescribed medication from pharmacies (cost ratio diabetes/no diabetes: 2.2) and inpatient treatment (1.8). Ten percent of the total statutory health insurance expense, in total €16.1 billion, was attributable to the medical care of people with Type 2 diabetes.

CONCLUSIONS

This nationwide study indicates that one in 10 Euros of healthcare expenses is spent on people with Type 2 diabetes in Germany. In the future, national statutory health insurance data can be used to quantify time trends of costs in the healthcare system.

Assessment of information needs in diabetes: Development and evaluation of a questionnaire

AIM

To develop a questionnaire suitable for assessing the information needs of individuals with diabetes mellitus types 1 and 2 in diverse healthcare settings (e.g. primary care or long-term care) and at different time points during the course of the disease.

METHODS

The initial questionnaire was developed on the basis of literature search and analysis, reviewed by clinical experts, and evaluated in two focus groups. The revised version was pilot-tested on 39 individuals with diabetes type 2, type 1 and gestational diabetes.

RESULTS

The final questionnaire reveals the most important information needs in diabetes. A choice task, a rating task and open-ended questions are combined. First, participants have to choose three topics that interest them out of a list with 12 general topics and specify in their own words their particular information needs for the chosen topics. They are then asked how informed they feel with regard to all topics (4-point Likert-scale), and whether information is currently desired (yes/no). The questionnaire ends with an open-ended question asking for additional topics of interest.

CONCLUSIONS

Careful selection of topics and inclusion of open-ended questions seem to be essential prerequisites for the unbiased assessment of information needs. The questionnaire can be applied in surveys in order to examine patterns of information needs across various groups and changes during the course of the disease. Such knowledge would contribute to more patient-guided information, counselling and support.

Drug-based pain management in people with dementia after hip or pelvic fractures: a systematic review protocol

BACKGROUND

Studies show that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent and how drug-based pain management is performed for people with dementia following a hip or pelvic fracture. The aim of this systematic review is to identify studies addressing drug-based pain management for people with dementia who have had a hip or pelvic fracture for which they had either an operation or conservative treatment. We will analyse to what extent and how the drug-based pain treatment for people with dementia is performed across all settings and how it is assessed in the studies.

METHODS

The development of this systematic review protocol was guided by the PRISMA-P requirements, which will be taken into consideration during the review procedure. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect will be searched, using keywords such as "analgesia", "dementia", "cognitive impairment", "pain treatment", "hip fracture" or "pelvic fracture". Publications published up to January 2016 will be included. The data extraction and a content analysis will be carried out systematically, followed by a critical appraisal.

DISCUSSION

This review will provide a valuable overview on the current evidence on drug-based pain management for PwD in all settings who were conservatively treated after a hip or pelvic fracture. The review may expose a need to enhance pain management for PwD. It may also provide motivation for healthcare providers and policymakers to give this topic their attention and to facilitate further research by considering aspects of care transitions in all settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037309.

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.

[Association of diabetes type 2 and depression - behavioural and biological aspects]

BACKGROUND AND OBJECTIVE

Type 2 diabetes and depression often appear together. Although health behaviour and risk factors partially explain this association, other potential mechanisms have yet to be elucidated.

METHODS

Explorative literature research for reviews on the topic in PubMed. Additional key-word guided research for studies in PubMed and Cochrane Library employing the keywords "diabetes" AND "depression" in combination with identified relevant single aspects (MeSH-terms) for certain neuroendocrine alterations, neuropathological und neurobiochemestric changes as well as the role of antidepressants.

RESULTS

There are no satisfying explanatory models for the complex interaction of both diseases concerning behavioural factors and pathophysiological changes. Currently there are only many single aspects of shared or interacting pathophysiology or behaviour conspicuity.

CONCLUSION

The objective of this review is to summarize these aspects and their contributions to the interacting pathophysiology of the two diseases.

Association of lay beliefs about causes of depression with social distance

OBJECTIVE

The aim of this study was to examine the association of lay attributions about causes of depression with attitudes and prejudiced behaviour towards people with depression.

METHOD

Subjects (1631 German-speakers aged 18 and over, randomly selected) were interviewed in two German cities by telephone using a standardized questionnaire. The survey assessed knowledge about depression, stereotypical attitudes and social distance towards persons with depression.

RESULTS

The results indicate that a majority of the respondents holds predominantly non-pejorative attitudes towards persons with depression. The majority estimated psychosocial causes as being most important for the genesis of depression. Stronger social distance was linked to an estimation of personal causes as relevant. Subgroup differences were apparent with respect to age, sex and reported contact to people with depression.

CONCLUSION

Improvements in the education of the public about depression should be based on a multifactorial model. Future interventions should promote contact with people with depression and place special emphasis on conveying information in a suitable manner depending on the needs of different target groups.

Medication costs by glucose tolerance stage in younger and older women and men: results from the population-based KORA survey in Germany

To estimate medication costs in individuals with diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal blood glucose values in a population-based sample by age and sex.Using the KORA F4 follow-up survey, conducted in 2006-2008 (n=2611, age 40-82 years), we identified individuals' glucose tolerance status by means of an oral glucose tolerance test. We assessed all medications taken regularly, calculated age-sex specific medication costs and estimated cost ratios for total, total without antihyperglycemic drugs, and cardiovascular medication, using multiple 2-part regression models.Compared to individuals with normal glucose values, costs were increased in known diabetes, undetected diabetes and impaired glucose regulation, which was more pronounced in participants aged 40-59 years than in those aged 60-82 years (cost ratios for all medications: 40-59 years: 2.85; 95%-confidence interval: 1.78-4.54, 2.00; 1.22-3.29 and 1.53; 1.12-2.09; 60-82 years: 2.04; 1.71-2.43, 1.17; 0.90-1.51 and 1.09; 0.94-1.28). Compared to individuals with diagnosed diabetes, costs were significantly lower among individuals with impaired glucose regulation across all age and sex strata, also when antihyperglycemic medication was excluded (40-59 years: 0.60; 0.36-0.98, 60-82 years: 0.74; 0.60-0.90; men: 0.72; 0.56-0.93; women: 0.72; 0.54-0.96).We could quantify age- and sex-specific medication costs and cost ratios in individuals with diagnosed diabetes, undetected diabetes and impaired glucose regulation compared to those with normal glucose values, using data of a population-based sample, with oral glucose tolerance test-based identification of diabetes states. These results may help to validly estimate cost-effectiveness of screening and early treatment or prevention of diabetes.

Patient time costs attributable to healthcare use in diabetes: results from the population-based KORA survey in Germany

AIMS

Patient time costs have been described to be substantial; however, data are highly limited. We estimated patient time costs attributable to outpatient and inpatient care in study participants with diagnosed diabetes, previously undetected diabetes, impaired glucose regulation and normal glucose tolerance.

METHODS

Using data of the population-based KORA S4 study (55-74 years, random sample of n = 350), we identified participants' stage of glucose tolerance by oral glucose tolerance test. To estimate mean patient time costs per year (crude and standardized with respect to age and sex), we used data regarding time spent with ambulatory visits including travel and waiting time and with hospital stays (time valued at a 2011 net wage rate of €20.63/h). The observation period was 24 weeks and data were extrapolated to 1 year.

RESULTS

Eighty-nine to 97% of participants in the four groups (diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal glucose tolerance.) had at least one physician contact and 4-14% at least one hospital admission during the observation period. Patient time [h/year (95% CI)] was 102.0 (33.7-254.8), 53.8 (15.0-236.7), 59.3 (25.1-146.8) and 28.6 (21.1-43.7), respectively. Age-sex standardized patient time costs per year (95% CI) were €2447.1 (804.5-6143.6), €880.4 (259.1-3606.7), €1151.6 (454.6-2957.6) and €589.2 (435.8-904.8).

CONCLUSIONS

Patient time costs were substantial--even higher than medication costs in the same study population. They are higher in participants with diagnosed diabetes, but also in those with undetected diabetes and impaired glucose regulation compared with those with normal glucose tolerance. Research is needed in larger populations to receive more precise and certain estimates that can be used in health economic evaluation.

Projection of the burden of type 2 diabetes mellitus in Germany: a demographic modelling approach to estimate the direct medical excess costs from 2010 to 2040

AIM

To model the future costs of Type 2 diabetes in Germany, taking into account demographic changes, disease dynamics and undiagnosed cases.

METHODS

Using a time-discrete Markov model, the prevalence of diabetes (diagnosed/undiagnosed) between 2010 and 2040 was estimated and linked with cost weights. Demographic, epidemiological and economic scenarios were modelled. Inputs to the model included the official population forecasts, prevalence, incidence and mortality rates, proportions of undiagnosed cases, health expenditure and cost ratios of an individual with (diagnosed/undiagnosed) diabetes to an individual without diabetes. The outcomes were the case numbers and associated annual direct medical excess costs of Type 2 diabetes from a societal perspective in 2010€.

RESULTS

In the base case, the case numbers of diabetes will grow from 5 million (2.8 million diagnosed) in 2010 to a maximum of 7.9 million (4.6 million diagnosed) in 2037. From 2010 to 2040, the prevalence rate amonf individuals ≥40 years old will increase from 10.5 to 16.3%. The annual costs of diabetes will increase by 79% from €11.8 billion in 2010 to €21.1 billion in 2040 (€9.5 billion to €17.6 billion for diagnosed cases).

CONCLUSIONS

The projected increase in costs will be attributable to demographic changes and disease dynamics, and will be enhanced by higher per capita costs with advancing age. Better epidemiological and economic data regarding diabetes care in Germany would improve the forecasting accuracy. The method used in the present study can anticipate the effects of alternative policy scenarios and can easily be adapted to other chronic diseases.

Diabetes incidence does not differ between subjects with and without high depressive symptoms--5-year follow-up results of the Heinz Nixdorf Recall Study

AIMS

Cross-sectional studies have consistently reported evidence for an association between diabetes and depressive disorders. However, only limited prospective studies have examined this association, reporting conflicting results. In a population-based cohort study, we compared cumulative incidences of diabetes between participants with and without high depressive symptoms.

METHOD

We analysed the 5-year follow-up data from the German Heinz Nixdorf Recall study of 3547 participants without diabetes at baseline [mean age 58.8 (sd 7.6) years, 47.5% male]. Depressive symptoms were defined using the Centre for Epidemiologic Studies Depression scale (cut point ≥ 17). Diabetes (diagnosed or previously undetected) was identified by self-reported physician-diagnosed diabetes, medication and high blood glucose levels. We estimated 5-year cumulative incidences with 95% confidence intervals and fitted multiple logistic regression models to calculate the odds ratios, adjusted for age, sex, physical activity, smoking, living with or without partner, and educational level.

RESULTS

The cumulative incidence of diabetes was 9.2% (95% CI 6.3-12.8) in participants with high depressive symptoms at baseline and 9.0% (95% CI 8.0-10.0) in participants without these symptoms. The age- and sex-adjusted odds ratio of diabetes in participants with depressive symptoms compared with those without was 1.13 [95% CI 0.77-1.68; fully adjusted 1.11 (95% CI 0.74-1.65)]. These results did not substantially change in several additional sensitivity analyses.

CONCLUSION

Our study did not show a significantly increased risk of developing diabetes in individuals with high depressive symptoms compared with those without high depressive symptoms during a 5-year follow-up period.

Costs of paediatric diabetes care in Germany: current situation and comparison with the year 2000

AIMS

To estimate direct costs of paediatric Type 1 diabetes care and associated factors in Germany for the year 2007 and to compare results with the costs for the year 2000.

METHODS

Our study includes clinical data and charges for any diabetes-related health care service of 14,185 continually treated subjects with paediatric diabetes aged < 20 years [52.5% male, mean age (SD) 12.1 (4.2) years], derived from a nationwide prospective patient documentation system (DPV). Health-care utilization was valued in monetary terms by using inpatient and outpatient medical fees and retail prices (perspective of the statutory health insurance). Associations between average total diabetes-related costs or various single cost categories per patient and age, sex, migration background, diabetes duration, and metabolic control were analysed by multiple regression procedures and by a two-part model for hospitalization costs. Total direct costs in the whole paediatric diabetes population in Germany were estimated. Mean costs per patient as well as total costs in the German paediatric diabetes population in 2007 were compared to 2000 costs (inflated to the year 2007).

RESULTS

Mean direct diabetes-associated costs per subject were €3524 (inter-quartile range: 1831-4743). Main cost categories were hospitalization (32%), glucose self-monitoring (29%), insulin pump therapy (18%), and insulin (15%). Based on the present estimation, the total costs of paediatric diabetes care in Germany exceeded €110 million in 2007. Compared with estimates of the year 2000, average costs per patient had increased by 20% and total costs for German paediatric diabetes care by 47%.

CONCLUSIONS

Direct costs for paediatric Type 1 diabetes care increased between 2000 and 2007, probably partly because of new therapeutic strategies and an increase in diabetes prevalence.

Blood glucose testing and primary prevention of Type 2 diabetes-evaluation of the effect of evidence-based patient information: a randomized controlled trial

AIMS

To compare the effect of our newly developed online evidence-based patient information vs. standard patient information about sub-threshold elevated blood glucose levels and primary prevention of diabetes on informed patient decision making.

METHODS

We invited visitors to the cooperating health insurance company, Techniker Krankenkasse, and the German Diabetes Center websites to take part in a web-based randomized controlled trial. The population after randomization comprised 1120 individuals aged between 40 and 70 years without known diabetes, of whom 558 individuals were randomly assigned to the intervention group receiving evidence-based patient information, and 562 individuals were randomly assigned to the control group receiving standard information from the Internet. The primary endpoint was acquired knowledge of elevated blood glucose level issues and the secondary outcomes were attitude to metabolic testing, intention to undergo metabolic testing, decisional conflict and satisfaction with the information.

RESULTS

Overall, knowledge of elevated glucose level issues and the intention to undergo metabolic testing were high in both groups. Participants who had received evidence-based patient information, however, had significantly higher knowledge scores. The secondary outcomes in the evidence-based patient information subgroup that completed the 2-week follow-up period yielded significantly lower intention to undergo metabolic testing, significantly more critical attitude towards metabolic testing and significantly higher decisional conflict than the control subgroup (n=466). Satisfaction with the information was not significantly different between both groups.

CONCLUSIONS

Evidence-based patient information significantly increased knowledge about elevated glucose levels, but also increased decisional conflict and critical attitude to screening and treatment options. The intention to undergo metabolic screening decreased. Future studies are warranted to assess uptake of metabolic testing and satisfaction with this decision in a broader population of patients with unknown diabetes.

Regional differences in the prevalence of known Type 2 diabetes mellitus in 45-74 years old individuals: results from six population-based studies in Germany (DIAB-CORE Consortium)

AIM

In Germany, regional data on the prevalence of Type 2 diabetes mellitus are lacking for health-care planning and detection of risk factors associated with this disease. We analysed regional variations in the prevalence of Type 2 diabetes and treatment with antidiabetic agents.

METHODS

Data of subjects aged 45-74 years from five regional population-based studies and one nationwide study conducted between 1997 and 2006 were analysed. Information on self-reported diabetes, treatment, and diagnosis of diabetes were compared. Type 2 diabetes prevalence estimates (95% confidence interval) from regional studies were directly standardized to the German population (31 December 2007).

RESULTS

Of the 11,688 participants of the regional studies, 1008 had known Type 2 diabetes, corresponding to a prevalence of 8.6% (8.1-9.1%). For the nationwide study, a prevalence of 8.2% (7.3-9.2%) was estimated. Prevalence was higher in men (9.7%; 8.9-10.4%) than in women (7.6%; 6.9-8.3%). The regional standardized prevalence was highest in the east with 12.0% (10.3-13.7%) and lowest in the south with 5.8% (4.9-6.7%). Among persons with Type 2 diabetes, treatment with oral antidiabetic agents was more frequently reported in the south (56.9%) and less in the northeast (46.0%), whereas treatment with insulin alone was more frequently reported in the northeast (21.6%) than in the south (16.4%).

CONCLUSION

The prevalence of known Type 2 diabetes showed a southwest-to-northeast gradient within Germany, which is in accord with regional differences in the distribution of risk factors for Type 2 diabetes. Furthermore, the treatment with antidiabetic agents showed regional differences.

Frequency and cost of diabetic ketoacidosis in Germany--study in 12,001 paediatric patients

AIMS

Recently, medical expenditures were found to be 2-fold increased in paediatric patients with diabetic ketoacidotic events (DKA) in the U.S., in particular due to hospitalization. Aim of our study was to analyse DKAs and associated costs in Germany, where structured diabetes care including education is available for all patients.

METHODS

For all 12,001 diabetic patients 0-19 years of age (52.6% male, mean age (SD) 12.6 (3.9) years) documented in a German-wide database, all DKAs were assessed, as well as costs for diabetes-related treatment. Associations between costs and DKA were estimated using log-linear models.

RESULTS

457 (3.8%) patients had at least 1 DKA during 2007. Total annual costs for patients without, with 1, or ≥ 2 DKAs were € 3,330 (95%-CI 3,292-3,368), € 6,935 (CI 6,627-7,244), and € 10,728 (CI 9,813-11,644), respectively, with largest differences for hospitalization costs (€ 693, € 4,145, € 8,092). Age-sex-diabetes duration-adjusted cost ratios for patients with 1, or ≥ 2 DKAs compared to patients without DKA were 2.2 (CI 2.1-2.3) and 3.6 (CI 3.1-4.1), respectively.

CONCLUSIONS

In Germany, paediatric diabetic patients with DKA had up to 3.6-fold higher diabetes-related costs compared to those without DKA. This cost excess was higher compared to a U.S. study, however, the proportion of patients with DKA was much lower (3.8% versus 14.9%). The lower frequency of DKA in Germany may be due to a higher access to and utilization of diabetes education. Interventions should reduce DKA and resulting hospital admission in pediatric patients in order to reduce costs and improve quality of life.

[Type 2 diabetes mellitus and depressive symptoms: what is the cause of what? A systematic literature review]

BACKGROUND

Diabetes mellitus type 2 and depressive symptoms are statistically associated. The question is if one of the two diseases is causal for the other.

METHODS

Systematic review using Medline and searching for prospective controlled population based observational studies and meta-analysis in English or German language.

RESULTS

Patients with type 2 diabetes have a higher incidence of depressive symptoms - compared to patients having no diabetes. And patients with depressive symptoms have a higher incidence of type 2 diabetes; however the findings for the first relation are only weak.

DISCUSSION

Knowing about this - even causal - co-morbidity is important in care, including a routine diagnostic approach to find out if the other disease is also present.

Diabetes and Incident Depression: Is the Association Mediated or Modified by Sociodemographic Factors or Co-morbidities? A Systematic Review

Diabetic patients suffer more frequently from depression. Aim was to evaluate sociodemographic parameters and co-morbidities and late complications as potential modifying factors in the occurrence of depression in diabetic individuals.

We performed a systematic review, based on established meta-analyses and additional original publications in 2005–2009 in Medline and PsycINFO. We included articles focusing on longitudinal studies which evaluated the appearance of depression in diabetic and non diabetic individuals and further analyzed interactions or separate additional influences of potential modifying factors.

8 eligible studies were identified. 6 studies were population based. Only 3 studies analyzed the interaction between the variables of interest and diabetes on the incidence of depression. Remaining used diverse other methods to control for associated factors.

The strongest influence was found for a general measure of co-morbidities but this influence was ambiguous. No significant modifying effect or interaction was found for sociodemographic factors.

There seems to be a clear need for more research concerning mediating and modifying factors or a more stringent presentation of results in order to identify groups at risk or to identify treatment strategies.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improvement in pregnancy-related outcomes in the offspring of diabetic mothers in Bavaria, Germany, during 1987-2007

AIMS

Reducing the risk of adverse outcomes in diabetic pregnancies to the level of risk in non-diabetic pregnancies is a major goal in diabetes care. So far there have not been any data to show whether progress is being made towards this goal.

METHODS

We used population-based data on 2,292,053 deliveries between 1987 and 2007 in Bavaria, Germany, to assess temporal trends for stillbirths, early neonatal mortality, preterm delivery, macrosomia and malformations in consecutive 7 year intervals. We estimated prevalences and prevalence odds ratios for these outcomes. For stillbirth, as the most severe adverse outcome, we assessed the contributions of several predictors using multiple regression models.

RESULTS

With the exception of early neonatal deaths, the risks for all outcomes were significantly increased in the offspring of mothers with pregestational diabetes in all three time periods (e.g. odds ratio for stillbirths in diabetic compared with non-diabetic mothers in 2001-2007, 1.89; 95% confidence interval 1.24, 2.87). However, the prevalence of stillbirths, premature delivery and macrosomia decreased over time in diabetic mothers (e.g. 1.71% for stillbirths in 1987-1993 and 0.66% in 2001-2007), as did the respective odds ratios. Maternal smoking, hypertension and substandard utilization of antenatal care were significantly associated with stillbirths in diabetic women.

CONCLUSIONS

Although the risk of adverse pregnancy outcomes is still increased in diabetic mothers, considerable improvement has been achieved. We hypothesize that this improvement is possibly due to improved diabetes care.

Reduced incidence of blindness in relation to diabetes mellitus in southern Germany?

AIMS

We estimated the incidence of blindness in the diabetic and non-diabetic population in 2008 and compared it with results from 1990-1998 in a neighbouring region.

METHODS

All newly registered blindness allowance recipients in 2008 were drawn up in a German region (population 4.5 million). We estimated sex-specific, age-specific and standardized incidence rates of blindness in the diabetic and the non-diabetic population and relative and attributable risks as a result of diabetes. A comparison to the data from 1990-1998 was performed using log-linear Poisson regression.

RESULTS

Four-hundred and sixty-eight cases were drawn up (63% female). One-hundred and twenty-two (26.1%) had diabetes. Blindness incidence rates (per 100, 000 person-years) standardized to the 2008 German population were: men 9.1 (95% confidence interval 7.8-10.5), women 9.9 (8.8-11.1); diabetic population: men 21.8 (11.6-31.9), women 19.7 (9.2-30.1); non-diabetic population: men 8.0 (6.6-9.5), women 9.1 (7.9-10.3). Relative risk of blindness, diabetic vs. non-diabetic population: men 2.7 (1.6-4.5), women 2.2 (1.3-3.8). Attributable risk among exposed: 63% in men, 54% in women. Population attributable risk: 12% in men, 8% in women. Incidences of blindness were significantly lower than in all years of the period 1990-1998 in both the diabetic and the non-diabetic population.

CONCLUSIONS

We found the incidence of blindness to be approximately 2.5-fold higher in the diabetic compared with the non-diabetic population. Fifty-eight per cent of the risk to become blind in diabetic individuals and 9% of the risk to become blind in the entire population were attributable to diabetes. The decrease of the blindness incidence observed during the 1990s may have continued.

[Memorandum III: Methods for Health Services Research (Part 2)]

The methodical quality of health services research studies is often subject to criticism. Common standards in the field of health services research have been lacking so far. Hence, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] decided to contribute to an improvement of this situation. The DNVF e. V. has already published part 1 of the Memorandum III"Methods for Health Services Research" for the 3 subject areas "Epidemiological Methods for Health Services Research", "Methods for Organisational Health Services Research" and "Methods for Quality of Life Research". The herewith published Part 2 of the Memorandum extends the spectrum by describing the methodological principles and minimum standards of "Methods of Health Economic Evaluations" and "Registries for Health Services Research". On 30 (th) August 2010, the member societies, mentioned as authors, approved this second part of the Memorandum III. 2 in-depth publications focussing on the 2 mentioned topics will be published in the next issues of this journal. This memorandum is intended for health services researchers who are planning, conducting and publishing studies as well as for reviewers who evaluate research proposals and publications on health services research studies. In accord with the expected advances in knowledge in health services research, it is planned to update the 2 parts of Memorandum III at appropriate intervals and to publish further parts from the huge spectrum of methods relevant to this field in the near future. Thus, the Memorandum has to be considered as work in progress.

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.