[Internal confirmation of diagnoses in routine statutory health insurance data: concept with examples and case definitions]. / Interne Validierung von Diagnosen in GKV-Routinedaten: Konzeption mit Beispielen und Falldefinition.

Over the course of the last few decades, statutory health insurance data have become increasingly important for health services research. Of particular interest in this context are diagnoses. Since all health insurance data are originally collected for billing purposes, secondary analyses should examine the completeness, plausibility, and validity of the information provided. While an external validation through, for example, a comparison with the physician's records or a second independent medical examination can be seen as a gold standard, this is often not feasible. For this reason, internal validation approaches are recommended for studies based upon diagnoses drawn from routine data. For such approaches, no established standards are currently available. The aim of this contribution is to introduce a generic internal validation concept for chronic diseases. Data employed in the present contribution stem from the health insuree sample of the AOK health insurance fund Hesse. Criteria for assessing the validity of diagnoses (e.g., repetitions, codes assigned by various physicians, prescriptions) are presented for three chronic diseases - heart failure, dementia, and tuberculosis. Building upon these criteria, algorithms for the definition of epidemiologically certain cases are developed and prevalence estimates formed on the basis of these algorithms are compared with other data sources (registers and surveys). Internal confirmation of the diagnoses of heart failure and dementia was possible in 97% and 80% of cases, respectively. The difference between the two diagnoses is due to the low rate of treatment with specific pharmaceuticals in the case of dementia. Prevalence estimates are comparable with those based on other sources. Inpatient discharge diagnoses of tuberculosis were internally confirmed in 100% and outpatient diagnoses in 40% of cases. For this reason, outpatient diagnoses were not considered for the case definition of tuberculosis. A comparison with tuberculosis surveillance data reveals a somewhat higher incidence in the insuree sample. In selecting and weighting criteria as well as employing a case definition, the research aim of the respective investigation must be taken into account. The adopted procedure is to be presented in a transparent manner.

[Herpes zoster in Germany. A retrospective analyse of SHL data]. / Herpes zoster in Deutschland. Eine retrospektive Analyse von GKV-Daten.

The incidence of herpes zoster in the elderly (50 years and older) 2004 in Germany was determined by retrospectively analysing representative treatment data of the statutory health insurance sample of AOK Hesse/KV Hesse. The overall observed incidence rate of herpes zoster was 9.4 cases per 1,000 person-years (PY). 10.1% of herpes-zoster-patients suffered at least 1 month from pain, the so called postherpetic neuralgia (PHN1), 6.9% had at least 3 months pain (PHN3). Incidence rate of herpes zoster rose markedly with age: from 6.8 per 1,000 PY in 50 to 54 year-olds to 12.4 PY in persons 80 years and older. Incidence rate in the immunocompromised was higher (11.6 per 1,000 PY) than in the immunocompetent (9.1 per 1,000 PY). According to a standardized extrapolation of the sample to the German population, about 300,000 persons 50 years and older suffered from acute herpes zoster on the year 2004 in Germany.

Medical costs of diabetic complications total costs and excess costs by age and type of treatment results of the German CoDiM Study.

AIMS: This study examined the medical costs of diabetic complications by age, type of treatment, and type of complication and researched the relationship between total and excess costs with respect to type of complications. METHODS: Patients with diabetes (n=26,971) were identified from a German statutory health insurance database by glucose-lowering drug prescriptions and ICD-10 diagnoses. Diabetes complications were defined as microvascular (eye and kidney diseases), foot complications (peripheral neuropathy, peripheral vascular disease), macrovascular (cardio- and cerebrovascular diseases), and uncontrolled glucose metabolism (glycaemic complications). Estimates of frequency and medical costs of complications were calculated for diabetic patients and an age- and sex-matched control group of persons without diabetes. RESULTS: Half (53%) of the medical costs per diabetes patient in 2001 (euro4,457) were spent for management of complications (euro2,380). In the control group, costs of these diseases were euro761 per person. Consequently excess costs of complication due to diabetes were estimated at euro1,619 (36%) and were caused for treatment of macrovascular (euro643, 14%), microvascular (euro458, 10%), foot complications (euro430, 10%) and glycaemic complications (euro88, 2%). Furthermore 12% were spent for management of hyperglycaemia (euro542). Excess costs for complications per diabetic patient were higher for insulin (euro4,395) versus non-insulin treated patients (euro587). Eye, kidney and foot complications were encountered 3 - 4 times more often in diabetic patients than in non-diabetic controls, whereas macrovascular diseases were only 1.6 times more frequent. Therefore the proportion of diabetes dependent excess costs of microvascular and foot complications was high (78%), and was considerably lower (56%) for macrovascular complications. CONCLUSIONS: A close relationship exists between diabetes related excess costs and the presence of microvascular and foot complications. It is important to identify these patients early in order to incorporate them into diabetes management programs. A better care of diabetes patients and subsequent prevention of these late complications promises not only to improve quality of life but also to be highly cost-effective.

Pharmacotherapeutic circles. Results of an 18-month peer-review prescribing-improvement programme for general practitioners.

OBJECTIVE: To assess the effectiveness of the pharmacotherapeutic circle (PTC), a general practitioner (GP) prescribing-improvement programme to enhance prescribing quality and reduce drug costs. DESIGN: Combined pre- and post-intervention time-series design using an internal comparison of subgroups and an external comparative control. SETTING: Small discussion groups meeting 8 times over 18 months. PARTICIPANTS: 79 GPs exceeding the mean drug costs/patient of all Hessian physicians by > or = 40%; 10 moderators. INTERVENTIONS: Peer-review feedback of prescription patterns based on guidelines targeting 3 suboptimal prescribing areas: drug prescriptions lacking evidence-based efficacy (target A); presumptive prescribing habits (target B); and underprescribing of new, effective therapies (target C). MAIN OUTCOME MEASURES AND RESULTS: Significant decreases in prescription rates for target A drugs were recorded for varicose vein medications (p = 0.006), peripheral vasodilators (p = 0.0001) and topical antirheumatics (p = 0.0145), but not for prokinetics/enzymes/digestives. Prescribing of target B drugs such as benzodiazepines and nonsteroidal anti-inflammatory drugs declined markedly (p = 0.0019 and 0.0014, respectively). Target C drug prescriptions such as for opioids and proton pump inhibitors were not significantly increased. Highly significant reductions in prescription costs were observed for target A and B drugs, irrespective of whether GPs were stratified into high, medium or low prescribers. When mean prescribing costs for PTC participants were compared with those of a control group comprising 8000 GPs over a 21-month period, PTC GPs decreased their costs by 2%, whereas drug costs for all Hessian physicians rose by 10%. CONCLUSIONS: PTCs appear to be an effective method to optimise the quality of drug prescribing and reduce drug costs.

[Prevalence and distribution of stroke and transient ischemic insults: secondary data analysis of a representative sample of insured members of the General Local Insurance Dortmund]. / Häufigkeit und Verteilung von Apoplexie und transitorischer ischämischer Attacke: Sekundäranalyse der Verwaltungsdaten von Versicherten der AOK-Dortmund.

Apoplexia is not only one of the leading causes of death, but also a major contributor to disability in the aged. Population based prevalence rates, though being of basic importance for describing and planning health care structures, are sparse in the Federal Republic of Germany. We estimated the prevalence of apoplexia and transient ischemic attack (TIA). Data were gathered from a 5% representative random sample of insured of the local statuatory health insurance (AOK) in Dortmund, Germany (n = 7447). Cases were identified by the diagnosis on medical certificates, being further validated internally by other patient data. The rough prevalence rate was 0.86% (m 0.79%, f 0.93%) for apoplexia and 0.6% (m 0.4%, f 0.78%) for TIA. Adjusted for age and sex to the whole population of the FRG (excluding the former German Democratic Republic) the prevalence rate was 0.75% (m 0.8%, f 0.7%) for apoplexia and 0.52% (m 0.41%, f 0.63%) for TIA. 65% of the insured with apoplexia were 70 years and older; their average age was 71.7 years. The average age of the insured with TIA was 65.4 years. Prevalence rates for apoplexia increased continuously by age and were higher for men than for women in all age groups. Prevalence rates for TIA also increased with age, but under men only to the age of 70; after that-simultaneous to a steep rise of apoplexia prevalence-no more TIAs were noticed.

[Drug therapy courses for family physicians--advanced education in pharmacotherapy]. / Pharmakotherapiezirkel für Hausärzte--Fortbildung in Pharmakotherapie.

UNLABELLED: General practitioners (GPs) are responsible for 70% (or roughly 30 billion DM) of the entire medication prescribed by practising doctors. Pharmacotherapy circles (PTC) are a further education, which focuses on the optimisation of prescription behaviour (best therapy possible in clinical pharmacology, the translatability into daily practice and guides the concept and contents of the further education. The concept of further education in pharmacotherapy circles developed by us follows the rules of quality assurance in medical care: ASSESSMENT: Recording prescriptions in one quarter for evaluation of prescription problems. Problem selection: Medicine groups, whose prescription frequency give an indication of prescription quality, i.e. vein and rheumatism ointments (as little as possible) and proton pump inhibitors and lipid reducers (as many as necessary). The problem analysis takes place as peer review by a group of physicians from the same field, and under the moderation of two doctors from the same field, who have been for at last one year, carefully instructed, in pharmacology and the moderations of groups. The formulation of guidelines shall be shown for an indication area, for which there is no robust therapy (e.g. venous medicaments). The purpose of theses guidelines shall be to optimise the treatment, strengthen the health consciousness of the patient and reduce the prescription of medicaments, whose efficacy has not been proven. The evaluation proves that these goals have been reached. The total reduction in costs is different for individual physicians depending on the original prescription level of the underlying medicament costs. Only the third of "high prescribers" showed economy reserves. There were savings in medicaments with non-proven efficacy among the lower and middle prescribers, however, there were increased expenditures and therapy improvements in other areas.

[Direct costs of ambulatory treatment of diabetes mellitus. Comparison of observed costs with estimated costs of adherence to the treatment standard]. / Die direkten Kosten der ambulanten Behandlung des Diabetes mellitus. Vergleich der beobachteten Kosten mit den Aufwendungen bei Einhaltung des Behandlungsstandards.

BACKGROUND: The aim of this investigation was to record the observed direct costs of the outpatient treatment and therapy control of diabetic patients based on patient-related analysis of health care expenses in a population-based sample and to compare these costs with those generated if the minimum requirements of the European IDDM and NIDDM Policy Groups are fulfilled. Up to now there are only few studies on this topic. PATIENTS AND METHOD: Medical records of a 5% random sample of all insured members of the AOK Dortmund (n = 6085) in 1990 provided the data basis. The direct diabetes-specific therapy and care costs were compiled per patient and year. RESULTS: The annual costs for antidiabetic drugs, monitoring of blood glucose and glycated hemoglobin, test strips for self-monitoring, checking serum cholesterol, triglycerides and creatinine as well as for fundoscopy amounted to a mean of DM 1218.-per each insulin-treated patient (n = 65), DM 211.-per patient on oral antidiabetic drugs (OAD, n = 177), and DM 42.-per patient treated by diet alone (n = 108). Provided that the minimal recommendations of the European IDDM and NIDDM Policy Groups were followed the calculated costs would be DM 1758.-, DM 287.- and DM 198.-, respectively. CONCLUSION: Fulfilling the minimum standards for diabetes care of the European IDDM and NIDDM Policy Groups, respectively, would cause additional costs per patient and year of DM 540.-for insulin-treated. of DM 76.-for OAD-treated and of DM 156.-for patients treated by diet alone. On the other hand adherence to the recommendations would reduce the annual costs for oral antidiabetic drugs by 40%. Improved care of diabetic patients would result in significantly higher costs, but these extra expenses would be probably compensated by a reduction or delay of late complication.

Costs of Diabetes Mellitus (CoDiM) in Germany, direct per-capita costs of managing hyperglycaemia and diabetes complications in 2010 compared to 2001.

INTRODUCTION: To identify direct health care costs of patients with diabetes in Germany in 2010, with focus on costs of treating hyperglycaemia and costs caused by diabetes complications, and to compare findings with results from the CoDiM study 2001. MATERIAL AND METHODS: The cost analysis was based on administrative data (18.75% random sample of 1.5 million insured persons). Medical costs covered by statutory health insurance and costs covered by nursing care insurance were included. Incremental differences in costs of patients with diabetes (n=30 987) and age and sex-matched subjects without a diagnosis of diabetes (controls) were estimated according to the number and type of complications. Costs were standardised to the German population. RESULTS: In 2010, incremental medical costs attributed to diabetes were € 2 391 (95% confidence interval: 2 257-2 524) per patient with diabetes. Of that amount, 26.5% were spent for the management of hyperglycaemia (€ 633 (622-644)) and 73.5% for the treatment of comp-lications (€ 1 758 (1 627-1 889)). Nursing care contributed incremental costs of € 289 (249-330), of which 98.8% was due to complications. From 2001 to 2010 the incremental per-capita costs for medical and nursing care decreased by 4.8% (controls: +3.9%), the per-capita costs for treating hyperglycaemia increased by 2.0% and the per-capita costs for complications decreased by 7.0%. CONCLUSION: Cost for diabetes is largely caused by management of complications. It is important to prevent complications by consequent management of diabetes as well as by primary prevention of its onset.

Direct costs of diabetes mellitus in Germany - CoDiM 2000-2007.

INTRODUCTION: The prevalence of treated diabetes in Germany and direct health care costs of individuals with diabetes were analysed for the 8-year period from 2000 to 2007, based on administrative data. Special interest was given to the incremental costs attributed to diabetes. MATERIAL AND METHODS: An 18.75% sample of all members of a large local German statutory health insurance provider, "AOK - Die Gesundheitskasse" in the federal state of Hesse was analysed with regard to cases of treated diabetes. To assess the incremental diabetes-related direct costs, the cost data of individuals with diabetes was compared to that of an age- and sex-matched group of persons without diabetes. Prevalence and costs were standardized according to the gender and age distribution of the German population. RESULTS: Between 2000 and 2007, the administrative prevalence of treated diabetes rose continuously in Germany, from 6.5 to 8.9% (+36.8%). The number of patients treated with 'insulin' or 'insulin & oral antidiabetic agents' increased by +54.7 and +61.7%, respectively. Direct costs per patient with diabetes, calculated using the unit costs reimbursed by statutory health and nursing care insurances, rose from € 5 197 to € 5 726 (+10.2%). Incremental per-capita costs were € 2 400 in 2000 and € 2 605 in 2007 (+8.5%). However, the total direct cost burden of diabetes in Germany grew from € 27.8 billion to € 42.0 billion (+51.1%). The incremental diabetes-related cost burden increased from € 12.9 billion to € 19.1 billion (+48.6%). CONCLUSIONS: There was a continuous increase in the prevalence of diabetes in Germany during the 8-year period. Although there was only a modest increase in annual diabetes-related per-capita costs, total healthcare expenditure rose substantially due to the growing number of patients being treated for diabetes.

[Health services research based on routine data generated by the SHI. Potential uses of health insurance fund data in health services research]. / Versorgungsforschung mit GKV-Routinedaten. Nutzungsmöglichkeiten versichertenbezogener Krankenkassendaten für Fragestellungen der Versorgungsforschung.

Conducting health services research requires a wealth of real-life health service data. A source of data which is for the most part free of bias is the data collected for administrative purposes by the statutory health insurance fund. These data have been increasingly used over the past few years. Based on these insuree-related and where possible cross-sector data, descriptive and analytic studies can be conducted. The focus of use thus far has primarily been the generation of basic data on morbidity, the utilization of benefits, and costs. As a rule, this information is presented according to sociodemographic variables and where applicable in terms of temporal trends and according to region. A further domain of interest is the evaluation of interventions (health political measures, legislation, programs) and the assessment of health service quality. Initial outcome studies have been published. Despite the growing acceptance and use of these data, a series of methodological and information technical challenges remain to be addressed: To be mentioned are, in addition to validation studies, the methodological requirements of analytic study designs and the possibility of a data linkage with primary data in order to increase the explanatory power of studies and to facilitate links with other databases such as records and survey data.

[Heterogeneity of costs of diabetic patients: the Cost of Diabetes Mellitus Study]. / Heterogenität der Kosten bei Patienten mit Diabetes mellitus: Die KoDiM-Studie.

BACKGROUND AND OBJECTIVE: Health economic studies in patients with diabetes mellitus have demonstrated that a large proportion of the excess cost is caused by the treatment of specific complications. It was the aim of this study to analyse the distribution of per capita cost of a large cohort of diabetic patients in order to develop new strategies for a better identification and care of high-risk patients. METHODS: The analysis was based on anonymous data on patients with diabetes and an age-matched control group from a large cohort of subjects insured by a large statutory health insurance fund (AOK Hesse) (n=305736). Costs were fully assessed and related to the state of complications and other criteria. RESULTS: The average cost was 5262 euros per diabetic patient and year. Excess costs due to the diabetes were estimated at 2507 euros. Costs were unevenly distributed, depending on the presence of complications. The average excess cost of patients with at least one complication was i 3730 euros (469 for patients without complication). In particular, patients on hemodialysis, after kidney transplantation or with lower leg amputation, stroke or with gangrene or foot ulcer incurred great costs. 5.3% of all diabetic patients incurred costs of > or = 20000 euros per year, totalling up to 33.6% of all costs of diabetic patients. Another 9.5% of patients incurred costs of between 10000 euros and 20000 euros per year. Both groups were responsible for 59.6% of total costs. In contrast, 55% of the patients incurred costs of < 2500 euros per year, amounting to 11.8% of all costs. CONCLUSIONS: There is a considerable variation of cost incurred in the management of diabetic patients, as demonstrated in a large population-based cohort of diabetics. This increased cost was largely due to the presence of complications. High-risk patients should be identified as early as possible so that they can receive intensive care to avoid the expensive complications of the disease.

The cost burden of diabetes mellitus: the evidence from Germany--the CoDiM study.

AIMS/HYPOTHESIS: The aim of this study was to identify the health care costs of diabetic patients in Germany in 2001, focusing on the influence of age, sex, and type of treatment. SUBJECTS AND METHODS: Annual direct costs of medical care and indirect costs of inability to work and early retirement in diabetic subjects were compared with costs of age- and sex-matched non-diabetic control subjects. The analysis was based on routine health care data from a random sample (18.75%) taken from a database of 1.9 million insured persons. Incremental differences in medical and national expenditure between subjects with and without diabetes were calculated. RESULTS: Annual direct mean costs per diabetic patient were 5,262 Euro, and indirect costs were 5,019 Euro. In the control group, mean direct and indirect costs were 2,755 Euro and 3,691 Euro, respectively. Analysis of cost components revealed that the high costs associated with the care of diabetic patients could be largely attributed to inpatient care and overall medication costs. Hypoglycaemic drugs amounted to only one-quarter of the medication costs. The total health care costs were correlated with the type of treatment. Direct excess costs increased with increasing age in insulin-treated patients, but were unaffected by age in patients receiving other types of treatment. CONCLUSIONS/INTERPRETATION: The Costs of Diabetes Mellitus (CoDiM) study is the first comprehensive study to provide estimates of costs associated with diabetes care in Germany. Direct costs of diabetic patients account for 14.2% of total health care costs, which includes the proportion that specifically accounts for diabetes-related costs (6.8%).

[Sample survey of persons insured in statutory health insurance institutions in Hessen--concept and realisation of person-related data base]. / Versichertenstichprobe AOK Hessen/KV Hessen -- Konzeption und Umsetzung einer personenbezogenen Datenbasis aus der Gesetzlichen Krankenversicherung.

Statutory health insurance data are being increasingly used for secondary data research. Longitudinal data can be prepared for research in health care, epidemiology or demand planning, in particular through the person-related nature of the data which is a precondition for the creation of inter-sector and inter-period data sets. This application possibility was introduced in a method study "person-related sampling of statutory health insurance data" and is now translated into practice on a larger scale for the first time in the regional sample "Versichertenstichprobe AOK Hessen/KV Hessen". For the collection and use of these data, model procedures were designed which take account of organisational (data access, contractual agreement, advisory board), technical (sampling, collection and storage of data) and confidentiality (data protection concept, pseudonymisation) aspects. The insured person-related sample may thus serve as a basis for the data pool planned for the national health system (Social Security Regulation 303 a-SGB V).

Inhibition of methanogenesis from acetate in granular sludge by long-chain Fatty acids.

The effect of four saturated long-chain fatty acids (caprylic, capric, lauric, and myristic) and one unsaturated long-chain fatty acid (oleic) on the microbial formation of methane from acetate was investigated in batch anaerobic toxicity assays. The tests were carried out with granular sludge from an upflow anaerobic sludge bed reactor. In this sludge, Methanothrix spp. are the predominant acetoclastic methanogens. Lauric acid appeared to be the most versatile inhibitor: inhibition started at 1.6 mM, and at 4.3 mM the maximum specific acetoclastic methanogenic activity had been reduced to 50%. Caprylic acid appeared to be only slightly inhibitory. Oleic acid was almost as inhibitory as lauric acid. Although adsorption of the inhibitor on the cell wall might play an important role in the mechanism of inhibition, the inhibition was found to be correlated with concentration rather than with the amount per unit of biomass. In practical situations, as in anaerobic waste treatment processes, synergism can be expected to enhance the inhibition of methanogenesis. In the present research a background concentration of lauric acid below its MIC strongly enhanced the toxicity of capric acid and (to an even greater extent) myristic acid.

Application of the upflow anaerobic sludge bed (UASB) process for treatment of complex wastewaters at low temperatures.

The feasibility of the upflow anaerobic sludge bed (UASB) process for the treatment of potato starch wastewater at low ambient temperatures was demonstrated by operating two 5.65-L reactors at 14 degrees C and 20 degrees C, respectively. The organic space loading rates achieved in these laboratory-scale reactors were 3 kg COD/m(3)/day at 14 degrees C and 4-5 kg COD/m(3)/day at 20 degrees C. The corresponding sludge loading rates were 0.12 kg COD/kg VSS/day at 14 degrees C and 0.16-0.18 kg COD/kg VSS/day at 20 degrees C.These findings are of considerable practical importance because application of anaerobic treatment at low ambient temperatures will lead to considerable savings in energy needed for operating the process. As compared with various other anaerobic wastewater treatment processes, a granular sludge upflow process represents one of the best options developed so far. Although the overall sludge yield under psychrophilic conditions is slightly higher than under optimal mesophilic conditions, this doesn't seriously hamper the operation of the process. The extra sludge yield, due to accumulation of slowly hydrolyzing substrate ingredients, was 4.75% of the COD input at 14 degrees C and 1.22% of the COD input at 20 degrees C.

[Prescribed drugs and diagnoses in over 60-year-old persons exemplified by cardiovascular diseases. Follow-up studies using federal health insurance data]. / Arzneimittelverordnungen und Diagnosen bei über 60jährigen Personen am Beispiel der Herz-Kreislauf-Erkrankungen. Verlaufsbeobachtungen unter Verwendung von Krankenkassendaten.

In Germany, there have been few investigations into prevalence and medical-therapy for cardiovascular disease (especially regarding cardio infarction) among the elderly. Our aim was to investigate the frequency of cardiovascular disease among over 60 year olds and to show their therapy as population related. The basis of our data was the documents of a representative study group of AOK (insurance) members from a North Rhine Westphalian Metropolis. The prevalence of cardiovascular problems was with 90% very high. 56% showed symptoms of at least two further illnesses from the three categories: the musculo-sceletal system, gastro-intestinal system, and their state of mind. All cardiovascular patients were treated with cardiovascular drugs; 2/3 continuously over a 4-quarter period. 43.9% of the aged population had hypertonia, women (47.1%) being slightly more affected than men (35.4%). The prevalence increased to 50% among 80 year olds. The degree of treatment in the case of female hypertensives was 90% and 82% in the case of males. The prevalence of cardiac infarction came to 3.5% among the elderly, and was notably higher for men than for women (6.7%/2.3%). Almost 90% of the cardiac infarction patients received on average anti-anginal vasodilators with 523 DDD per year. The vast majority of patients received three types of medicines simultaneously. The 1-year mortality of the elderly cardiac infarction patients was, when compared to a random sample of the same age, 7 times higher. Apoplexy among the aged had a prevalence of 2.8% and increased rapidly with age (60-69 years/1% to 5% > or = 70 years). The increase affected, above all, men, whose year's mortality was 15 times higher than that of a random sample of the same age. The apoplexy patients had a large amount of cardiovascular medications prescribed to them.

[The incidence and prevalence of malignant diseases. A secondary data analysis of a representative random sample of those with local compulsory medical insurance in Dortmund]. / Häufigkeit und Verteilung von Malignomerkrankungen. Sekundärdatenanalyse einer repräsentativen Stichprobe von Versicherten der AOK Dortmund.

Prevalence and distribution of malignant neoplasms were obtained in 1988 and 1989 from a representative random sample of 5% of insured members of the statutory health insurance company in Dortmund, Germany (7447 persons). Data were gathered from medical certificates the diagnosis being further validated internally by other patient data. The cancer prevalence in the sample was 2.3% (males 1.6%, females 3.0%). The average age of the 174 patients with cancer was 67.5 years, half of them 70 years or over. The most frequent cancer was that of the breast (32.2%), followed by that of the colorectum (14.3%) and the skin (12.5%). Standardized for age and sex the prevalence of cancer for the whole population of the Federal Republic of Germany (excluding the former German Democratic Republic) was calculated as 2.2% (males 1.7%, females 2.5%), i.e. 1.33 million patients. The incidence of cancer for 1989 was 0.54%. Taking into account special methodological considerations, the secondary analysis of data obtained from the described source provides information relevant to the care of patients with cancer and thus makes a valuable contribution to the documentation of medical care provision.

[Estimation of the incidence of diabetes in the Federal Republic of Germany based on insurance data. A secondary data analysis of a representative random sample of locally insured persons in the city of Dortmund]. / Schätzung der Diabeteshäufigkeit in der Bundesrepublik Deutschland anhand von Krankenkassendaten. Sekundärdatenanalyse einer repräsentativen Stichprobe AOK-Versicherter der Stadt Dortmund.

All records relating to medical prescriptions and services relating to diabetes for a representative sample (n = 6478) of inhabitants of Dortmund in 1988, who were members of the Local Health Insurance in Dortmund, were analysed. 264 patients (4.08%) were receiving antidiabetic drugs during that year, 198 (3.06%) oral ones, 42 (0.65%) insulin and 24 (0.37%) both. 12.41% of all those insured over the age of 60 were on antidiabetic drugs, more women than men (5.08 vs 2.94%; P less than 0.001). The most frequently used oral antidiabetics were sulphonylurea ones (95.1%), while the proportion of biguanides was only 4.4%. On the basis of established diagnosis, regular blood sugar and HbA1 tests, as well as optic fundi examination, a further 104 persons (1.60%) are assumed to have diabetes but not treated by drugs. This sample indicates an overall prevalence of diabetes of 5.68% among the population. Relating it to the age and sex pattern of the population of the Federal Republic of Germany this corresponds to a prevalence of diagnosed diabetes of 4.82%. Thus there are probably a little less than 4 million diabetic citizens of the Federal Republic of Germany.

Drug utilization research in primary health care as exemplified by physicians' quality assessment groups.

Drugs in primary health care are often prescribed for nonrational reasons. Drug utilization research investigates the prescription of drugs with an eye to medical, social and economic causes and consequences of the prescribed drug's utilization. The results of this research show distinct differences in drug utilization in different age groups and between men and women. Indication and dosage appear irrational from a textbook point of view. This indicates nonpharmacological causes of drug utilization. To advice successfully changes for the better quality assessment groups of primary health care physicians get information about their established behavior by analysis of their prescriptions. The discussion and the comparisons in the group allow them to recognize their irrational prescribing and the social, psychological and economic reasons behind it. Guidelines for treatment are worked out which take into account the primary health care physician's situation. After a year with 6 meetings of the quality assessment groups the education process is evaluated by another drug utilization analysis on the basis of the physicians prescription. The evaluation shows a remarkable improvement of quality and cost effectiveness of the drug therapy of the participating physicians.