Prescribing of valproate and oral antiepileptics for women of childbearing age and during pregnancy in Germany between 2010 and 2020.

PURPOSE: To examine prescriptions of valproate and oral antiepileptic drugs (OAED) in Germany irrespective of the indication in women in general and particularly in women of childbearing age (13-49 years) and during pregnancy between 2010 and 2020, that is, before, during and after the implementation of the EU risk minimization measures (RMMs). METHODS: Analysis of claims data. STUDY POPULATION: all women continuously insured with the AOK health insurance fund in the respective observation year (2010-2020) and the previous year. OAED were identified by ATC code N03. Period of pregnancy was calculated based on birth information in claims data. MAIN OUTCOMES MEASURES: (i) prevalent use of valproate/OAED: number of women with at least one prescription of valproate/OAED per year divided by all women of the study population (rate per 1000 women); (ii) percentage of OAED recipients with at least one valproate prescription during pregnancy (13-49 years) in the respective observation year. RESULTS: Prevalence rate/1000 women for valproate use decreased by -31.33% across all age groups (2010-2014: -7.48%; 2014-2018: -16.47%; 2018-2020: -11,17%) with a strong reduction in women 13-49 years between 2014 and 2018 (-28.74%). The rate for OAED across all age groups rose from 33.43/1000 women in 2010 to 41.03/1000 (+22,73%). Valproate use during pregnancy of women with OAED declined from 1.29% in 2010 to 0.59% in 2020 (-54,26%) (2010-2014: -5.14%; 2014-2018: -42.31%; 2018-2020: -16.69%). CONCLUSION: Even if, due to the descriptive nature of the study, no causal relationship can be postulated between the RMMs and the strong decrease in valproate prescriptions, our results are compatible with the hypothesis that the measures have improved drug therapy safety.

[Algorithm for the Classification of Type 1 and Type 2 Diabetes Mellitus for the Analysis of Routine Data]. / Algorithmus zur Unterscheidung von Diabetes mellitus Typ 1 und Typ 2 bei der Analyse von Routinedaten.

BACKGROUND: Diabetes mellitus is a disease of high public health relevance. To estimate the temporal development of prevalence, routine data of statutory health insurances (SHI) are being increasingly used. However, these data are primarily collected for billing purposes and the case definition of specific diseases remains challenging. In this study, we present an algorithm for differentiation of diabetes types analyzing SHI routine data. METHODS: The basis for the analysis was an age and sex-stratified random sample of persons of the Barmer SHI with a continuous insurance duration from 2010 to 2018 in the magnitude of 1% of the German population. Diabetes was defined in the reporting year 2018, as documentation of (1) a "confirmed" ICD diagnosis E10.- to E14.- in at least two quarters, (2) a "confirmed" ICD diagnosis E10.- to E14.- in one quarter with an additional prescription of an antidiabetic drug (ATC codes A10), or (3) an ICD diagnosis E10.- to E14.- in the inpatient sector, outpatient surgery, or work disability. Individuals were assigned to a diabetes type based on the specific ICD diagnosis E10.- to E14.- and prescribed medications, differentiated by insulin and other antidiabetics. Still unclear or conflicting constellations were assigned on the basis of the persons' age or the frequency and observation of the diagnosis documentation over more than one year. The participation in a disease management program was considered in a sensitivity analysis. RESULTS: The prevalence of documented diabetes in the Barmer sample was 8.8% in 2018. Applying the algorithm, 98.5% of individuals with diabetes could be classified as having type 1 diabetes (5.5%), type 2 diabetes (92.6%), or another specific form of diabetes (0.43%). Thus, the prevalence was 0.48% for type 1 diabetes and 8.1% for type 2 diabetes in 2018. CONCLUSION: The vast majority of people with diabetes can be classified by their diabetes type on the basis of just a few characteristics, such as diagnoses, drug prescription, and age. Further studies should assess the external validity by comparing the results with primary data. The algorithm enables the analysis of important epidemiological indicators and the frequency of comorbidities based on routine data differentiated by type 1 and type 2 diabetes, which should be considered in the surveillance of diabetes in the future.

[Development and Internal Validation of Case Definitions for Prevalence Estimation of Microvascular Complications of Diabetes in Routine Data]. / Entwicklung und interne Validierung von Falldefinitionen für die Prävalenzschätzung mikrovaskulärer Komplikationen des Diabetes in Routinedaten.

BACKGROUND: Surveillance of diabetes requires up-to-date information on the prevalence of diabetes and its complications over time. For this purpose, statutory health insurance (SHI) data is being increasingly used, as the data is available in a timely fashion and case numbers enable detailed estimates also of diabetes complications. The aim of the present study was the development and internal validation of case definitions for the prevalence estimation of diabetic retinopathy (DRP), diabetic polyneuropathy (DPN) and diabetic foot syndrome (DFS). METHODS: Persons with diabetes differentiated by type 1, type 2, and other diabetes in an age- and sex-stratified sample of persons insured by Barmer SHI in 2018 (n=72,744) comprised the study popuation. Based on the central ICD codes for microvascular complications (DRP: H36.0; DPN: G63.2; DFS: E1X.74/.75), case definitions were developed including additional ICD codes for complications without direct diabetes reference. Subsequently, the case definitions were internally validated. For the validation, coding in the inpatient setting (m1S) or repeatedly in the outpatient setting (m2Q) as well as coding of specific procedures (EBM, OPS) and drug prescriptions or by relevant specialists were considered. Additionally, we analysed the documentation of the diagnoses in the previous years. RESULTS: In 2018, the prevalence of the central ICD codes was 8.4% for DRP (H36.0), 18.9% for DPN (G63.2) and 13.4% for DFS (E1X.74/.75). After inclusion of additional ICD codes in the case definition, prevalence increased significantly for DRP (9.6%) and DPN (20.7%), and barely for DFS (13.5%). Internal validation confirmed the majority of diagnoses (DRP: 96.7%; DPN: 96.5% DFS: 95.8%) and m2Q represented the most relevant criterion. When up to four previous years were considered, prevalences were up to 30% higher for DPN and DFS and up to 64% higher for DRP. CONCLUSION: The inclusion of additional ICD codes in the case definition of microvascular complications of diabetes appears meaningful, as this increases the sensitivity of the prevalence estimate. Internal validation suggests that the documented diagnoses are plausible. However, not all diagnoses are documented annually, leading to an underestimation of the prevalence using a cross-sectional study design of one year.

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project.

BACKGROUND: The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years. METHODS: This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented. RESULTS: A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest. CONCLUSIONS: We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

[Operationalization of Quality Indicators with Routine Data Using the Example of the Evaluation of "Integrated Care Healthy Kinzigtal"]. / Operationalisierung von Qualitätsindikatoren mittels Routinedaten am Beispiel der Evaluation der "Integrierten Versorgung Gesundes Kinzigtal".

AIM: As part of the 10-year evaluation of Gesundes Kinzigtal Integrated Care (IVGK, Innovation Fund Project 01VSF16002), a multidisciplinary group of experts agreed on 101 quality indicators (QI) to evaluate the quality of regionally integrated care with its focus on health and prevention programs. One criterion was that the selected QI should in principle be suitable for mapping using routine data. The aim of the study was to investigate how many and in what way the QI developed can actually be mapped in Germany with routine data and for what reasons operationalization was restricted or not possible. MATERIAL AND METHODS: The operationalization of the QIs was performed using pseudonymized billing data of the AOK Baden-Württemberg from 2006 to 2015, which the Scientific Institute of the AOK (WIdO) provided to the evaluation team. All operationalized indicators were binary coded (criterion fulfilled yes/no). The diagnoses, procedures, or drugs named in the numerator and denominator definitions were operationalized using ICD-10 codes (inclusion and exclusion diagnoses), EBM codes, OPS codes, ATC codes. Indicator prevalences were examined over time to check for abnormalities as an indication of possible misscoding. RESULTS: Ninety of the 101 indicators were operationalizable with routine data. Fourteen of the 90 indicators could only be operationalized with restrictions, as corresponding service codes were only introduced or existing codes were changed during the observation period. Seventy-six of 90 indicators could be operationalized without restrictions. In this context, 15 of these 76 indicators required pre- and follow-up periods, which meant that they could not be presented for all years. Eleven of 101 QIs could not be operationalized because EBM codes were only introduced after 2015 or were not recorded as individual services for all physician groups (e. g., spirometry and long-term ECG). Striking trends in indicator prevalences could be explained. CONCLUSION: Routine data enable resource-saving quality monitoring. A change in the data basis during the observation period, for example through the introduction or deletion of billing codes, makes the longitudinal, routine data-based quality assessment more difficult, but enables further or new indicators to be operationalized for later periods.

Comparative risks of bleeding, ischemic stroke and mortality with direct oral anticoagulants versus phenprocoumon in patients with atrial fibrillation.

PURPOSE: The pivotal trials for stroke prevention in non-valvular atrial fibrillation (NVAF) compared rivaroxaban, dabigatran, and apixaban with warfarin, as did most claims-based studies. Comparisons with phenprocoumon, the most frequently used vitamin K antagonist (VKA) in Germany, are scarce. METHODS: Risk of bleeding, ischemic stroke, and all-cause mortality in patients with NVAF were analyzed using data for 2010 to 2014 from a large German claims database. New users of oral anticoagulants from January 2012 to December 2013 were included and observed over 1 year. Baseline characteristics were adjusted using propensity score matching and logistic regression. Several sensitivity analyses were carried out. RESULTS: Fifty-nine thousand four hundred forty-nine rivaroxaban, 23,654 dabigatran, 4894 apixaban, and 87,997 matched phenprocoumon users were included. Adjusted hazard ratios (95% confidence intervals) compared with phenprocoumon were as follows: hospitalized bleedings: rivaroxaban 1.04 (0.97; 1.11), dabigatran 0.87 (0.77; 0.98), and apixaban 0.65 (0.50; 0.86); ischemic stroke: rivaroxaban 1.05 (0.94; 1.17), dabigatran 1.14 (0.96; 1.35), and apixaban 1.84 (1.20; 2.84); all-cause mortality: rivaroxaban 1.17 (1.11; 1.22), dabigatran 1.04 (0.95; 1.13), and apixaban 1.14 (0.97; 1.34). CONCLUSIONS: With rivaroxaban, no significant differences were observed compared to phenprocoumon with regard to hospitalized bleedings or ischemic strokes. Dabigatran was associated with fewer bleedings and a similar risk of ischemic strokes compared to phenprocoumon. Apixaban was also associated with fewer bleedings but was unexpectedly associated with more ischemic strokes, possibly reflecting selective prescribing. The association of rivaroxaban with higher all-cause mortality unrelated to bleedings or strokes has been described previously but remains to be explained.

Knee instability in patients with traumatic knee disorders: a cohort study in primary care.

BACKGROUND: There is a lack of knowledge about the course of knee instability in patients with traumatic knee disorders. OBJECTIVE: The aim of the study was to determine the course of traumatic knee instability during 1-year follow-up and to observe the treatment of knee instability by GPs. METHODS: Patients (n = 134) aged 18-65 years with traumatic knee disorders who consulted their GP within 5 weeks after trauma were enrolled in a prospective cohort study. Data were collected at baseline and at 3, 6 and 12 months follow-up. Magnetic resonance imaging (MRI) and physical examination of the knee were performed at baseline and at 1-year follow-up. RESULTS: At baseline, 28% of the 134 patients had no knee instability, 17% reported knee instability (according Lysholm score), 31% tested positive on knee instability (according Lachman test) and 24% both self-reported and tested positive on instability of the knee. At baseline and at 1-year follow-up, no clear differences between MRI findings, treatment and course of the defined groups of knee instability were found. At 1-year follow-up, patients with both self-reported and tested positive seemed to have worse outcomes. CONCLUSION: During 1-year follow-up, it was unclear if there were differences regarding course, treatment and MRI findings of the knee between no instability and the three defined knee instability groups. Statistical power was lacking in the comparisons made and therefore studies with more patients are needed.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]. / Triple Aim - Evaluation in der Integrierten Versorgung Gesundes Kinzigtal - Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit.

BACKGROUND: The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care. OBJECTIVES: To evaluate the impact of the ICSGK on the Triple Aim. MATERIALS AND METHODS: The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension. RESULTS AND CONCLUSIONS: Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Prevalence of inflammatory bowel disease: estimates for 2010 and trends in Germany from a large insurance-based regional cohort.

OBJECTIVE: A worldwide increase in prevalence of inflammatory bowel disease (IBD) has been reported. For Germany, latest publications not restricted to actively treated disease present data of the 1980s. This study estimates the administrative 1-year period IBD prevalence in 2010 and investigates the trend in prevalence of actively treated disease between 2001 and 2010. MATERIAL AND METHODS: Utilizing an insurance-based cohort (n = 311,001 in 2001 to 265,102 in 2010), case definition was based on ICD-10 codes. The prevalence of active treatment was based on internally validated IBD cases of the respective year. The 1-year period prevalence in 2010 accounts for cases actively treated in at least one of the years between 2001 and 2010. Estimates were directly standardized by age and sex to the population of Germany. The change in prevalence of actively treated disease over the years was evaluated by means of Poisson regression. RESULTS: The IBD prevalence in 2010 was 744 (95% confidence interval [CI]: 707-775) per 100,000 (Crohn's disease: 322 [95% CI: 302-346], ulcerative colitis: 412 [95% CI: 389-436] per 100,000). The prevalence of actively treated disease increased significantly between 2001 (344 [95% CI: 324-364] per 100,000) and 2010 (493 [95% CI: 464-519] per 100,000; increase in prevalence by 42% [95% CI: 31%-53%], p trend = 6.0 × 10(-19)). CONCLUSION: In line with worldwide reports, our results based on a large insurance cohort suggest a considerable increase in IBD prevalence in Germany since the 1980s. The significant increase in prevalence of actively treated disease in our cohort highlights the need to adapt healthcare services and deal with the burden associated with increasing numbers of IBD patients.

Predictive factors for new onset or progression of knee osteoarthritis one year after trauma: MRI follow-up in general practice.

OBJECTIVE: To prospectively evaluate prognostic factors for new onset or progression of degenerative change on follow-up MRI one year after knee trauma and the association with clinical outcome. METHODS: Within a prospective observational cohort study in general practice, we studied a subgroup of 117 patients with acute knee trauma (mean age 41 years, 43% women). Degenerative change was scored on MRI at baseline and after one year follow-up. Multivariate logistic regression analysis was performed to evaluate prognostic factors for new onset or progressive degenerative change on follow-up MRI. Association between new or progressive degeneration and clinical outcome after one year was assessed. RESULTS: On follow-up MRI 15% of patients with pre-existing knee osteoarthritis showed progression and 26% of patients demonstrated new degenerative change. The only statistically significant prognostic variable in the multivariate analysis was bone marrow oedema on initial MRI (OR 5.29 (95% CI 1.64-17.1), p = 0.005). A significant association between new or progressive degenerative change and clinical outcome was found (p = 0.003). CONCLUSION: Bone marrow oedema on MRI for acute knee injury is strongly predictive of new onset or progression of degenerative change of the femorotibial joint on follow-up MRI one year after trauma, which is reflected in clinical outcome.

Ten-Year Evaluation of the Population-Based Integrated Health Care System "Gesundes Kinzigtal".

BACKGROUND: The population-based integrated health care system called "Gesundes Kinzigtal" (Integrierte Versorgung Gesundes Kinzigtal, IVGK) was initiated more than 10 years ago in the Kinzig River Valley region, which is located in the Black Forest in the German state of Baden-Württemberg. IVGK is intended to optimize health care while maximizing cost-effectiveness. It consists of programs for promoting health and for enabling cooperation among service providers, as well as of a shared-savings contract that has enabled resources to be saved every year. The goal of the present study was to investigate trends in the quality of care provided by IVGK over the past ten years in comparison to conventional care. METHODS: This is a non-randomized observational study with a control-group design (Kinzig River Valley versus 13 structurally comparable control regions), employing data collected by AOK, a large statutory health-insurance provider in Germany, over the period 2006-2015. Quality assessment was conducted with the aid of a set of indicators, developed by the authors, that was based exclusively on claims data. The statistical analysis of the trends in these indicators over time was conducted with preset criteria for the relevance of any observed changes, as well as preset mechanisms of controlling for confounding factors. RESULTS: For 88 of the 101 evaluable indicators, no relevant difference was seen between the trend over time in the region of the intervention and the average trend in the control regions. Relevant differences in favor of the IVGK were observed for six indicators, and negatively divergent trends compared to the controls were observed for seven indicators. In the main summarizing statistical analysis, no positive or negative difference was found between the Kinzig River Valley and the other regions with respect to trends in the health-care indicators over time. CONCLUSION: An evaluation based on 101 indicators derived from health-insurance data did not reveal any improvement of the quality of care by IVGK and the totality of the programs that were implemented under it. However, under the conditions of the shared-savings contract, no relevant diminution in the quality of care was observed over a period of 10 years either, compared with structurally similar control regions without an integrated care model.

MRI follow-up of conservatively treated meniscal knee lesions in general practice.

OBJECTIVE: To evaluate meniscal status change on follow-up MRI after 1 year, prognostic factors and association with clinical outcome in patients with conservatively treated knee injury. METHODS: We analysed 403 meniscal horns in 101 conservatively treated patients (59 male; mean age 40 years) in general practice who underwent initial knee MRI within 5 weeks of trauma. We performed ordinal logistic regression analysis to analyse prognostic factors for meniscal change on follow-up MRI after 1 year, and we assessed the association with clinical outcome. RESULTS: On follow-up MRI 49 meniscal horns had deteriorated and 18 had improved. Age (odds ratio [OR] 1.3/decade), body weight (OR 1.2/10 kg), total anterior cruciate ligament (ACL) rupture on initial MRI (OR 2.4), location in the posterior horn of the medial meniscus (OR 3.0) and an initial meniscal lesion (OR 0.3) were statistically significant predictors of meniscal MRI appearance change after 1 year, which was not associated with clinical outcome. CONCLUSION: In conservatively treated patients, meniscal deterioration on follow-up MRI 1 year after trauma is predicted by higher age and body weight, initial total ACL rupture, and location in the medial posterior horn. Change in MRI appearance is not associated with clinical outcome.

[Development of an indicator set for the evaluation of the population-based integrated healthcare model 'Gesundes Kinzigtal' (Healthy Kinzigtal)]. / Entwicklung eines Indikatorensets zur Evaluation der Integrierten Versorgung Gesundes Kinzigtal.

INTRODUCTION: The project "INTEGRAL-10-year evaluation of the population-based integrated health care model 'Gesundes Kinzigtal' (Healthy Kinzigtal)" (ICM-GK) is funded by the Innovation Committee of the Federal Joint Committee (G-BA) (grant no. 01VSF16002). The evaluation is to be based on a set of indicators that can be captured in routine data. On the one hand, they can be used to assess ICM-GK programs that are program-specific and geared towards prevention and disease management. On the other hand, possible negative side effects of the ICM-GK, which is designed as a "shared savings contract", are to be examined by also observing care needs not covered by the ICM-GK contract. Since an indicator set for the evaluation of regional integrated care (IC) programs in Germany is not yet available, a suitable indicator set should be developed. METHODS: RESULTS: The methodological framework links the OECD concept for quality assessment of health systems with Kessner's tracer methodology. Disease groups with a high prevalence ("common diseases"), prevention potential and potential for improvement through IC were selected as tracers. The literature search resulted in 239 QIs and the QI database search in 293 QIs, which were supplemented by 21 QIs from the focus groups. Out of a total of 553 QIs, 251 QIs remained after removal of duplicates and comparison with the data basis. This preliminary QI set was reduced to 101 QIs by consensus. In addition, 48 health reporting indicators were supplemented which serve to classify regional quality results. The final QI set maps the following 19 disease categories/tracers: heart failure (16 QIs), myocardial infarction (4 QIs), CHD (10 QIs), stroke (6 QIs), metabolic syndrome (7 QIs of which 5 were diabetes-related), COPD (6 QIs), asthma (3 QIs), chronic pain (5 QIs), back pain (3 QIs), geriatrics (7 QIs), dementia (8 QIs), osteoporosis (3 QIs), rheumatism (3 QIs), multiple sclerosis (2 QIs), depression (4 QIs), antibiotic therapy (3 QIs), drug safety (1 QI), child care (5 QIs), early detection/prevention (5 QIs). 33 of these QIs are dedicated to five tracers that are not explicitly ICM-GK programs. Most QIs assess aspects of the effectiveness of care for the chronically ill and measure process quality. DISCUSSION: The set of indicators initially enables the quality assessment of regional, cross-indication care quality in the population-based integrated health care model 'Gesundes Kinzigtal' on the basis of routine data. Although the QI set focuses on effectiveness and process quality, it also includes QIs for preventive and acute care, coordination of care, patient orientation and safety, and outcomes. In contrast to other QI sets, both primary care and specialist health care and integrated, cross-sectoral and cross-professional care aspects have been considered. The benefits of the QI set for comparisons of regional quality and the evaluation of different IC programs remain to be tested. CONCLUSION: On the basis of a broadly based research and participatory development process, a set of indicators has been developed that enables comprehensive evaluation of the regional quality of care of cross-indication, integrated care models focusing on common diseases. In order to be able to increasingly evaluate aspects of care coordination and patient orientation, health promotion as well as nursing, palliative and emergency care in the future, it would be helpful if routine data were collected or made accessible in these areas as well.

[Outpatient care for child and adolescent psychiatric disorders--data from an insuree-related epidemiological study]. / Ambulante Versorgung kinder- und jugendpsychiatrischer Störungen--Daten einer versichertenbezogenen epidemiologischen Studie.

The aim of the study was to examine the extent to which psychiatric disorders are documented as a diagnosis requiring treatment in children and adolescents as well as to investigate the frequency with which non-medicinal interventions are utilized. The database comprised an 18.75% random sample of insurees from the AOK statutory health insurance fund Hessen. The data allowed an examination of the care-seeking behaviour of 55,545 children and adolescents aged 0 to 18 years in the year 2006. With respect to all psychiatric diagnostic categories, a psychiatric diagnosis was documented for 19.3% of children and adolescents in 2006. 27% of children and adolescents had received more than one psychiatric diagnosis. Up to the age of 14 years, psychiatric diagnoses were more frequently documented for boys than for girls, while this pattern was reversed from the age of 15 years upwards. Typical differences in the spectrum of services received were evident depending on the psychiatric diagnosis made. Younger age groups predominantly received logopedic treatment, occupational therapy, and physiotherapy/therapeutic exercise. With increasing age, the utilization of psychiatric and psychotherapeutic services expanded. Outpatient care is primarily provided by pediatricians and general physicians followed by practice-based child and adolescent psychiatrists as well as outpatient child and adolescent psychiatric clinics. While not all diagnoses necessitate psychiatric or psychotherapeutic interventions, it may be assumed that the predominant seeking of care from pediatricians and general physicians is reflective of continued inadequate access to child and adolescent psychiatrists or other specialized facilities and professional groups.

[Internal diagnostic validation of patients with a chronic wound: possibilities of identification on the basis of routine data]. / Interne Diagnosevalidierung von Patienten mit einer floriden chronischen Wunde - Möglichkeiten der Identifizierung auf der Basis von Routinedaten.

OBJECTIVE: There are still few epidemiological data on patients with chronic wounds (leg ulcers, diabetic foot ulcers and pressure ulcers). Statutory health insurance (SHI) data is increasingly being used for questions relating to healthcare science. When using this data, which is primarily collected for billing purposes, the methodological procedure for defining cases must be presented transparently. Here, it must be checked whether the target group can be validly defined using the coded diagnoses and, if necessary, further information from routine data. Therefore, the aim of this contribution is, on the one hand, to develop criteria with the help of which patients with a florid (active) chronic wound can be identified safely or as doubtful cases in routine data and, on the other hand, to determine the corresponding frequency estimates. METHODS: Initially, a literature research was carried out to identify parameters relevant to care in patients with chronic wounds. In the next step, these were divided into specific, less specific and non-specific criteria (visual validity) in a multi-stage consensus procedure with regard to the specificity for wound care. On this basis, three different case definitions are used to identify florid chronic wounds. Based on an SHI sample of insured persons, frequency estimates were made for various case definitions (safe and questionable cases). RESULTS: Of the 21 parameters identified in the literature, eight were classified as specific, six as less specific and eight as non-specific criteria for the identification of patients with chronic florid wounds. Using diagnostic coding alone for the target diseases, an administrative prevalence of chronic wounds of 1.13% was observed for the year 2010. If a case is defined using the less specific and/or the specific criteria, prevalence drops to 0.79%; if only the specific criteria are used, prevalence drops only marginally to 0.78%. These changes were observed in patients with leg ulcers and diabetic foot ulcers, but not in patients with pressure ulcers. Here, the lowest administrative prevalence (0.18%) can be seen when only looking at the diagnoses, but this increases slightly when taking wound-relevant treatments into account (specific and less specific criteria: 0.25%). CONCLUSION: It is possible to define patients with a chronic florid wound on the basis of wound-relevant treatments using SHI data and to make estimates of administrative prevalence. Depending on the question, the criteria for defining cases can be narrowed down or broadened. The comparison provides information on the internal validity of diagnostic coding. However, further studies are needed to verify external validity.

Performance of the adapted Diabetes Complications Severity Index translated to ICD-10.

OBJECTIVES: To assess the performance of the adapted Diabetes Complications Severity Index (aDCSI) translated to International Classification of Diseases, Tenth Revision (ICD-10) in predicting hospitalizations, mortality, and healthcare-associated costs. STUDY DESIGN: Retrospective closed cohort study based on secondary data analysis. METHODS: We translated the aDCSI to ICD-10 and calculated aDCSI scores based on health insurance claims data. To assess predictive performance, we used multivariate regression models to calculate risk ratios (RRs) of hospitalizations and mortality and linear predictors of cost. RESULTS: We analyzed a sample of 157,115 patients with diabetes mellitus. RRs of hospitalizations (total and cause specific) rose with increasing aDCSI scores. Predicting total hospitalizations over a 4-year period, unadjusted RRs were 1.22 for an aDCSI score of 1 (compared with a score of 0), 1.55 for a score of 2, 1.77 for a score of 3, 2.11 for a score of 4, and 2.72 for scores of 5 and higher. Cause-specific hospitalizations and mortality showed similar results. Costs clearly increased in each successive score category. CONCLUSIONS: Our study supports the validity of the aDCSI as a severity measure for complications of diabetes, as it correlates to and predicts total and cause-specific hospitalizations, mortality, and costs. The aDCSI's performance in ICD-10-coded data is comparable with that in International Classification of Diseases, Ninth Revision-coded data.

Study protocol for a quasi-experimental claims-based study evaluating 10-year results of the population-based integrated healthcare model 'Gesundes Kinzigtal' (Healthy Kinzigtal): the INTEGRAL study.

INTRODUCTION: Patients often experience interface problems when treated by different specialists and in different healthcare sectors. Integrated care concepts aim to reduce these problems. While most integrated healthcare models focus on individual diseases, the integrated care model 'Gesundes Kinzigtal' applies a population-based approach and addresses the full spectrum of morbidities for a population defined by area of residence-the Kinzigtal. A special feature of the model is the joint savings contract between the regional management company and the statutory health insurers. The INTEGRAL study aims at assessing the effectiveness of 'Gesundes Kinzigtal' under routine conditions in comparison to conventional care over a period of 10 years in order to understand the benefits but also the potential for (unintended) harms. METHODS AND ANALYSIS: Database Claims data from statutory health insurance funds 2005-2015. The evaluation consists of a quasi-experimental study, with Kinzigtal as intervention region, at least 10 further regions with a similar population and healthcare infrastructure as primary controls and an additional random sample of insurees from the federal state of Baden-Württemberg as secondary controls. Model-specific and 'non-specific' indicators adopted from the literature and enriched by focus group interviews will be used to evaluate the model's effectiveness and potential unintended consequences by analysing healthcare utilisation in general. Temporal trends per indicator in the intervention region will be compared with those in each control region. The overall variation in trends for the indicators across all regions provides information about the potential to modify an indicator due to local differences in the healthcare system. ETHICS AND DISSEMINATION: Ethic Commission of the Faculty of Medicine, Philipps-University Marburg (ek_mr_geraedts_131117). Results will be discussed in workshops, submitted for publication in peer-review journals and presented at conferences. TRIAL REGISTRATION NUMBER: DRKS00012804.

[Anti-Diabetic Medication During the First Four Years of Treatment. A Study Based on Claims Data]. / Antidiabetische Medikation in den ersten vier Therapiejahren. Eine Studie auf Basis von Krankenkassendaten.

Background Ever since the UKPDS study reassessed the usefulness of the substance metformin in 1998, it has been the first-line medication in anti-diabetic treatment. In addition, new classes and agents released on the market have given rise to new treatment options. The present study investigates prescription practice at the onset of treatment and in the years thereafter and measures it against German diabetes guidelines. Database and Methods Database: Statutory health insurance sample AOK/KV Hesse; Ages: 40 and over (N = 142514). STUDY POPULATION: New users of anti-diabetic medication in 2008 (no medication during the preceding 730 days) (n = 1882). Investigation of anti-diabetic medication for four years after initial prescription with regard to substance spectrum, combination treatments, changes in treatment. Log-binomial model: factors influences onset of treatment with metformin versus sulfonylureas (age, sex, duration of illness, comorbidity). Results In 2008 67.9 % of patients began treatment exclusively with metformin, 17.8 % exclusively with sulfonylureas, and 6.7 % exclusively with insulin. Patients diagnosed as obese were significantly more likely to receive metformin. Elderly (80 years and over) or who had been diagnosed with diabetes at least three years prior or patients with renal or cerebrovascular illnesses were significantly less likely to receive metformin. Over the course of treatment, the number of patients receiving multiple medications increased from 5 % to 30 %. (The most frequent combinations were metformin/DPP4 inhibitor, metformin/sulfonylureas, and metformin/insulin.) Conclusion The findings show that German patient care guidelines on diabetes are reflected in prescription practice. Renal diseases are taken into account as potential contraindications for metformin treatment. In the wake of the expansion of approval for metformin in 2015 - reducing the creatinine clearance level to which application is possible - this first-line medication will be available for an ever larger circle of patients in the future.