Treatment patterns of individualized real-life tapering approaches based on shared decision-making in rheumatoid arthritis.

OBJECTIVE: To provide real-world evidence on patient-individual tapering patterns of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients in daily clinical practice. METHODS: Data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021 were analyzed. Participants consist of RA patients in sustained remission who were eligible for DMARD tapering at enrolment. Data from RA patients who experienced tapering of DMARDs at least once during the observational period (n = 200) were used. Descriptive analyses of medical outcomes at baseline and at time of first tapering, time to first tapering, tapering patterns by substance group, and tapering intensity were documented. RESULTS: We did not observe meaningful differences in either disease activity or quality of life measures between substance groups at enrolment, time of first tapering, and at 6 or 12 months after tapering. Median time until first tapering varied between substance groups (csDMARDs: 108 days; bDMARDs: 189 days; combination: 119 days). Most patients received one iteration of tapering only (147/200 patients, 73.5%). Dose reduction was applied for patients treated with csDMARDs (79/86 patients, 91.8%), spacing of interval was the most frequent strategy for patients treated with bDMARDs only (43/48 patients, 89.5%). Necessity for increased DMARD dosage was observed in only 10% of patients (20/200). Tapering intensity by substance was overall heterogenous, indicating high individualization. CONCLUSION: We identify highly heterogeneous tapering patterns between substance groups and within substances. Identification and recognition of patient-individual approaches of tapering will help to further improve the management of RA for both patients and rheumatologists.

Patient-individual tapering of DMARDs in rheumatoid arthritis patients in a real-world setting.

OBJECTIVE: We aim to provide real-world evidence on the effectiveness of patient-individual tapering of DMARDs for patients with RA in daily clinical practice using medical records and claims data. METHODS: We utilize data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021. Participants consist of RA patients in sustained remission (>6 months) who were eligible for tapering at enrolment. Patients treated with individual tapering based on shared decision making (n = 200) are compared with patients without any dose reduction (n = 237). The risk of loss of remission and the risk of flare is assessed with risk-adjusted Kaplan-Meier estimators and Cox regressions. We evaluate differences in costs 1 year before and after baseline based on claims data for the subgroup of patients insured at one major sickness fund in Germany (n = 76). RESULTS: The risk of flare (hazard ratio 0.88, 95% CI 0.59, 1.30) or loss of remission (hazard ratio 1.04, 95% CI 0.73, 1.49) was not statistically different between the individual tapering group and the continuation group. Minor increases of disease activity and decreases of quality of life were observed 12 months after baseline, again with no statistically significant difference. Drug costs decreased by 1017€ in the individual tapering group while they increased by 1151€ in the continuation group (P < 0.01). CONCLUSION: Individual tapering of DMARDs does not increase the average risk of experiencing flares or loss of remission. Encouraging rheumatologists and patients to apply tapering in shared decision making may be a feasible approach to allow individualization of treatment in RA.

The Choice of Transcatheter Aortic Valve Implementation (TAVI): Do Patient Co-morbidity and Hospital Ownership Type Matter?

BACKGROUND: Innovative technologies challenge healthcare systems, as evidence on costs and benefits frequently usually are slow to reflect new technology. We investigated these dynamics for Germany, using the emergence of transcatheter aortic valve implementation (TAVI) as an alternative to conventional aortic valve replacements (CAVR). OBJECTIVE: We focused on the role of patient co-morbidity-which would be a medical explanation for adopting TAVI-and hospital ownership status, hypothesizing that for-profit facilities are more likely to capitalize on the favorable reimbursement conditions of TAVI. METHODS: The analysis uses claims data from the Techniker Krankenkasse, the largest health insurance fund in Germany, for the years 2009-2015, covering 2892 patients with TAVI and 9523 with CAVR. The decision on TAVI versus CAVR was estimated for patient-level data, that is, socioeconomic data as well as co-morbidity. At the hospital level, we included the ownership type. We also controlled for effects of the respective owner (rather than the type of ownership), including a random intercept. RESULTS: While the co-morbidity score of TAVI patients was much higher in the early years, over time, the score almost converged with that of CAVR patients. This is in agreement with emerging evidence that suggests the use of TAVI also leads to better patient outcomes. Our results indicate that the type of ownership does not drive the switch to TAVI. We found little, if any, effect from the respective owner, regardless of ownership type. CONCLUSION: Overall, the effects of co-morbidity suggest that providers acted responsibly when adopting TAVI while evidence was still emerging.

[Stepwise Diagnostics, Federal Joint Committee Directive and Actual Care in the Case of Sleep-related Breathing Disorders - An Analysis Based on Claims Data of the Techniker Krankenkasse]. / Stufendiagnostik nach der Richtlinie des G-BA und Versorgungswirklichkeit bei vermuteter Schlafapnoe ­ eine Analyse basierend auf Routinedaten der Techniker Krankenkasse.

In 2004, the Federal Joint Committee (G-BA) published a new directive for examination and treatment methods with respect to sleep-related breathing disorders for SHI-accredited physicians. The examination procedure is classified in four steps: anamnesis, clinical assessment, cardiorespiratory polygraphy (PG) and cardiorespiratory polysomnography (PSG). Starting with the date of the first PSG we analysed 1. whether this examination was preceded by a polygraphy, 2. whether there was a gain of diagnostic information through PSG, and 3. whether a PSG was used for the first adjustment examinations and controls after prescription of a positive airway pressure device. The analysis is based on claims data from the Techniker Krankenkasse (2009-2012). Diagnostic services were identified by fee schedule codes (EBM) for outpatient services and by procedure codes (OPS) for inpatient services. Sleep disorders were operationalised by ICD-10 codes and information was completed by prescriptions of a CPAP equipment.The study is based on data from 6.6 million persons who were permanently insured from 01.01.2009 to 30.06.2012 by TK. A preceding PG 90 (180) days before PSG was found for less than 56% (73%) of the analysed insured persons. By the latter procedure, only about 60% of the cases with no clear diagnostic information (G47.39) in the preceding quarter could be specified. Prescription of a positive airway pressure device within 90 days after PSG was found for about 45% of the insured. Concerning the stepwise diagnostic procedure for sleep disorders for SHI-accredited physicians, the directive was followed only partly. Against the background of an evidence-based, effective, and efficient diagnostic approach, the results show a clear need for action.

The costs of hazardous alcohol consumption in Germany.

Hazardous alcohol consumption in Germany is a main threat to health. By using insurance claim data from the German Statutory Health Insurance and a classification strategy based on ICD10 diagnoses-codes we analyzed a sample of 146,000 subjects with more than 19,000 hazardous alcohol consumers. Employing different regression models with a control function approach, we calculate life years lost due to alcohol consumption, annual direct and indirect health costs, and the burden of pain and suffering measured by the Charlson-Index and assessed pain diagnoses. Additionally, we simulate the net accumulated premium payments over expenses in the German Statutory Health Insurance and the Statutory Pension Fund for hazardous alcohol consumers from a lifecycle perspective. In total, €39.3 billion each year result from hazardous alcohol consumption with an average loss of 7 years in life expectancy. Hazardous alcohol consumers clearly do not "pay their way" in the two main German social security systems and also display a higher intangible burden according to our definitions of pain and suffering.

Long-term sick leave and graded return to work: What do we know about the follow-up effects?

The implementation of a graded return-to-work (RTW) program to reintegrate those in long-term sickness started in Germany in 1971. Based on a return plan by the physician and insured, participants increase their working hours slowly over a specified period of time. Using data on sick leaves from claims data of the Techniker Krankenkasse, we consider sick-leave spells starting from October 2010 to January 2011 with a successful return to work within 517 days. We applied a propensity score matching between participants and non-participants to further analyze differences in sickness spells, medical demand and treatment costs in a follow-up period of 540 days and hence estimate the average treatment effect on the treated (ATT) for the RTW participation with respect to sickness time, sickness benefits and medical expenditures. We found significant but rather small differences in medical costs between treatment and control group. In detail, RTW participants showed slightly lower expenditures on hospitals but higher for ambulatory services and pharmaceuticals. Moreover, differences in expenditure were related to the condition of the initial sickness spell. Reasons behind this findings may be a different perception of the own health care status and a higher need for medical services. Overall, our findings differ between diagnosis groups of the initial sickness period.

Comparative risk for cardiovascular diseases of dipeptidyl peptidase-4 inhibitors vs. sulfonylureas in combination with metformin: Results of a two-phase study.

AIMS: The aim was to assess whether the use of additional data from the Disease Management Program (DMP) diabetes mellitus type 2 to minimize the potential for residual confounding will alter the estimated risk of either myocardial infarction, ischemic stroke or heart failure in patients with type 2 diabetes using sulfonylureas compared to dipeptidyl peptidase-4 (DPP-4) inhibitors in addition to metformin based on routine health care data. METHODS: We conducted a nested two-phase case-control study using claims data of one German health insurance from 2004 to 2013 (phase 1) and data of the DMP from 2010 to 2013 (phase 2). Adjusted odds ratios (ORs) for the combined cardiovascular event myocardial infarction, ischemic stroke or heart failure were calculated using a two-phase logistic regression. RESULTS: Phase 1 comprised 3179 patients (289 cases; 2890 controls) and phase 2 comprised 1968 patients (168 cases; 1800 controls). We observed an adjusted OR of 0.83 for the combined cardiovascular event (95% CI: 0.61-1.13). CONCLUSIONS: We observed a non-significantly reduced risk for cardiovascular diseases in patients using DPP-4 inhibitors compared to sulfonylureas in addition to metformin. This finding was not altered by the inclusion of additional information of the DMP in the analysis. However, due to the low power of this study, further studies are needed to reproduce our findings.

The costs and consequences of obesity in Germany: a new approach from a prevalence and life-cycle perspective.

With the steadily growing health burden of obesity in Germany, the measuring and quantification of its costs and relevant economic consequences have become increasingly important. The usual quantifications via previous cost-of-illness approaches mostly have several weaknesses, e.g., applying "indirect methods" by using "population-attributable fractions" to identify parts of costs that can be accrued to obesity, second using highly aggregated data and third often only displaying part of the costs. This article presents a new approach and a new estimation of the cost and consequences of obesity in Germany using claims data from a German health insurance company. A sample of 146,000 individuals was analyzed with both a prevalence and a life-cycle focus on the cost and consequences of obesity. With additional data sets, we calculate the deaths per year due to obesity, the excess costs per year and several intangible consequences usually referred to as "pain and suffering". Our results show that the cost estimations of obesity in Germany so far have been largely underestimated. The annual direct costs of obesity in Germany amount to approximately €29.39 billion and the indirect costs to an additional €33.65 billion. A total of 102,000 subjects die prematurely each year because of obesity, and there is a significant excess of unemployment, long-term nursing care, and pain and suffering due to obesity. From a lifetime perspective, every obese man is equal to an additional burden of €166,911 and each woman of €206,526 for the social security system in Germany. Obesity due to unhealthy eating is thus about to replace tobacco consumption in terms of costs and consequences as the main hazardous lifestyle factor and thus should be more intensively focussed by public health policy.

Long-term sick leave and the impact of a graded return-to-work program: evidence from Germany.

The implementation of a graded return-to-work (RTW) program to reintegrate the long-term sick started in Germany in 1971 and has been manifested in the Social Code Book V since 1989. Based on a return plan by the physician and the insured, participants increase their working hours slowly over a specified period of time. As participants are still classified as incapable of working they still receive sick leave benefits. Using claims data from the Techniker Krankenkasse, the largest German sickness fund, the study aims at identifying participants and analyzing the full return-to-work and the impact of the RTW program. Thereby, we account for socio-economic factors, insurance-based characteristics, and medical and health-related information. We consider a possible selection bias by using individual weights to analyze determinants of length of the sickness absence by applying models for survival analysis (Cox proportional hazard model). As a main result - depending on the central assumption of unconfoundedness - sickness absence is positively related to participation in the RTW program for those with sickness absence longer than 120 days. For mental disorders, our results indicate an even stronger effect. The study results emphasize the need further promotion of this instrument among those insured, physicians and employers, as occupational health management is one key for a successful return-to-work.

Costs and treatment patterns of incident ADHD patients - a comparative analysis before and after the initial diagnosis.

BACKGROUND AND OBJECTIVES: The costs and treatment patterns of attention deficit hyperactivity disorder (ADHD) are subjects of health services research in Germany and worldwide. Previous publications focused mainly on prevalent patients and thus research gaps were identified regarding costs and treatment patterns of incident patients before and after the first diagnosis. METHODS: Analyses were conducted using claims data obtained from a large German sickness fund (Techniker Krankenkasse). Inclusion criteria consisted of patients with at least two secured outpatient or one inpatient ADHD diagnosis in 2007. Incidence was ensured by defining a baseline period without ADHD-diagnosis in 2006. In addition to diseaserelated cost analyses compared to a control group including age group comparisons, comorbidities, the proportion of multimodal treatment and medication treatment patterns were described. RESULTS: In total, 9083 newly diagnosed ADHD patients were identified (73 % male; mean age: 12.9 years (SD: 10.3)). The mean total cost of ADHD patients during the year after the first diagnosis exceeded the mean total cost of the year before by 976 € (Differencein-Difference-estimator: 1006 €). Our analyses have shown that 10 % of ADHD patients have been treated with multimodal therapy. In addition, 11 % of the investigated ADHD population have received methylphenidate or atomoxetine preceeding the date of diagnosis in the relevant observation period. DISCUSSION: This study provides important insights into the costs as well as the treatment patterns of incident ADHD patients. ADHD-related costs and medications can be identified prior to the date of the first ADHD diagnosis. Although, multimodal therapy is presented as an optimal treatment option by many international guidelines and experts, its proportion for treatment is low (10 %). Further research is necessary to identify reasons for the low proportion of multimodal therapy and (cost-)effectiveness has to be evaluated in comparison to other treatment options. In addition, ADHD-related costs could be identified before the first diagnosis is documented. The reasons for medication prior to diagnosis have to be further investigated.

Exploring Health System Responsiveness in Ambulatory Care and Disease Management and its Relation to Other Dimensions of Health System Performance (RAC) - Study Design and Methodology.

BACKGROUND: The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. METHODS AND ANALYSIS: The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: (i) cross-sectional survey data from a postal survey and (ii) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. DISCUSSION: RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two important areas of health policy: in ambulatory and chronic disease care.

'Know before you go': information-seeking behaviour of German patients receiving health services abroad in light of the provisions of Directive 2011/24/EU.

OBJECTIVE: While Directive 2011/24/EU on cross-border patient mobility makes specific provisions in relation to information availability and accessibility, little empirical evidence exists to guide best practice. This paper explores the information-seeking behaviour of German patients who received planned care abroad. METHODS: A postal survey among German patients treated in other European countries was carried out by Techniker Krankenkasse, a major German sickness fund. The influence of certain predictors on whether patients informed themselves before travelling for care was investigated using multiple logistic regression. Types and sources of information were analysed using descriptive statistics. RESULTS: Information activity was contingent on patients' level of education, type of service, regularity of treatment abroad and awareness of entitlement to cross-border services. Respondents most frequently enquired about elements of reimbursement, entitlement to services and cost-saving, and consulted their sickness fund for information. Differences in both content and medium of choice were observed between patient groups. CONCLUSION: A structured and inclusive approach to information provision should be adopted. National Contact Points should collaborate with a range of stakeholders, who will vary depending on the health care system; however, patient organizations, health professionals and third-party payers should always be represented. Dynamically monitoring cross-border movements can help determine the range, medium and language of relevant information.

[jeder-fehler-zaehlt.de: Content of and prospective benefits from a critical incident reporting and learning system (CIRS) for primary care]. / Das hausärztliche Fehlerberichts- und Lernsystem 'jeder-fehler-zaehlt.de' - Berichtsbestand und Nutzungsperspektiven.

Critical incident reporting and learning systems (CIRS) have been recommended as an instrument to promote patient safety for a long time. However, both their scientific value and their actual impact have been disputed. The nationwide German CIRS for primary care has been in operation since September 2004. Incident reports are available online, and the question is how to make use of this large database to promote patient safety. A descriptive analysis of the content was performed, classifying, in particular, types of error and contributing factors. Its usage is presented for the period from 2004 to 2013 where a total of 483 complete reports have been recorded. Their severity ranges from 35.6 % with no tangible harm to patients to 14.6 % with important harm (or errors contributing to mortality). The majority of them (74.2 %) were process errors, compared to 25.8 % knowledge/skills errors. The main areas involved were treatment/medication (54.2 %) and diagnosis/tests (16.4 %). The results of the analysis of the CIRS cannot be used as an epidemiological data source. And yet they will generate hypotheses for further research in the field of patient safety. Moreover, they will enable practice teams to make themselves familiar with and learn from critical incident analysis. In spite of the specific difficulties in ambulatory care, CIRS should be promoted in this sector to enable learning. Participation in CIRS can be increased by enhanced feedback.

Informed consumer or unlucky visitor? A profile of German patients who received dental services abroad.

OBJECTIVES: A common characteristic of sending countries in cross-border dental care is that of high costs and/or high copayments for dental services. This study aims to provide an insight into the characteristics of German patients receiving planned and emergency (unplanned) dental care abroad and their satisfaction with received services. METHODS: The Europabefragung is a postal survey carried out by Techniker Krankenkasse for patients who are treated in EU/EEA countries. This study uses data from the Europabefragung 2012. The survey was sent to 45 189 individuals; descriptive statistics for the subset of respondents who received emergency (unplanned) or planned dental treatment are presented. RESULTS: There were 18 339 responses to the questionnaire, out of which 17 543 were deemed valid; 1416 respondents had received emergency (unplanned) (78%) or planned (22%) dental care and were included in the analysis. There were clear differences between unplanned and planned treatments regarding country and type of treatment as well as satisfaction with different aspects of treatment and the need for follow-up care. Overall, satisfaction with treatment was high for both groups; individuals who had received planned treatment were more satisfied on all aspects of care and reported a need for follow-up care less frequently. CONCLUSIONS: While German patients who received both emergency (unplanned) and planned services abroad are mostly satisfied with their experience, some concerns arise with regard to continuity of care. Types of information provided to patients seeking care abroad and dissemination modalities should be carefully planned.

Continuity of care in the cross-border context: insights from a survey of German patients treated abroad.

BACKGROUND: Continuity of care is important for outcomes and patient satisfaction and includes additional considerations in the context of cross-border health care. Although this has been discussed in research and was picked up in the recently transposed Directive on patients' rights (2011/24/EU), there is limited evidence about related issues actually encountered by patients crossing borders. METHODS: An anonymous postal survey was carried out by the Techniker Krankenkasse, one of the largest sickness funds in Germany. The questionnaire was sent to 45 189 individuals who had received treatment in EU/EEA countries and included items on relational, management and informational continuity. RESULTS: The survey had a response rate of 41% (n = 17 543). Of those respondents who had travelled for care (n = 3307), ∼19% (n = 570) did so due to a relationship of trust with a given provider. Only 8% of all respondents required emergency follow-up services due to complications, the majority of which was obtained back in Germany. Twelve percentage of those who were prescribed medication abroad (n = 4208) reported problems, spanning unknown products, dispensation and reimbursement. Information exchange between providers across borders was rare and largely carried out by the patients themselves. CONCLUSIONS: Although relational continuity may be important to specific groups of patients travelling for care, it is primarily informational continuity and its interrelation with management continuity that need to be addressed in the cross-border context. Information exchange should be endorsed at European level. Additional focus is required on informing patients about documentation rights and requirements and providing health records that are comprehensive and comprehensible.

Socioeconomic factors and effect of evidence-based patient information about primary prevention of type 2 diabetes mellitus--are there interactions?

BACKGROUND: Having shown in a recent randomized controlled trial that evidence-based patient information (EBPI) significantly increased knowledge on primary prevention of diabetes compared to standard patient information, we now investigated interaction between socioeconomic status (SES) and the effect of an EBPI. FINDINGS: 1,120 visitors (aged 40-70 years, without known diabetes) to the "Techniker Krankenkasse" and the "German Diabetes Center" websites were randomized. The intervention group received a newly developed on-line EBPI, the control group standard on-line information. The primary outcome measure was knowledge, classified as "good/average/poor". We analyzed associations of knowledge with socioeconomic variables (education, vocational training, employment, subjective social status) combined with intervention effect including interactions, adjusted for possible confounding by knowledge before intervention, self-reported blood glucose measurements, blood pressure, blood lipid levels, age and gender. Logistic regression models were fitted to the subpopulation (n = 647) with complete values in these variables.Education (high vs. low) was significantly associated with knowledge (good vs. average/poor); however, there was no significant interaction between education and intervention. After adjustment, the other socioeconomic variables were not significantly associated with knowledge. CONCLUSIONS: Socioeconomic variables did not significantly change the effect of the intervention. There was a tendency towards a lower effect where lower educated individuals were concerned. Possibly the power was too low to detect interaction effects. Larger studies using SES-specific designs are needed to clarify the effect of SES. We suggest considering the socioeconomic status when evaluating a decision aid, e.g. an EBPI, to ensure its effectiveness not only in higher socioeconomic groups. TRIAL REGISTRATION: Current Controlled Trials ISRCTN22060616 (Date assigned: 12 September 2008).

Estimating colorectal cancer treatment costs: a pragmatic approach exemplified by health insurance data from Germany.

BACKGROUND: The cost of colorectal cancer (CRC) treatment is a crucial parameter to inform cost-effectiveness analyses on CRC screening but it is not readily available and therefore often lacking. We aimed to elaborate and exemplify a pragmatic approach to estimate CRC treatment cost based on health insurance data from Germany. METHODS: We included two groups of persons who were continuously health-insured between 2005-2010: A) Cases: Persons with a hospital discharge diagnosis of CRC (ICD C18-C20) between 2007-2010 and no such a diagnosis between 2005-2006 (to focus on incident CRC cases); B) Controls: Persons without a diagnosis of CRC during the observation period, matched to CRC cases by age and sex (matching factor: 1∶5). We considered in-patient, out-patient and drug costs and calculated incremental costs as the difference in means between cases and controls. We divided costs into three phases of care (initial, intermediate and end-of-life phase). RESULTS: The initial, the intermediate and the end-of-life phase included 12,792, 5,280, and 3,779 CRC cases, respectively, and 63,960, 26,400, and 18,895 controls. The mean incremental costs--annualized for each phase--were €26,000, €2,300, and €51,700, respectively. The costs of the initial phase of care were higher for rectal than for colon cancer. Annualized stage-specific cost estimates ranged from €15,000 to €21,300 for early stages and from €29,800 to €35,000 for late stages. CONCLUSION: This pragmatic and feasible approach provided plausible estimates of CRC treatment costs in Germany; being transferable to other settings, it may thus facilitate to weigh up potential savings in treatment costs against the resources required for CRC control programs in various countries.

The bone evaluation study (BEST): patient care and persistence to treatment of osteoporosis in Germany.

OBJECTIVE: Data on fracture frequency and medical care of patients with osteoporosis are still insufficient. We aimed to analyze frequency of osteoporosis-related fractures and multiple fractures, re-fracture rates, treatment prevalence, and persistence to osteoporosis-related medication in Germany. METHODS AND MATERIALS: Using claims data of a state health insurer (2006 - 2009), we performed a retrospective "real world" analysis. Inclusion criteria were age of 50 years or older and an osteoporosis diagnosis or a prescription for defined osteoporosis-related medication. We assessed fractures, frequencies, and the number of multiple fractures per patient as well as time to follow-up fracture and drug persistence using Kaplan-Meier analysis. RESULTS: Within the observation period, 27% of the osteoporosis patients sustained fractures; of those with fractures, 69% had multiple fractures. For patients with multiple fractures, re-fracture rate after 360 days was between 69% for patients who received parathyroid hormone and 85% for patients who received no anti-osteoporotic medication 360 days before follow-up fracture. In the patient population, persistence rates after 1 year were between 58% for parathyroid hormone and 2% for other osteoporosis-specific drugs (alfacalcidol, fluorides, nandrolone, calcitonin). CONCLUSIONS: In Germany, the number of patients with osteoporosis-attributable fractures is high. There are still deficits in proper treatment as well as in drug persistence. Low persistence lead to a relatively high proportion of patients with follow-up fractures.