Assessment of the Efficiency of Consolidation Treatment through Injections of Expanding Resins by Geotechnical Tests and 3D Electrical Resistivity Tomography.

The design and execution of consolidation treatment of settled foundations by means of injection of polyurethane expanding resins require a proper investigation of the state of the foundation soil, in order to better identify anomalies responsible for the instability. To monitor the injection process, a procedure has been developed, which involves, in combination with traditional geotechnical tests, the application of a noninvasive, geophysical technique based on the electrical resistivity, which is strongly sensitive to presence of water or voids. Three-dimensional electrical resistivity tomography is a useful tool to produce effective 3D images of the foundation soils before, during, and after the injections. The achieved information allows designing the consolidation scheme and monitoring its effects on the treated volumes in real time. To better understand the complex processes induced by the treatment and to learn how variations of resistivity accompany increase of stiffness, an experiment was carried out in a full-scale test site. Injections of polyurethane expanding resin were performed as in real worksite conditions. Results confirm that the experimented approach by means of 3D resistivity imaging allows a reliable procedure of consolidation, and geotechnical tests demonstrate the increase of mechanical stiffness.

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

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

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

AIMS: Patient time costs have been described to be substantial; however, data are highly limited. We estimated patient time costs attributable to outpatient and inpatient care in study participants with diagnosed diabetes, previously undetected diabetes, impaired glucose regulation and normal glucose tolerance. METHODS: Using data of the population-based KORA S4 study (55-74 years, random sample of n = 350), we identified participants' stage of glucose tolerance by oral glucose tolerance test. To estimate mean patient time costs per year (crude and standardized with respect to age and sex), we used data regarding time spent with ambulatory visits including travel and waiting time and with hospital stays (time valued at a 2011 net wage rate of €20.63/h). The observation period was 24 weeks and data were extrapolated to 1 year. RESULTS: Eighty-nine to 97% of participants in the four groups (diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal glucose tolerance.) had at least one physician contact and 4-14% at least one hospital admission during the observation period. Patient time [h/year (95% CI)] was 102.0 (33.7-254.8), 53.8 (15.0-236.7), 59.3 (25.1-146.8) and 28.6 (21.1-43.7), respectively. Age-sex standardized patient time costs per year (95% CI) were €2447.1 (804.5-6143.6), €880.4 (259.1-3606.7), €1151.6 (454.6-2957.6) and €589.2 (435.8-904.8). CONCLUSIONS: Patient time costs were substantial--even higher than medication costs in the same study population. They are higher in participants with diagnosed diabetes, but also in those with undetected diabetes and impaired glucose regulation compared with those with normal glucose tolerance. Research is needed in larger populations to receive more precise and certain estimates that can be used in health economic evaluation.

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

AIM: To model the future costs of Type 2 diabetes in Germany, taking into account demographic changes, disease dynamics and undiagnosed cases. METHODS: Using a time-discrete Markov model, the prevalence of diabetes (diagnosed/undiagnosed) between 2010 and 2040 was estimated and linked with cost weights. Demographic, epidemiological and economic scenarios were modelled. Inputs to the model included the official population forecasts, prevalence, incidence and mortality rates, proportions of undiagnosed cases, health expenditure and cost ratios of an individual with (diagnosed/undiagnosed) diabetes to an individual without diabetes. The outcomes were the case numbers and associated annual direct medical excess costs of Type 2 diabetes from a societal perspective in 2010€. RESULTS: In the base case, the case numbers of diabetes will grow from 5 million (2.8 million diagnosed) in 2010 to a maximum of 7.9 million (4.6 million diagnosed) in 2037. From 2010 to 2040, the prevalence rate amonf individuals ≥40 years old will increase from 10.5 to 16.3%. The annual costs of diabetes will increase by 79% from €11.8 billion in 2010 to €21.1 billion in 2040 (€9.5 billion to €17.6 billion for diagnosed cases). CONCLUSIONS: The projected increase in costs will be attributable to demographic changes and disease dynamics, and will be enhanced by higher per capita costs with advancing age. Better epidemiological and economic data regarding diabetes care in Germany would improve the forecasting accuracy. The method used in the present study can anticipate the effects of alternative policy scenarios and can easily be adapted to other chronic diseases.

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

AIMS: Recently, medical expenditures were found to be 2-fold increased in paediatric patients with diabetic ketoacidotic events (DKA) in the U.S., in particular due to hospitalization. Aim of our study was to analyse DKAs and associated costs in Germany, where structured diabetes care including education is available for all patients. METHODS: For all 12,001 diabetic patients 0-19 years of age (52.6% male, mean age (SD) 12.6 (3.9) years) documented in a German-wide database, all DKAs were assessed, as well as costs for diabetes-related treatment. Associations between costs and DKA were estimated using log-linear models. RESULTS: 457 (3.8%) patients had at least 1 DKA during 2007. Total annual costs for patients without, with 1, or ≥ 2 DKAs were € 3,330 (95%-CI 3,292-3,368), € 6,935 (CI 6,627-7,244), and € 10,728 (CI 9,813-11,644), respectively, with largest differences for hospitalization costs (€ 693, € 4,145, € 8,092). Age-sex-diabetes duration-adjusted cost ratios for patients with 1, or ≥ 2 DKAs compared to patients without DKA were 2.2 (CI 2.1-2.3) and 3.6 (CI 3.1-4.1), respectively. CONCLUSIONS: In Germany, paediatric diabetic patients with DKA had up to 3.6-fold higher diabetes-related costs compared to those without DKA. This cost excess was higher compared to a U.S. study, however, the proportion of patients with DKA was much lower (3.8% versus 14.9%). The lower frequency of DKA in Germany may be due to a higher access to and utilization of diabetes education. Interventions should reduce DKA and resulting hospital admission in pediatric patients in order to reduce costs and improve quality of life.

Inpatient and outpatient health care utilization of children and adolescents with type 1 diabetes before and after introduction of DRGs.

OBJECTIVE: To analyze the frequency and length of hospital stays as well as the frequency of diabetes-associated outpatient visits of children and adolescents with type 1 diabetes before and after the introduction of DRGs (diagnosis-related groups) in German hospitals. METHODS: For this prospective cohort study, data from 2000 (before introduction of DRGs) to 2008 (after introduction) was extracted from the German diabetes documentation software DPV. Incidence rates of hospitalizations, length of hospital stays as well as the incidence rates of outpatient visits of 21,502 children and adolescents were estimated. The associations between the target parameters and DRG introduction, age, sex, diabetes duration, calendar year and migration background were estimated using generalized linear mixed models. RESULTS: Incidence of hospitalization was 0.45 (95% CI 0.44-0.45) per person-year (PY), mean number of hospital days 2.77/PY (95% CI: 2.76-2.79). Children had 5.3 (95% CI: 5.3-5.3) outpatient visits per PY on average. The number of hospital stays, inpatient days, and outpatient visits decreased significantly between 2000 and 2008. Time of introduction of DRGs was related to a significant rise in the number of hospital stays and outpatient visits (p<0.05). There was no significant relation to the number of hospital days. Compared with children younger than eleven years of age, 11- to 14-year-old children had significantly more, adolescents older than 14 years significantly less hospital stays (RR 1.2, 95% CI: 1.14-1.23 and 0.92, 95%, CI: 0.87-0.97, respectively). Migration background was significantly associated with worse results for all analyzed target variables (RR 1.21 for hospital stays, 1.26 for hospital days, 1.07 number of outpatient visits). CONCLUSIONS: The introduction of DRGs in the care of patients with pediatric diabetes mellitus resulted in a leveling of the reduction of the number of outpatient visits and hospital stays. Especially adolescents at the age of puberty and patients from families with migration background seem to require particular attention in health care.

Differences in trends in estimated incidence of myocardial infarction in non-diabetic and diabetic people: Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) registry.

AIMS/HYPOTHESIS: One major objective of the St Vincent Declaration was to reduce the excess risk of myocardial infarction in patients with diabetes mellitus. We estimated the trend of the incidence and relative risk of myocardial infarction in the diabetic and non-diabetic populations in southern Germany from 1985 to 2006. METHODS: Using data from the Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) Project in southern Germany, we ascertained all fatal and non-fatal first myocardial infarctions between 1985 and 2006 (n = 14,891, age 25-74 years). We estimated the diabetic and the non-diabetic populations using data on diabetes prevalence from surveys, and evaluated incidence of myocardial infarction in the two estimated populations. To test for time trends, we fitted Poisson regression models. RESULTS: Of individuals with first myocardial infarction, 71% were male and 28% known to have diabetes. In the non-diabetic population, myocardial infarction incidence decreased by about 1.5% to 2.0% per year. A comparable decrease was seen in the population of diabetic women. However, in the population of diabetic men, incidence of myocardial infarction increased by about 1% per year. Over the whole study period, myocardial infarction incidence decreased by 34% and 27% in non-diabetic men and women respectively (RR 0.66, 95% CI 0.59-0.74 and 0.73, 0.62-0.87 respectively). In diabetic women, it decreased by 27% (RR 0.73, 0.61-0.88), whereas in diabetic men, it increased by 25% (RR 1.25, 1.07-1.45). CONCLUSIONS/INTERPRETATION: Our results suggest that the St Vincent goal of reducing excess cardiovascular morbidity in diabetic individuals has not been achieved and that the situation in men has actually got worse.

Cost comparison analysis: pentaerythrithyl tetranitrate (PETN) and isosorbide dinitrate (ISDN) prescribed to diabetic patients in primary care practices in Germany.

INTRODUCTION: Both pentaerythrithyltetranitrate (Pentalong, PETN) and isosorbide dinitrate (ISDN) are commonly used in the therapy of ischemic heart disease (IHD). However, little is known about the therapeutic patterns in diabetic patients and no comparative data are available regarding the prescription costs of these two substances. Thus, the aim of this investigation was to compare the costs for PETN and ISDN therapy in diabetic patients in primary care. MATERIAL AND METHODS: All continuously treated patients aged > or = 40 years with diabetes (anti-diabetic agents) and IHD or angina pectoris (ICD codes) and newly started on PETN or ISDN therapy (index date) in the period 2000-2005 were selected from a database containing data from 400 practices throughout Germany (Disease Analyzer, IMS Health). Prescriptions costs for PETN and ISDN, as well as costs for cardiovascular comedication, were determined for the period 183 days before and after the index date, and that changes in costs after the index date were calculated. Differences in costs between the two groups were evaluated using multivariate regression, adjusting for age, sex and comorbidity. Patients in Eastern (n = 137, age 71 +/- 10 years, 55% male) and Western Germany (n = 212, age 73 +/- 9 years, 50% male) were analyzed separately since there is a longer history of PETN use in Eastern Germany. RESULTS: Significantly more patients were treated with PETN in Eastern Germany (61 vs. 11%, p < 0.05). The patient groups treated with PETN and ISDN differed with respect to sex and comorbidity. PETN therapy was more expensive than ISDN therapy in both German regions (adjusted cost differences were 10 and 17 Euro). However, when comedication was taken into account, a smaller cost increase after the index date was observed in the PETN group than in the ISDN group (non-significant cost savings of 43 and 52 Euro after adjustment for Western and Eastern Germany, respectively). CONCLUSION: PETN therapy tends to produce a saving in costs compared to ISDN therapy in diabetic patients when costs for comedication are taken into account and after adjustment for age and comorbidity. The prescription patterns in Eastern and Western Germany and the patient characteristics of those receiving PETN and ISDN differed, indicating differences in patients selection and prescribing by physicians in the two regions.

Economics in pediatric type 1 diabetes - results from recently published studies.

OBJECTIVE: Type 1 diabetes in childhood is increasing worldwide. Several therapy components and models of pediatric diabetes care have been introduced. Economic aspects are of increasing interest to decide appropriate strategies in clinical practice. However, knowledge in pediatric diabetes is limited. METHODS: We conducted a literature research to identify and describe systematically recently published analyses on the economics of pediatric diabetes. RESULTS: We substracted ten analyses. Four were cost of illness studies. The main result is that hospitalization, mainly due to metabolic control, education, and acute complications, seems to be a large cost component. Only one study took the perspective of society, including indirect costs. Four of the six studies which evaluated interventions in pediatric diabetes care focussed on ambulatory or home care strategies. Detailed evaluation of new technologies, pharmacotherapy, or screening for late complications is lacking. Except one, all studies performed cost comparison analyses. Evidence is limited, however, diabetes care models may be effective and, possibly, cost saving compared to routine care. CONCLUSIONS: Health economic studies in pediatric diabetes are scarse and limited with respect to topics and quality. Hospitalization has a large impact on health care costs in diabetic children and adolescents. Models in pediatric diabetes care like home intervention may be cost effective compared to more traditional strategies of care. However, further studies are warranted which evaluate clinical and cost effectiveness in pediatric diabetes.

Clinical and cost-effectiveness of primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting: model based on the KORA Survey 2000.

AIMS: To analyse the clinical and cost-effectiveness of the primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting using population-based data (KORA Survey in Augsburg, Germany, total population approximately 600,000). METHODS: Decision analytic model, time horizon 3 years. INTERVENTIONS: Staff education, targeted screening and lifestyle modification or metformin in people aged 60-74 years with a body mass index of > or = 24 kg/m(2) and prediabetic status (fasting glucose 5.3-6.9 mmol/l and 2-h post load glucose 7.8-11.0 mmol/l) (target population approximately 72,500), according to the Diabetes Prevention Program trial. MAIN OUTCOME MEASURES: Cases of Type 2 diabetes prevented, cost (Euro), incremental cost-effectiveness ratios (ICERs). RESULTS: Under model assumptions, 14 908 people in the target population would develop diabetes if there was no intervention, 184 cases would be avoided with lifestyle intervention and 42 cases with metformin intervention. From the perspective of statutory health insurance and society, costs for lifestyle modification were 856,507 euro (574,241 pounds) and 4,961,340 euro (3,326,307 pounds), respectively, and for metformin 797,539 euro (534,706 pounds) and 1,335,204 euro(895,181 pounds). Up to 5% of the costs were due to staff education and up to 36% to screening. Lifestyle was more cost effective than metformin. ICERs for lifestyle vs. 'no intervention' were 4664 euro (3127 pounds) and 27,015 euro (18,112 pounds) per case prevented from the statutory health insurance and societal perspective. CONCLUSIONS: Total cost and cost per case of diabetes avoided was high. Staff education and screening had a considerable impact. In view of the low participation in a routine healthcare setting, with both strategies only a small number of cases of diabetes would be prevented. Before implementing the programme, efforts should be made to improve patient participation in order to achieve better clinical and cost-effectiveness of the prevention of Type 2 diabetes in 'real world' clinical practice.

Incremental prescription and drug costs during the years preceding diabetes diagnosis in primary care practices in Germany.

INTRODUCTION: To evaluate incremental drug prescription costs before diabetes diagnosis in primary care patients in Germany. MATERIAL AND METHODS: Based on 400 primary care practices throughout Germany (Disease Analyzer, IMS Health, Frankfurt, Germany), we selected only patients receiving continuous treatment (age >or= 40 years) and ascertained drug prescriptions and costs up to 6 years before diabetes was diagnosed. For control, we selected age- and sex-matched nondiabetics (n = 6,294 pairs, age 65.5 +/- 10.5 years, 44 % male). We evaluated incremental prescriptions and costs by calculating differences and ratios between patients with and without a diabetes diagnosis. We also evaluated predictors of cost differences using multivariate regression models. The data used for the evaluation was taken from the period 1993 to 2002. RESULTS: The mean number of prescriptions in the year preceding diagnosis in men and women increased 15 % and 19 %, respectively (p < 0.001). Prescription costs were 21 % (men) and 28 % (women) higher in subjects who were destined to receive a diabetes diagnosis (269 and 264 Euros per person) compared to controls (p < 0.001). Incremental prescriptions and costs were already present six years preceding diagnosis. Cardiovascular drugs had the largest impact, accounting for about two-thirds of incremental prescriptions and costs. Women had higher numbers of prescriptions and costs, however, differences and ratios were comparable to men. Incremental costs were higher in patients with private compared to statutory health insurance, and in Western compared to Eastern Germany. DISCUSSION: Numbers of prescriptions and costs in primary care patients with future diabetes diagnosis in Germany were already increased six years before clinical detection, reflecting increased cardiovascular risk even before clinical diabetes diagnosis.

Sex differences in the associations of socioeconomic status with undiagnosed diabetes mellitus and impaired glucose tolerance in the elderly population: the KORA Survey 2000.

BACKGROUND: Sex differences in the associations of socioeconomic status (SES) with prevalence of undiagnosed diabetes mellitus, impaired glucose tolerance (IGT) and known risk factors of type 2 diabetes mellitus were investigated in an elderly population. METHODS: Oral glucose tolerance tests were carried out in 1354 randomly selected subjects (697 men, 657 women) aged 55-74 years in the population-based KORA Survey 2000, Augsburg, Germany. Odds ratios (ORs) and 95% confidence intervals (CIs) for undiagnosed diabetes or IGT by education, occupation and income were estimated using logistic regression controlling for age, waist circumference, blood pressure, triglycerides, physical activity, smoking and alcohol intake. RESULTS: All three SES variables were significantly inversely related to body mass index, waist circumference and low physical activity in women (P < 0.05). In men, these associations were weaker or absent. Using the lowest category as reference, occupational status was significantly associated with undiagnosed diabetes in women (adjusted OR 0.5; 95% CI 0.3-0.8) after controlling for risk factors in multivariate regression. The OR was also reduced with higher income in women (adjusted OR, diabetes: 0.7; 95% CI 0.5-1.03). Among men, no significant relations of the SES indicators with unknown diabetes were observed. However, the odds of having IGT was lower with higher occupational status in men (adjusted OR 0.7; 95% CI 0.5-0.9). CONCLUSIONS: Undiagnosed type 2 diabetes was related to low SES defined by occupation or income in women only. In men, low occupational status was independently associated with higher IGT risk. Educational level was not related to glucose disorders in both sexes in the elderly population.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

Cost-effectiveness of type 2 diabetes screening: results from recently published studies.

Type 2 diabetes screening is recommended by various international diabetes associations. We conducted a literature research to identify and describe systematically recently published cost effectiveness analyses (CEA) for type 2 diabetes screening. Three analyses were included. One of them was conducted in Germany, based on the data of the KORA survey S4 (1999/2001). Two studies came from the US. The German as well as one of the US studies evaluated cost per detected diabetic case as main outcome. In contrast to the US study, the German study considered incomplete participation in the screening programs as baseline case. HbA1 c testing combined with the oral glucose tolerance test (OGTT) was more expensive than OGTT or fasting glucose testing, but also most effective in detecting cases, due to high participation in this screening strategy. The second US study investigated the lifetime cost effectiveness of type 2 diabetes screening, based on a Markov model to calculate cost per quality-adjusted life year (QALY). Effectiveness data were derived from two large intervention studies in clinically diagnosed (not identified by screening) diabetic subjects. The authors conclude that type 2 diabetes screening is cost effective, in particular targeted screening in elderly hypertensive subjects. Diabetes screening may be cost effective. However, the effectiveness of early detection and treatment of type 2 diabetes has not yet been shown, and data regarding the course of early detected diabetes are lacking so far. In the future, the most important question is whether type 2 diabetes screening and early treatment is effective with respect to clinical outcomes.

Direct costs of pediatric diabetes care in Germany and their predictors.

INTRODUCTION: Cost-of-illness study to evaluate diabetes-related direct costs for the care of diabetic children and adolescents in Germany from the perspective of the statutory health insurance. MATERIAL AND METHODS: For all continuously treated patients < 20 years of age from 89 pediatric departments (n = 6437, 52 % male, mean age 12.5 [SD 3.8], diabetes duration 5.2 [3.3] years), diabetes-related hospitalization, ambulatory care, insulin management, glucose self measurement, and treatment with antihypertensive drugs in 2000 were ascertained, as well as metabolic control (HbA1c). Costs per patient-year were calculated in Euros (EUR) based on year 2000 prices. Using multivariate regression, the associations between costs and age, sex, diabetes duration, and metabolic control were evaluated. RESULTS: Mean total costs per patient-year were EUR 2611 (interquartile range 1665 - 2807). Blood glucose self measurement, hospitalization, and insulin accounted for 37 %, 26 %, and 21 % of the costs, respectively, followed by ambulatory care (9 %), injection equipment and glucagon sets (7 %), and treatment with antihypertensive drugs (0.1 %). The total costs were significantly increased for higher age, longer diabetes duration, and higher HbA1c (p < 0.01). The costs for hospitalization were significantly associated with pubertal age (10 - 14 years) and poor metabolic control (HbA1c SDS > 5) (p < 0.001). Based on the present estimations, the total direct costs for the care of all diabetic subjects in Germany < 20 years would be EUR 66.8 (95 % CI 65.4 - 68.1) million in 2000. DISCUSSION: Among the direct medical costs of childhood diabetes, the highest economic burden was due to glucose self measurement, hospitalization, and insulin. The costs were considerably higher in adolescents with poor metabolic control, especially the costs for hospitalization. Outpatient education programs in pediatric diabetes care, in particular targeting children with poor metabolic control, should be encouraged, including their evaluation with respect to cost and effectiveness.

Hospitalization among diabetic children and adolescents and the general population in Germany. German Working Group for Pediatric Diabetology.

OBJECTIVE: To compare hospitalization in a multicenter-based cohort of diabetic children and adolescents (aged 1-19 years) in Germany with that of the general population. RESEARCH DESIGN AND METHODS: Based on standardized documentation, hospital stays after manifestation were ascertained in diabetic subjects 1-19 years of age in 1997. Hospitalization data in the general German population were derived from official statistics. Incidence rates and numbers of hospital days were estimated. Ratios of hospitalization incidences and numbers of hospital days between the diabetic and the general population were calculated. Costs for hospital care in the German diabetic population in 1997 were determined. RESULTS: A total of 5,874 patients came from 61 pediatric centers (52% male, age [mean +/- SD] 12.2 +/- 4.3 years, diabetes duration 4.6 +/- 4.4 years). Hospitalization incidence rates and hospital days per person-year (95% CI) were 0.27 (0.25-0.29) and 1.80 (1.75-1.84) in the diabetic population and 0.0948 (0.0946-0.0949) and 0.6416 (0.6412-0.6420) in the general population. The standardized ratio of hospital incidences was 3.1 (2.9-3.2), and the ratio of numbers of hospital days was 2.8 (2.7-2.9). Costs for hospital care after manifestation were estimated to be $506 (U.S. dollars) per person-year and $12.4 million in the whole German diabetic population aged 1-19 years in 1997; including hospital stays at diabetes onset, total annual costs were $24 million ($970 per person-year). CONCLUSIONS: Diabetic children and adolescents in Germany had an approximately three times higher hospitalization risk and three times more hospital days than the age-matched general population. Including hospitalization at diabetes onset, the annual costs of hospital care for the German diabetic population aged 1-19 years amounted to approximately 1% of all costs for hospital care in this age-group. Thus, costs were largely overproportional (diabetes prevalence 0.1%).

[Prescribing behavior of primary care physicians in diabetes therapy: effect of drug budgeting]. / Primärärztliches Verordnungsverhalten bei der Diabetestherapie: Einfluss der Arzneimittelbudgetierung.

BACKGROUND AND OBJECTIVE: In spite of the great importance of diabetes in Germany, little is known about the medical treatment of diabetic patients by primary health care practices and the effects of the drug budget, introduced by the German Health Care Structure Reform Act (GSG) from 1993. PATIENTS AND METHODS: Computerized data (MediPlus, IMS HEALTH) on prescriptions of the most important drugs were analysed in 2892 diabetic patients of 362 primary care physicians for the period of July 1992 to December 1994. RESULTS: There was an initial decrease in prescriptions per treated patient of antidiabetic drugs and antihypertensive drugs according to the GSG, which was not maintained during the study period. Nevertheless, a cost saving per treated patient with respect to beta-blocker and ACE inhibitors was observed, mainly as a result of a change of preparations and a drop in drug company sales prices. When beginning of a new therapy with oral antidiabetics, the physicians increasingly used acarbose rather than less expensive sulphonylureas. A previous trend of increased use of ACE inhibitors and diuretics for antihypertensive treatment was maintained. In 1993 and 1994, the number of prescriptions and the prescription costs for lipid lowering drugs decreased compared to the values of the last six months of 1992. A global decrease in prescription use of drugs without proven efficacy observed in the first six months of 1993, did not persist. CONCLUSION: The data show, that the drug budget had no relevant long term impact on drug prescribing by internists and general practitioners for diabetic patients.

[Drug prescriptions and costs in diabetic polyneuropathy]. / Arzneimittelverordnungen und Kosten bei diabetischer Polyneuropathie.

BACKGROUND AND OBJECTIVE: Numerous medications are used in the treatment of diabetic polyneuropathy (PNP) without evidence of their efficacy. This study was undertaken to obtain the costs of drugs prescribed to patients with PNP throughout the Federal Republic of Germany in primary-care practices. PATIENTS AND METHODS: Data (stored in the Medi-Plus data bank of the Institute for Medical Statistics, Frankfurt) from 400 primary-care practices were analysed for the year 1996 with regard to diagnoses and prescriptions for 40,112 diabetics over the age of > or = 20 years. A polyneuropathy (PNP) had been diagnosed in 3548 patients (8.8%) (age: 68 +/- 12 years, 56% women). The cost of medications listed for the treatment of PNP was identified and extrapolated to the total prescription cost for treated diabetic PNP in the whole of Germany. In addition the proportion of costs for drugs with unproven efficacy was calculated. RESULTS: Antidepressives were prescribed for 13%, carbamazepine for 4%, and lipoic (thioctic) acid for 41% of diabetics with PNP. Annual costs per patient (mean value) were DM 203 for lipoic acid, DM 53 for vasoactive drugs and DM 42 for analgesics. Projection for the estimated total number of diabetic patients with PNP treated in primary care practices (n = 361,400) gave a total cost of DM 116 million (95% confidence limit: DM 109-123), of which DM 41 million (35%) was for medications of unproven efficacy. CONCLUSION: In Germany one third of drug costs for diabetic patients with PNP in primary care is for medications of unproven efficacy. Cost-effective guidelines for the treatment of diabetic PNP are urgently required.

[Drug prescribing in primary health care for diabetic and non-diabetic patients: effect of therapeutic drug budgeting]. / Primärärztliche Arzneimittelverordnungen bei Diabetikern und Nichtdiabetikern: Einfluss der Arzneimittelbudgetierung.

With computerised data on drug prescriptions, which were collected among a sample of 362 internist, general and medical practitioners throughout Germany, the effects of the drug budget, based on the German Health Care Structure Reform Act (GSG), on diabetic patients were analysed. The data of 3053 diabetic patients (10% random sample) were compared with the same number of nondiabetic patients for the period of July 1992 to December 1994. The frequency of consultations per patient increased in both groups during the study period (p < 0.01). Diabetic patients had more contacts with the physicians than nondiabetic subjects (p < 0.01). The prescriptions and costs among the patients with diabetes decreased in the first six month of 1993 (-10%/ -16%). In the following time costs increased and exceeded the values of 1992 by about 13%. The costs per prescription decreased during the study period about 10%. The data show that costs as well as prescriptions per consultation between diabetic and nondiabetic patients remained in the same ratio. The proportion of consultations with > or = 1 prescription increased in diabetic patients after the GSG. A refusal to prescribe drugs in primary health care practices among diabetic patients was not observed. There was also no restriction on prescription drug use among diabetic patients compared with nondiabetics.