>> So far, the Federal Insurance Office (BVA), as the guardian of the DMP data treasures, has only evaluated the risk-adjusted evaluation reports for diabetes for the approval years 2003 to 2008 and has come to the positive conclusion that “the comparison of the mean values to the individual medical target values with the results from epidemiological studies shows that the mean values collected from the DMP participants have significantly more positive values for some target values." However, further individual analyzes only show that with many DMPs there is an improvement in blood pressure control and smoking status over time (task tobacco consumption) can be observed and blood sugar control (measured via the HbA1c value) can be maintained or improved with a variety of DMPs. The BVA then draws the conclusion that “the hypothesis can be derived from the available medical data that the insured persons taking part in DMP benefit significantly from their participation”. However, the complication rates of microangiopathy, especially those of diabetic foot syndrome (DFS), have remained almost the same over the years. This is despite the fact that regulations are integrated into all DMPs, which, among other things, are intended to detect and treat diabetes-related complications at an early stage.
This is what Dr. Holger Lawall, head of the angiology/diabetology department at the Asklepios Westklinikum Vascular Center in Hamburg, in his specialist article on “Diabetic Foot Syndrome” in the “German Health Report Diabetes 2015” states that diabetic foot syndrome is considered one of the main complications of patients with diabetes mellitus. The most significant consequences of diabetic foot problems are ulcerations and small (minor) and high (major) amputations. The numbers are alarming not only because, according to Lawall, an estimated 250,000 people with diabetes in the Federal Republic of Germany have a foot lesion and around 1 million diabetics have an increased risk of suffering a foot injury, but because the rate of new cases “remains unchanged at 2.2 to 5. 9 percent", the prevalence increases with increasing age - between 5 and 10 percent for patients over 50 years old - and at least one in four diabetics will suffer from DFS in the course of their life. So it's no wonder that the risk of major amputations for diabetics is still around 20-fold increased and amounts to around 16,000 per year, with over 70 percent of these being carried out on people with diabetes mellitus, according to Lawall. This not only causes an often unnecessary loss of quality of life, but also costs: at around 2.5 billion euros per year (Hauner 2006), a large part of the expenses that the statutory health insurance in Germany has to spend on diabetes is caused by the DFS alone.
The real, existing incorrect care has led to doctors in particular coming together to combat it. And with success. A kind of lighthouse project is the “Diabetic Foot Cologne and Surroundings” network, which has made quite a remarkable development since 2002, evolving from an association to coordinate collegial cooperation to a functioning network with participating doctors and hospitals. which is now also supported by health insurance companies. In 2012 it received the health award from the state of North Rhine-Westphalia “due to the particularly innovative character of the further development of the North Rhine-Westphalian health care system,” as it said
NRW Health Minister Barbara Steffens formulated.
And apparently with success, as can be read in the “Quality Report 2009” of the Cologne network: In the integrated care offered by the network, in which 75 % of all patients cared for in the network are enrolled, from 2005 to 2008 in 82 of 3,277 treatments ( 2.5 %) an amputation was performed above the ankle. The goal of performing major amputations in fewer than 5 % patients with acute DFS was thus achieved.
Since then, such footnets have also existed in some other regions such as Düsseldorf, Essen, as well as in the areas of Eu-
region and North Rhine. There are five networks here alone in which around 10,000 people have been treated since 2003, and according to the Cologne quality report, “the need for leg amputations has been reduced by three quarters”. Similar approaches of this kind also exist in Munich, Hamburg and Berlin.
Nevertheless, these networks differ, above all in terms of the level of commitment in terms of the therapeutic approach, but also in terms of the quality standards to which the participating doctors have committed themselves.
This is exactly where Cologne, but also Berlin, makes a difference, although the latter is a special case anyway. The care program for the treatment of diabetic foot syndrome in the federal capital is primarily not just the initiative of doctors, but also that of a health insurance company: AOK Nordost. Here, Petra Riesner, at AOK Nordost - The Health Insurance Fund as team leader responsible for the area of care - strategy, programs and contracts, noticed when checking the levels of target achievement of the quality assurance goals in the DMP Diabetes that:
• the annual foot examination specified in the DMP was not carried out completely on all diabetics,
• when an abnormal foot status was identified, a referral was not always made or a referral was made too late to a specialist,
• the treatment and further treatment of the abnormal foot was initiated with a long delay,
• Amputations occurred even though only low levels of severity (such as Wagner/Armstrong OA) were consistently stated in the DMP documentation.

As part of a more detailed assessment of the DMP documentation, the information provided by the treating physicians regarding the severity of the DFS (Wagner grades and Armstrong classifications) was then specifically examined in a further care analysis. The AOK Nordost data for the Berlin region showed the following picture for type 1 diabetics:
• DFS was documented in around 14.5% of the insured persons, of which 8.2% of the insured persons had a severity level above Wagner 0.
And for type 2 diabetics:
• DFS was documented in around 9.5% of the insured persons, of which 16.3% of the insured persons had a severity level above Wagner 0.

An urgent need for action was seen here. The actual goal of DMP is to be able to detect and treat diabetes-related complications at an early stage. In relation to the diabetic comorbidity DFS, this means that a foot inspection and examination should be carried out for all diabetics at least once a year. If there is already an increased risk, these medical check-ups should be carried out at shorter intervals, because the early initiation of multi-professional treatment can have a positive effect on the severe end stages of the secondary diseases of diabetes.
At that time, AOK Nordost took these identified anomalies in the data evaluations as an opportunity to conduct a random survey of the affected insured persons. For this purpose, 105 insured persons who were diagnosed with an “abnormal foot status” were interviewed by telephone. For example, it was noticeable that around 83% of the insured people receiving primary care had not been referred for specialist treatment. On the other hand, it was positive that around 89 % of the diabetics called stated that they would at least check their feet independently or with the help of relatives and examine them for abnormalities.
In 2011, AOK Nordost took the results of the assessment of the DMP documentation and the patient survey as an opportunity to work for the Berlin region with the support and advice of Dr. Dirk Hochlehnert from the Cologne foot network and in collaboration with some committed Berlin diabetologists to develop and conclude a care contract for the treatment of patients with DFS, because in the conclusion it had to be stated that apparently - according to Riesner - "the regulations in the DMP alone are not enough “to be able to optimize the supply situation”.
Since then, AOK Nordost policyholders who are enrolled in the DMP diabetes mellitus type 1 or type 2 and suffer from DFS or who have been diagnosed with an abnormal foot status can now take part in this care contract. If you are treated by a doctor who also takes part in this contract.
However, only 21 doctors are currently doing this, most of whom had already been involved in a Berlin-Brandenburg foot network before the contract was advertised and were happy to take the opportunity. However, after this initial phase, the acquisition of additional doctors is rather difficult, because only doctors with a focus on diabetology and a specialization in the treatment of diabetic feet can take part in this care contract: A special requirement for participation is certification as an outpatient foot treatment facility by the AG Fuß der German Diabetes Society (DDG), which is associated with costs and further investments. In addition, these 21 participating doctors are mainly spread across the western part of Berlin. In some Berlin districts, not a single doctor working in diabetology could be found who was willing to take on the further training and certification, but also the investment for the additional necessary staff (such as a wound nurse).
This is certainly also due to the fact that the contract was initially limited. However, since mid-2013, this has been running for an indefinite period, even if it can be terminated by the health insurance company at any time, for example if the supply in accordance with the contract cannot meet expectations in terms of quality and economy.
But it certainly doesn't look like that. Internal, but as yet unpublished, evaluations show that for the period of the second contract year (and thus the observation year 2013) the 1,400 insured persons treated in this way have a 16 percent lower risk of being amputated. Beyond all quality of life parameters, this also means that the risk of hospitalization falls by 16%. But conversely, the insured people treated “normally” in other DMPs from all other health insurance companies in Berlin still have more feet completely or partially amputated than actually necessary. “How is the health insurance landscape coping with such an increase?
Harald Möhlmann, Managing Director of Supply Management at AOK Nordost, rightly asks. And he adds: “Actually, such a supply contract would have to be rolled out nationwide, perhaps even nationwide, as soon as we have published the figures and they are recognized as evident. <<