>> Depressive disorders are among the most common illnesses in Germany. The Robert Koch Institute (RKI) reports a lifetime prevalence of 19 percent, with women being significantly more affected (25 percent) than men (12 percent) (RKI 2010). Compared to other illnesses, this condition is of particularly high social significance, not least due to the relatively high number of deaths from suicide and the significant loss of productivity.
The increase in hospitalizations due to depressive episodes (ICD-10: F32) and recurrent depressive disorders (F33) within a decade is astonishing: In the first decade of the 21st century, the number of hospitalizations increased by an average of 6.7 percent annually – compared to 0.1 percent pa for all hospitalizations (Federal Statistical Office: Specialist Series 12, Series 6.2.1). According to figures from INSIGHT Health, outpatient statutory health insurance expenditures for antidepressants (ATC group N06A) also recorded an above-average increase. Between 2007 and 2010, expenditures rose by an average of 4.4 percent pa – compared to 4.1 percent pa for all medications.
Regional variations in depression
Several recent studies point to significant regional differences in depressive disorders that cannot be explained by a single cause. In addition to differing morbidity and care structures, different prescribing and hospital admission behaviors of physicians in the regions likely also play a role. The following exemplary study results shed light on these regional variations:
• The RKI points to a lower frequency of depression among men in Saxony-Anhalt and Thuringia (RKI 2011).
• In its morbidity atlas, BARMER GEK notes an increase in diagnoses in Bavaria and Berlin (BARMER GEK 2011).
• In its Health Fact Check, the Bertelsmann Foundation examined the number of acute hospital admissions for depressive episodes (ICD-10: F32-F33) at the federal state level. According to the study, in 2009, North Rhine-Westphalia had 90 percent more hospital admissions per capita than Saxony (Bertelsmann Foundation 2011).
The aim of the INSIGHT Health analysis is now to describe the outpatient care situation of statutory health insurance (GKV) insured persons with antidepressants in the regions of the Association of Statutory Health Insurance Physicians (KV) and thus to uncover care anomalies.
The analysis will primarily focus on the importance of the selection of parameters to be considered. This will be done using three value types: packs, defined daily doses (DDD), and pharmacy selling prices (AVP).
In addition, two different perspectives on the care situation are taken: In order to be able to compare the volume of outpatient antidepressant prescriptions (ATC group N06A) in the individual KV regions in 2010, the values are, in a first step, compared to the number of GKV insured persons (KM6 membership statistics, as of 01.07.2010) in the regions.
Within the statutory health insurance system, 19.4 million packs with 813 million DDDs were billed in 2010, corresponding to expenditures (valued at AVP) of EUR 1.2 billion.
To identify regional characteristics at the patient level and account for regionally varying prescription intensity, the values per patient are analyzed in a second step. For this purpose, those pseudonymized statutory health insurance patients who received at least one billed antidepressant prescription in 2010 were filtered from the INSIGHT Health patient tracking database. Furthermore, only patients who consistently appear in the panel (e.g., who do not change their pseudonym due to a change of health insurance provider) and whose gender, year of birth, and region can be clearly assigned were included. These inclusion criteria resulted in a study population of 2.57 million patients. Their average age is 60 years, and the proportion of female patients is 70 percent.
The data source is the statutory health insurance prescriptions for finished medicinal products billed in community pharmacies. INSIGHT Health's National Prescription Information (NVI) database, with approximately 670 million statutory health insurance prescriptions annually, covers well over 99 percent of the total statutory health insurance prescription volume. In addition, data with pseudonymized patient references are available for 430 million statutory health insurance prescriptions, allowing the medication history of approximately 40 million statutory health insurance policyholders to be mapped in a patient-centered view. Regional allocation is based on the prescribing physician's location.
Insured-related antidepressant care
Looking at the number of antidepressant prescriptions prescribed per statutory health insurance member, it is particularly striking that the new federal states are below the average of 0.28 packs per capita, while in the Saarland health insurance association, with an average of 0.34 packs per capita, over 50 percent more antidepressant prescriptions are made than in, for example, the Brandenburg health insurance association. However, it would be incorrect to conclude from this that the most antidepressants are prescribed in Saarland. For example, the packs differ depending on the number of tablets, the strength of the active ingredient, etc.
If we take the daily therapeutic doses (DDD) as a comparison measure, the following picture emerges: Bavaria has the highest value at 19.6 DDD per capita, Saarland is in the middle range, and Saxony-Anhalt has the lowest per capita consumption at 14.3 DDD. However, it should be noted that a comparison of daily doses across active ingredients can only be interpreted with limitations, as DDD are purely statistical values that can deviate significantly from the actual prescription (PDD - Prescribed Daily Doses) from active ingredient to active ingredient. Furthermore, such an analysis does not take into account the DDD of individual active ingredients and active ingredient combinations, which are subject to different interpretations. Nevertheless, this can be used to identify initial trends and certain prescribing differences between the KV regions. The high number of packs of antidepressants per person insured under statutory health insurance in Saarland is mainly due to the fact that more smaller packs are prescribed in Saarland (and this applies not only to the indication of depression) than in other countries.
A comparison based on pharmaceutical expenditures reveals a different picture: Expenditure on antidepressants per statutory health insurance member in Mecklenburg-Western Pomerania, at €14.09, is over 60 percent higher than per capita expenditure in Bremen (€8.45), with a national average of €11.70. It should be noted that this pure AVP analysis does not take into account discounts and co-payments. However, it can be assumed that even then, the ratios between the states would not change significantly (Fig. 1).
Patient-related antidepressant care
The analysis of the care situation of those insured with statutory health insurance (GKV) who are treated with antidepressants also reveals different regional characteristics depending on the analysis dimension. The highest number of packs per patient is recorded in the KV Schleswig-Holstein (3.71), while the lowest is recorded in Berlin (3.14), compared to a nationwide average of 3.48. Comparing the daily doses per patient (with the aforementioned limitations), Mecklenburg-Western Pomerania ranks first with 242 DDD per capita and Bremen last with 190 DDD. On average, patients received 222 DDD, with men receiving eight percent more (234 DDD) than women (217 DDD).
An east-west divide can be observed when comparing regional expenditures on antidepressants per statutory health insurance patient. As with expenditures per insured person, Mecklenburg-Western Pomerania leads the way with €193 per patient. This expenditure is even more than 85% higher than the average expenditure in the Bremen statutory health insurance system (€104), compared to the national average of €149.
Conclusion
There is a surprisingly high degree of regional variation in antidepressant prescriptions. However, depending on the type of value, the picture differs. This can pose a pitfall in data interpretation, as often only one or two dimensions are considered, depending on the purpose of the analysis.
Looking at the statistically averaged daily doses per insured person, there tends to be a south-north divide, while antidepressant spending per patient is more of an east-west divide. It is noteworthy that higher patient-related spending in the regions is primarily associated with increased costs per DDD (i.e., more expensive drugs), but less so with the number of packs.
The results suggest that differences in morbidity cannot explain all differences in care. Adjustment for this would require further studies. Another key clue could be the different prescribing behavior of physicians. For example, the share of expenditure on patented antidepressants in Mecklenburg-Western Pomerania is over 30%, whereas in Bremen it is less than 10%.
Avoid pitfalls
The most important finding of the analysis, however, can be derived directly from a parallel examination of the three maps in Figure 1. Depending on which value types are analyzed, different regional care situations emerge. The pitfall here, however, lies less in the limited view of individual parameters, since due to the high complexity and multicausality, and depending on the research question, one must always select a selection of factors to be considered. Rather, it lies in the misinterpretation or overinterpretation of individual analysis results. Therefore, when interpreting the results presented here, it must also be considered that only a brief overview of drug care in the area of depression has been shed.
Further analyses are necessary to determine the extent to which regional variations indicate partial over-, under-, or mistreatment. For example, additional insights can be gained through more detailed regional analysis and a differentiated analysis by drug groups, as well as age- and gender-adjusted comparisons. Furthermore, it should be considered that depression is also treated with non-pharmacological approaches.
by: Dr. André Kleinfeld / Christian Bensing
