Despite numerous research successes for patients, there have not (yet) been any noticeable advances in approved drug therapy in drug therapy for Alzheimer's disease in recent years. The need for improved therapy options is immense. According to current figures from the 2012 dementia report, around 1.3 million people in Germany probably suffer from this disease. The following analyzes provide insight into the reality of outpatient care with anti-dementia drugs.

> The increasing importance of dementia for our healthcare system is evident. For example, a key sentence in the recently published 2012 Dementia Report from the Berlin Institute for Population and Development is: “The more advanced the age, the higher the probability of developing dementia. […] Around a third of people over the age of 90 have dementia.” Given demographic developments, the number of dementia patients will increase significantly in the future.
The cholinesterase inhibitors donepezil, rivastigmine and galantamine for mild and moderate Alzheimer's dementia and the NMDA (N-methyl-D-aspartate) antagonist memantine for the moderate and severe form of the disease are currently used in Germany to treat Alzheimer's dementia authorized. The patent protection for some of these anti-Alzheimer's preparations expired in the last few months, including rivastigmine on July 31, 2012 (source: SHARK patent database, INSIGHT Health).

80 million DDD anti-dementia drugs
In Germany, around 1.3 million packs of anti-dementia drugs were prescribed to those insured by statutory health insurance in the outpatient sector in 2011. This corresponds to around 80.2 million daily therapy doses (Defined Daily Doses - DDD) with drug expenditure (valued at pharmacy sales prices without deduction of discounts and additional payments) amounting to 327 million euros. A daily therapy dose cost an average of 4.08 euros. In the previous year, the average prices per DDD were 16 cents higher at 4.24 euros (source: regioMA, INSIGHT Health). However, due to the entry of generic offers into the market and the discount agreements that are being introduced, the effective savings on the part of the cost bearers are likely to be significantly greater in 2012, although this cannot be quantified due to the confidential discount levels of the contracts in accordance with Section 130a Paragraph 8 SGB V.
43% of patients received less than 183 DDD pa
In purely mathematical terms, assuming continuous medication and a given level of therapy compliance, the annual drug costs are just under 1,500 euros per patient. However, many sufferers are not treated with anti-dementia drugs or are not treated continuously.
As an analysis by INSIGHT Health shows, only a few patients receive continuous drug therapy with anti-dementia drugs in everyday care. Around 43 percent of patients treated with medication receive less than 183 DDD per year. The reasons for this are manifold, such as lack of patient compliance, deliberate prescription of lower daily therapy doses, discontinuation of therapy due to intolerance, ineffectiveness or, in multimorbid patients, due to the dangers of polymedication. Approximately 21 percent of patients receive at least 365 daily doses of therapy per year (source: Patient Tracking, INSIGHT Health).
Therapy changes to newly available and, above all, discounted generics may exacerbate the problem of compliance. Among other things, pointed out that substitution in anti-dementia therapy should be assessed rather critically due to the specific symptoms of the disease, as some dementia patients refuse to take a medication that looks different.
east-west gradient
A current analysis based on the regioMA database provides information on regional characteristics in outpatient drug supply with anti-dementia drugs. The data is based on a survey of over 99 percent of the GKV prescriptions billed via pharmacy computer centers and thus represents a valid reflection of the reality of outpatient GKV care. The database provides specific regional care figures for 60 regions. The regions are aligned as best as possible with the official structure of the statutory health insurance associations (17 KV regions and 63 KV districts). The 17 KV regions are mapped 1:1. Of the 63 KV districts, three districts have fewer than 300,000 inhabitants. For data protection reasons, these are combined with a neighboring district from the same KV region. The database also enables analyzes of prescribed daily therapy doses (DDD). INSIGHT Health determines the factors for determining the daily therapy doses per pharmaceutical central number (PZN) on a monthly basis based on the DDD definition (WHO/WIdO) in coordination with the IGES Institute, Berlin. The indicator "DDD per insured person" is determined with the help of the GKV insured person figures. The number of insured persons in the 60 KV districts is determined on the basis of the KM6 statistics from the federal government and the number of inhabitants according to DeStatis.
As the analyzes show, around 1.1 daily doses of anti-dementia therapy are currently billed per insured person within the statutory health insurance (as of 2011). Especially in the new federal states, a particularly large number of DDDs are prescribed for each insured person. The front runner is the KV district of Dresden with almost 2 DDD per insured person. The only exception in the east is the KV district of Berlin (0.9). In the West the picture is the opposite. With a few exceptions, the prescribed DDD indicators are below average. What stands out here are the regions of Marburg (1.5), Lüneburg (1.4) as well as the left Lower Rhine, Lower Franconia and Saarland (1.3 each), which are above the national average. By far the lowest values are recorded in Bremen (0.3), followed by Stade and Oldenburg (each 0.7). It is mainly the northern regions that are characterized by a particularly low prescription density (see Fig. 1).
In 2008 and 2009, INSIGHT Health presented analyzes of the outpatient care situation in the area of anti-dementia drugs, which produced comparable regionalized results on the east-west, north-south and urban-rural divide at the level of the 17 KV regions (see the articles in MVF 03/2008 and 05/2009).

urban-rural divide
Regionalized drug consumption data on anti-dementia drugs were also used to analyze the connection between population density (inhabitants per square kilometer; as of December 31, 2010) and prescribed DDD per insured person in 2011 based on the 60 KV districts. Population density served as a measure of urbanity (city vs. country). The result was a trending negative relationship (r=-0.22), which, however, fell short of the significance level.
A study by Bohlken, Selke and van den Bussche based on the GAmSI data came to a similar conclusion in 2011: the supply of anti-dementia drugs is more intensive in regional states (Brandenburg and Lower Saxony) than in city states (Hamburg and Berlin). Both studies tend to refute the theory that a lower level of care for patients with dementia can be assumed in rural areas.
Correlation with old age rate
A predictor for the increased values in the eastern federal states can, among other things, be: the higher average age of the population living there or the old age quota can be used. Age is considered a central correlate of dementia (see Dementia Report 2012). In the present study, the elderly ratio is operationalized as the proportion of those over 60 years of age among those insured by statutory health insurance.
Nationwide, 28 percent of those insured by statutory health insurance are older than 60 years. In the eastern German states, the proportion of people over 60 is already 33 percent. Since dementia is age-related, the results presented are only partly surprising:
At the level of the 60 KV districts, the DDD variables per insured person and age (operationalized via the proportion of people over 60 years of age among GKV insured people) correlate highly significantly (r=0.72). Figure 2 shows that the proportion of older people in the GKV insured population is particularly high in Saxony, Saxony-Anhalt and Thuringia (e.g. Chemnitz district with 36 percent, Dessau 35 percent, Gera 34 percent). There are also key supply areas for anti-dementia drugs. This proportion is lower in city states and metropolises. However, age alone cannot explain the regional differences. Bohlken, Selke and van den Bussche also stated this in 2011. In addition to the old-age rate, other influencing factors could include There may also be differences in the attitude towards anti-dementia therapy between the contracted doctors (city vs. country; East vs. West), specialization of the doctors, pharmaceutical sales and KV requirements.
In Mecklenburg-Western Pomerania, the explanatory approach of the elderly quota falls short. Although the coverage of anti-dementia drugs is significantly increased here (1.9 DDD per insured person), the proportion of older people in this region is only slightly above average (31 percent). However, Mecklenburg-Western Pomerania is a country with one of the lowest population densities.

Conclusion
The results presented allow a selective depiction of the current situation of drug therapy with antidementia drugs. The care of people with dementia in Germany is multifactorial. Regional variations are extremely exciting and cannot be explained solely on the basis of individual factors. Since the results outlined were determined on the basis of aggregated prescription data, implications for healthcare practice must also be derived with due caution. Higher prescription rates do not in any way equate to better quality of care. <<
from:
Christian Bensing / Dr. André Kleinfeld*