Diabetes mellitus is one of the widespread diseases in Germany. Depending on estimates, the number of diabetics is between 6 and 10 million German citizens. The number of new cases per year is constantly increasing. (Hauner 2010: 8) According to the two KoDim studies (Hauner et al. 2007; Köster et al. 2010), the total costs for the treatment of diabetes mellitus in Germany in 2000 amounted to 27.8 billion euros. In 2007, 42.0 billion euros were already spent. This corresponds to a growth of 51.1 %. The costs for medical care for diabetics alone rose from 12.9 to 19.1 billion euros from 2000 to 2007. Around a third of this goes towards medical care for diabetics and their supply with insulin, cannulas, blood sugar test strips and lancets. The remaining two thirds are spent each year on the treatment of secondary diseases associated with diabetes mellitus.

>> Diabetes mellitus is a widespread disease with immense health economic importance, which is reflected, among other things, in the cost burden on health insurance companies. Accordingly, this disease was one of the first to be included in structured treatment programs, the so-called disease management programs. Since then, health policy and self-administration have paid the greatest attention to defining requirements for DMPs and their implementation.
In times of e-health, it is not surprising to find offers of the consumables required for the treatment of diabetes mellitus on the Internet on relevant online trading or auction portals such as ebay, amazon, hood.de or auvito. The situation is different when “private” offers are offered for sale, as is the case on eBay or at hood.de. On Sunday, May 27, 2012, there were 1,321 offers of blood sugar test strips on eBay, 857 of which (approx. 65 %) were from private individuals. At hood.de there were 31 of the 43 offers, i.e. 72 %. The question that arises here, among many others, is where exactly are these blood sugar test strips offered for sale taken from, and what effects does this have on whom? The central question is whether these private offers of consumables, which diabetics would have to use in self-management of their disease, should be viewed as a fundamental adherence problem?
In the following article, Section 2 provides insights into the key points of each DMP and the requirements for patients who take part in the DMP for diabetes mellitus. This is followed in Section 3 by an analysis of the test strips that can be found on eBay and offered by private individuals in conjunction with an initial attempt to explain what was observed. The resulting economic and health consequences are discussed and an attempt is made to measure the social damage caused by such deficits in the self-management of diabetics. A discussion in Section 4 rounds off the article, in which, among other things, effective options for resolving the adherence problems that have become apparent in diabetes mellitus are discussed. A conclusion (Section 5) rounds off the article.

Self-management and its deficits
The core points of every disease management program (DMP) are guideline-oriented and evidence-based treatment, strengthening the patient's sensitivity and self-management, optimal use of means and resources and central (benchmarking) documentation for epidemiological evaluation and quality assurance. The stated aim of these programs is to protect patients from the long-term consequences of their disease. (Haas 2011: 68) According to studies (cf. Schnellbächer 2010: 167 f.), diabetics who are enrolled in a DMP have an improved quality of life than diabetics without such support. However, the prerequisite for this is that diabetics experience an intensive examination of their disease through training and consultation and thus develop the skills to be able to cope with the demands placed on them. The diabetic plays a crucial role in the treatment of his disease. (Kulzer et al. 2011: 33, Lange 2006) If these skills are not developed on the part of the patient, they should be adequately trained. All of this is referred to as self-management in the context of diabetes mellitus, which also meets the criteria for adherence.
The minimum components of diabetic self-management that meet the requirements of DMPs for patients with type 2 diabetes are:1
• regularly measuring blood sugar levels,
• determining the amount of bread units to be consumed with the next meal,
• determining the amount of insulin to be administered and its application,
• the precise documentation of these three values,
• the timely replacement of used materials (insulin, cannulas, blood sugar test strips and lancets) as well
• presenting this documentation to the treating doctor.

The documentation that must be created permanently, for example in the form of a diabetes diary, is the essential basis for treatment by the supervising doctor. (Kulzer et al. 2011: 34) This shows the cessation of diabetes mellitus. At the same time, it is the information basis for checking the amount of insulin and test strips used.
According to studies, keeping a diabetes diary is already possible. T. associated with significant problems. Franke compared the entries in 94 of his patients' handwritten diabetes diaries with the data automatically stored in their blood glucose meter. He was able to determine that half of the values entered were incorrect or fictitious because they did not match the electronically documented data. (no date 2008)
Documenting the amount of insulin administered requires the patient to adhere to the therapy. Experience has shown that patients with low awareness of their illness are more likely to forego their medication. (Gensthaler 2008) If the medication is documented at all in such cases, it can be assigned to the “fictional” category.
If the already limited amount of time for direct doctor-patient contact is then taken into account, the current design of self-management does not even meet the requirements of “self-testing with external control” (Kulzer 2011 after Stegmaier 2011: 15). Adequate care and support for a diabetic cannot be guaranteed if the doctor has to rely exclusively on the patient's statement when asked about the need for used materials and cannot trust them. Such structures contribute to, among other things, the phenomena described in the following section with the consequences outlined.

Blood sugar test strips gone astray
The underlying analysis of the test strips offered by private individuals is based on an observation of the offers on eBay that has been going on for around 1.5 years. From the beginning of 2011 to the end of May 2012, for example: The inventory of and receipt of test strip offers is collected daily. Occasionally, daily detailed analyzes were carried out.
Basically, it can be stated that the number of blood sugar test strip offers remained relatively constant in the period from the beginning of August 2011 to the end of December 2011, see the trend line in Figure 1. There was a significant jump in the number of offers at the beginning of August 2011. Up to this point in time The number of offers of test strips made by private individuals fluctuated around 200, see the beginning of the solid line. Since then, fluctuations with greater deviations around a value of 900 can be observed. A closer look at the fluctuations shows that there is an upward swing at the beginning and towards the end of the month. In the middle of the month and on
-limits there is the smallest number of offers. At the turn of the year, private offers on eBay fell significantly. (Fig. 1).
The dotted line shows the number of commercially available blood glucose test strips. This has remained roughly constant to this day - except for the jump at the beginning of August 2011 - and fluctuates around the value 300.
Detailed analyzes based on key dates provide insights into the offer structure. One such analysis is based on the number of packs per offer and the pack size offered. Packs of 10, 25, 50, 100 or 200 test strips are commercially available. On Tuesday, May 15, 2012 at 10:30 a.m., 1,147 private offers were displayed on eBay when the product name “blood sugar test strips” was entered. Upon closer inspection, blood sugar test strips were found in 1,005 of the offers. The remaining 142 offers contained blood glucose meters, insulin pens and pumps, lancets, cannulas or diabetes diaries, all from private individuals!
Of the 1,005 offers with blood sugar test strips, ten were offers of packs of 10, 28 were offers of packs of 25, 891 were offers of packs of 50 and 76 were offers of packs of 100, see also Fig. 2, in which this is shown in relative terms.
In a next step, the number of packs per offer was recorded. It became clear that behind the ten offers of packs of 10 there were exactly 44 packs. The 28 offerings of 25 packs contained 74 packs. Of the 891 offers of 50 packs there were 1,844 packs and of the 76 offers of 100 packs there were 111 packs. A total of 105,590 test strips were available for purchase on eBay.
A subsequent question is whether these sellers were those who offered blood glucose test strips for the first time or for the repeated time on May 15, 2012. Ebay supports such an analysis idea because, as is well known, the previous sales of the respective seller can be displayed with details of the date, content and price. A review of all offers based on exactly this information showed that 86 % private providers repeatedly sold test strips.

Only 14 % were first-time providers.
A further analysis is to consider whether the providers wait for bids over a defined period of time or whether they enable immediate buying. This is important because these offers cover an available number of packs and a specified price. In addition, the duration of the offer is significantly shorter. The share of buy-it-now offers on May 15, 2012 was 14.1 %. These offers contained an average of five 50-packs. It took about a day and a half for these listings to sell. The bids on this day averaged 2.1 packs of 50 with a remaining term of 3 days. If it is assumed that a pack of 50 was auctioned or bought for around 20 euros, the sellers were able to generate 54,370 euros from these offers alone. Extrapolated to the year, around 7.6 million euros are generated.

Economic and health consequences
Blood sugar test strips sold privately are usually test strips that were prescribed by a doctor, picked up from a pharmacy by a diabetic or a relative without additional payment, but are not used to measure blood sugar levels. A first economic consequence of the annual sales of test strips realized via eBay is the direct financial damage caused to statutory health insurance companies: If a pack of 50 costs around 30 euros for a health insurance company, then using the above values the expenditure would be 11.4 million euros per year. To the extent that these expenses do not lead to the desired goal: self-control of blood sugar levels, but to additional income, this is a direct financial loss.
This damage must be supplemented by indirect damage. This results from the health consequences of not using the test strips. To approach this question, it is necessary to consider the situation from which the test strips are taken. As a rule, it is a diabetes situation, i.e. someone suffers from diabetes mellitus and has been asked by their doctor to regularly determine their blood sugar levels using the prescribed test strips, taking into account the amount of bread units to be consumed with the next meal the corresponding amount of an insulin preparation can be reacted to the value.
If the test strips to be sold are taken out of such a situation, they are missing from the diabetic's self-management. The results are derailments that are not noticed or noticed too late (hypo- or hyperglycemia) with the known short-term acute damage to the diabetic's organism or the threatening situation that develops in the long term. These resulting health problems for diabetics mean an additional financial burden on their health insurance.

Origin of the test strips and their demand
What kind of diabetes situation do the test strips come from? Either it is your own or someone else's diabetes situation. In your own diabetes situation, some of the prescribed test strips can be saved from the outset for the intended sale on eBay, i.e. not used. To a corresponding extent, blood sugar levels would not be measured. On the doctor's side, this leads to an incorrect perception of the success of the treatment if he had prescribed more test strips for use, but only a fraction of them were actually used, resulting in poorly controlled diabetes mellitus. A second option is to feign a higher need. Instead of the average z. B. If 150 test strips are used per month, the patient can be prescribed 250 blood sugar test strips from the outset. The excess 100 test strips will be sold.
In the context of a third-party diabetes situation, a distinction must be made as to who takes the initiative to “divert” the test strips. On the one hand, this can be the diabetic in the unfamiliar diabetes situation or the person who is involved in this situation as a participant. The latter could be “enterprising” relatives or nursing staff. Both could either divert a portion of the available amount of test strips or, if contact with the doctor goes through them, have a correspondingly larger amount of test strips prescribed and “set aside” the excess amount. The fact that there are most likely empirical findings for this can be deduced from the existence of almost 2 million hits on google.de when “theft” and “care” are entered as search terms.
However, it is also conceivable that the initiative comes from the diabetic himself. When giving the test strips to the other person, the action is based on motives such as gratitude, connection to the caring relative or carer or even “buying affection”. This can basically be observed with any personal service. The motive is reinforced when those relying on the service are elderly people who live alone and lack communication options.
The basic motive for the provider's actions is to realize a tax-free additional income either from one's own illness or from that of someone else. For example, if a provider manages to sell two packs of 50 test strips for 20 euros each month, they can earn 480 euros annually at the expense of the statutory health insurance, which had spent 720 euros on this.
Two groups of diabetics have a demand for these offers. On the one hand, these are the privately insured diabetics who have chosen a tariff with a deductible for their health insurance. Such a tariff saves you up to 150 euros in monthly contributions. If you purchase it yourself, e.g. B. 100 test strips per month, on the one hand, this is worthwhile if the privately insured diabetic buys them on eBay for 40 euros or less. On the other hand, it saves compared to the pharmacy retail price, which is usually above 20 euros for a pack of 50. On the other hand, these are the type II diabetics with statutory insurance who, due to the regulation restrictions passed by the Federal Ministry of Health on March 17, 2011 and which came into force on October 1, 2011, now have to purchase the blood sugar test strips on their own account. The latter presupposes that these diabetics have a correspondingly developed awareness of the disease.

discussion
The starting point for the observed phenomenon is an adherence problem in the treatment of diabetes mellitus. In contrast to compliance, adherence is seen as the responsibility shared by the patient and the medical staff for adhering to the therapy plans and thus also the success of the therapy. (Rödel 2011) This is where counseling concepts that focus on therapy adherence come into play. (Lange 2012) Modern telemedicine systems can also provide a solution, using the example of diabetes mellitus to offer both parties involved support in achieving therapeutic success.
On the patient side, a so-called telediabetic system relieves the burden of all documentation tasks. For this purpose, the blood glucose meter and the insulin pen must be equipped with a storage and sending function. The measured blood sugar values are saved with the date and time. The insulin pen also saves the amount of insulin administered with the date and time. Since the blood glucose meter allows you to enter the bread units to be consumed with the next meal, this value is also available with the date and time. Both memories are read out regularly and the values are immediately stored on a patient-related data portal for further use.
Furthermore, based on this data, the patient can be given immediate feedback on the quality of their self-management via a traffic light function. The traffic light switches to “red” if a serious self-management error that needs to be corrected immediately is detected. A “yellow” indicates a developing error. With information about this in conjunction with a clear recommendation, the error can be corrected through changes in self-management. If at the same time the attending physician has the patient's traffic light available and uses it on his computer system in the practice, the feedback from the telediabetic system could possibly be supplemented by a medical one, which corresponds exactly to the medical side of the adherence approach. Relieving the diabetic of the documentation does not only result in an increase in quality of life for the diabetic. This is particularly advantageous for the entire treatment situation itself. With such a system, the doctor has complete and error-free documentation of all diabetes-relevant data for the first time. In this way, he can arrive at a reliable therapy recommendation, which has by no means been the case so far.
A telediabetic system can also provide the attending physician with current consumption data regarding insulin and test strips “at the push of a button”. If it is assumed that a new lancet is used for each prick, the number of blood sugar values measured can also be used to determine the consumption of lancets, as can the use of cannulas. The data also shows when an insulin cartridge was changed and how much residual insulin was still contained in the removed cartridge. Responding to this, for example during the next patient training session, helps to reduce the amount of unused insulin.

Conclusion
The blood sugar test strips offered privately on eBay are an expression of a typical adherence problem in the care of chronically ill people. If the diabetic himself is not committed to adherence to therapy, at least the medical staff should have starting points to support the patient. The handwritten diabetes diaries, which have previously had immense deficiencies, have not fulfilled this task. Digital documentation created with a telediabetic system is more likely to meet this requirement. It can also make a contribution to avoiding the social costs of current adherence problems. <<