In a recent healthcare analysis, INSIGHT Health examined drug therapy for insulin-dependent diabetes mellitus by age, gender, and region using routine data. The results show anomalies in all parameters examined, indicating a need for action in healthcare.
>> Diabetes mellitus describes a group of diseases in which blood sugar levels are elevated due to reduced insulin action and/or insulin production. The disease has enormous epidemiological significance, as the following facts (taken from RKI 2011) clearly outline:
• Nine percent of the adult population has been diagnosed with diabetes.
• Based on diagnoses, diabetes is increasing, regardless of the aging population.
• A significant proportion of those affected experience long-term complications, some of which are serious.
80 to 90 percent of adult diabetics suffer from type 2 diabetes mellitus, which, at least in the early stages, can be treated without medication. This changes over time, not least depending on the success of measures to change the living environment and lifestyle of those affected, and with advancing age, so that various medications are used in conjunction with the disease. Oral antidiabetics and/or insulin are usually the primary treatments. In contrast to type 2 diabetes, type 1 diabetes predominantly develops in childhood and adolescence. Type 1 diabetics are dependent on insulin from the outset. The analyses presented below refer to insulin-dependent diabetes mellitus (without differentiating between diabetes types).
Age/gender distribution
The age distribution of patients treated with insulin in the outpatient setting was compared with the age distribution of statutory health insurance (SHI) members. All patients who received at least one insulin prescription from the "A10C" group of the ATC (Anatomical Therapeutic Chemical Classification System) of the European Pharmaceutical Market Research Association (EphMRA) in the past three years were included. The data source was anonymized prescription data from approximately 40 million SHI patients from a routine database of the information service provider INSIGHT Health.
As Figure 1 clearly illustrates, insulin supply is predominantly in the older age groups, far disproportionately to the average age distribution of statutory health insurance policyholders.
Approximately 1.6 million statutory health insurance (GKV) insured persons in the sample examined were treated with insulin in the last three years. These patients are distributed almost evenly between the two sexes (51 percent women, 49 percent men). If we also consider the age groups in 20-year intervals, we see a clear focus of care for both sexes on the 60- to 79-year-olds. 51.3 percent of insulin patients are in this age group, 18.8 percent are at least 80 years old, and 21.8 percent are between 40 and 59 years old. In contrast, the younger age groups are only sparsely represented (20-39 years: 6.3 percent; 0-19 years: 1.8 percent). The treatment focus for older patients corresponds to the higher diabetes prevalence in the older and older age groups.
There is a notable difference between men and women in two age groups: In the 40- to 59-year-old age group, 26.8 percent of treated men are treated, but only 16.9 percent of treated women. Conversely, in the 80-year-old and older age group, 26.1 percent of female insulin patients are treated compared to only 11.3 percent of male insulin patients. This significantly higher proportion of women treated with insulin in the 80-year-old and older group cannot be explained solely by the higher female population in the older age groups. Other factors must be at play here.
Regional differences
A second analysis examined whether regional differences in insulin medication existed. For this purpose, outpatient prescriptions of the same ATC group (A10C) from 2010 were categorized according to the regions of the statutory health insurance associations (KV regions), each based on 1,000 insured persons. The data source was a routine database from INSIGHT Health, which annually records almost all billed statutory health insurance (GKV) prescriptions from the outpatient sector. In a subsequent step, expenditures per insured person were calculated and compared. The pharmacy selling price (AVP – without deduction of manufacturer discounts and patient co-payments) was used for this purpose.
In 2010, a total of 11.9 million insulin prescriptions were paid for by statutory health insurance (GKV). This corresponds to 171.3 prescriptions per 1,000 GKV insured persons nationwide. As Figure 2 shows, the figures vary considerably between the KV regions. Physicians prescribed insulin with above-average frequency, particularly in the new KV regions and federal states. Saarland, Rhineland-Palatinate, and Berlin also performed above average. Bavaria and Baden-Württemberg, in particular, recorded comparatively few prescriptions per 1,000 insured persons.
Not only the number of prescriptions, but also the expenditures per statutory health insurance insured person vary considerably from region to region. With an average of €17 per insured person, the highest figure is €31 (Mecklenburg-Western Pomerania) and the lowest figure is €13 (Baden-Württemberg). Regional expenditure differences are almost identical to the differences in prescriptions.
Conclusion
Analogous to the regional differences in insulin medication, the German Health Care Advisory Council had already identified significant regional differences in the consumption of antidiabetics, citing these as indications of regional oversupply (SVR 2000). The Robert Koch Institute (RKI) also recently identified an east-west and north-south divide in self-reported diabetes diagnoses (RKI 2011). This underscores a continued need for optimization in diabetes care—both in terms of quality and cost-effectiveness.
by: Christian Bensing
Dr. André Kleinfeld*
Regulations continuously increasing
>> As a recent healthcare analysis by INSIGHT Health shows, the number of prescriptions for blood glucose test strips is still increasing. In the first quarter of 2011, 13 percent more blood glucose test strips were prescribed to statutory health insurance (GKV) patients than in the same period in 2008 (see Figure 1). In the last twelve months, over 1.2 billion test strips (blood tests only) were prescribed – at an average pharmacy selling price of €0.73 per test strip.
Urine and other tests, on the other hand, play a negligible role in the market, accounting for less than 0.3 percent of all prescribed test strip sales. There are significant differences between the regions of the statutory health insurance associations (KV). In the Bavarian Association of Statutory Health Insurance Physicians, the fewest test strips were prescribed to statutory health insurance members in 2010, with an average of 15, compared to the national average of 18 (see Figure 2).
Physicians in Hamburg issued the most prescriptions per capita, with 22 test strips. This is notable given that Hamburg and Schleswig-Holstein were the regions with the fewest antidiabetic units (ATC group A10) per capita in 2010. Compared to 2009, those with statutory health insurance received an average of 0.9 more test strips. Notably, the increases in the six eastern German KV regions, with 1.9 additional test strips per insured person, significantly exceed the eleven western German KV regions (+0.6). Similar figures were also observed in the previous year, indicating a trend. By: Christian Bensing
Dr. André Kleinfeld*
