Disease Management in the European Context

1
Disease Management in the European Context

• DMPs for persons with Type 2 Diabetes
• Bonn, 11th January 2007

2
AGENDA

• Implementation of DMPs in Germany a brief
  introduction
• DMP Diabetes how it works
• First results of DMP
• DMP in Germany - perspectives

3
Prevalence of Diabetes mellitus

• Germany has a population of 82.5 million (2005)
• approximately 5 to 6 million people have diabetes
• 90 have Type 2-Diabetes
• 10 have Type 1-Diabetes
• estimated number of unreported cases is about 1.5
  million
• until 2010 the number of people with diabetes
  will clearly increase

4
Prevalence of Diabetes in Germany
Prevalence of diabetes differentiated between
age, sex and region
woman
men
Per cent
age
eastern region of Germany western region of
Germany
Robert Koch Institut Diabetes mellitus 2002
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Risk factors

• About 50 of Germans are obese (BMI gt 25)
• More than 40 have a sedentary lifestyle
• 20 of people between 45 to 65 years old have a
  riskfactor combination defined as metabolic
  syndrom (abdominal obesity, hypertension,
  lipometabolic disorder)

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Complications
Estimated incidence for complications p.a. in
diabetics and caused by diabetes
Incidence per year in diabetics 20.000 44.000 3
.100 23.000 - 29.000 2.100
caused by Diabetes unknown unknown 2.000 12.5
00 26.000 unknown
Complication Myocardial Infarction Stroke Blind
ness Amputation End stage renal disease
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Costs of Diabetes Care

• Estimated costs for treatment of diabetes amount
  to approximately 5 Billion Euro (2002)
• The avarage costs per person were about 5,000
  Euro per year
• 50 due to hospital treatment
• 27 due to pharmaceuticals
• 13 due to outpatient treatment
• 10 miscellaneous

The incidence of complications lead to additional
charges the most expensive complications are
diabetic food syndrome and end stage renal
disease!
Häussler, Hagenmeyer, Storz, Jessel Weißbuch
Diabetes in Deutschland, 2006
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Experts identified deficiencies in Care of
chronically ill patients
Result of an expert report in 2001(1)

• Oversupply and undersupply
• Inadequate drug therapy
• Not a sufficient basic care
• unneeded (double)-examinations
• Not a sufficient focus on comorbidity and
  complications

Medical Problems
Economical problems

• Chronically ill patients cause cost above the
  avarage
• 40 of patients cause 75 of the costs

Experts recommended the introduction of DMP for
chronically ill patients
(1) www.svr-gesundheit.de
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DMP as a reactions on deficiencies
Organisational problems

• Care of chronically ill patients requires
  organisational changes

• Coordination and cooperation between primary care
  and special care
• Inadequate identification and treatment of
  complications
• Variability in treatment or therapy

medical problems
The care of chronically ill patients should be
reorganized!
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Elements of German DMP

• 137 f SGB V National Committee determines the
  design of the programs including six elements

1

• Evidence based
• guide lines

• Treatment based on evidence based guidelines

2

• Quality
• assurance

• Realization of measures regarding quality
  assurance

3

• Definition of criteria for incription and of
  duration of the
• programs

• Inscription
• criteria

4

• Training

• Training for physicians an for patients

5

• Definition of documentation items and
  documentation
• interval

• Dokumentation

6

• Definition of evaluation criteria, criteria
  accreditation
• of the programs and for duration of the programs

• Evaluation

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To finance the programs a connection to german
risk structure compensation scheme was
established
Risk structure compensation scheme did not
consider different morbidity of funds
Deficiencies in Care of chronically ill patients
137 f regulates the structured programs for
chronically ill patients 137 g regulates the
accreditation by the Bundesversicherungsamt"
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AGENDA

• Implementation of DMPs in Germany a brief
  introduction
• DMP Diabetes how it works
• First results of DMP
• DMP in Germany - Perspektives

13
Developement of DMP
National Committee
Recomendation for indications Diabetes
mell. Asthma/COPD CHD Breast Cancer
Definition of demands Including Medical
recom- Mendations Inscription ...
Ministery of Health
Bundesversicherungsamt
Accreditation if health insurance makes an
application and fulfills the criteria
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Complex procedure - Presentation of Regional
Association of Physicians in Bavaria
http//www.kvb.de/servlet/PB/show/1002877/DMP-Diab
-Praesentation-2004-10-18.pdf
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Integration of different levels of Care
Hospital
Specialist
Physician who coordinates care (usually general
practitioner) Organizes long term care
and standardized documentation
Rehabilitation
Other
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Interfaces and criteria for referral - DMP
Diabetes -
Hospital
diabetologist
DMP-Doctor
referral
hospitalisation

• when patient
• does not meat
• treatment goals
• to ophtalmologist
• to nephrologist
• ...

• in emergencies
• diabetic foot syndrom
• Severe metabolic disorders
• ...

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AGENDA

• Implementation of DMPs in Germany a brief
  introduction
• DMP Diabetes how it works
• First results of DMP
• DMP in Germany - Perspektives

18
DMP Diabetes Typ 2Status quo (August 2006)

• DMP Diabetes mellitus Typ 2
• Start
• March 2003
• - Status quo
• Implementation nationwide

Patients participating 1.5 Mio, Physicians
participating 42.561 (82 ) Hospitals
participating 445
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DMP Diabetes Typ 1Status quo (August 2006)

• DMP Diabetes mellitus Typ 1
• StartMarch 2005- Status quointroduced in 11
  Regions(Baden-Württemberg, Brandenburg,
  Bremen,Mecklenburg-Vorpommern,
  Rheinland,Rheinland-Pfalz, Sachsen-Anhalt,Schles
  wig-Holstein, Thüringen,Westfalen-Lippe, Hessen
  ab 1.1.07)

Patients participating 17.000 Physicians
participating 809 (12 ) Hospitals
participating 50
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Effects of DMP

• Evaluation by law
• clinical
• economical
• Quality of life

• ELSID-Studie
• Uni Heidelberg
• DMP
• DMP
• no DMP

Data of health insurance / Quality assurance
Patient questionaires
Improvement of Care ?
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Evaluation by law

• German Federal (Social) Insurance Authority
  defines criteria

Data of the standardized documentationdata
from health insurance companylife quality
questionaire (SF36)costs of administration
The evaluation is meant to compare programs of
different heath insurance companies!
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DMP-Study of University of Heidelberg

• Prospective, controlled Study comparing
• Effects of optimal DMP
• in comparison to Routine-DMP and
• Treatment without DMP (usual care)
• 3-arm Study (each arm includes 40-50 Practices
  with 20-25 Patienten 2 regions, Rheinland Pfalz
  and Sachsen-Anhalt)

Start in 2005, first results in 2007!
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Data interpretation health insurrance

• AOK-Data of 5 regions, including 217.000 Patients
  
• Starting point May 2006
• Item achievement of treatment goals BP and HbA1c
  
• Methods
• A Analysis of all documentations with equal
  runtime
• B Analysis of a Cohort of patients with equal
  duration of participation (same starting point)

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DMP Diabetes Typ 2Achievment of treatment goals
BP
80
74
62
57
54
47
Patients 250.000 (HbA1c) bzw. 188.000
(Blutdruck) Time of observation 12 Quartale
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DMP Diabetes Typ 2Achievment of treatment
goals BP
Methode B

• Die Kohorten sind nach Einstiegskohorten
  definiert
• EQ Einstiegsquartal 6 2.Q 2003 7 3.Q 2003
  8 4.Q 2003

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DMP Diabetes Typ 2Achievment of treatment goals
- HbA1c
Methode A
59
53
47
41
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DMP Diabetes Typ 2Achievment of treatment goals
- HbA1c
Methode B
EQ Einstiegsquartal 9 1.Q 2004 10 2.Q 2004
11 3.Q 2004
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AGENDA

• Implementation of DMPs in Germany a brief
  introduction
• DMP Diabetes how it works
• First results of DMP
• DMP in Germany - Perspektives

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Perspectives of DMP

• Simplification of documentation
• Reduction of items
• Implementation of e-DMP
• Development DMP Heart failure and Obesity as part
  of integration of multimorbidity
• Consideration of multimorbidity

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Thank you!