Statutory Health Insurance Carriers Research Articles

The Agreement Between Diagnoses as Stated by Patients and Those Contained in Routine Health Insurance Data.

The frequency of medical diagnoses is a figure of central importance in epidemiology and health services research. Prevalence estimates vary depending on the underlying data. For a better understanding of such discrepancies, we compared patients' diagnoses as reported by themselves in response to our questioning with their diagnoses as stated in the routine data of their health insurance carrier. For 6558 adults insured by BARMER, one of the statutory health insurance carriers in Germany, we compared the diagnoses of various illnesses over a twelve-month period, as reported by the patients themselves in response to our questioning (October to December 2021), with their ICD-10-based diagnosis codes (Q4/2020-Q3/2021). The degree of agreement was assessed with two kappa values, sensitivity, and specificity. The patients' stated diagnoses of diabetes and hypertension agreed well or very well with their diagnosis codes, with kappa and PABAK values near 0.8, as well as very high sensitivity and specificity. Moderately good agreement with respect to kappa was seen for the diagnoses of heart failure (0.4), obesity, anxiety disorder, depression, and coronary heart disease (0.5 each). The poorest agreement (kappa ≤ 0.3) was seen for posttraumatic stress disorder, alcohol-related disorder, and mental and somatoform disorder. Agreement was worse with increasing age. Diagnoses as stated by patients often differ from those found in routine health insurance data. Discrepancies that can be considered negligible were found for only two of the 11 diseases that we studied. Our investigation confirms that these two sources of data yield different estimates of prevalence. Age is a key factor; further reasons for the discrepancies should be investigated, and avoidable causes should be addressed.

The Outcome of Laparoscopic Versus Open Appendectomy in Childhood.

Appendectomy in children is performed either lapa - roscopically (LA) or by open surgery (OA). We studied whether, and how, the outcome is affected by the technique used and by the intraoperative conversion of LA to OA. We analyzed routine data from children and adolescents in three age groups (1-5 years, 6-12 years, and 13-17 years) who were insured by the AOK statutory health insurance carrier in Germany and who underwent appendectomy in the period 2017-2019. General surgical complications and reoperations within 90 days were assessed with relevant indicators. Associations between the surgical technique and these indicators were studied with logistic regression. Of the 21 541 patients included in the study, general surgical complications were observed in 2.1% and reoperations in 1.8% overall. Broken down by age group, the corresponding figures were 5.4% and 4.4% (age 1 to 5), 2.5% and 1.8% (age 6 to 12), and 1.5% and 1.6% (age 13 to 17). The main risk factors for complications and reoperations were acute complicated appendicitis and conversion from LA to OA. Regression analysis revealed similar outcomes with OA compared to LA in the 1-to-5 age group, (odds ratios and 95% confidence intervals: 1.1 [0.6; 2.1] for general surgical complications and 1.5 [0.8; 2.7] for reoperations), but worse outcomes with OA in the other two age groups (age 6 to 12: 1.9 [1.2; 2.9] and 2.1 [1.5; 2.9]; age 13 to 17: 1.7 [1.0; 2.9] and 2.2 [1.4; 3.6]). When conversions were assigned to the LA group, the odds ratio (OA compared to LA) for reoperation across all age groups was 3.5 [2.8; 4.4] in patients with acute uncomplicated appendicitis and 4.2 [3.4; 5.3] in patients with complicated appendicitis. Complicated appendicitis also increased the rate of general surgical complications and the length of stay in hospital. Among children in the two older age groups, LA was followed by fewer general surgical complications and reoperations than OA. These differences were less pronounced when conversions were counted as belonging to the LA group. Children aged 1-5 appear to benefit the least from the lapa - roscopic technique.

The Treatment of Patients With an Unruptured Abdominal Aortic Aneurysm and a Concomitant Malignancy—Short- and Long-Term Results.

Having cancer adversely effects the outcome of treatment for an unruptured abdominal aortic aneurysm (AAA). A retrospective secondary analysis was performed on the basis of anonymized data from AOK, a German nationwide statutory health-insurance carrier. Data were evaluated from all of the 20 683 patients who underwent either endovascular (EVAR, 15 792) or open surgical (OAR, 4891) treatment for an unruptured AAA in the years 2010-2016. It was determined in each case whether the patient had a known cancer at the time of the procedure to treat AAA. The analysis concerned patient characteristics, periprocedural complications, and survival after the procedure up to 31 December 2018. 18 222 patients were free of cancer. In accordance with the known 6:1 sex ratio of AAA, 85.3% of the cancer-free patients and 92.8% of those with cancer were men. At the time of their AAA procedure, 1398 had cancer of the intestine (n = 318), lung (n = 301), prostate (n = 380), or bladder or ureter (n = 399). One-year survival after the AAA procedure was 91.5% in cancer-free patients and 84%, 74.4%, 85.8%, and 85.5% in the patients with the respective types of cancer just mentioned. Having cancer was a significant risk factor for periprocedural mortality (OR 1.326, p = 0.041) and for long-term survival (HR 1.515; p < 0.001). Having cancer is a risk factor for periprocedural mortality and long-term survival in patients undergoing treatment for an unruptured AAA. This implies that the indications for surgery should be considered with care, particularly in patients with lung cancer, whose 5-year survival rate is only 37.2%.

The Utilization of Medical Services by Doctors in Outpatient Practice.

The Utilization of Medical Services by Doctors in Outpatient Practice.

The Long-Term Sequelae of Traumatic Brain Injury over 10 Years of Follow-Up-a Matched Cohort Study Based on Routine Data of a German Statutory Health Insurance Carrier.

The acute effects of traumatic brain injury (TBI) are well documented, but there is no systematic quantification of its long-term sequelae in German-language literature. The purpose of this article is to compare the frequency of conditions linked to prior TBI with their frequency in the non-brain-injured population. A matched cohort study was carried out on the basis of routine data from the BARMER statutory health insurance carrier. The exposure group consisted of patients treated over the period 2006-2009 for TBI at a variety of treatment intensities, including persons with multiple organ trauma. The control group consisted of BARMER insurees without prior TBI who were matched with the patients in the exposure group for age, sex, and pre-existing diseases. Late sequelae were sought in the routine data for a period of ten years after the injury. The outcome rates of the exposure and control groups were compared with Kaplan-Meier estimators and Poisson regression. 114 296 persons with TBI in the period 2006-2009 were included in the study. The mortality within ten years of TBI was 305 per 1000 individuals. The relative mortality in the exposure group was higher than that in control individuals of the same age and sex, with an incidence rate ratio (IRR) of 1.67 (95% confidence interval, [1.60; 1.74]). Immobility, dementia, epilepsy, endocrine disorders, functional disorders, depression, anxiety, cognitive deficits, headache, and sleep disorders were also more common in the exposure group. Persons with TBI requiring high-intensity treatment displayed the highest relative incidence rates of the conditions studied over 10 years of follow-up. Persons who had been admitted to the hospital because of TBI had higher relative incidence rates for epilepsy and dementia than those who had been cared for on an outpatient basis. Adverse sequelae of TBI can still be seen ten years after the exposure. These patients die earlier than persons without TBI and suffer earlier and more frequently from associated conditions.

Household deprivation, comorbidities and COVID-19 hospitalization in 690,115 children/adolescents

Abstract Background Studies document that adults in disadvantaged socio-economic positions have elevated risks of a severe course of COVID-19, but it is unclear if this holds true for children. We investigate in this population-based study whether young people from socio-economically disadvantaged households in Germany had a higher risk of COVID-19 hospitalization compared with more affluent counterparts. We also examined if differences were related to comorbidities that predict severe courses in children. Methods We included data from all 690,115 children and adolescents (0-18 years) enrolled in a statutory health insurance carrier. Daily hospital diagnoses of COVID-19 were recorded from 1.1.2020 to 13.7.2021. Logistic regressions were used to compare children from households with an indication of poverty (e.g. long- or short-term unemployed) with children from households with insurance holders in regular employment. We also assessed socio-economic characteristics of the area of residence. We controlled for age, sex, days under observation, nationality, and comorbidities (e.g. obesity). Findings A COVID-19 hospital diagnosis was a rare event (n = 1637). Children of long-term unemployed parents had a 1·36 times (95% CI 1·21-1·51) higher adjusted odds of hospitalization compared with those of employed parents. Elevated odds were also found for short-term unemployed or low-wage employment. Those living in poor areas had a 3·02 (1·81-5·22) higher odds of hospitalization than those in less deprived areas. Comorbidities were strongly related to hospitalization, but their adjustment did not change main estimates for household deprivation. Discussion Results suggest that children from poor households are at higher risk of severe courses of COVID-19 than their affluent counterparts. This underlies the need to implement effective Public Health strategies to protect deprived children from COVID-19 and other infectious disease even in high income countries such as Germany. Key messages • Children and adolescents from poor families seem to be at higer risk for sever courses of COVID-19. • Comorbidities were no key mediating factor in this study.

Association of Household Deprivation, Comorbidities, and COVID-19 Hospitalization in Children in Germany, January 2020 to July 2021

Adults in disadvantaged socioeconomic positions have elevated risks of a severe course of COVID-19, but it is unclear whether this holds true for children. To investigate whether young people from disadvantaged households have a higher risk of COVID-19 hospitalization and whether differences were associated with comorbidities that predispose children to severe courses. This population-based cohort study included all children and adolescents (aged 0-18 years) who were enrolled in a statutory health insurance carrier in Germany during the observation period of January 1, 2020, to July 13, 2021. Logistic regressions were calculated to compare children from households with and without an indication of poverty. Age, sex, days under observation, nationality, and comorbidities (eg, obesity, diabetes) were controlled for to account for explanatory factors. Disadvantage on the household level was assessed by the employment status of the insurance holder (ie, employed, long- or short-term unemployed, low-wage employment, economically inactive). Socioeconomic characteristics of the area of residence were also assessed. Daily hospital diagnoses of COVID-19 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes U07.1 and U07.2) were recorded. Comorbidities were assessed using inpatient and outpatient diagnoses contained in the insurance records. A total of 688 075 children and adolescents were included, with a mean (SD) age of 8.3 (5.8) years and 333 489 (48.4%) female participants. COVID-19 hospital diagnosis was a rare event (1637 participants [0.2%]). Children whose parents were long-term unemployed were 1.36 (95% CI, 1.22-1.51) times more likely than those with employed parents to be hospitalized. Elevated odds were also found for children whose parents had low-wage employment (odds ratio, 1.29; 95% CI, 1.05-1.58). Those living in low-income areas had 3.02 (95% CI, 1.73-5.28) times higher odds of hospitalization than those in less deprived areas. Comorbidities were associated with hospitalization, but their adjustment did not change main estimates for deprivation. In this cohort study, children who had parents who were unemployed and those who lived in low-income areas were at higher risk of COVID-19 hospitalization. This finding suggests that attention must be paid to children with SARS-CoV-2 from vulnerable families and closer monitoring should be considered. A number of explanatory factors, including comorbidities, were taken into account, but their analysis yielded no clear picture about underlying processes.

The State of Care for Persons With a Diagnosis of Depression.

Depression is one of the most common mental illnesses. There are well-known deficiencies in the care of patients with depression, particularly at the interfaces between health service areas or sectors. The aim of this study was to analyze the characteristics and state of care of persons with a diagnosis of depression. The analysis was based on diagnosis and billing data obtained from a statutory health insurance carrier in Germany. Patients carrying a diagnosis of depression in 2018 (ICD-10 F32, F33, F34.1) were identified and studied with respect to their utilization of care services for depression. Sociodemographic characteristics and the degree of severity of depression were also taken into account. More than 285 000 individuals with a diagnosis of depression were included in the analysis. Their mean age was 57.5 years, and 67.5% were female. About three-quarters had at least one comorbid mental disorder. Primary care physicians were involved in the treatment of depression for 82.8% of patients with severe depression; 41.1% of such patients had contact with a medical specialist, and 9.2% with a psychologist-psychotherapist. Antidepressants were prescribed for 60.3% of patients with severe depression, and 10.2% were receiving psychotherapeutic services in accordance with the psychotherapy directive. Our findings point to existing deficiencies in the care of patients with depression, particularly in the establishment of the diagnosis and in the assessment of disease severity. These are essential matters for the initiation of guideline-oriented therapy and therefore deserve to be more strongly emphasized in continuing medical education.

Polymyalgia Rheumatica.

Polymyalgia rheumatica (PMR) is among the most common inflammatory rheumatic diseases in older adults. Presumed risk factors include female sex, previous infections, and genetic factors. No epidemiological data on PMR in Germany have been available until now. This review is based on publications retrieved by a selective literature search in PubMed. Moreover, the administrative incidence and prevalence of PMR in the years 2011-2019 was determined from data of the AOK Baden-Württemberg statutory health insurance carrier for insurees aged 40 and older. In addition, we quantified the number of consultations with physicians involved in the diagnosis. The annual age- and sex-standardized incidence and prevalence of PMR from 2011 to 2019 were 18.6/100 000 persons and 138.8/100 000 persons, respectively. The incidence was higher in women than in men (21.8/100 000 vs. 12.8/100 000 persons per year). 60% of the cases were diagnosed in primary care practices. The treatment of PMR with orally administered glucocorticoids usually results in a treatment response within a few days to weeks. Approximately 43% of patients experience recurrent symptoms within a year, requiring adjustment of the glucocorticoid dose. For older patients with impaired physical ability, additional non-pharmacological treatment with exercise programs plays an important role. PMR usually takes an uncomplicated course under treatment and can be managed in primary care, but these patients are often multimorbid and require frequent follow-up. Along with research on the etiology of the disease, further studies are needed to identify the risk factors for a chronic course and to evaluate the potential effects of non-pharmacological measures.

The Decline in Outpatient Antibiotic Use.

A central component of the German antibiotic resistance strategy is to monitor the outpatient prescribing of systemic antibiotics nationwide, across all of the statutory health-insurance providers, in order to provide a basis for targeted quality-assurance measures. All outpatient drug prescription data from patients covered by the statutory health-insurance carriers in Germany in the age groups 0-14, 15-64, and ≥ 65 years were assessed. The chosen primary outcome measure under study was the prescription rate (number of antibiotic prescriptions per 1000 insurees per year) for the years 2010 to 2018. Over the period of the study, a 21% decline was seen in the use of systemic antibiotics in outpatients, from 562 to 446 prescriptions per 1000 insurees per year in 2010 and 2018, respectively. The most marked reduction in the prescription rate-by 41%-was seen among child and adolescent insurees (in other age groups: -17% among those aged 15-64, -12% among those aged 65 and older). A downward trend was seen in all regions of Germany, and for most of the active substance groups for which data were obtained. In 2018, the prescription rate varied by a factor of 1.8 among regions, with the highest rate in the Saarland (572 per 1000 insurees per year) and the lowest in Brandenburg (318 per 1000 insurees per year). The observed nationwide decline in the prescription of antibiotics to outpatients in all age groups may be a result of the numerous initiatives that have been put into action to reinforce the appropriate use of antibiotics in Germany. A change in pediatric prescribing practices is demonstrated by the marked reduction in this age group. The remaining major differences across German regions underscore the importance of regionally tailored programs for the promotion of rational antibiotic use.

Lipedema—Pathogenesis, Diagnosis, and Treatment Options

Lipedema is often unrecognized or misdiagnosed; despite an estimated prevalence of 10% in the overall female population, its cause is still unknown. There is increasing awareness of this condition, but its differential diagnosis can still be challenging. In this article, we summarize current hypotheses on its pathogenesis and the recommendations of current guidelines for its diagnosis and treatment. This review is based on publications about lipedema that were retrieved by a selective search in the MEDLINE, Web of Science, and Cochrane Library databases. The pathophysiology of lipedema remains unclear. The putative causes that have been proposed include altered adipogenesis, microangiopathy, and disturbed lymphatic microcirculation. No specific biomarker has yet been found, and the diagnosis is currently made on clinical grounds alone. Ancillary tests are used only to rule out competing diagnoses. The state of the evidence on treatment is poor. Treatment generally consists of complex decongestive therapy. In observational studies, liposuction for the permanent reduction of adipose tissue has been found to relieve symptoms to a significant extent, with only rare complications. The statutory healthinsurance carriers in Germany do not yet regularly cover the cost of the procedure; studies of high methodological quality will be needed before this is the case. The diagnosis of lipedema remains a challenge because of the hetero - geneous presentation of the condition and the current lack of objective measuring instruments to characterize it. This review provides a guide to its diagnosis and treatment in an interdisciplinary setting. Research in this area should focus on the elucidation of the pathophysiology of lipedema and the development of a specific biomarker for it.

The Prevalence, Comorbidity, Management and Costs of Irritable Bowel Syndrome.

Insufficient data are available on the administrative incidence and prevalence of irritable bowel syndrome (IBS) in Germany, as well as on its comorbidities, diagnostic evaluation, treatment, and costs. We analyzed routine data from a statutory health insurance carrier with approximately eight million insurees. IBS was identified from the ICD-10 codes K58.0, K58.9, and F45.32 (outpatient care by a physician, outpatient and inpatient care in a hospital). The cumulative incidence for the year 2017 was determined by the exclusion of insurees who had carried the diagnosis of IBS in any of the preceding 12 years. The frequencies of comorbid diseases and of diagnostic and therapeutic measures were compared with those of persons in age- and sex- matched control groups without IBS. In 2017, the administrative incidence of IBS was 0.36%, and its prevalence was 1.34%. Persons with IBS were often documented as having other gastrointes- tinal diseases, headache, back pain, and mental disorders. There was evidence for the insufficient use of ultrasound and colonoscopy and for the excessive use of computed tomography and magnetic resonance imaging for diagnostic evaluation. The costs of medical care for insurees with IBS in the year of their initial diagnosis were higher than those of other insurees without the diagnosis of IBD (€ 3770 vs. € 2788) and rose in each of the eight years preceding the initial diagnosis. Patients with IBS in Germany are likely not receiving sufficient diag- nostic evaluation in conformity with the relevant guidelines. The high prevalence of comorbid mental disorders and other pain syndromes implies that the complaints of patients with IBS need to be more comprehensively evaluated and treated.

Outpatient Antibiotic Prescription.

In view of the rise in antibiotic resistance and Clostridium difficile superinfection, close monitoring of antibiotic prescribing practices is essential so that targeted quality assurance measures can be taken. We analyzed nationwide data from multiple statutory health insurance carriers on prescriptions of systemic antibiotics in the years 2008-2014, with special attention to cephalosporins and fluoroqinolones. Prescribing rates were characterized in terms of defined daily doses (DDD) per 1000 statutory insurees per year and were analyzed separately for each age group and each federal state in Germany. Trends were analyzed with joinpoint regression. Antibiotic prescribing rates for persons aged 15 to 69 increased slightly overall during the period of observation. On the other hand, there was a significant decline in antibiotic prescribing rates for persons under age 15 in all of the German states, with a mean annual decrease of 6.8%. There was also a slight decline in antibiotic prescribing rates for persons aged 70 and above, mainly accounted for by fluoroquinolones. Cephalosporin prescribing rates rose significantly in all states, by an overall average of 7.6% per annum. Cephalo - sporin prescribing rates rose significantly in all age groups except persons under age 15, for whom there was a decline that did not reach statistical significance. This study revealed an overall decline in outpatient antibiotic prescriptions for persons under age 15 as well as other major changes in prescribing practices for the types of antibiotics studied. The observed marked rise in cephalosporin prescribing rates in all German states demands special attention because of the associated danger of increased antibiotic resistance and C. difficile superinfection. Oral cephalosporins are not recommended as drugs of first choice in current guidelines.

Myocardial Infarction Risk Due to Aircraft, Road, and Rail Traffic Noise: Results of a Case–Control Study Based on Secondary Data

Traffic noise can induce stress reactions that have effects on the cardiovascular system. The exposure-risk relationship between aircraft, road, and rail traffic noise and myocardial infarction is currently unknown. 19 632 patients from the Rhine-Main region of Germany who were diagnosed with myocardial infarction in the years 2006-2010 were compared with 834 734 control subjects. The assignment of persons to groups was performed on the basis of billing and prescription data from three statutory health insurance carriers. The exposure of all insurees to aircraft, road, and rail traffic noise in 2005 was determined from their residence addresses. As estimators of risk, odds ratios (OR) were calculated by logistic regression analysis, with adjustment for age, sex, regional social status variables, and individual social status (if available). The evaluation was performed on the basis of the continuous 24-hour noise level and the categorized noise level (in 5 decibel classes). The linear model revealed a statistically significant risk increase due to road noise (2.8% per 10 dB rise, 95% confidence interval [1.2; 4.5]) and railroad noise (2.3% per 10 dB rise [0.5; 4.2]), but not airplane noise. Airplane noise levels of 60 dB and above were associated with a higher risk of myocardial infarction (OR 1.42 [0.62; 3.25]). This higher risk is statistically significant if the analysis is restricted to patients who had died of myocardial infarction by 2014/2015 (OR 2.70 [1.08; 6.74]. In this subgroup, the risk estimators for all three types of traffic noise were of comparable magnitude (3.2% to 3.9% per 10 dB rise in noise level). In this study, a substantial proportion of the population was exposed to traffic noise levels that were associated with an albeit small increase in the risk of myocardial infarction. These findings underscore the importance of effective traffic noise prevention.

The problems of long-term treatment with benzodiazepines and related substances.

Benzodiazepine abuse and dependence have been recognized and widely discussed for more than 40 years. With more than 230 million daily doses prescribed in Germany per year, the burden of reimbursement on the statutory health insurance carriers is high, albeit with a slight decline from year to year. At present, about 50% of all prescriptions in Germany are issued privately, even for patients who have statutory health insurance. We selectively review the literature on the epidemiology and treatment of benzodiazepine dependence and abuse in Germany. Estimates of the number of benzodiazepine-dependent persons in Germany range from 128 000 to 1.6 million. Most estimates take no account of the large number of private prescriptions (i.e., those that are not reimbursed by the statutory health insurance scheme), while many exclude prescriptions for elderly persons, for whom these drugs are frequently prescribed. For the outpatient treatment of benzodiazepine withdrawal, it is recommended that the drug should first be switched to an equivalent dose of another benzodiazepine with an intermediate or long-acting effect; the dose should then, in general, be reduced weekly. In case of consumption of a high dose (≥ 20 mg diazepam equivalent), hospitalization and the additional administration of carbamazepine or valproic acid are recommended. Flumazenil treatment can improve with - drawal symptoms and leads to higher abstinence rates. Antidepressants should be given only if the patient is depressed. The dependence potential of nonbenzodiazepine drugs such as zolpidem and zopiclon must also be borne in mind. Benzodiazepines are generally highly effective when first given, but they should generally be given only for strict indications and for a limited time. If these drugs still need to be given beyond the short term, timely referral to a specialist is indicated, and possibly also contact with the addiction aid system.

The Management of Thyroid Nodules

In Germany, about 59 000 thyroid operations are performed each year for uni- or multinodular goiter, most of them for diagnostic purposes. The rate of detection of thyroid cancer in such operations is relatively low, at 1:15. Evidence suggests that the preoperative tests recommended in guidelines for estimating the risk of cancer are not being performed as often as they should. In the present study, we determined the measures that were actually taken to diagnose and treat thyroid nodules and compared the findings with the guideline recommendations. We retrospectively analyzed data from a single, large statutory healthinsurance carrier in Germany (AOK), determining the diagnostic and therapeutic measures that were reimbursed for 25 600 patients in whom a uni- or multinodular goiter was newly diagnosed in the second quarter of 2006 (none of these patients had carried such a diagnosis 1 year previously). We recorded the diagnostic measures performed in the preceding 9 months and all other tests and treatments, including surgery and radioactive iodine treatment, in the 2 years thereafter. Among patients who underwent surgery for uninodular goiter, the preoperative diagnostic studies included ultrasonography (in 100% of patients), scintigraphy (94%), measurement of thyroid-stimulating hormone (95%), measurement of calcitonin (9%), and fine-needle aspiration cytology (FNAC)(21%). An ultrasonographic examination was billed for only 28% of patients with uninodular goiter in the two years after the diagnosis was made. 13% of patients with uninodular goiter who were not operated on were given L-thyroxine, even though this is against guideline recommendations. Inadequate preoperative risk stratification of thyroid nodules may explain the large number of thyroid operations that are performed for diagnostic purposes, resulting in a low percentage of malignancies detected. Preoperative FNAC and calcitonin measurement should be used in the diagnostic evaluation of thyroid nodules far more often than this is now done. As a rule, follow-up ultrasonography should be performed for all thyroid nodules that are not operated on. Patients with non-operated thyroid nodules should not be given thyroxine. A limitation of this study is that diagnostic measures were only recorded if they were performed in the 9 months before surgery, with earlier diagnostic measures (if any) being missed.

The Epidemiology of Osteoporosis

Osteoporosis is a widespread disease of the skeleton that becomes more common with advancing age. Its prevalence is still inadequately documented. The goal of this study is to determine how common osteoporosis is in Germany. The routine billing data of a large statutory health insurance carrier in Germany (the TK company) from the years 2006 to 2009 were anonymized and retrospectively analyzed. Insurees aged 50 and above with osteoporosis were identified either from their bearing the diagnosis of osteoporosis or of osteoporosis-related fractures, or from their having received prescription medication for osteoporosis. The prevalence and incidence of osteoporosis and the frequency of osteoporotic fractures were calculated for TK insurees and extrapolated to the overall German population. The prevalence of osteoporosis among persons aged 50 and above, as revealed by diagnoses of osteoporosis or osteoporotic fractures, or by the prescription of medication for osteoporosis, was found to be 14% (240,657 of 1.7 million insurees) in the year 2009; the sex-specific prevalence was 24% in women and 6% in men. An extrapolation of these figures implies that 6.3 million persons in Germany have osteoporosis. The incidence of osteoporosis in the same age group, as revealed by a diagnosis of osteoporosis or prescription of medication for osteoporosis, was found to be 2.1% per year, with 104,528 insurees having an index event for osteoporosis (initial diagnosis of osteoporosis or first prescription of a medication for osteoporosis). An extrapolation of this figure implies that 885,000 persons newly develop osteoporosis in Germany each year. Over the period of observation, 52% of the affected persons (total, 172,473 persons) sustained fractures, many of which were multiple. Osteoporosis is still common in Germany. The large number of insurees with single and multiple fractures implies that the treatment of this disease in Germany needs to be improved.

Alternative Approaches to the Treatment of Fecal Incontinence

Biofeedback and anal electrostimulation are considered to be established techniques for the treatment of chronic fecal incontinence when the involuntary loss of stool cannot be stopped by surgery, by general measures such as optimizing stool consistency, or by the treatment of an underlying proctological condition. In fact the terms “biofeedback” and “electrical stimulation” cover a wide range of therapies, which have been subjected to varying methods of evaluation. The available literature on the subject does not allow a systematic comparison of different forms of treatment (1). No general recommendation to treat fecal incontinence in any particular way can be derived from the individual studies published to date (2). Despite this, certain types of treatment without any clear evidence of efficacy are now reimbursable by the statutory health insurance carriers in Germany, while others cannot be ordered. The frequent result is a fruitless struggle with the Medical Service of Health Insurance Companies in Germany (Medizinischer Dienst der Krankenversicherung, MDK) and with the statutory health insurance carriers (Gesetzliche Krankenversicherungen, GKV), ending in the refusal of payment for indicated treatment. Such conflicts are annoying, and the denial of treatment for our patients is regrettable. Yet there is a real lack of evidence-based treatment due to the inadequacy of scientific study in this area.

The Effect of Introducing Rebate Contracts to Promote Generic Drug Substitution, on Doctors’ Prescribing Practices

As of 1 April 2007, pharmacists in Germany filling prescriptions covered by the statutory health insurance system (Gesetzliche Krankenversicherung, GKV) are required, whenever possible, to dispense a preparation that contains the same active substance and for which a rebate contract is in effect. The physician can block drug substitution by crossing out "aut idem" ("or the like") on the prescription form. The latter option has existed since 2002. We studied the possible effect of the introduction of rebate contracts on the use of the no-substitution option. Three independent random samples were taken from the routine data of the Gmünder ErsatzKasse (GEK, a statutory health insurance carrier). The samples consisted of 0.5% of the insured adult population in the month of October in the years 2006, 2007, and 2008 (n = 6195; n = 6300; n = 6845). Within these sample groups, all medication orders in which the physician could potentially have exercised a no-substitution option were selected, and the corresponding prescriptions were examined. The percentage of no-substitution prescriptions rose from October 2006 to October 2007, and then rose still further to October 2008 (14.4%, 18.4%, 19.0%; p for trend < 0.0001). Considerable differences were seen between physicians belonging to different regional Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen). In about one-quarter of the no-substitution prescriptions for 2007 and 2008 (25.1%, 25.7%), the prescribed medication was itself included in a rebate contract. The use of the no-substitution option is not uniform across Germany at present. Rebate contracts and the no-substitution option require further evaluation. Moreover, the dispensing of medications urgently needs a more stable regulatory framework.