Download PDF
Exp Clin Endocrinol Diabetes 2016; 124(02): 111-119
DOI: 10.1055/s-0042-101159
Article
© Georg Thieme Verlag KG Stuttgart · New York

Regional Disparities in Diabetes Care for Pediatric Patients with Type 1 Diabetes. A Cross-sectional DPV Multicenter Analysis of 24 928 German Children and Adolescents

B. Bohn
1   Institute of Epidemiology and Medical Biometry, ZIBMT, German Center for Diabetes Research (DZD), University of Ulm, Ulm, Germany
,
J. Rosenbauer
2   Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center at University of Düsseldorf, Düsseldorf, Germany
,
A. Icks
2   Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center at University of Düsseldorf, Düsseldorf, Germany
3   Department of Public Health, Faculty of Medicine, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
,
C. Vogel
4   Children’s Hospital Chemnitz, Chemnitz, Germany
,
P. Beyer
5   Clinic for Pediatrics, Protestant Hospital, Oberhausen, Germany
,
H. Rütschle
6   Pediatric Diabetes Practice, Mutterstadt, Germany
,
U. Hermann
7   Pediatric Diabetes Practice, Reutlingen, Germany
,
P. M. Holterhus
8   Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Kiel/Christian-Albrechts University of Kiel, Kiel, Germany
,
V. Wagner
9   Pediatric Practice, Rostock, Germany
,
S. von Sengbusch
10   Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics, University of Lübeck, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
,
K. Fink
1   Institute of Epidemiology and Medical Biometry, ZIBMT, German Center for Diabetes Research (DZD), University of Ulm, Ulm, Germany
,
R. W. Holl
1   Institute of Epidemiology and Medical Biometry, ZIBMT, German Center for Diabetes Research (DZD), University of Ulm, Ulm, Germany
,
for the DPV initiative › Author Affiliations
Further Information

Publication History

received 24 June 2015
first decision 18 August 2015

accepted 25 August 2015

Publication Date:
19 February 2016 (online)

Also available at
    Permissions and Reprints

Abstract

Background: Data on regional differences in the quality of medical care in Germany are scarce. This study aimed to compare outcome quality and medical treatment of pediatric patients with type 1 diabetes between the federal states of Germany.

Methods: 24 928 patients (< 18 years of age) with type 1 diabetes and German residence were selected from the Diabetes-Patienten-Verlaufsdokumentation database. Indicators of outcome quality were HbA1C, overweight prevalence, and rate of severe hypoglycemia. To reflect medical treatment, use of insulin pumps and use of rapid-acting or long-acting insulin analogues were analyzed. Logistic regression models were created for binary variables with federal state as independent predictor. Linear regression was applied for HbA1C and Poisson regression for rate of severe hypoglycemia. Confounders: Sex, age, diabetes duration, migratory background.

Results: Disparity was observed for indicators of outcome quality between the 16 federal states of Germany (all p<0.05). After adjustment, HbA1C varied between 55.8 mmol/mol and 67.3 mmol/mol, overweight prevalence between 10.0 and 15.3%, severe hypoglycemia ranged from 0.06 events/PY to 0.21 events/PY. Overall, the best outcome quality appeared to be present in Saxony. Medical treatment also differed. The percentage of pediatrics on insulin pumps varied between 26.3 and 51.8%. The use of rapid-acting analogues ranged from 56.6 to 96.2% and the use of long-acting analogues varied between 41.9 and 96.9% (all p<0.0001).

Conclusions: Medical treatment and outcome quality in pediatrics with type 1 diabetes differed within Germany. Disparities in individual socioeconomic status, regional deprivation, or differences in medical reimbursement decisions might have contributed to the patterns observed.

Key words

type 1 diabetes - children and adolescents - regional differences - federal states of Germany - outcome quality - medical treatment
 

  • References

  • 1 Rosenbauer J, Bächle C, Stahl A et al. Prevalence of type 1 diabetes mellitus in children and adolescents in Germany [abstract]. Diabetologia 2012; 55 (Suppl. 01) S369
    PubMedGoogle Scholar
  • 2 Holterhus PM, Beyer P, Bürger-Büsing J et al. Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Kindes- und Jugendalter. Mainz: Verlag Kirchheim+Co GmbH; German: 2009
    Google Scholar
  • 3 Craig ME, Twigg SM, Donaghue KC et al. for the Australian Type 1 Diabetes Guidelines Expert Advisory Group. National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults. Australian Government Department of Health and Ageing; Canberra: 2011
    Google Scholar
  • 4 Hauner H, Köster I, Schubert I. Prevalence of diabetes mellitus and quality of care in Hesse, Germany, 1998–2004: Analysis of the sample AOK Hessen/KV Hessen, 1998–2004. Dtsch Arztebl Int 2007; 104: A2799-A2805
    PubMedGoogle Scholar
  • 5 Rosenbauer J, Dost A, Karges B et al. Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria. Diabetes Care 2012; 35: 80-86
    CrossrefPubMedGoogle Scholar
  • 6 Arday DR, Fleming BB, Keller DK et al. Variation in diabetes care among states: Do patient characteristics matter?. Diabetes Care 2002; 25: 2230-2237
    CrossrefPubMedGoogle Scholar
  • 7 Gomes MB, Cobas RA, Matheus AS et al. Regional differences in clinical care among patients with type 1 diabetes in Brazil: Brazilian Type 1 Diabetes Study Group. Diabetol Metab Syndr 2012; 4: 44
    CrossrefPubMedGoogle Scholar
  • 8 Gerber PA, Spirk D, Brändle M et al. Regional differences of glycaemic control in patients with type 2 diabetes mellitus in Switzerland: a national cross-sectional survey. Swiss Med Wkly 2011; 141: w13218
    PubMedGoogle Scholar
  • 9 Kjome R, Røraas T, Granås A et al. Regional differences in sales of glucometer strips and antidiabetics. Tidsskr Nor Laegeforen 2012; 132: 1453-1457
    CrossrefPubMedGoogle Scholar
  • 10 Schipf S, Werner A, Tamayo T et al. Regional differences in the prevalence of known type 2 diabetes mellitus in 45–74 years old individuals: Results from six population-based studies in Germany (DIAB-CORE Consortium). Diabetic Med 2012; 29: e88-e95
    CrossrefPubMedGoogle Scholar
  • 11 Tamayo T, Claessen H, Rückert IM et al. Treatment pattern of type 2 diabetes differs in two German regions and with patients’ socioeconomic position. PLoS ONE 2014; 9: e99773
    CrossrefPubMedGoogle Scholar
  • 12 Bohn B, Scheuing N, Jehle PM et al. Are insulin analogues detemir or glulisine used preferentially in overweight/obese subjects? A German multicentre analysis of 38 560 type 2 diabetic patients from the DPV registry. Exp Clin Endocrinol Diabetes 2014; 22: 602-607
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Schaffrath Rosario A, Kurth BM, Ellert U et al. Body mass index percentiles for children and adolescents in Germany based on a nationally representative sample (KiGGS 2003–2006). Eur J Clin Nutr 2010; 64: 341-349
    CrossrefPubMedGoogle Scholar
  • 14 Ly TT, Maahs DM, Rewers A et al. International Society for Pediatric and Adolescent Diabetes. ISPAD Clinical Practice Consensus Guidelines 2014. Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2014; 15: 180-192
    CrossrefPubMedGoogle Scholar
  • 15 Bundesinstitut für Bevölkerungsforschung [Internet]. Wiesbaden: Bundesinstitut für Bevölkerungsforschung; c 2015. [updated 2015; cited 2015 Aug 14]. Bevölkerung unter 18 Jahren in Deutschland (Kreisebene), Anteil in Prozent, 2013; [about 1 screen]. Available from http://www.bib-demografie.de/DE/ZahlenundFakten/02/Karten/k_02_01_unter_18jaehrige_2013.html?nn=3074116 German
  • 16 Kurth BM, Schaffrath Rosario A. Overweight and obesity in children and adolescents in Germany. Bundesgesundheitsbl 2010; 53: 643-652 German
    CrossrefPubMedGoogle Scholar
  • 17 Moss A, Klenk J, Simon K et al. Declining prevalence rates for overweight and obesity in German children starting school. Eur J Pediatr 2012; 171: 289-299
    CrossrefPubMedGoogle Scholar
  • 18 Saaddine JB, Fagot-Campagna A, Rolka D et al. Distribution of HbA(1c) levels for children and young adults in the U.S.: Third National Health and Nutrition Examination Survey. Diabetes Care 2002; 25: 1326-1330
    CrossrefPubMedGoogle Scholar
  • 19 Grintsova O, Maier W, Mielck A. Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review. Int J Equity Health 2014; 13: 43
    CrossrefPubMedGoogle Scholar
  • 20 Lièvre M, Marre M, Robert JJ et al. Cross-sectional study of care, socio-economic status and complications in young French patients with type 1 diabetes mellitus. Diabetes Metab 2005; 31: 41-46
    CrossrefPubMedGoogle Scholar
  • 21 Berkowitz SA, Karter AJ, Lyles CR et al. Low socioeconomic status is associated with increased risk for hypoglycemia in diabetes patients: The Diabetes Study of Northern California (DISTANCE). J Health Care Poor Underserved 2014; 25: 478-490
    CrossrefPubMedGoogle Scholar
  • 22 Haag N, Roppelt A. Der Ländervergleich im Fach Mathematik. In: Stanat P, Pant HA, Böhme K, Richter D. (eds.) Kompetenzen von Schülerinnen und Schülern am Ende der vierten Jahrgangsstufe in den Fächern Deutsch und Mathematik: Ergebnisse des IQB-Ländervergleichs 2011. Münster: Waxmann; 2012: 117-127 German
    Google Scholar
  • 23 Schroeders U, Hecht M, Heitmann P et al. Der Ländervergleich in den naturwissenschaftlichen Fächern. In Pant HA, Stanat P, Schroeders U, Roppelt A, Siegle T, Pöhlmann C. (eds.). IQB-Ländervergleich 2012: Mathematische und naturwissenschaftliche Kompetenzen am Ende der Sekundarstufe I. Münster: Waxmann; 2013: 141-158 German
    Google Scholar
  • 24 Statista [Internet]. Hamburg: Statista GmbH; c 2015. [updated 2015; cited 2015 Aug 14]. Einkommensverteilung (monatliches Haushaltsnettoeinkommen in Euro) in Ost- und Westdeutschland zum 1. Januar 2008; [about 1 screen]. Available from http://de.statista.com/statistik/daten/studie/36400/umfrage/einkommensverteilung-in-ost--und-westdeutschland/. German
  • 25 Maier W, Holle R, Hunger M et al. The impact of regional deprivation and individual socio-economic status on the prevalence of type 2 diabetes in Germany. A pooled analysis of five population-based studies. Diabetic Med 2013; 30: e78-e86
    CrossrefPubMedGoogle Scholar
  • 26 Voigtländer S, Berger U, Razum O et al. The impact of regional and neighbourhood deprivation on physical health in Germany: a multilevel study. BMC Public Health 2010; 10: 403
    CrossrefPubMedGoogle Scholar
  • 27 Maier W, Fairburn J, Mielck A et al. Regional deprivation and mortality in Bavaria. Development of a community-based index of multiple deprivation. Gesundheitswesen 2012; 74: 416-425 German
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Ozegowski S, Sundmacher L. Ensuring access to health care – Germany reforms supply structures to tackle inequalities. Health Policy 2012; 106: 105-109
    CrossrefPubMedGoogle Scholar
  • 29 Icks A, Rosenbauer J, Holl RW et al. Hospitalization among diabetic children and adolescents and the general population in Germany. German Working Group for Pediatric Diabetology. Diabetes Care 2001; 24: 435-440
    CrossrefPubMedGoogle Scholar
  • 30 Gesundheitsberichterstattung des Bundes [Internet]. Bonn: Statistisches Bundesamt; c 2015. [updated 2014 Dec 11; cited 2015 Aug 14]. Europäische Gesundheitsindikatoren (ECHI). Indikator 63 der ECHI shortlist: Praktizierende Ärzte und Ärztinnen, je 100.000 Einwohner; [about 1 screen]. Available from https://www.gbe-bund.de/gbe10/trecherche.prc_them_rech?tk=80000&tk2=80408&p_uid=gast&p_aid=4418569&p_sprache=D&cnt_ut=1&ut=80408 German
  • 31 Sopp P, Wagner A. Internet. Düsseldorf: Hans-Böckler-Stiftung; c 2015. [updated 2015; cited 2015 Aug 14]. Gesundheit. Versicherte in der gesetzlichen Krankenkasse nach Status; [about 2 screens]. Available from http://www.boeckler.de/45250.htm German
    Google Scholar
  • 32 Huber J, Mielck A. Morbidity and healthcare differences between insured in the statutory (“GKV”) and private health insurance (“PKV”) in Germany. Review of empirical studies. Bundesgesundheitsbl 2010; 53: 925-938 German
    CrossrefPubMedGoogle Scholar
  • 33 Wild F. Supply of insulins in private health insurance compared to statutory health insurance. Gesundh ökon Qual manag 2009; 14: 200-203 German
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Bundesministerium der Finanzen [Internet]. Berlin: Bundesministerium der Finanzen; c 2015. [updated 2015 June 11; cited 2015 Aug 14]. Länderfinanzausgleich. Daten zum Länderfinanzausgleich; [about 3 screens]. Available from http://www.bundesfinanzministerium.de/Web/DE/Themen/Oeffentliche_Finanzen/Foederale_Finanzbeziehungen/Laenderfinanzausgleich/laenderfinanzausgleich.html German
  • 35 Ärztekammer Schleswig-Holstein . Bundesverdienstkreuz für Dr. Simone von Sengbusch. Schleswig-Holsteinisches Ärzteblatt 2011; 64: 48 German
    PubMedGoogle Scholar
  • 36 Deutsche Diabetes Gesellschaft e.V. [Internet]. Berlin: Deutsche Diabetes Gesellschaft e.V.; c 2015. [updated 2015; cited 2015 Aug 14]. Regionalgesellschaften; [about 2 screens]. Available from http://www.deutsche-diabetes-gesellschaft.de/ueber-uns/regionalgesellschaften.html German
  • 37 Fachkommission Diabetes der Sächsischen Landesärztekammer. Praxis-Leitlinie Diabetes mellitus Typ 2. Dresden; German: 2009
    Google Scholar