Epidemiology of Complications and Total Treatment Costs from Diagnosis of Type 2 Diabetes in Germany (ROSSO 4)

Abstract

Objective: To determine the occurrence of complications and treatment costs in the first 6 years from diagnosis of Type 2 diabetes in the primary care level.

Design: The German multi-centre, retrospective epidemiological cohort study ROSSO observed patients from diagnosis in 1995-1999 until the end of 2003 or loss to follow-up.

Setting: 192 randomly contacted primary care practices and all patient records of newly diagnosed type 2 diabetes patients.

Participants: All 3,142 patients insured in a public health insurance plan.

Main Outcome Measures: Diabetes-related complications were documented from patient files. Treatment costs were attributed using the doctor's tariff, hospital DRGs and medication price lists for Germany.

Results: At diagnosis, already 22.4% of patients presented with CHD, 15.4% with CHF, 5.8% with pAOD, 3.1% with stroke and 3.9% with AMI, but less than 0.5% with documented microvascular complications. 7.4% of patients were diagnosed with prior depression and, 5.0% with polyneuropathy. Within a mean of 6.5 years of follow-up 114 patients (3.6%) died. The cumulated occurrence of AMI and stroke rose without a lag phase almost linearly from diagnosis reaching 6.7% for AMI and 7.7% for stroke. The total number of strokes was significantly higher than AMI (181 strokes vs. 109 AMI; p≤0.001). As expected, the rate of microvascular complications was low during this early disease stage but nevertheless reached 2.8 % of patients (amputation, dialysis and blindness combined). Mortality and stroke rates did not differ significantly between sexes but men suffered more frequently from AMI (4.8% men, 2.2% women; p < 0.001). Total costs of diabetes care was 1,288 € (1,610 $)for the first treatment year with diagnosed diabetes and rose to 3,845 € (4,806 $) in year seven. Costs for treating complications dominated already in the first year after diagnosis. The mean direct treatment costs amounted to 3,210 € (4,013 $) per patient and year for the first 6.5 years.

Conclusion: ROSSO is the first epidemiological cohort study examining longitudinal epidemiological data of the same patients over more than five years (up to eight years) for type 2 diabetes mellitus in primary care practices, starting from diagnosis. The rate of complications rose linearly from diagnosis without a lag phase. Stroke occurred more often than myocardial infarction, the latter more often in men. Total treatment costs were dominated by costs of treating complications from early on, suggesting a costs saving potential by early detection of diabetes as well as by secondary prevention and patient empowerment in the period following diagnosis.

Key words

Blood glucose - cohort study - long-term outcome - observational study - retrospective - epidemiology - self-monitoring - SMBG - type 2 diabetes mellitus - diabetic late complications - general practitioner - GP - primary care - ROSSO

References

• 1 Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic.  Nature. 2001;  414 782-787
• 2 Liebl A, Neiss A, Spannheimer A, Reitberger U, Wagner T, Gortz A. Costs of type 2 diabetes in Germany. Results of the CODE-2 study.  Dtsch Med Wochenschr. 2001;  126 585-589
• 3 Rathmann W, Haastert B, Icks A, Lowel H, Meisinger C, Holle R. et al . High prevalence of undiagnosed diabetes mellitus in Southern Germany: target populations for efficient screening. The KORA survey 2000.  Diabetologia. 2003;  46 182-189
• 4 Rathmann W, Icks A, Haastert B, Giani G, Lowel H, Mielck A. Undiagnosed diabetes mellitus among patients with prior myocardial infarction.  Z Kardiol. 2002;  91 620-625
• 5 Bellach BM, Knopf H, Thefeld W. The German Health Survey. 1997/98.  Gesundheitswesen. 1998;  60 ((Suppl 2)) S59-S68
• 6 Thefeld W. Prevalence of diabetes mellitus in the adult German population.  Gesundheitswesen. 1999;  61 ((Spec No)) S85-S89
• 7 Hauner H, Koster I, Ferber L von. Outpatient care of patients with diabetes mellitus in 2001. Analysis of a health insurance sample of the AOK in Hesse/KV in Hesse.  Dtsch Med Wochenschr. 2003;  128 2638-2643
• 8 Koster I, Ferber L von, Ihle P, Schubert I, Hauner H. The cost burden of diabetes mellitus: the evidence from Germany-the CoDiM Study.  Diabetologia. 2006;  49 1498-1504
• 9 Leiden HA van, Dekker JM, Moll AC, Nijpels G, Heine RJ, Bouter LM. et al . Blood pressure, lipids, and obesity are associated with retinopathy: the hoorn study.  Diabetes Care. 2002;  25 1320-1325
• 10 Leiden HA van, Dekker JM, Moll AC, Nijpels G, Heine RJ, Bouter LM. et al . Risk factors for incident retinopathy in a diabetic and nondiabetic population: the Hoorn study.  Arch Ophthalmol. 2003;  121 245-251
• 11 DECODE Study Group, on behalf of the European Diabetes Epidemiology Group . Glucose tolerance and cardiovascular mortality: comparison of fasting and 2-hour diagnostic criteria.  Arch Intern Med. 2001;  161 397-405
• 12 Bruno G, Cavallo-Perin P, Bargero G, Borra M, Calvi V, D'Errico N. et al . Prevalence and risk factors for micro- and macroalbuminuria in an Italian population-based cohort of NIDDM subjects.  Diabetes Care. 1996;  19 43-47
• 13 Jager A, Kostense PJ, Ruhe HG, Heine RJ, Nijpels G, Dekker JM. et al . Microalbuminuria and peripheral arterial disease are independent predictors of cardiovascular and all-cause mortality, especially among hypertensive subjects: five-year follow-up of the Hoorn Study.  Arterioscler Thromb Vasc Biol. 1999;  19 617-624
• 14 Elm E von, Egger M. The scandal of poor epidemiological research.  BMJ. 2004;  329 868-869
• 15 Martin S, Schneider B, Heinemann L, Lodwig V, Kurth HJ, Kolb H. et al . Self-monitoring of blood glucose in type 2 diabetes and long-term outcome: an epidemiological cohort study.  Diabetologia. 2006;  49 271-278
• 16 http://www.kranken-haus-aok.de/m02/m02_05/ , Last visited. 18-4-2005. Ref Type: Internet Communication
• 17 Hinzpeter B, Klever-Deichert G, Wendland G, Lauterbach KW. Coronary disease and social security. A simulation model on cost analysis.  Herz. 2000;  25 515-525
• 18 Szucs TD, Schwenkglenks M, Paschen B, Follath F. Cost effectiveness of bisoprolol in treatment of heart failure in Germany. An analysis based on the CIBIS-II study.  Med Klin (Munich). 2000;  95 663-671
• 19 Banz K, Dinkel R, Hanefeld M, Schwanebeck U. Evaluation of the potential clinical and economic effects of bodyweight stabilisation with acarbose in patients with type 2 diabetes mellitus. A decision-analytical approach.  Pharmacoeconomics. 1998;  13 449-459
• 20 Laaser U, Breckenkamp J, Niermann U. Cost-effectiveness-analysis of medical interventions in patients with stroke in germany under special consideration of “stroke units”.  Gesundh ökon Qual manag. 1999;  4 176-183
• 21 Holler D, Claes C, Schulenburg JM der. Treatment costs and quality of life of patients with peripheral arterial occlusive disease-the German perspective.  Vasa. 2004;  33 145-153
• 22 Dahmen HG. Diabetic foot syndrome and its risks: amputation, handicap, high-cost sequelae.  Gesundheitswesen. 1997;  59 566-568
• 23 Gesundheitsbericht für Deutschland 1998 .In Statistisches Bundesamt ed Wiesbaden: Metzler-Poeschel (Stuttgart) 1998: 341-345
• 24 Rathmann W, Haastert B, Giani G. Drug prescriptions and costs in diabetic polyneuropathy.  Dtsch Med Wochenschr. 1999;  124 681-686
• 25 Weber C, Neeser K, Wenzel H, Schneider B. , Cost of type 2 diabetes in Germany over 8 years (the ROSSO study No. 2). Journal of Medical Economics 2006; accepted for publication 9. February 2006.
• 26 Köhler A, Hess R. Kölner Kommentar zum EBM 2. edn. Köln: Deutscher Ärzte-Verlag 2002
• 27 Wezel H, Liebold R. , Handkommentar zum einheitlichen Bewertungsmassstab für ärztliche Leistungen (EBM). 2001. Sankt Augustin, Asgard-Verlag Dr. Werner Hippe. Ref Type: Catalog
• 28 Arzneiverordnungsreport 2004 .Berlin Heidelberg: Springer 2004
• 29 http://www.oecd.org/dataoecd/13/53/31963451.xls , Last visited. 18-4-2005. Ref Type: Internet Communication
• 30 UK Prospective Diabetes Study (UKPDS) . XI: Biochemical risk factors in type 2 diabetic patients at diagnosis compared with age-matched normal subjects.  Diabet Med. 1994;  11 534-544
• 31 Rathmann W, Haastert B, Icks A, Giani G, Holle R, Koenig W. et al . Prevalence of the metabolic syndrome in the elderly population according to IDF, WHO, and NCEP definitions and associations with C-reactive protein: the KORA Survey 2000.  Diabetes Care. 2006;  29 461
• 32 Bertoni AG, Hundley WG, Massing MW, Bonds DE, Burke GL, Goff Jr DC. Heart failure prevalence, incidence, and mortality in the elderly with diabetes.  Diabetes Care. 2004;  27 699-703
• 33 Kannel WB. Hazards, risks, and threats of heart disease from the early stages to symptomatic coronary heart disease and cardiac failure.  Cardiovasc Drugs Ther. 1997;  11 ((Suppl 1)) 199-212
• 34 Nichols GA, Gullion CM, Koro CE, Ephross SA, Brown JB. The incidence of congestive heart failure in type 2 diabetes: an update.  Diabetes Care. 2004;  27 1879-1884
• 35 Maru S, Koch GG, Stender M, Clark D, Gibowski L, Petri H. et al . Antidiabetic drugs and heart failure risk in patients with type 2 diabetes in the U.K. primary care setting.  Diabetes Care. 2005;  28 20-26
• 36 Lustman PJ, Clouse RE. Depression in diabetic patients: the relationship between mood and glycemic control.  J Diabetes Complications. 2005;  19 113-122
• 37 Gallo JJ, Bogner HR, Morales KH, Post EP, Ten HT, Bruce ML. Depression, cardiovascular disease, diabetes, and two-year mortality among older, primary-care patients.  Am J Geriatr Psychiatry. 2005;  13 748-755
• 38 UK Prospective Diabetes Study 6 . Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors.  Diabetes Res. 1990;  13 1-11
• 39 Liebl A, Spannheimer A, Reitberger U, Gortz A. Costs of long-term complications in type 2 diabetes patients in Germany. Results of the CODE-2 Study.  Med Klin (Munich). 2002;  97 713-719
• 40 Graf J. “DMP” lernt laufen.  Gesundheit und Gesellschaft. 2002;  5 10-11
• 41 Brown JB, Nichols GA, Glauber HS, Bakst AW. Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis.  Diabetes Care. 1999;  22 1116-1124

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