Download PDF
Exp Clin Endocrinol Diabetes 2016; 124(05): 294-299
DOI: 10.1055/s-0035-1569380
Article
© Georg Thieme Verlag KG Stuttgart · New York

High Quality of Diabetes Care Based Upon Individualised Treatment Goals – A Cross Sectional Study in 4784 Patients in Germany

C. Kloos
1   Endocrinology and Metabolic Diseases, University Hospital Jena, Jena, Germany
,
N. Müller
1   Endocrinology and Metabolic Diseases, University Hospital Jena, Jena, Germany
,
P. Hartmann
2   Deutsche BKK, Stuttgart, Germany
,
T. Lehmann
3   Computer Sciences and Documentation, Institute of Medical Statistics, University Hospital Jena, Jena, Germany
,
A. Sämann
4   Practice for Dialysis, Saalfeld, Germany
,
J. Roth
1   Endocrinology and Metabolic Diseases, University Hospital Jena, Jena, Germany
,
G. Wolf
1   Endocrinology and Metabolic Diseases, University Hospital Jena, Jena, Germany
,
U. A. Müller
1   Endocrinology and Metabolic Diseases, University Hospital Jena, Jena, Germany
› Author Affiliations
Further Information

Publication History

received 13 September 2015
first decision 18 December 2015

accepted 22 December 2015

Publication Date:
29 January 2016 (online)

Also available at
    Permissions and Reprints

Abstract

Objective: Recent guidelines recommend an individualized approach towards patients with diabetes mellitus. Data of a programme dealing with quality of diabetes care, “Diabetes TÜV” of the Deutsche BKK was reappraised in the light of recent evidence applying these recommendations.

Patients and Methods: Data originates from a population-based study in primary diabetes care in Germany. Patients with diabetes mellitus insured by the Deutsche BKK were invited to participate. From 2000 to 2004 data of 4 784 patients participated. Double or multiple visits were not included. HbA1c was analysed in 0.5% categories and in age groups below and above 70 years. HbA1c was DCCT adjusted.

Results: A total of 368 patients with diabetes mellitus type 1 (DM1) (42% women, HbA1c 54 mmol/mol (7.1%), BP 136/79 mmHg) and 4 416 patients with diabetes type 2 (DM2) (44% women, HbA1c 48.6 mmol/mol (6.6%), BP 142/81 mmHg) were included.). An HbA1c of 53 mmol/mol (7%) or less was found in 70%, less than 64 mmol/mol (8%) in 87% of all patients, and higher than 86 mmol/mol (10%) in 2.8%. The detailed analysis shows that an HbA1c of <=47.6 mmol/mol (6.5%) is achieved of 38% of people with DM1 and 56% with DM2, an HbA1c <=66 mmol/mol (8.0%) of 79% and 88%, respectively.

The mean systolic blood pressure (BP) was 142 mmHg, the diastolic BP was 81 mmHg. Systolic BP increased with age (systolic BP: < 50 years 131 mmHg; 50–70 years 142 mmHg; > 70 years 144 mmHg/diastolic BP: < 50 years 81 mmHg; 50–70 years 82 mmHg; > 70 years 80 mmHg). Using WHO grading, BP is mainly mildly elevated (grade 1: 41% (n=1942); grade 2, 17% (n=820) grade 3 6% (n=281). In 10 patients (0.2%) HbA1c above 86 mmol/mol (10.0%) coincides with a BP WHO grade 3.

Conclusions: In recent years new evidence is available regarding treatment targets. The reappraisal of a cross sectional study of a quality assurance programme of a German health insurance in a differentiated way demonstrates that more than 2/3 of the people with diabetes mellitus meet their specific goals. Only very few patients are at imminent risk due to bad glycaemic control and high blood pressure. Old patients may be at risk of overtreatment. Strategies aiming at adapting pharmacological interventions in older patients must be conceived.

Key words

diabetes mellitus - HbA1c - blood pressure - quality of care
 

  • References

  • 1 Schiel R, Müller UA, Sprott H et al. The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990. Diabetologia. 1997 40. 1350-1357
    PubMedGoogle Scholar
  • 2 Liebl A, Neiss A, Spannheimer A et al. Complications, co-morbidity, and blood glucose control in type 2 diabetes mellitus patients in Germany – results from the CODE-2 study. Exp Clin Endocrinol Diabetes 2002; 110: 10-16
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Stone MA, Charpentier G, Doggen K et al. On behalf of the GUIDANCE Study Group. Quality of Care of People With Type 2 Diabetes in Eight European Countries: Findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care 2013; 36: 2628-2638
    CrossrefPubMedGoogle Scholar
  • 4 Inzucchi SE, Bergenstal RM, Buse JB et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012; 55: 1577-1596
    CrossrefPubMedGoogle Scholar
  • 5 Inzucchi SE, Bergenstal RM, Buse JB et al. Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia. 2015 58. 429-442
    PubMedGoogle Scholar
  • 6 Stone MA, Wilkinson JC, Charpentier G et al. GUIDANCE Study Group. Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries. Diabetes Res Clin Pract 2010; 87: 252-260
    CrossrefPubMedGoogle Scholar
  • 7 German Medical Association, National Association of Statutory Health Insurance Physicians, Association of the Scientific Medical Societies in Germany. National guidelines Therapy of type 2 diabetes – long version. Version 4 11/2014. Available from http://www.leitlinien.de/nvl/diabetes/therapie Accessed Februay 17 2015
    PubMedGoogle Scholar
  • 8 James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311: 507-520 DOI: 10.1001/jama.2013.284427.
    CrossrefPubMedGoogle Scholar
  • 9 Grüßer M, Hoffstadt K, Jörgens V. Preventive care for early detection of diabetes mellitus complications: a model project in Wolfsburg. Z ärztl Fortbild Qual Sich 2000; 94: 411-416
    PubMedGoogle Scholar
  • 10 Busse R. Disease management programs in Germany's statutory health insurance system. Health Aff (Millwood) 2004; 23: 56-67
    PubMedGoogle Scholar
  • 11 Wolf G, Müller N, Tschauner T et al. Prevalence of renal insufficiency in the diabetes TUV of the Deutsche BKK. Med Klin (München) 2006; 10: 441-447
    PubMedGoogle Scholar
  • 12 Blum M, Kloos C, Müller N et al. Prevalence of diabetic retinopathy: Check-up program of a public health insurance company in Germany 2002-2004. Ophthalmologe 2007; 104: 502-504
    PubMedGoogle Scholar
  • 13 Sämann A, Tajiyeva O, Müller N et al. Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross-sectional study. Diabet Med 2008; 25: 557-563
    CrossrefPubMedGoogle Scholar
  • 14 Sämann A, Lehmann T, Heller T et al. A retrospective study on the incidence and risk factors of severe hypoglycemia in primary care. Fam Pract 2012; 30: 290-293
    PubMedGoogle Scholar
  • 15 Kloos C, Müller N, Wolf G et al. Better HbA1c and blood pressure control in patients with diabetes mellitus treated at a primary health care level 10 years after initiation of a diabetes quality improvement program. Exp Clin Endocrinol Diabetes 2011; 119: 459-62
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Müller UA, Femerling M, Risse A et al. Intensified treatment and education of type-1 diabetes mellitus as clinical routine: A nation-wide quality-circle experience in Germany. Diabetes Care 1999; 22 (Suppl. 02) B29-B34
    PubMedGoogle Scholar
  • 17 Böhm BO, Dreyer M, Fritsche A et al. Guideline for therapy of diabetes mellitus type 1 (2011). http://www.awmf.org/leitlinien/detail/ll/057-013.html (Accessed June 10, 2015)
    PubMedGoogle Scholar
  • 18 UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-853
    CrossrefPubMedGoogle Scholar
  • 19 Ohkubo Y, Kishikawa H, Araki E et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin dependent diabetes mellitus: a randomized prospective 5-year study. Diab Res Clin Pract 1995; 28: 103-117
    CrossrefPubMedGoogle Scholar
  • 20 The diabetes control and complication trial research group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-986
    CrossrefPubMedGoogle Scholar
  • 21 Huppertz E, Pieper L, Stridde E et al. Diabetes mellitus in German primary care: quality of glycaemic control and subpopulations not well controlled – results of the DETECT Study. Exp Clin Endocrin Diab 2009; 117: 6-14
    PubMedGoogle Scholar
  • 22 The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545-2559
    CrossrefPubMedGoogle Scholar
  • 23 ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358: 2560-2572
    CrossrefPubMedGoogle Scholar
  • 24 Duckworth W, Abraira C, Moritz T et al. VADT Investigators: Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360: 129-139
    CrossrefPubMedGoogle Scholar
  • 25 The ORIGIN Trial Investigators. Gerstein HC, Bosch J, Dagenais GR et al. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med 2012; 367: 319-328
    CrossrefPubMedGoogle Scholar
  • 26 Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 1987; 30: 123-131
    CrossrefPubMedGoogle Scholar
  • 27 Hippisley-Cox J, Coupland C. Development and validation of risk prediction equations to estimate future risk of blindness and lower limb amputation in patients with diabetes: cohort study. BMJ 2015; 351: h5441
    CrossrefPubMedGoogle Scholar
  • 28 American Diabetes Association. Standards of medical care in diabetes 2015. Diabetes Care 2015; 38 (Suppl. 01) S1-S93
    PubMedGoogle Scholar
  • 29 Canadian Diabetes Association. Clinical practice guidelines for Diabetes mellitus Type 2. Available at: http://guidelines.diabetes.ca/bloodglucoselowering/a1ctarget Accessed July 4, 2015
    PubMedGoogle Scholar
  • 30 Pani LN, Korenda L, Meigs JB et al. Effect of aging on A1C levels in individuals without diabetes: evidence from the Framing-ham Offspring Study and the National Health and Nutrition Examination Survey 2001–2004. Diabetes Care. 2008 31. 1991-1996
    PubMedGoogle Scholar
  • 31 Roth J, Müller N, Kloos C et al. One normal range for HbA1c for all age groups? The effect of aging on HbA1c in the people without diabetes. Diabetologia 2014; 57 (Suppl1) S1-S564
    PubMedGoogle Scholar
  • 32 Wen SW, Kramer MS, Hoey J et al. Terminal digit preference, random error, and bias in routine clinical measurement of blood pressure. J Clin Epidemiol 1993; 46: 1187-1193
    CrossrefPubMedGoogle Scholar
  • 33 Dost A, Hofer S, Herbst A et al. Factors contributing to terminal digital preference in 91398 patients with diabetes mellitus in germany and austria: possible impact on therapeutic decisions. Diabetic Medicine 2009; 26: 947-948
    CrossrefPubMedGoogle Scholar
  • 34 Hagen B, Altenhofen L, Haß W et al. Disease Management Programs 2007 in Northrhine: breast cancer, diabetes mellitus type 1/type 2, coronary artery disease, Asthma, COPD. KV Northrhine. Report. 2007 http://www.kvno.de/importiert/qualbe_dmp07.pdf Accessed at June 15 2015
    PubMedGoogle Scholar
  • 35 Schiel R, Netzer C, Junghänel J et al. 1- und Typ 2- Diabetes mellitus in der hausärztlichen Betreuung: Ergebnisse einer vergleichenden Untersuchung in Thüringen und Ostvorpommern. Z Evid Fortbild Qual Gesundh wesen (ZEFQ) 2009; 103: 453-460
    PubMedGoogle Scholar
  • 36 Blumenstock G, Selbmann HK. Evaluation des Modellvorhabens Südwürttemberg zur abgestuften, flächendeckenden ambulanten Versorgung von Patienten mit Diabetes mellitus. Z ärztl Fortbild Qual Gesundh wes 2005; 99: 185-189
    PubMedGoogle Scholar
  • 37 Rothe U, Müller G, Schwarz P et al. Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a federal state of Germany. Diabetes Care 2008; 31: 863-868
    CrossrefPubMedGoogle Scholar
  • 38 Cooper JG, Claudi T, Jenum AK et al. Quality of care for patients with type 2 diabetes in primary care in Norway is improving. Results of cross-sectional surveys of 33 general practices in 1995 and 2005. Diabetes Care. 2009 32. 81-83
    PubMedGoogle Scholar
  • 39 Larsen ML, Horder M, Mogensen EF. Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus. N Engl J Med 1990; 323: 1021-1025
    CrossrefPubMedGoogle Scholar
  • 40 Sämann A, Kaiser J, Hunger-Dathe W et al. Population-based measurement of quality of diabetes care using HbA1c values in the state of Thuringia/ Germany. Exp Clin Endocr Diab 2004; 112: 531-537
    Article in Thieme ConnectPubMedGoogle Scholar