Exp Clin Endocrinol Diabetes 2009; 117(1): 6-14
DOI: 10.1055/s-2008-1073127
Article

© Georg Thieme Verlag KG Stuttgart · New York

Diabetes Mellitus in German Primary Care: Quality of Glycaemic Control and Subpopulations not well Controlled – Results of the DETECT Study

E. Huppertz 1 , L. Pieper 1 , J. Klotsche 1 , E. Stridde 2 , D. Pittrow 3 , S. Böhler 3 , H. Lehnert 4
  • 1Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden
  • 2Pfizer GmbH, Karlsruhe
  • 3Institut für Klinische Pharmakologie, Technische Universität Dresden
  • 4Warwick Medical School, Coventry, UK
Weitere Informationen

Publikationsverlauf

received 25.02.2008 first decision 19.03.2008

accepted 19.03.2008

Publikationsdatum:
09. Mai 2008 (online)

Abstract

Introduction: The quality of glycaemic control of patients with T1D and T2D can be assessed with HbA1c levels. We aimed to assess the quality of glycaemic control and the prevalence of inadequately controlled diabetes in German primary care, and to determine simple patient and treatment related factors associated with poor control.

Material and Methods: Using a nationwide probability sample of 3 188 general practices (response rate 50.6%), a total of 55,518 patients were assessed in DETECT, a cross-sectional and prospective multistage epidemiological study. Diabetes diagnoses were based on physician assessment. HbA1c values were taken from the patient charts.

Results: The quality of metabolic control was unsatisfactory on the whole in the 277 people with T1D (e.g. mean HbA1c=7.4%±1.4%). The 8 188 people with T2D had a mean HbA1c of 6.89%±1.2%. 38.8% of individuals had an HbA1c≥7.0%. The situation was less favourable in subjects with a longer history of diabetes – in many cases in those with diabetes for 5–9 years, but generally in those with a plus-10-year history of diabetes – and also in younger men with a shorter disease history. Patients with a short T2D history, especially older subjects had more favourable values. With regard to age, a higher percentage of patients had an HbA1c≥7.0% (42.0% and 40.6%) in the 45–54 and 55–64 year olds. With respect to the correlation between HbA1c and treatment modality, we identified the best metabolic control in T2D patients without drug therapy for diabetes, and the worst in patients on combination regimens (OAD/insulin). The average duration of diabetes in the various treatment groups differs substantially. The average duration was highest (12.1 y) in the insulin group. Oral treatment was the predominant treatment modality in all HbA1c categories.

Conclusion: T1D treatment needs to be improved overall. The situation as regards T2D is less clear-cut. When people with T2D start requiring more intensive and complex treatment in response to disease progression, the treatment efforts of patients and physicians evidently fail to keep up with the actual pace of metabolic deterioration. Early and strict alignment with approximately normal HbA1c targets is essential. Close attention should be paid to T2 diabetics with a 5–9-year diabetes history, with the aim of preventing any loss of metabolic control. Likewise, patients aged 45–64 y and younger men require more attention.

References

  • 1 Altenhofen L, Haß W, Oliveira J, Brenner G. Modernes Diabetesmanagement in der ambulanten Versorgung. 1st edn. Köln: Deutscher Ärzte-Verlag 2002
  • 2 American Diabetes Association . Standards of Medical Care in Diabetes–2007.  Diabetes Care. 2007;  30 ((Suppl. 1)) S4-S41
  • 3 Böhler S, Lehnert H, Stalla GK, Zeiher AM, März W, Silber S, Wehling M, Ruf G, Reineke A, Wittchen HU. Diabetes and cardiovascular risk-evaluation and management in primary care: progress and unresolved issues.  Exp Clin Endocrinol Diabetes. 2004;  112 157-170
  • 4 Cleary PA, Orchard TJ, Genuth S, Wong ND, Detrano R, Backlund JY, Zinman B, Jacobson A, Sun W, Lachin JM, Nathan DM. DCCT/EDIC Research Group . The effect of intensive glycemic treatment on coronary calcification in type 1 diabetic participants of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study.  Diabetes. 2006;  55 3556-3565
  • 5 Gasser T, Müller HG. Kernel estimation of regression functions. In: Gasser T, Rosenblatt M (Eds). Smoothing Techniques for Curve Estimation. 1st edn. New York 1979: 23-68
  • 6 Harris SB, Worrall G, Macaulay A, Norton P, Webster-Bogaert S, Donner A, Murray A, Steward M. Diabetes Management in Canada: Baseline Results of the Group Practice Diabetes Management Study.  Can J Diabetes. 2006;  30 ((2)) 131-137
  • 7 Hastie T, Tibshirani R. Generalized Additive-Models – Some Applications.  Journal of the American Statistical Association. 1987;  82 ((398)) 371-386
  • 8 Hauner H, Köster I, Ferber L von. Prävalenz des Diabetes mellitus in Deutschland 1998–2001.  Dtsch Med Wochenschr. 2003;  128 2632-2638
  • 9 Häussler B, Hagenmeyer EG, Storz P, Jessel S. Weissbuch Diabetes in Deutschland. 1st edn. Stuttgart: Thieme-Verlag 2006
  • 10 Icks A, Rathmann W, Haastert B, Mielk A, Holle R, Löwel H, Giani G, Mesinger C. for the KORA study group . Versorgungsqualität und Ausmaß von Komplikationen an einer bevölkerungsbezogenen Stichprobe von Typ-2-Diabetespatienten – Der KORA Survey 2000.  Dtsch Med Wochenschr. 2006;  131 73-78
  • 11 IDF Clinical Guidelines Task Force .Global guideline for Type 2 diabetes. International Diabetes Federation. Brussels 2005
  • 12 Köster I, Hauner H, Ferber L von. Heterogenität der Kosten bei Patienten mit Diabetes mellitus: Die KoDiM-Studie.  Dtsch Med Wochenschr. 2006;  131 804-810
  • 13 Lehnert H, Wittchen HU, Pittrow D, Bramlage P, Kirch W, Böhler S, Höfler M, Ritz E. Prävalenz und Pharmakotherapie des Diabetes in der primärärztlichen Versorgung.  Dtsch Med Wochenschr. 2005;  130 323-328
  • 14 , Nationale Versorgungs-Leitlinie Diabetes mellitus Typ 2, Kurzfassung, 1. Auflage Mai 2003, korrigierte Version 1.7.2002
  • 15 Ott P, Köhler C, Hanefeld M. Grunddaten der „Diabetes in Deutschland”-Studie (DIG).  Der Diabetologe. 2006;  1 ((Suppl. 1)) 544-548
  • 16 Pittrow D, März W, Zeiher AM, Pieper L, Klotsche J, Glaesmer H, Ruf G, Stalla GK, Lehnert H, Koch U, Silber S, Böhler S, Wittchen HU. Prävalenz, medikamentöse Behandlung und Stoffwechseleinstellung des Diabetes mellitus in der Hausarztpraxis.  Med Klin. 2006;  101 635-644
  • 17 , Qualitätssicherungsbericht 2005 – Disease-Management-Programme in Westfalen-Lippe – DMP Diabetes mellitus Typ 2. Gemeinsame Einrichtung Disease-Management-Programme Westfalen-Lippe. Dortmund, July 2006
  • 18 Rathmann W, Giani G. Qualität der Arzneimittelversorgung bei Patienten mit Diabetes mellitus Typ 2 in Deutschland.  Dtsch Med Wochenschr. 2003;  128 1183-1186
  • 19 Rothenbacher D, Brenner H, Rüter G. Typ-2-Diabetes-mellitus: Betreuung von chronisch Kranken in der Hausarztpraxis.  Dtsch Arztebl. 2005;  102 A2408-A2412
  • 20 Royall RM. Model robust confidence intervals using maximum likelihood estimators.  International Statistical Review. 1986;  54 ((2)) 221-226
  • 21 Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, Narayan KMV. Improvement in Diabetes Processes of CARE and Intermediate Outcomes: United States, 1988–2002.  Ann Intern Med. 2006;  144 465-474
  • 22 Sämann A, Nordmann S, Kaiser J, Hunger-Dathe W, Kloos C, Braun A, Müller UA. Evaluation der Diabetes-Karte für Thüringen – Ein Projekt zur kontinuierlichen Behandlungsqualität in der primären Versorgung von Patienten mit Diabetes mellitus in Thüringen.  Diabetologie. 2006;  1 ((Suppl. 1)) A363
  • 23 Scherbaum WA, Landgraf R. et al . Evidenzbasierte Leitlinie – Therapie des Diabetes mellitus Typ 1.  , Version 05/ 2003; 
  • 24 Schulze J, Rothe U, Müller G, Kunath H. Fachkommission Diabetes Sachsen . Verbesserung der Versorgung von Diabetikern durch das sächsische Betreuungsmodell.  Dtsch Med Wochenschr. 2003;  128 1161-1166
  • 25 Starke D, Altenhofen L, Brenner G, Hagen B, Hass W, Möhr G. Qualitätssicherungsbericht 2005 – Disease-Management-Programme in Nordrhein.  , Nordrheinische Gemeinsame Einrichtung Disease-Managment-Programme GbR. Düsseldorf, September 2006; 
  • 26 StataCorp .Stata Statistical Software. Release 9.2 (2006) College Station, TX: Stata Corporation 2006
  • 27 Stojakovic TS, Scharnagl H, Glaesmer H, Pieper L, Klotsche J, Stalla GK, Lehnert H, Zeiher AM, Silber S, Koch U, Böhler S, Pittrow D, Ruf G, März W, Wittchen HU. Ziele und Design der DETECT-Studie.  Der Lipidreport. 2005;  14 4-8
  • 28 Stratton IM, Adler AI, Hawn N, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC. Holman RR on behalf of the UK Prospective Diabetes Study Group . Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35).  BMJ. 2000;  321 405-412
  • 29 Uebel T, Barlet J, Szecsenyi J, Klimm HD. Die Sinsheimer-Diabetes-Studie. Eine repräsentative Querschnittsstudie zur Versorgungsqualität von Typ 2-Diabetikern in der Hausarztpraxis.  Zeitschrift für Allgemeinmedizin. 2004;  80 497-502
  • 30 UK Prospective Diabetes Study (UKPDS) Group. . Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34).  Lancet. 1998;  352 854-864
  • 31 UK Prospective Diabetes Study (UKPDS) 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
  • 32 Wittchen HU, Glaesmer H, März W, Stalla G, Lehnert H, Zeiher AM, Silber S, Koch U, Böhler S, Pittrow D, Ruf G. for the DETECT-Study Group . Cardiovascular risk factors in primary care: methods and baseline prevalence rates – The DETECT program.  Current Medical Research and Opinion. 2005;  21 619-629
  • 33 Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group . Effect of Intensive Therapy on the Microvascular Complications of Type 1 Diabetes Mellitus.  JAMA. 2002;  287 2563-2569
  • 34 Zenker M. , Die Situation der ambulanten medizinischen Versorgung in den neuen Bundesländern, Kassenärztliche Vereinigung Thüringen, Weimar, October 2006; 
  • 35 , ZI-ADT „Anteile von erwachsenen Diabetespatienten (18 Jahre und älter) an allen Patienten und Anzahl der Praxiskontakte nach Fachgruppen”. Data source ZI-ADT Panel, 4. quarter 2003. Information provided by Zentralinstitut für die kassenärztliche Versorgung, Berlin, March 21 and March 22 2007

Correspondence

Dr. med. Dipl-Ök. E. Huppertz

Technische Universität Dresden

Institut für Klinische Psychologie und Psychotherapie

Chemnitzer Straße 46

01187 Dresden

Telefon: +49/351/463 38 58 3

eMail: eduard.huppertz@t-online.de