Evaluation of the potential clinical and economic effects of bodyweight stabilisation with acarbose in patients with type 2 diabetes mellitus. A decision-analytical approach.

Bodyweight is an acknowledged independent risk factor for coronary heart disease (CHD). The present model analysis was undertaken to investigate the clinical and economic impact of bodyweight gain in patients with type 2 (non-insulin-dependent) diabetes mellitus and its effects on the development of CHD. Based on a retrospective re-evaluation of data from the Diabetes Intervention Study (DIS), patients with type 2 diabetes mellitus and stable bodyweight (group A) had a significantly lower rate of combined CHD events (30.3%) than patients showing a bodyweight gain (group B; 38.2%) over 10 years. Prevention of bodyweight gain, therefore, appears to be a meaningful strategy in the management of diabetes mellitus. In addition to this clinical advantage, prevention of CHD will also result in economic savings associated with avoided treatment of coronary events. Based on the clinical outcomes from the DIS, the calculated per-patient net savings for a patient with type 2 diabetes mellitus and stable bodyweight amounted to 1085 deutschmarks (DM) when compared with a patient experiencing a bodyweight increase. In a further step, the above situation was projected to current type 2 diabetes mellitus practice. Oral first-line treatment of type 2 diabetes mellitus is usually initiated with glibenclamide (glyburide), which is known to increase bodyweight (reflecting group B). The novel alpha-glucosidase inhibitor acarbose, in contrast, appears to be as effective as glibenclamide, but has the advantage of being bodyweight-neutral (reflecting group A). From the clinical viewpoint, acarbose can thus be considered an alternative to glibenclamide. From the viewpoint of drug costs, monotherapy with acarbose is 4 times as expensive as glibenclamide in Germany, resulting in per-patient incremental costs of DM3527 for acarbose over 10 years. Balanced against the potential 10-year cost saving of DM1085 resulting from the potential of acarbose to prevent CHD, around one-third of the incremental cost of acarbose may be recouped by this single effect. However, further possible benefits of acarbose, including the avoidance of hypoglycaemia and the deferral of costly insulin therapy, may improve the economic value of this novel antidiabetic agent. Given the indirect approach of this evaluation and its many limitations, the above findings need critical appraisal, and comparative trials are urgently required to substantiate our preliminary results.

The effects of dementia in German acute care hospitals.

In this study a representative sample of German acute care hospitals is used to describe the effects of dementia within acute care hospitals. Data from hospital patients above age 60 with the diagnosis dementia (ICD 290, 293, 294 and 310), collected over an observation period of 12 years, are compared with nondemented hospital patients at the same ages. The differences in the average length of stay between demented and nondemented patients are only relatively small in German acute care hospitals. The degree of multimorbidity is higher and hospital infections are more frequent for demented patients. The main differences occur with mortality: demented inpatients of both sexes experience a hospital mortality which is about twice as high as for nondemented patients at the same ages.

[Long-term changes in availability of domestic nursing care based on family structure changes--a model calculation]. / Langfristige Veränderungen in der Verfügbarkeit häuslicher Unterstützungspotentiale aufgrund familiärer Strukturverschiebungen--Eine Modellrechnung.

A central hypothesis in German family sociology is the observation of a disruption of family structures. If this disintegration prevails up to highest ages it must, among others, lead to an increasing inability to perform nursing care within families. The most important person in case of a need for nursing care is the spouse. The main topic of this paper is to determine whether demographic and familiar developments in Germany will increase or decrease the share of men and women at higher ages with a living spouse within the next decades. In spite of a slowly increasing share of the never-married and the divorced, on the average elderly men and women will be married to a greater and widowed to a much lesser proportion within the next decade. The Dutch LIPRO-model is used to calculate the exact numerical developments. The surprising result is primarily due to the fact that the actual high shares of the widowed are a consequence of distortions caused by the two World Wars. During the next few decades, these unusual developments will disappear even among the most elderly.

[Future population growth in the Augsburg area--model calculations using the DEPOP model]. / Die zukünftige Bevölkerungsentwicklung im Raum Augsburg--Modellrechnungen mit dem DEPOP-Modell.

Regional population forecasts are on average even more uncertain than nationwide projections, due to the greater importance of migration and the unstable smaller absolute numbers. Other than national projections, local or regional calculations do normally have an explicit goal. In this paper, a projection of the population and age structure in the region of Augsburg is used to demonstrate some specific aspects of local population projections used for public health purposes. If institutions of childhood ages are to be projected the results are primarily determined by the assumptions on migration. If questions of old age are to be answered, the main factor of influence is the development in mortality. Depending on the specific alm of a local population projection, the principal insecurity about the future should be integrated by calculating confidence bands for those demographic parameters, that are most important for the specific question.

[Regional differences of results of disability assessment for domestic health care needs in 1995 and possible explanations]. / Regionale Unterschiede in den Begutachtungsergebnissen des häuslichen Pflegebedarfs im Jahr 1995 und deren mögliche Erklärungen.

In 1995 a statutory nursing care insurance was set up in Germany. The MDK (Medical Service of Health Care Insurance Institutions) has been asked to evaluate the eligibility of the individual patients. Within a few months after this body began its work, strong regional differences in incidence became visible. A survey of 1995 MDK records from Bavarian counties was selected to determine whether and how sociodemographic or socioeconomic variables may explain these differences. An age incidence rate of nursing care, standardised according to age and sex, was correlated with a variety of explanatory factors. Only two variables in the multiple regression model were statistically significant: the refusal rate by local MDK officials and the regional supply of outpatient care facilities. Further work is needed to improve the process of evaluation and to minimise unexplained regional differences.

The fertility of migrants before and after crossing the border: the ethnic German population from the former Soviet Union as a case study.

PIP: This study measures whether and how change in residence affected the fertility of women who spent part of their reproductive life span in the former Soviet Union and another part of their life in Germany. The sample includes women who were younger than 41 years of age at the time of the border crossing. The study includes age of the migrant and period of residence abroad. Data were obtained for 1985, 1989, 1990, and 1991 from studies conducted by the German Government on the integration of ethnic Germans from the republics of the former Soviet Union. The pooled sample includes 2026 women. Fertility is determined before and after border crossings. Findings indicate that the relative fertility level of women before migrating to Germany was over 50% higher than fertility in Germany. The relative fertility level in the early period after migration was only about 40% of the German fertility rates at the same age periods. The findings are not necessarily representative for all migrant groups or for all religious minorities. It is suggested that the immediate adaptation to highly competitive West German conditions of living might have caused the decline in fertility among migrants.^ieng

[Demographic aging in the old and new German states]. / Demographische Alterung in den alten und neuen Landern Deutschlands.

PIP: "One of the social phenomena receiving most attention worldwide is the one of ¿demographic aging'. The term describes a relative change in the age structure of a population, which cannot be explained by natural criteria alone. The thesis that a population is aging or getting younger is dependent on a measurement concept for demographic aging. This essay will introduce the Billeter-measure as such a concept. With its help, an analysis of regional difference between the old and new German states (Lander) is undertaken." (EXCERPT)^ieng

[A new model for economic studies of therapies exemplified by postoperative parenteral nutrition]. / Ein neues Modell zur Wirtschaftlichkeitsuntersuchung von Therapien am Beispiel der postoperativen parenteralen Ernährung.

In this economic evaluation we compared the costs of a new therapeutic system (two-chamber bag) in total parenteral nutrition (TPN) with the comparative standard therapeutic systems (multiple-bottle system in intensive care patients followed by a combination solution (glass bottles) on the ward). In the model, standard treatment algorithms of a 10-day course TPN for patients after major gastric surgery were specified for both application systems, the two-chamber bag and the comparative system. Based on the standard treatment pattern, the resource utilisation (manpower services, medical needs, material) was assessed. In a base case analysis the types and amounts of resources were valued using salaries, prices and tariffs to assess the costs. The costs per day and per case of the therapeutic systems were compared. Sensitivity analyses were carried out to validate the cost-estimates. The total costs per patient of the two-chamber bag amounted to DM 2324.41, which was substantially less than the DM 2728.99 cost of the comparative system. The average daily costs for the two-chamber bag system were 12% to 23% lower than for the comparative system. The results were shown to be valid for the whole range of tested parameters. This model makes it possible to obtain an economic evaluation of various therapeutic modalities without undertaking a prospective randomized study with the attendant high time and cost requirements.

[Development of dementia to the year 2050. Model calculations for Germany with special reference to future mortality progress]. / Die Entwicklung der Demenz bis zum Jahr 2050. Modellrechnungen für die Bundesrepublik Deutschland unter besonderer Berücksichtigung von zukünftigem Mortalitätsfortschritt.

On the basis of existing age structures of the demented, a demographic-epidemiological model (DEPOP) is used to project the number of demented to the year 2050 in Germany. In particular a future progress in survivorship of the oldest is assumed in the simulation run in continuation of the already visible path of demographic aging. Taking future mortality reductions into calculation the total number of the demented population will increase at least threefold. Together with the stagnation or decline of the total population, this signifies a considerable increase in the relative importance dementia results.

Life expectancy in Germany: possible reasons for the increasing gap between East and West Germany.

The current life expectancy of East and West Germans is different. After the late 1980s, life expectancy at birth in both regions, which was comparable in the early 1950s, became almost three years lower in East Germany. Life-table calculations of German birth cohorts since 1900 revealed that a difference between the groups in cardiovascular disease prevalence was associated with the difference in life expectancy. Whereas migration, environmental pollution, and health-care differences accounted for only a small part of the gap, evidence emerged that lifestyle and social patterns may have caused the less favourable trend in cardiovascular disease. The life-expectancy curve has flattened in East Germany while continuously increasing in West Germany. During the 1960s and 1970s, such opposite trends were due to steeply increasing blood-pressure and cholesterol levels in East Germany and more favourable social development in West Germany--a better average social class (higher educational levels and a lower proportion of working-class individuals), a higher gross national product, and a higher proportion of GNP spent on health. Both the cardiovascular-risk-factor trends and the social gradient have contributed to the gap between the populations of East and West Germany in life expectancy.

A survey of nosocomial infections and their influence on hospital mortality rates.

Nosocomial infections play an important role in contributing to hospital mortality. In order to obtain a large sample a survey was conducted between 1978 and 1989 of more than 66,000 patients in German acute care hospitals. The data were used to assess the influence of nosocomial infections on mortality rates. Hospital infections were more frequent in female patients, but mortality with or without nosocomial infection was higher in male patients. Nosocomial infections increased hospital mortality threefold when raw numbers were used. Controlling for age and sex, the existence of at least one nosocomial infection (diagnosed at the second or a later day of hospital stay) increased hospital mortality by a factor of two. The influence of nosocomial infections was shown to be small for some diseases, such as malignancy, but was greater for others such as metabolic and immunological diseases or trauma. In the case of trauma, nosocomial infections increased hospital mortality rates by a factor of three even after controlling for age.

[Hospital infections and their consequences in patients of advanced age]. / Krankenhausinfektionen und deren Konsequenzen bei Patienten im höheren Lebensalter.

On the basis of a representative survey of more than 66,000 patients in German acute hospitals from 1978 to 1989 the incidence and consequences of nosocomial infections on length of hospital stay and mortality for patients above age 60 are discussed. Infection rates are higher for female patients and increase with age for both sexes. Surprisingly the length of stay differences due to nosocomial infections are smaller in absolute and relative terms for older patients. The consequences on mortality, however, strongly concentrate on older patients. Using realistic assumptions on incidence and mortality and on possible degrees of infection the number of "preventable deaths" due to nosocomial infections are calculated. For 1990 the results sum up to more than 6000 deaths at ages above 60 alone for the Federal Republic of Germany within its former borders.

[Mortality in relation to type of insurance--an empirical study with representative German data 1974 to 1990]. / Die Sterblichkeit nach Krankenkassenzugehörigkeit--Eine empirische Untersuchung mit repräsentativ bundesdeutschen Daten von 1974 bis 1990.

In Germany different forms of insurance funds (private funds, social security for blue collar or for white collar workers, firm-specific funds) secure against sickness risks. Actual governmental policy is to increase the competition between funds by introducing the possibility to switch from one to the other. In order to compensate for the differences in risk of health status between individual members a compensation payment planned according to age and sex of the members. In 1974 a representative sample of the adult West German population has been asked about its sickness fund membership (among other questions). A new epidemiological concept, the demographic variant of the relative survival method, is used here to determine whether mortality in the 16 years after 1974 differed between the sickness fund members. Even after exact demographic control members of private sickness funds survived considerably better than members of other insurance funds. The highest mortality was found for members of the social security of blue collar workers (AOK). These results show that apart from the pure demographic factors other important health related differences exist between members of different sickness funds.

[Suicide mortality by age groups in both parts of Germany]. / Die Suizidsterblichkeit der Geburtsjahrgänge in beiden Teilen Deutschlands.

In the past a long-term comparison of suicides between the two German states has been prevented by the lack of published data on suicide mortality in the former GDR. These data are available now, showing a surprising similarity in the developments. The level of suicide mortality has been higher in the GDR from the beginning, but both countries experienced very similar reductions in the absolute und relative importance of suicide for overall mortality since the mid 1970's. A cohort analysis of suicide mortality is able to contribute to the explanation of the gap in suicide mortality between East and West Germany. The excess suicide mortality in East Germany is the result of a cohort effect and heavily concentrates on male and female birth cohorts from 1925 to 1945. For these cohorts the excess mortality due to suicide explains up to 25 percent of the total excess mortality compared with the same West German birth cohorts.

[External migration and population trends in Germany]. / AuSSenwanderungen und Bevolkerungsentwicklung in Deutschland.

PIP: "Since 1945 immigration has become the most important demographic parameter [affecting population trends in Germany]. The relevance of migration for the population development of Germany...is not only pointed out by the annual migration balance sheet, but even more by the age structure and the gender composition of the migrants. Since immigrants are usually rather young, this group possesses a particular demographic dynamic which influences the population development considerably." The authors suggest that not only the number of migrants but also their age structure be taken into account by people who create social policy and do regional planning or other activities with a demographic component. (EXCERPT)^ieng

[Mortality trends of birth cohorts in both German states: results and possible explanations]. / Die Sterblichkeitsentwicklung der Geburtsjahrgange in den beiden deutschen Staaten: Ergebnisse und mogliche Erklarungshypothesen.

PIP: Life tables for cohorts born after 1900 are used to compare mortality trends in East and West Germany. An attempt is made to explain the observed differences by examining factors such as medical care, environmental pollution, behavioral and dietary patterns, and migration.^ieng

[The long-term development of labor force potential using alternative assumptions of (net) migration to Germany]. / Die langfristige Entwicklung des Erwerbspersonenpotentials bei alternativen Annahmen uber die (Netto)Zuwanderung nach Deutschland.

"Using model calculations to the year 2050, this paper shows the decisive role that assumptions on future (net) migration to Germany will play in the long-term development of the labor force potential. The particular focus of this paper is to point out the importance of (net) migration not only in terms of absolute figures, but more importantly in terms of the age and gender structure. The annual net migration of 500,000 or 250,000 persons leads, depending on the assumption of its age structure, to extreme differences in the long-term development of the labor force potential." (SUMMARY IN ENG AND FRE AND RUS)

Male and female fertility: a comparison of age-specific and cohort fertility of both sexes in Germany.

PIP: Data from German sample surveys was used to compare male and female fertility by birth cohort from 1902-04 to 1959-61. The results indicated that prior to 1930 male fertility was higher, and there was a wide range between male and female fertility. The gap narrowed over time among males aged over 40 years, whose mortality declined markedly over time. There were differences in male and female completed fertility for all age cohorts. The war years had an effect on the sex ratio, and the result was a reduced number of births. The marriage market when there was a surplus of male partners yielded a smaller share of childless women and a larger number of births. Factors affecting reproductive potential were the age difference between spouses, the length of the reproductive life span, the sex ratio, male migration, cohort size, and female survivorship. Male and female models can never separately adequately explain true population development. Cohort estimates showed female fertility peaks for cohorts 1950-52 at 15-19 years, 1944-46 at 20-24 years, 1932-40 at 25-29 years, and 1932-34 at 30-34 years. Between 1965 and 1970 there was a baby boom. Completed fertility for cohorts declined from the early 1900s. Male fertility for all cohorts showed smaller rates for men aged under 25 years and larger rates above age 30 years compared to women. Age specific fertility rates for men for all cohorts fluctuated like female rates. Before 1928, men had more children. The decline in male fertility rates at ages 35-39 years ended at cohorts 1938-40. A declining trend in male cohort fertility was evident for all periods for men aged over 40 years. The 1902-04 cohort for men aged over 40 years was about five times as high as female fertility. By the 1929 cohort male and female fertility differences were minimal. Even when the sex ratio was in equilibrium cohort fertility of males and females may be different because not all people reproduce. The share of childlessness within cohorts depends on the scarcity of one sex, such as was evidenced in the shortage of males after 1945.^ieng

[Does obesity increase mortality? An empirical evaluation of German hospital data]. / Führt Ubergewicht zu einer erhöhten Sterblichkeit? Eine empirische Uberprüfung mit deutschen Krankenhausdaten.

The vast majority of investigations on the relationship between BMI (body mass index) and mortality results in a U-shaped relationship. Using a randomly selected number of more than 32,000 patients of German acute hospitals the U-shaped relationship is confirmed for mortality from cardiovascular diseases. BMI and mortality are not related over wide ranges of BMI for mortality from all causes. Only at the very extremes (heavy overweight and underweight) the number of deaths per number of patients in a certain BMI-class are increased.