[Cooperation, Job Satisfaction and Burn Out - Sustainability in Outpatient Mental Health Care among Medical Specialists in Germany]. / Kooperation, Berufliche Zufriedenheit und Burnout ­ Nachhaltigkeit in der psychiatrisch-neurologischen Versorgung am Beispiel niedergelassener Fachärzte in Deutschland.

Objective Cooperation, job satisfaction, and burn out risk are indicators of sustainability in mental health services. Thus they were assessed among registered medical specialists in outpatient mental health care in Germany. Method A postal survey consisting of three questionnaires about cooperation, job satisfaction, and burnout was carried out among all registered medical specialists in outpatient mental health care in Germany (n = 4,430). Results 14.1 % (n = 626) of the specialists responded to the survey. Quality and quantity of cooperation regarding mental health care services were rated diverse, job satisfaction was assessed medium to high, and burnout risk was low to medium. Higher job satisfaction correlated with good quality of cooperation, fewer years of practice, fewer patients' chronically ill, more patients who as well seek psychotherapy, and less time spent on cooperation. Low burn out risk correlated with good quality of cooperation, higher age, single practice setting and a higher amount of patients who as well seek psychotherapy. Conclusion Quality and quantity of cooperation in outpatient mental health care - especially regarding community mental health care institutions - should be fostered. Aspects to be considered to reinforce job satisfaction and minimize burn out risk are age, years of practice, quality and quantity of cooperation, practice setting, and the mixture of patients.

Job Maintenance through Supported Employment PLUS: A Randomized Controlled Trial.

Sickness absence from work due to experienced distress and mental health issues has continuously increased over the past years in Germany. To investigate how this alarming development can be counteracted, we conducted a randomized controlled trial evaluating a job coaching intervention to maintain the working capacity of members of staff and ultimately prevent sickness absence. Our sample included N = 99 employees who reported mental distress due to work-related problems. The intervention group (n = 58) received between 8 and 12 individual job coaching sessions in which they worked with a professional job coach to reduce their mental distress. The control group (n = 41) received a brochure about mental distress. Data were collected before the start of the study, at the end of the job coaching intervention, and at a 3-month follow-up. These data included the number of sickness absence days as the primary outcome and questionnaire measures to assess burnout indicators, life satisfaction, and work-related experiences and behaviors. Compared with the control group, the results indicated no reduction in sickness absence in the intervention group but fewer depressive symptoms, a heightened ability of the participants to distance themselves from work, more experience of work-related success, less depletion of emotional resources, and a greater satisfaction with life when participants had received the job coaching. Thus, although we could not detect a reduction in sickness absence between the groups, job coaching was shown to be a viable intervention technique to benefit employees by contributing to re-establish their mental health. We discuss the implications of the study and outline future research.

Hospital utilization outcome of an assertive outreach model for schizophrenic patients - results of a quasi-experimental study.

We assessed whether an Assertive Outreach (AO) program for patients with schizophrenia implemented in German routine care in rural areas reduces psychiatric hospital admissions and/or psychiatric hospital days. We conducted a quasi-experimental controlled study with 5 assessments in 12 months. Data collection included health care utilization (Client Sociodemographic and Service Receipt Inventory), and clinical parameters. The assessments took place in the practices of the psychiatrists. Admission incidence rates were calculated. For bivariate group comparison, we used U-tests, T-tests and Chi(2)-Tests, multivariate analysis was conducted using zero-inflated regression models. For hospital outcomes, data of 295 patients was analysed. No statistically significant differences between AO and TAU patients in terms of hospital admissions or hospital days were found. Overall hospital utilization was low (8%). Advantages of AO over TAU referring to hospital utilization were not found. However, a spill-over effect might have reduced hospital utilization in both groups. Further research should differentiate patient subgroups. These two appear to be key factors to explain effects or absence of effects and to draw conclusions for the mental health care delivery.

Using Smartphones to Monitor Bipolar Disorder Symptoms: A Pilot Study.

BACKGROUND: Relapse prevention in bipolar disorder can be improved by monitoring symptoms in patients' daily life. Smartphone apps are easy-to-use, low-cost tools that can be used to assess this information. To date, few studies have examined the usefulness of smartphone data for monitoring symptoms in bipolar disorder. OBJECTIVE: We present results from a pilot test of a smartphone-based monitoring system, Social Information Monitoring for Patients with Bipolar Affective Disorder (SIMBA), that tracked daily mood, physical activity, and social communication in 13 patients. The objective of this study was to investigate whether smartphone measurements predicted clinical symptoms levels and clinical symptom change. The hypotheses that smartphone measurements are (1) negatively related to clinical depressive symptoms and (2) positively related to clinical manic symptoms were tested. METHODS: Clinical rating scales were administered to assess clinical depressive and manic symptoms. Patients used a smartphone with the monitoring app for up to 12 months. Random-coefficient multilevel models were computed to analyze the relationship between smartphone data and externally rated manic and depressive symptoms. Overall clinical symptom levels and clinical symptom changes were predicted by separating between-patient and within-patient effects. Using established clinical thresholds from the literature, marginal effect plots displayed clinical relevance of smartphone data. RESULTS: Overall symptom levels and change in clinical symptoms were related to smartphone measures. Higher overall levels of clinical depressive symptoms were predicted by lower self-reported mood measured by the smartphone (beta=-.56, P<.001). An increase in clinical depressive symptoms was predicted by a decline in social communication (ie, outgoing text messages: beta=-.28, P<.001) and a decline in physical activity as measured by the smartphone (ie, cell tower movements: beta=-.11, P=.03). Higher overall levels of clinical manic symptoms were predicted by lower physical activity on the smartphone (ie, distance travelled: beta=-.37, P<.001), and higher social communication (beta=.48, P=.03). An increase in clinical manic symptoms was predicted by a decrease in physical activity on the smartphone (beta=-.17, P<.001). CONCLUSIONS: Clinical symptoms were related to some objective and subjective smartphone measurements, but not all smartphone measures predicted the occurrence of bipolar symptoms above clinical thresholds. Thus, smartphones have the potential to monitor bipolar disorder symptoms in patients' daily life. Further validation of monitoring tools in a larger sample is needed. Conclusions are limited by the low prevalence of manic and depressive symptoms in the study sample. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 05663421; http://www.controlled-trials.com/ISRCTN05663421 (Archived by WebCite at http://www.webcitation.org/6d9wsibJB).

Age- and gender-specific mortality risk profiles for depressive outpatients with major chronic medical diseases.

BACKGROUND: As leading causes of death, chronic medical diseases, particularly common cardiovascular diseases, are associated with depression. The combination of depression and chronic medical disease in turn is linked with poorer health and premature death. Despite numerous studies on mortality in people with depression and chronic medical disease, the effects of age and gender were not consistently considered. To appropriately estimate mortality in the clinical setting, we aimed to analyse age- and gender-specific mortality profiles in outpatients with depression and chronic medical disease by considering depression severity. METHODS: We examined data from N=327,018 outpatients with depression aged 18 years and older (mean=60 years), which we obtained from German electronic health-insurance claims data covering the years 2007-2010. We considered major chronic medical disease groups: cardiovascular diseases, diabetes, diseases of the respiratory system and cancer. To analyse both adjusted mortality risk and rates over one year in a comprehensive manner, we calculated General Estimation Equation (GEE) Poisson models for binary data. RESULTS: The mortality risk increased with age and was higher for males. Especially patients below 60 years of age with cancer or diabetes had an increased mortality risk, but not patients with cardiovascular disease. Mortality was comparably increased in patients with severe depression, diabetes or respiratory disease. LIMITATIONS: We did not have data from a control group without depression. CONCLUSIONS: Notably, not cardiovascular diseases but cancer and, to a lesser extent, diabetes, both in younger patients, respiratory diseases and severity of depression require particular attention in outpatient care to reduce mortality.

Job Maintenance by Supported Employment: An Overview of the "Supported Employment Plus" Trial.

The number of days of absence from work associated with mental illness has risen dramatically in the past 10 years in Germany. Companies are challenged by this issue and seek help for the physical and mental health of their employees. Supported Employment concepts such as the Individual Placement and Support (IPS) model have been designed to bring jobless persons with mental disorders back to work. In the randomized, controlled SEplus trial, a modified IPS-approach is tested concerning its ability to shorten times of sick leave of persons with mental distress or a mental disorder and to prevent them from losing their job. The trial is outlined in this study protocol.

Aspects of Sustainability: Cooperation, Job Satisfaction, and Burnout among Swiss Psychiatrists.

PURPOSE: Greater sustainability in mental health services is frequently demanded but seldom analyzed. Levels of cooperation, job satisfaction, and burnout are indicators of social sustainability in this field and are of particular importance to medical staff. Because registered psychiatrists play a central role, we assessed the status quo and interactions between these three factors among registered psychiatrists in Switzerland. METHOD: A postal survey with three standardized questionnaires about cooperation, job satisfaction, and burnout was conducted among all registered psychiatrists in the German-speaking part of Switzerland (n = 1485). Addresses were provided by the Swiss Medical Association. RESULTS: Response rate was 23.7% (n = 352), yielding a largely male sample (62.8%; n = 218) aged 55.5 ± 8.7 years old. Quantity (47 ± 56.2 contacts over 3 months) and duration (91.1 ± 101.6 min per week) of cooperation was found to be diverse depending on the stakeholder. Quality of cooperation was greatest in general practitioners (81.5%) while it was worst in community mental health providers (54.9%). Overall job satisfaction was assessed rather high (3.7 ± 0.8), and burnout rates were below crucial values (Emotional Exhaustion, 2.9 ± 0.8; Depersonalization, 1.9 ± 0.5). Both were positively influenced by cooperation. The strongest correlation was found between job satisfaction and burnout, and both had significant inverse relationships in all dimensions. CONCLUSION: To foster sustainability in outpatient mental health care regarding cooperation, job satisfaction, and burnout, personal aspects such and age or years of registration, organizational aspects, such as networking and practice setting, as wells as supportive aspects such as psychotherapy, and self-help groups, must be considered. Quality of cooperation should be reinforced in particular. Because Integrated and Managed Care models cover several of these factors, the models should be more strongly embedded in health care systems.

Differences in EQ-5D-3L health state valuations among patients with musculoskeletal diseases, health care professionals and healthy volunteers.

BACKGROUND: Results from existing studies indicate that different respondent groups' health state valuations in cost-utility analyses are not equivalent. OBJECTIVES: The objectives in our study were to analyse differences in health state valuations among three respondent groups in the context of medical rehabilitation in Germany. METHODS: Using the time trade-off (TTO) technique, valuations of EQ-5D-3L health states were obtained from patients with musculoskeletal diseases, healthy volunteers and health care professionals. We used linear mixed models to predict TTO utilities and specified and tested interaction effects. RESULTS: We identified statistically significant (p < 0.05) differences among the three groups in six out of 42 health states. On average, patients' TTO values were somewhat higher compared with other respondent groups. Most of these differences occurred in severe health states. Mean differences and mean absolute differences were 0.02 and 0.14 for patients vs healthy volunteers and 0.06 and 0.14 for patients vs health care professionals. Furthermore, significant effects among respondents were observed for seven of the 22 possible interactions describing differences between respondent groups. Coefficients associated with significant interaction effects ranged from 0.08 to 0.18 (absolute values). CONCLUSION: The results of our study suggest that TTO valuations of health states differ depending on the specific respondent group from which valuations are obtained. On average, these differences were small. However, researchers and decision makers should remain aware of these differences when interpreting incremental cost-utility assessments.

Hell is other people? Gender and interactions with strangers in the workplace influence a person's risk of depression.

We suggest that interactions with strangers at work influence the likelihood of depressive disorders, as they serve as an environmental stressor, which are a necessary condition for the onset of depression according to diathesis-stress models of depression. We examined a large dataset (N = 76,563 in K = 196 occupations) from the German pension insurance program and the Occupational Information Network dataset on occupational characteristics. We used a multilevel framework with individuals and occupations as levels of analysis. We found that occupational environments influence employees' risks of depression. In line with the quotation that 'hell is other people' frequent conflictual contacts were related to greater likelihoods of depression in both males and females (OR = 1.14, p<.05). However, interactions with the public were related to greater likelihoods of depression for males but lower likelihoods of depression for females (ORintercation = 1.21, p<.01). We theorize that some occupations may involve interpersonal experiences with negative emotional tones that make functional coping difficult and increase the risk of depression. In other occupations, these experiences have neutral tones and allow for functional coping strategies. Functional strategies are more often found in women than in men.

Support from the Internet for Individuals with Mental Disorders: Advantages and Disadvantages of e-Mental Health Service Delivery.

Mental disorders are common in almost all industrialized countries and many emerging economies. While several trials have shown that effective treatments exist for mental disorders, such as pharmacotherapy, psychological interventions, and self-help programs, the treatment gap in mental health care remains pervasive. Unrestricted access to adequate medical care for people with mental disorders will be one of the pressing public mental health tasks in the near future. In addition, scarcity of financial resources across the public mental health sector is a powerful argument for investigating innovative alternatives of delivering mental health care. Thus, one challenge that arises in modern mental health care is the development of innovative treatment concepts. One possibility for improving mental health care services is to deliver them via the Internet. Online-based mental health services have the potential to address the unmet need for mental health care.

Antidepressants: relationship to the time to psychiatric readmission and probability of being in hospital in depressive patients.

INTRODUCTION: Although antidepressants play a major role in the treatment of patients with depression, it is unclear which specific antidepressants are more efficacious than others. This study aims to analyze the relationship between several antidepressant substances and the time to readmission as well as the probability of being in hospital in a given week by using prescription data. METHODS: The database was health-insurance claim data from the new Federal States in Germany. The analysis consisted of all patients with unipolar depression at their index admission in 2007 (N = 1803). Patients were followed up for 2 years after discharge from index hospitalization. Statistical analyses were conducted by discrete-time hazards models and general estimation equation models, accounting for various predictors. RESULTS: Of all prescribed antidepressant substances, sertraline was related to an increased time to readmission by 37% and to a reduction in the probability of being in hospital in a given week by 40%. However, it was prescribed to only about 5% of the patients. CONCLUSION: In this study, only sertraline appeared to have clinical and economic advantages. It is remarkable that just a minority of patients received sertraline in our study, thus differing from the prescription pattern in the US.

[Aspects of sustainability in outpatient health care for demented individuals]. / Aspekte der Nachhaltigkeit in der ambulanten Versorgung von Menschen mit Demenz.

OBJECTIVES: The aim of the study was to analyze outpatient health care for demented individuals concerning the sustainability indicators coordination, cooperation and networking as well as finding solutions for present problems in those fields. METHODS: A systematic literature research in several relevant databases and telephone interviews with experts concerning outpatient care for demented individuals were conducted. The interviews were content analyzed. RESULTS: Deficits range from problems with financial compensation, difficulties on the interface of provided measures and lack of resources to individual factors as lack of knowledge, interest and willingness for intense coordination, cooperation and networking. CONCLUSION: Active promotion of patient centered, community and trans-sectoral health care as proposed in integrated care models seem to foster sustainability of outpatient health care for demented individuals.

Cost of illness for bipolar disorder: a systematic review of the economic burden.

OBJECTIVES: Recent reviews lack important information on the high cost-of-illness worldwide for bipolar disorder (BD). Therefore, the present study systematically analyzed those costs, their driving components, and the methodological quality with which the few existing cost-of-illness investigations have been performed. METHODS: In June 2012, we conducted a systematic literature review of electronic databases to identify relevant cost-of-illness studies published since 2000. Their methodological quality was assessed. Costs were standardized by first extrapolating them to 2009 using country-specific gross domestic product inflators and then converting them into US dollars via purchasing power parities (PPP). RESULTS: The main characteristics of 22 studies were evaluated. Ignoring outliers, costs per capita ranged from 8,000 to 14,000 US$-PPP for overall direct healthcare, from 4,000 to 5,000 US$-PPP for direct mental healthcare, and from 2,500 to 5,000 US$-PPP for direct BD-related care. Indirect costs ranged from 2,000 to 11,000 US$-PPP. Inpatient care was the main cost driver in three studies; drug costs, in two studies. Methodological quality was deemed satisfactory. CONCLUSIONS: The cost variance was great between studies. This was likely due to differences in methodology rather than healthcare systems, thereby making such comparisons difficult. The results showed that BD has a substantial economic burden on society. To gain more evidence, international standardized checklists are needed when undertaking cost-of-illness studies.

Effectiveness and efficiency of assertive outreach for Schizophrenia in Germany: study protocol on a pragmatic quasi-experimental controlled trial.

BACKGROUND: A model of assertive outreach (AO) in which office-based psychiatrists collaborate with ambulatory nursing services for providing intensive home-treatment is currently being implemented in rural areas of Lower Saxony, Germany. The costs of the model are reimbursed by some of the statutory health insurance companies active in Lower Saxony. Effectiveness and efficiency of this model for patients suffering from schizophrenia is evaluated in a pragmatic and prospective trial. METHODS: Quasi-experimental controlled trial: patients receiving the intervention are all those receiving AO; controls are patients not eligible for AO based on their health insurance affiliation. ELIGIBILITY CRITERIA: clinical diagnosis of schizophrenia (ICD-10 F.20), aged at least 18 years and being moderately to severely impaired in global functioning. PRIMARY OUTCOME: admission and days spent in psychiatric inpatient care; secondary outcomes: clinical and functional status; patient satisfaction with chronic care; health care costs. Follow-up time: 6 and 12 months. DISCUSSION: The study faces many challenges typical to pragmatic trials such as the rejection of randomisation by service providers, the quality of treatment as usual (TAU) to which the intervention will be compared, and the impairment of the study subjects. Solutions of how to deal with these challenges are presented and discussed in detail. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: http://ISRCTN34900108, German Clinical Trial Register: http://DRKS00003351.

[A literature- and expert-based analysis of the outpatient treatment of depressive ill people in Germany]. / Eine literatur- und expertengestützte Analyse der Versorgungspraxis von depressiv erkrankten Menschen in Deutschland.

OBJECTIVE: This study analyses deficits in outpatient care for depressed persons in Germany and seeks to identify possibilities for improvement. METHOD: Literature search and expert interviews. RESULTS: The outpatient depression care does not consider guidelines. A numerous possibilities to optimise outpatient treatment of depressive ill people were identified. CONCLUSIONS: Incentives should be systematically set to encourage services that are specific for treating chronic disorders. Systematic incentive for the improvement of the outpatient depression care should be given for example in particular for the achievements, which are important for the care of chronic disorders.

The cost of depression - a cost analysis from a large database.

BACKGROUND: Depression poses a serious economic problem. We performed a cost-of-illness study using data from a German health insurance company to determine which costs are unique to that disease. METHODS: The analysis included every adult and continuously insured person. Using claims data from 2007 to 2009, we calculated the costs incurred by persons with depression, including services provided for inpatient and outpatient care, drugs and psychiatric outpatient clinics. Subgroup analyses were done using demographic and disease-specific variables. Longitudinal predictors of depression-related costs were obtained through a generalized estimating equations (GEE) analysis. RESULTS: This investigation involved 117,220 persons. Mean annual depression-specific costs per person were €458.9, with those costs decreasing over the study period. The main cost component (43.9% of the total) was inpatient care. It was found that persons with a severe course of disease and unemployed persons are more costly than other persons. The GEE analysis revealed that gender, age, residency within an urban area, occupational status and the type of diagnosis had a significant impact on these costs. LIMITATIONS: Due to data constraints, we were unable to include all cost categories that might be related to depression and we had no control group of persons without depression. CONCLUSIONS: Due to the influence of the severity of the disease on costs, effective treatment strategies are important in order to prevent a progression of the disease and an increase in costs.

Self-perceived quality of life predicts mortality risk better than a multi-biomarker panel, but the combination of both does best.

BACKGROUND: Associations between measures of subjective health and mortality risk have previously been shown. We assessed the impact and comparative predictive performance of a multi-biomarker panel on this association. METHODS: Data from 4,261 individuals aged 20-79 years recruited for the population-based Study of Health in Pomerania was used. During an average 9.7 year follow-up, 456 deaths (10.7%) occurred. Subjective health was assessed by SF-12 derived physical (PCS-12) and mental component summaries (MCS-12), and a single-item self-rated health (SRH) question. We implemented Cox proportional-hazards regression models to investigate the association of subjective health with mortality and to assess the impact of a combination of 10 biomarkers on this association. Variable selection procedures were used to identify a parsimonious set of subjective health measures and biomarkers, whose predictive ability was compared using receiver operating characteristic (ROC) curves, C-statistics, and reclassification methods. RESULTS: In age- and gender-adjusted Cox models, poor SRH (hazard ratio (HR), 2.07; 95% CI, 1.34-3.20) and low PCS-12 scores (lowest vs. highest quartile: HR, 1.75; 95% CI, 1.31-2.33) were significantly associated with increased risk of all-cause mortality; an association independent of various covariates and biomarkers. Furthermore, selected subjective health measures yielded a significantly higher C-statistic (0.883) compared to the selected biomarker panel (0.872), whereas a combined assessment showed the highest C-statistic (0.887) with a highly significant integrated discrimination improvement of 1.5% (p < 0.01). CONCLUSION: Adding biomarker information did not affect the association of subjective health measures with mortality, but significantly improved risk stratification. Thus, a combined assessment of self-reported subjective health and measured biomarkers may be useful to identify high-risk individuals for intensified monitoring.

The benefit of long-term growth hormone (GH) replacement therapy in hypopituitary adults with GH deficiency: results of the German KIMS database.

OBJECTIVE: To evaluate the treatment effects of long-term growth hormone (GH) replacement therapy in adults with GH deficiency (GHD) who were followed in KIMS Germany (Pfizer International Metabolic Database), a national surveillance study. DESIGN: The analysis was performed using baseline and long-term data (range: 4-10 years) of 440 consecutively documented patients (216 women and 224 men) with GHD, aged 20 to 49 years, enrolled in KIMS Germany. Serum insulin-like growth factor I (IGF-I), fasting blood glucose, fasting serum total cholesterol and low-density lipoprotein cholesterol (LDL-C) as well as body mass index (BMI), waist circumference (WC) and hip circumference (HC) at baseline and at last visit were studied. Furthermore, QoL-AGHDA score was determined to assess quality-of-life (QoL). RESULTS: The mean dose of GH over all years was 0.41 mg per day in women and 0.37 mg per day in men. IGF-I and IGF-I SDS levels (standard deviation score) increased significantly (p<0.001) during GH treatment. The QoL-AGHDA score decreased significantly (p<0.001), indicating long-lasting improvement in QoL. In total cholesterol, LDL-C and fasting blood glucose, no significant changes were found. Only six patients developed type 2 diabetes during follow-up. Females and males similarly increased significantly in BMI, WC and HC. During GH treatment, recurrences of pituitary or central nervous system tumours or further de novo neoplasia were reported in 6 or 11 patients, respectively. The number of the most frequently reported GH treatment-associated adverse events was low. CONCLUSION: These observational data show long-term beneficial effects of GH replacement therapy on QoL and show no significant effects on total cholesterol, LDL-C or BMI, WC and HC. Additionally, our data indicate that GH replacement therapy in adults is well tolerated.

[Costs of diabetes care and treatment satisfaction in type 2 diabetes patients treated with a basal-bolus (ICT) insulin regimen in outpatient care: results of the LIVE-COM study]. / Diabetesbezogene Kosten und Therapiezufriedenheit bei ICT-behandelten Typ-2-Diabetikern in der ambulanten Versorgung: Ergebnisse der LIVE-COM-Studie.

BACKGROUND AND PURPOSE: Costs for diabetes treatment burden statutory health care systems. Aim of the LIVE-COM study (Long Acting Insulin Glargine versus Insulin Detemir Cost Evaluation Comparison) was to assess resource utilization and costs of diabetes care as well as patient reported outcomes in a random sample of type 2 diabetes patients treated with either insulin glargine (GLA) or detemir (DET) as part of a basal-bolus regimen in a primary care setting. PATIENTS AND METHODS: LIVE-COM is a non-interventional, cross-sectional study performed between April and September 2008 in 138 randomly selected centers of primary care physicians in Germany. From 1731 type 2 diabetes patients (GLA: n = 1150; DET: n = 581) with statutory health insurance status and pretreatment with either GLA or DET for at least 6 months as part of a basal-bolus therapy, total direct costs of diabetes care (for insulins, oral antidiabetic drugs, test strips, needles, lancets, Hypokits®) were calculated from total recorded expenditures, for a period of six months, from the perspective of statutory health insurance. Patient-reported outcomes were assessed using validated questionnaires (SF-12, DTSQs, ITEQ). RESULTS: Mean total costs per patient over six months were lower with GLA based therapy compared with DET based therapy (972 euro ± 374 euro vs. 1135 euro ± 477 euro, p < 0.001). Adjusted by ANCOVA: 932 euro (95% CI: 905, 957 euro) vs. 1.061 euro (95% CI: 1025, 1099 euro, p < 0.001). The adjusted mean single costs for basal insulin (223 euro vs. 246 euro), bolus insulin (241 euro vs. 289 euro), test strips (347 euro vs. 393 euro) and needles (67 euro vs. 80 euro) were significantly lower in the GLA group (p < 0.001, each), whereas costs of OAD (36 euro vs. 35 euro), lancets (14 euro vs. 15 euro) and Hypokits® (1.9 euro vs. 1.0 euro) did not differ significantly. Glycemic parameters (HbA1c, fasting blood glucose) were better on GLA based therapy (p < 0.01) and associated with lower daily total insulin doses (68 U vs. 79 U). Furthermore, slightly better results in patient-reported outcomes were found in GLA patients. CONCLUSION: In a head-to-head comparison over six months a glargine vs. detemir based basal-bolus therapy in type 2 diabetes patients was associated with lower total costs of diabetes care Δ: -128 euro/patient) mainly caused by savings of consumables. Further health services research with larger sample sizes should be conducted to obtain a more comprehensive analysis of economic aspects of insulin analogs or other innovative drugs in routine practice.

Nonadherence in outpatient thrombosis prophylaxis with low molecular weight heparins after major orthopaedic surgery.

BACKGROUND: According to some current guidelines, extended thromboprophylaxis after hip and knee arthroplasties is recommended. Outpatient prophylaxis with low molecular weight heparins (LMWH) is an important part of this prophylaxis, although the rates of adherence to these regimens is not known. QUESTIONS/PURPOSES: We determined (1) the degree of nonadherence (NA) of patients with LMWH outpatient prophylaxis, and (2) whether specific independent factors explain NA. METHODS: NA was determined by syringe count and by indirect and direct questions to patients. We defined six different NA indicators. To identify factors explaining LMWH NA, we used three different logistic regression models. RESULTS: NA rates ranged between 13% and 21% depending on the indicator used for measurement. Patients who were nonadherent missed between 38% and 53% of their outpatient LMWH injections. If patients attended an outpatient rehabilitation program, the probability for their NA increased substantially. Moreover, the NA probability increased with each additional day between acute hospitalization and start of rehabilitation (linking days). NA was lower for patients who feared thrombosis or who believed antithrombotic drugs to be the most important measure in thromboprophylaxis. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.