[Sex-specific differences in drug utilisation in different phases of life]. / Geschlechtsspezifische Inanspruchnahme bei der Arzneimittelversorgung in verschiedenen Lebensphasen.

The aim of the present study is to analyse sex-specific differences in drug utilisation during different phases of life using relevant diseases as examples. We used a cohort of 1.7 million subjects who were insured with the Gmünder ErsatzKasse (GEK), a German health insurance fund, for at least one day in all four quarters of 2009. We analysed subjects with outpatient diagnoses of the following diseases: attention-deficit/hyperactivity disorder (ADHD) (0-17 years), hypothyroidism (18-49 years), osteoporosis (50-79 years) and coronary heart disease (80 + years). Analysis was performed on an active-substance level. A number of differences were observed in drug treatment for the selected diseases (for example, substances for ADHD were prescribed more often in males and for hypothyroidism more often in females), as well as in prescribing practices relating to other drugs used in these groups. However, clear explanations for these differences, such as drug approval status, were not always apparent.

[Perceptions of GPs and community pharmacists on hypnotic prescribing on private prescriptions]. / Privat statt Kasse? Einstellungen von Hausärzten und Apothekern zur Verordnung von Hypnotika.

BACKGROUND AND AIM: Zolpidem and zopiclone ("Z-drugs") and benzodiazepine hypnotics are reimbursed by the statutory health insurance for short-term use and in exceptional cases for longer periods. A large proportion is prescribed on private prescriptions. The aim of this study was to assess the perceptions of general practitioners (GPs) and community pharmacists (CPs) on private prescriptions of hypnotics regarding frequency, reasons and measures for reduction. METHODS: A questionnaire was mailed to a random sample of 1,350 GPs and 600 CPs in 2012.  Questions were partly identical. Due to multiple testing, only p-values ≤ 0.01 were considered statistically significant. RESULTS: 458 GPs and 202 CPs returned questionnaires (response 33.9 % and 33.7 %). According to the CPs, the proportions of private prescriptions was higher for Z-drugs than for benzodiazepines (57.5 vs. 47.4 %; p < 0.0001). The proportion of private prescriptions of Z-drugs was higher in the eastern than in the western part of Germany (78.2 vs. 52.3 %; p < 0.0001). For benzodiazepines no such differences were found. As most relevant reasons for private prescriptions, the specifications of the Arzneimittel-Richtlinie and patients' demands were named. Patients with long-term use receive more often private prescriptions. CONCLUSIONS: A switch to private prescriptions for patients with long-term use seems conflicting, because such patients with (iatrogenic) dependence are indicated exceptional cases. Practicable changes of the regulatory framework are needed, their benefits and harms should be evaluated.

Variation in antibiotic prescriptions: is area deprivation an explanation? Analysis of 1.2 million children in Germany.

PURPOSE: Inadequate use of antibiotics can lead to problems such as resistance. Overuse is especially a problem for children, since they are more affected by acute (often virus-caused) infections. While the problem has been addressed internationally over the past several years, regional variations in prescriptions are striking. Therefore, the present study aims to analyze regional variations in antibiotic prescription on a district level in Germany and tries to identify reasons for those variations through adding possible influencing factors to the analysis on individual and district levels. METHODS: We analyzed 1.2 million children insured in a German health insurance fund. Antibiotic prescriptions were quantified in 2010 and reasons for prescriptions were analyzed in multilevel regressions based on the district of residence, regional deprivation, and age and sex of the child. RESULTS: Thirty-six percent of all children aged 0-17 years received an antibiotic prescription in 2010. In the south, prevalences are generally lower, and also to the very north. The highest prevalences are found in the close-to-border districts in the west, as well as in a band throughout the middle of Germany, in rather low population density areas. Regional variation in the prevalence range from 19 to 53 % between districts. Regional deprivation can explain part of this variation. CONCLUSIONS: Including area deprivation measures helped identify an influence of especially regional income and occupational deprivation on antibiotic prescriptions for children. Regional analysis such as this can help identify specific regions and groups of persons to address information programs on the risks of preventable antibiotic consumption and alternative treatment methods.

[Prescription of high-potency opioids in 2011]. / Verordnung von starken Opioiden im Jahr 2011.

BACKGROUND: The aim of this study was to analyze the prescription of high-potency (WHO step III) opioids with respect to regional differences and to assess the proportion of opioid-naïve new users of transdermal fentanyl. METHODS: Prescription claims data of the largest single German health fund (BARMER GEK) with 9.1 million insured persons from the year 2011 were used. For new users of transdermal fentanyl who had had no prescription in the preceding 6 months it was studied whether they had received other high-potency or low-potency opioids before. RESULTS: A total of 18.9 million defined daily doses (DDD) of high-potency opioids were included corresponding to a mean of 208.6 DDD per 100 persons. Significant regional differences were found with lower values in the south, ranging from 145.9 DDD in Baden-Württemberg to 259.5 DDD per 100 persons in Lower Saxony. Fentanyl was the most frequently used step III opioid (40.8% of DDDs) which is nearly only given transdermally. Of the 11,184 patients with new use of transdermal fentanyl 80.7% had received no other high-potency opioid before and 52.9% had received neither low-potency nor high-potency opioids before. The first prescription exceeded the smallest available dose of 12.5 µg/h for over half of the patients starting treatment. CONCLUSIONS: Although oral morphine, oxycodone and hydromorphone are recommended as first-line step III opioids, transdermal fentanyl seems to be prescribed too often as the first choice and might not be appropriate.

[Prescription of TNF-alpha inhibitors and regional differences in 2010]. / Versorgung mit TNF-α-Blockern und regionale Unterschiede im Jahr 2010.

Tumor necrosis factor alpha (TNF-α) inhibitors are an important treatment option for rheumatoid arthritis and other chronic inflammatory diseases. However, attention should be paid to severe adverse drug reactions and very high costs of therapy. The objective of this study was to examine the prescription and costs of TNF-α inhibitors as well as regional differences at the district level in Germany. For this purpose, prescription claims data of a German health fund with 9.1 million insured persons from the year 2010 were analyzed. A total of 45,229 packs (0.1% of all prescribed drugs) and 3.15 million defined daily doses (DDD) of TNF-α inhibitors were prescribed. This leads to a total pharmacy revenue of 163.18 million Euro (share 4.1%) and 1 DDD costs on average 51.61 Euro. For 10,078 patients at least one TNF inhibitor was prescribed (prescription prevalence 111 per 100,000) with a higher proportion of women (125 vs. 92 per 100,000). The average revenue per insured person was often higher in districts of eastern Germany (>30 Euro) for reasons unknown. Provided that use is appropriate to indications there are only low saving potentials.

[Regional differences in the use of 'no substitution' in the elderly after introduction of rebate contracts]. / Regionale Unterschiede in der Nutzung des Aut-idem-Verbots bei Älteren nach Einführung der Rabattverträge.

AIM: As of 1 April 2007, pharmacists in Germany filling prescriptions covered by the statutory health insurance system (Gesetzliche Krankenversicherung, GKV) are required, whenever possible, to dispense a preparation for which a rebate contract is in effect. The physician can block drug substitution by crossing out 'aut idem' ('or the like') on the prescription form, for which regional variations were found. We have studied the differences between physicians belonging to different regional Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, KVs) in the use of the no-substitution option in the elderly. METHODS: We used claims data of the Gmünder ErsatzKasse (GEK) and drew a random sample stratified according to the 17 KVs and 3 age groups (65-74; 75-84; 85+ years) of at least 75 continuously insured persons in October 2008 per stratum. After that, all prescriptions in which the physician could potentially have exercised a no-substitution option were selected and all relevant original prescriptions were examined. All estimates were weighted according to KVs, age groups and sex as of the structure of the GKV. RESULTS: The sample comprised of 3 672 persons and 5 745 prescriptions. The percentage of no-substitution prescriptions was 20.1% (95% confidence interval [95% CI] 18.7-21.5) and we found no differences according to age and sex. Considerable differences were seen between the KVs that vary 6.8-fold between 6.2% (95% CI: 3.2-9.2) in Saarland and 42.2% (95% CI: 34.1-50.4) in Saxony. CONCLUSION: The use of the no-substitution option does not depend on age and sex of the patient but rather depends on regional factors. These considerable regional differences show that, in several regions, the use of the no-substitution regulation influences the effect of rebate contracts.

[Implementation of "aut idem" before and after introduction of rebate contracts]. / Umsetzung der Aut-idem-Regelung vor und nach Einführung der Rabattverträge.

OBJECTIVE: Due to the aut-idem regulation pharmacies are obligated to substitute medications within the statutory health insurance system to low-priced generics or to dispense the prescribed drug (if only a compound is prescribed low-priced generics have to be dispensed). Since April 1st, 2007 pharmacies have to replace non-rebated by rebated drugs. We aimed to investigate if the prescribing of compounds and substitutions in pharmacies has changed after the introduction of rebate contracts. METHODS: We used claims data of the Gmünder ErsatzKasse (GEK) and drew 3 random samples of 1,000 relevant prescriptions each in October 2006, 2007 and 2008. After that, all relevant original prescriptions were screened. RESULTS: Between October in 2006, 2007 and 2008, we observed no change in prescribing compounds only (6.0 %; 7.7 %; 6.8 %; p = 0.47). Prescribing compounds was associated with, e. g. dentists, small packages (N1 vs. N3) and antiinfectives. We found a considerable increase in medications that were substituted in pharmacies (2006: 11.3 %; 2007: 29.1 %; 2008: 39.2 %; p <0.0001). CONCLUSION: Only through the introduction of rebate contracts an increasing amount of substituted medications took place in pharmacies. Before that, the aut-idem regulation had no considerable regulatory effect.